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10096420-DS-17 | 10,096,420 | 25,396,519 | DS | 17 | 2204-07-20 00:00:00 | 2204-07-23 15:57:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Coronary catheterization with Percutaneous Coronary Intervetion
to proximal left anterior descending artery with placement of
Drug Eluding Stent in the middle left anterior descending
History of Present Illness:
___ y/o M hx of HPL, and MI ___ with 90% stenosis of mid-RCA s/p
BMS and ___ rheolytic thrombectomy and 90% mid-LAD stenosis s/p
DES to LAD who presented to the ED after sudden onset of chest
pressure this am while working in his yard. His symptoms were
typical of prior episodes when he was having a MI. He was
sweating profusely and have crushing, non-radiating chest pain.
He says that over the last few weeks he was getting more
fatigued with activities he was usually able to do with no
problem. Per his wife, with the onset of the chest pressure, he
started sweating more than usual and they knew he was having a
heart attack. He stated that he tried a SL nitro with no
relief, but his prescription was ___ year old. Per his wife he
also appeared to lose consciousness for a few minutes while in
the car, but was arousable. He was taken by truck back to the
house and EMS was called, an EKG was notable for ST elevations
and a code STEMI was called.
He was taken directly to the cath lab where had systolic BPs
ranging from 80-96/50-60s, he recieved 210 cc contrast, was
loaded with Plavix 600mg, and started on heparin drip. LHC via
the right radial artery revealed 100% occlusion of the mid-LAD
within the prior stent. This was stented with a DES. In
addition, there was a 80% stenosis of the origin of the diagonal
branch within the LAD stent. There was a 3 mm segment of
intraluminal filling defect 15 mm distal to the stent likely
representing embolized thrombus and patient was started on
integrilin drip.
Vitals on transfer were 93/66 90 42 92% on 3L.
.
On arrival to the floor, patient stable, he had complaints of
residual chest discomfort with exhalation, but much improved.
He described is "when you just had a headache and it goes a way,
you know you had a headache not too long ago". Otherwise he had
no c/o SOB, cough, arm, neck or jaw pain. Denies f/c, n/v,
abdominal pain, ___ edema.
Past Medical History:
- CAD s/p PCI to ___ ___, mLAD ___, PTCA of mLAD and diag ___,
- colon cancer s/p colectomy (___)
- nephrolithiasis
- s/p cholecystectomy
- HPL
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION:
VS: T=98.2 BP=105/49 HR=107 RR=24 O2 sat=97%
GENERAL: WDWN 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 xanthalesma.
NECK: Flat neck veins.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
.
DISCHARGE:
GENERAL: WDWN 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 xanthalesma.
NECK: Flat neck veins.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
Pertinent Results:
ADMISSION LABS:
___ 12:23PM BLOOD WBC-9.5 RBC-4.60 Hgb-14.3 Hct-42.2 MCV-92
MCH-31.0 MCHC-33.8 RDW-13.0 Plt ___
___ 06:44PM BLOOD Neuts-82.0* Lymphs-11.9* Monos-5.6
Eos-0.1 Baso-0.4
___ 12:23PM BLOOD ___ PTT-23.6* ___
___ 06:44PM BLOOD Glucose-134* UreaN-11 Creat-1.0 Na-141
K-4.0 Cl-108 HCO3-23 AnGap-14
___ 12:23PM BLOOD CK(CPK)-89
___ 12:23PM BLOOD CK-MB-2 cTropnT-<0.01
___ 06:44PM BLOOD Calcium-8.9 Phos-2.8 Mg-1.9
___ 01:40AM BLOOD HDL-32 CHOL/HD-3.8 LDLmeas-77
.
.
STUDIES:
(___) CXR: In comparison with the study of ___, there is
little overall change. Cardiac silhouette remains within normal
limits. Mild indistinctness of pulmonary vessels could reflect
some elevated pulmonary venous pressure. No acute focal
pneumonia or pleural effusion
.
.
(___) CATH: ASSESSMENT
Coronary angiography: right dominant
.
LMCA: Normal
.
LAD: 100% occlusion of the mid LAD within the prior stent.
There was a 80% stenosis of the origin of the diagonal branch
within the LAD stent. The distal LAD was a large disbtribution
vessel that supplied the apex. There were small ___ and ___
diagonal branches that supplied the anterolateral wall.
.
LCX: The proximal and distal LCx had minimal lumen
irregularities. Threw was a large OMB that supplied the
posterolater wall. It was free of significant disease.
.
RCA: The RCA stent was widely patent. The was a 50% margin
stenosis distal to the stent that supplied a large PDA branch
and medium size posterolateral branches.
.
Interventional details
.
The indication for the procedure was an anterior STEMI.
.
The procedure was performed from the right radial artery without
complications
.
Unfractionated heparin was used to achieve an ACT > 250 seconds.
Eptifibatide was given as a double bolus.
.
Using a ___ XB3.5 guiding catheter and a 0.014 OTW BMW wire, the
LAD was dilated with a 2.5 mm balloon. There was lesion
rigidity in the distal portion of then stent and a 2.75 mm x 12
mm Apex NC balloon was used to fully expand the stent. A 2.0
mm balloon was used to dilated the diagonal branch prior to
additional stent implantation. A 2.75 mm x 14 mm Resolute
drug eluting stent was then deployed within the stent and was
post dilated with a 3.0 mm balloon to 22 atms pressure. This
resulted in no residual stenosis within the stent and TIMI 3
flow into the distal vessel.
.
There was a 50-60% stenosis of the origin of the diagonal branch
but TIMI 3 flow into the distal vessel.
.
There was a 3 mm segment of intraluminal filling defect 15 mm
distal to the stent that likely represented embolized thrombus.
It was laminar and seen in the ___ but not the ___ projections.
It will be treated with continued antiplatelet therapy and
GPIIB-IIIa antagonists for 18 hours. Consideration for long
term anticoagulation with warfarin with evidence of an LV
aneurysm.
.
The patient was painfree at the end of the procedure, but the
EKG showed improved but persistent ST elevation in the anterior
precordial leads.
.
ASSESSMENT
1.Anterior ST elevation due to LAD stent occlusion
2.Successful drug-eluting stent of the mid LAD
PLAN
1.Aspirin 325 mg daily for one month then 81 mg daily
thereafter
2.Plavix 75 mg daily
3.Eptifibatide infusion x 18 hours
4.Echocardiogram for LV akinesis: consider anti-coagulation
Brief Hospital Course:
___ man with CAD s/p PCI to mRCA ___, mLAD ___, PTCA of
mLAD ISR and diag ___, and colon CA s/p colectomy ___ presenting
with substernal chest pressure while working in the yard. This
is in the setting of increasing fatigue with daily activities.
He presented to the ED where his ECG was consistent with an
anterior STEMI and he was taken emergently to the cath lab.
.
## STEMI - Left heart cath showed an occlusion of the mid-LAD at
the site of a previous stent, 80% stenosis at the diag origin,
and a 50% margin stenosis distal to the RCA stent. A
drug-eluting stent was placed in the mid LAD with TIMI 3 flow
into the distal vessel following stent placement. The patient
had persistent ST elevations and Q-waves on post-procedure ECG
suspicious for LV dyskinesis. He was started on an Integrilin
gtt intraop x 18 hours total. Started on Heparin gtt after
Integrellin given risk of developing LV Mural thrombus. Pt had
an Echo on ___ that showed Mild symmetric left ventricular
hypertrophy with regional left ventricular dysfunction(akinesis)
c/w LAD territory MI. Preserved right ventricular function. No
pathologic valvular disease. Based on this finding the patient
was started on Warfarin with a Lovenox bridge. We continued the
patient on Plavix 75mg daily, ASA 81mg daily, Metoprolol XL
150mg daily, atorvastatin 80mg/day. Lisinopril was started on
___, 2.5mg daily. Given extensive CAD history, patient may
benefit from ICD to decrease risk of SCD, will need to consider
in > 90 days. His lisinopril could be uptitrated in the future
and spironolactone could be initiated if his BP allows these
medication changes.
.
## TRANSITIONAL
- Consider/discuss ICD placement > 90 days post PCI
- Start spironolactone and uptitrate ACEI if BP allows
- PCP to monitor INR and smoking cessation
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Aspirin 325 mg PO DAILY
2. Simvastatin 40 mg PO DAILY
3. Metoprolol Tartrate 50 mg PO DAILY
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
RX *atorvastatin 80 mg one tablet(s) by mouth daily Disp #*30
Tablet Refills:*2
3. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg one tablet(s) by mouth daily Disp #*30
Tablet Refills:*2
4. Lisinopril 2.5 mg PO DAILY
hold for SBP < 90
RX *lisinopril 2.5 mg one tablet(s) by mouth daily Disp #*30
Tablet Refills:*2
5. Warfarin 5 mg PO DAILY16
please check with your PCP about specific dosing based on the
blood level INR
RX *warfarin 2 mg 2.5 tablet(s) by mouth daily Disp #*75 Tablet
Refills:*2
6. Outpatient Lab Work
Chem-7, INR on ___ with result to Dr. ___ at
Phone: ___
Fax: ___
ICD-9 428 CHF
7. Enoxaparin Sodium 100 mg SC BID
RX *enoxaparin 100 mg/mL one syringe twice a day Disp #*8
Syringe Refills:*2
8. Metoprolol Succinate XL 150 mg PO DAILY
hold for SBP<100, HR<60
RX *metoprolol succinate 100 mg 1.5 tablet(s) by mouth daily
Disp #*45 Tablet Refills:*2
Discharge Disposition:
Home
Discharge Diagnosis:
ST elevation myocardial infarction
Acute on chronic systolic congestive heart failure
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
You were admitted for chest pain, which was due to a heart
attack. You were evaluated by cardiologist and they performed a
procedure that involved opening the blocked vessel and placing a
drug eluting stent. After the procedure you had an
echocardiogram of the heart that showed the poor movement of the
left and lower side of the heart. This poor movement increases
your risk of developing a clot in that part of your heart. To
prevent clot formation, you will need to take a blood thinner
medicine called Warfarin. This is in addition to the Plavix and
Aspirin. You will need to have blood levels of the Warfarin
checked regularly and communicate with the ___
clinic at ___ about those results. You will need to
use the Lovenox injections until the blood level of Warfarin
(called INR) is between 2.0 - 3.0. You can stop Lovenox
injections at that time when the ___ clinic says it
is OK.
Please stop smoking. Continuing smoking will significantly
increase your risk for additional heart attacks, and strokes,
not to mention the risks of multiple cancers.
Because your heart is weak, please weigh yourself every day in
the morning before breakfast. Call Dr. ___ weight
increases more than 3 pounds in 1 day or 5 pounds in 3 days.
Watch for trouble breathing and your legs for signs of swelling.
Call Dr. ___ you notice any of those symptoms.
MEDICATIONS:
START Warfarin 5mg by mouth daily, change dose after discussion
with your PCP
START ___ 75mg/day and Aspirin 81mg/day, do not
miss any doses or stop taking this medicine unless Dr. ___
that it is OK.
START Lovenox ___ injection twice daily
Followup Instructions:
___
|
10096420-DS-18 | 10,096,420 | 26,321,485 | DS | 18 | 2204-08-17 00:00:00 | 2204-08-22 11:54:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Hematuria, left abdominal pain
Major Surgical or Invasive Procedure:
EGD ___
History of Present Illness:
Patient is a ___ M with history of large anterior STEMI in
___ (Tx w/ DES to LAD, subsequent LV akinesis now on
coumadin, EF ___, nephrolithiasis in the past who was
transferred this AM from ___ with a 4x6mm obstructing
ureteral stone, hematuria, and HCT drop.
Two nights prior to presentation, he began feeling localized
pain in left lower abdomen, slowly worsening. No radiation of
pain. No hematuria or tea colored urine. Episode of pain felt
similar to prior kidney stones. Morning of presentation, he had
an episode of nausea/vomiting, so he presented to the ___ at ___
___. CT of the abdomen/pelvis was done for ?
retroperiotoneal bleed (though patinet had radial access for
stenting) and for evalution for the presence of kidney stone.
The patient was found to have 4x6mm obstructing ureteral stone
at the mid left ureter with mild left hydronephrosis and
proximal ureteral dilation. His only recent medication changes
are doubling lisinopril and decreasing his metoprolol.
Of note, he had one episode hematuria this AM. He had a large
hematocrit drop (36 on last discharge from ___ --> 25.4 at
___, 24.7 now). At ___, he had heme-negative stool
on rectal exam. INR was 3.0. UA at ___ with many RBCs
and positive LEs. At OSH, the patient got either 500cc or 1000cc
(unclear documentation), zofran 4 mg, and morphine.
In the ___, initial vitals: Urology was consulted in the ___ who
felt that stent in the emergent setting was necessary, and
recommended flomax 0.4 qHS x2 weeks, PRN tylenol, and
breakthrough narcotics. Per Urology, wanted to pursue
conservative management with trail of passage. Per Urology, his
hematuria demonstrated evidence of old, tea-colored urine and
was not concerning for active hemmorhage. ___ Cardiology was
also contacted in the ___, who recommended admission to medicine
for inpatient management of active issues. Per discussion with
Dr. ___ patient's cardiologist, anticoagulation has not
been reversed. The patient had a large anterior MI and must
remain on aspirin and Plavix. He is on Coumadin for prophylaxis
of mural thrombus. FFP could be given if hemodynamic instability
develops. In the ___, the patient received 250cc over 1.5 hours,
2mg morphine IV, 1000mg APAP. Patient also took home Plavix and
ASA. Patient received 1 unit pRBCs in the ___. Vitals prior to
transfer: 98.1 91 98/52 18 98%.
Currently, the patient denies chest discomfort. He currently
denies abdominal pain.
ROS: per HPI, denies fever, chills, night sweats, headache,
vision changes, rhinorrhea, congestion, sore throat, cough,
shortness of breath, chest pain, abdominal pain, nausea,
vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria.
Past Medical History:
- CAD s/p PCI to mRCA ___, mLAD ___, PTCA of mLAD and diag ___,
- colon cancer s/p colectomy (___)
- nephrolithiasis
- s/p cholecystectomy
- HDL
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory. No known
family history of nephrolithiasis.
Physical Exam:
Admission physical exam:
VS - Temp 98.0 F, BP 105/56, HR 91, RR 18 , O2-sat 99% RA
Admission weight 97.4kg
GENERAL - NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no JVD
HEART - Distant heart sounds, but from what could be appreciated
RRR, nl S1-S2, no MRG
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use
ABDOMEN - Overweight. NABS+, soft/NT/ND, no masses upon
palpation, no rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions or petechiae
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric
Discharge physical exam:
Vitals: T 98.1 BP 98/60 (98-120/58-62) HR 85 (78-112) RR 18 O2
Sat 97% on RA
General: Sitting up in bed in NAD.
HEENT: EOMI. PERRL. MMM. OP
Neck: Supple. No JVD
CV: RRR. No M/R/G.
Lungs: Nml work of breathing. No accessory muscle use. CTAB
posteriorly. No crackles or wheezes.
Abd: NABS+. Soft. NT/ND.
Ext: Warm, well perfused. 2+ PTs bilaterally. No pitting edema.
Pertinent Results:
Admission labs:
___ 02:05PM BLOOD WBC-9.7 RBC-2.61*# Hgb-8.3*# Hct-24.7*#
MCV-95 MCH-31.8 MCHC-33.7 RDW-14.7 Plt ___
___ 02:05PM BLOOD Neuts-77.0* Lymphs-17.7* Monos-5.0
Eos-0.2 Baso-0.2
___ 02:10PM BLOOD ___ PTT-34.5 ___
___ 02:05PM BLOOD Glucose-106* UreaN-27* Creat-1.1 Na-137
K-4.1 Cl-107 HCO3-24 AnGap-10
___ 09:20AM BLOOD Calcium-8.4 Phos-4.1 Mg-1.9 Iron-110
___ 09:20AM BLOOD calTIBC-359 Ferritn-109 TRF-276
Hematocrit trend: 24.7 -> 28.2 -> 29.4 -> 27.2 -> 32.4 -> 25.7
-> 30.4 -> 28.3
EGD report:
Normal mucosa in the stomach. Evidence of solid food was noted
in the stomach. Nodular areas in the duodenal bulb with
superficial erythema consistent with duodenitis was noted in the
bulb. Otherwise normal EGD to third part of the duodenum
Renal Ultrasound:
FINDINGS:
The right kidney measures 11.4 cm.
The left kidney measures 12.0 cm.
There is mild caliectasis in the left kidney, but no
hydronephrosis, stone or mass in either kidney. Right side
ureteral jet is seen. No left ureteral jet is visualized.
There may be a prominent vessel in the porstate (image 23).
IMPRESSION: Mild left caliectasis. No ureteral jet on the left
visualized.
KUB: IMPRESSION: No nephrolithiasis seen. Left paraspinal
calcifications likely located within a known left paraspinal
mass that may represent a nerve sheath tumor.
Microbiology:
___ 7:30 am SEROLOGY/BLOOD
**FINAL REPORT ___
HELICOBACTER PYLORI ANTIBODY TEST (Final ___:
NEGATIVE BY EIA.
(Reference Range-Negative).
Discharge labs:
___ 07:18AM BLOOD WBC-4.9 RBC-3.10* Hgb-9.7* Hct-28.3*
MCV-91 MCH-31.2 MCHC-34.1 RDW-14.6 Plt ___
___ 08:15AM BLOOD Neuts-81* Bands-0 Lymphs-11* Monos-6
Eos-2 Baso-0 ___ Myelos-0
___ 07:18AM BLOOD ___ PTT-25.8 ___
___ 07:18AM BLOOD Glucose-115* UreaN-14 Creat-1.2 Na-141
K-4.0 Cl-107 HCO3-25 AnGap-13
Brief Hospital Course:
Patient is a ___ year old male with history of large anterior
STEMI in ___ (Tx w/ DES to LAD, subsequent LV
akinesis now on coumadin, EF ___, nephrolithiasis in the
past who was transferred this AM from ___ with a 4x6mm
obstructing ureteral stone, hematuria, and hematocirt drop.
#. GI bleed resulting in anemia: Patient was noted to have a 14
point hematocrit drop at the OSH. He had a CT abdomen/pelvis
that did not show a retroperitoneal bleed. The patient was
guaiac positive upon admission. He was placed on a PPI drip and
received vitamin K. He also received 2 units of pRBCs during
this admission. His HCT was trended daily and remained stable.
He had no bowel movement during this admission. GI was consulted
in light of his 14 point HCT drop. He was taken for EGD, which
showed no active signs of bleeding through the duodenem.
Biopsies were taken; biopsies of the duodenum showed chronic
inactive duodenitis, with foveolar metaplasia. Gastric biopsies
were benign. The patient was discharged on PPI and had follow-up
appointment arranged with his outpatient gatroenterologist
regarding this admission for GI bleed to address the need for
colonsocopy versus push enteroscopy to visualize the rest of the
patient's small bowel.
.
#. Nephrolithiasis: Patient initially presented to OSH with
pain/symptoms that were consistent with nephrolithiasis in the
past. CT scan at the OSH showed obsturction with hydorureter and
hydornephrosis. The patient was treated conservatively with pain
medication and Flomax initially. Serum creatinine was noted to
increase during the admission; Urology was going to take the
patient for ureteral stent placement. However, the patient
passed his stone, and no procedure was necessary. With passage
of the stone, the patient's serum creatinine was noted to be
downtrending. Patient was encouraged to follow-up with his PCP
or ask for a referal to nephrology for follow-up regarding his
kidney stones.
#. Anterior STEMI: The patient had a large anterior MI ___
and remained on aspirin and Plavix throughout this admission. He
was on Coumadin for prophylaxis of mural thrombus. Review of TTE
fomr previous admission showed that there was no mural thrombus
in the left ventricle. During this admission, the patient was
given Vitamin K and warfarin was held in light of his GI bleed.
Beta blocker was initially held, but restarted when there was no
evidence of active bleeding (appropriate increase in hematocrit
to 2 units of pRBCs and stable hemodyanmics). Lisinopril was
restarted at low dose, 2.5mg daily on day of discharge.
Outpatient follow-up with the patient's Cardiologist so that
discussion regarding reinitiation of warfarin in the setting of
reduced EF but known source of GI bleeding could be had. Upon
discharge, patient's cardiologist was made aware that the
patient's warfarin was discontinued.
Medications on Admission:
1. Aspirin EC 81 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Lisinopril 2.5 mg PO DAILY
5. Warfarin 5 mg PO DAILY16
7. Enoxaparin Sodium 100 mg SC BID
8. Metoprolol Succinate XL 100 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Nitroglycerin SL 0.3 mg SL PRN chest pain
Notify ___ if administering
5. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth every 12 hours Disp
#*60 Tablet Refills:*0
6. Senna 1 TAB PO BID:PRN constipation
7. Lisinopril 2.5 mg PO DAILY
HOLD for SBP < 100
RX *lisinopril 2.5 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
8. Docusate Sodium 100 mg PO BID
hold for loose stools
9. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Nephrolithiasis
Gastrointestinal bleed
Secondary diagnosis:
Coronary artery disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of you during your hospitalization
at ___.
You were hospitalized because of kidney stones and found to have
a new anemia (low red blood cell count). This anemia was
attributed to a bleed in your gastroentestinal tract as a result
of the combination of aspirin, Plavix, and coumadin that you
were started on after your heart attack. You received 2 units of
blood while hospitalized, and your red blood cell level remained
stable. You had an EGD that did not show evidence of active
bleeding which is good news.
In the interim, we recommend that you continue a medication
called pantoprazole, which will help prevent GI bleeding.
Discuss with your gastroenterologist when to stop this
medication.
Continue taking aspirin and Plavix EVERY DAY as you had been
doing prior to this hospitalization. STOP taking coumadin (also
known as warfarin) as the risk of bleeding is greater than it's
benefit at the present time. Follow-up with your cardiologist
about re-starting coumadin.
Keep all hospital follow-up appointments. Your ___
hospital follow-up appointments are provided in a list for you
in your discharge paperwork.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
10096969-DS-17 | 10,096,969 | 25,079,335 | DS | 17 | 2190-02-05 00:00:00 | 2190-02-05 16:33:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
right sided weakness, difficulty speaking
Major Surgical or Invasive Procedure:
None
History of Present Illness:
PER ADMITTING RESIDENT:
___ is a ___ year old right handed male with a
history of hypertension and prostate cancer who presented after
acute onset of right sided weakness and slurred speech. Mr.
___
awoke this morning in his usual state of health and then around
6:30am while driving to the grocery store had sudden onset chest
pain and then developed difficulty speaking and right sided
weakness. He does not remember the exact details after the
onset
of the pain, but was apparently able to pull his car over to the
side of the road and call his daughter-in-law. His speech was
garbled and daughter-in-law thought he was having a stroke.
Called ___ and then met him where he had pulled over on the side
of the road. Had right face, arm, leg weakness and slurred
speech.
Taken to ___ where initial ___ stroke scale
was
18. Initial BP-164/87 (7:20am), P-86. Head CT showed 4cm left
thalamic hemorrhage with intraventricular extension. Facial
weakness and degree of dysarthria improved somewhat but right
arm/leg weakness persisted. He received a dose of zofran for
nausea and then was transferred to ___ for further care.
Symptoms have since remained fixed.
On neuro ROS, the pt endorses several months of headaches, but
denies loss of vision, blurred vision, diplopia, dysarthria,
dysphagia, lightheadedness, vertigo, tinnitus. Has had
longstanding decreased hearing in right ear. Denies
difficulties
producing or comprehending speech until this morning. Denies
focal weakness, numbness, parasthesiae until this AM. No bowel
or
bladder incontinence or retention. Denies difficulty with gait
until this AM.
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. Had been
under tremendous stress recently with death of his wife and
son's
legal problems.
Past Medical History:
-hypertension, reportly was not under good control at last PCP
visit but no adjustments made to his medications
-prostate cancer ___ years ago s/p radiation therapy.
Social History:
___
Family History:
FAMILY HISTORY:
- Mother with hypertension, heart disease and high
cholesterol.
- Unknown family history about father as he left the family when
Mr. ___ was young.
Physical Exam:
Physical Exam on Admission:
Vitals: T: 98.2 P: 84 R: 16 BP: 143/65 SaO2: 97%
.
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: WWP, 2+ radial, DP pulses bilaterally.
Skin: no rashes or lesions noted.
.
Neurologic:
-Mental Status: Alert, oriented to first/last name only. Unable
to relate history and does not remembers events of this AM. Has
word finding difficulties and stuttering with confabulation at
times. Receptive language and comprehension appears intact and
he can point at correct objects. He was unable to repeat 3
objects and unable to recall at 3 minutes (potentially secondary
to his expressive language deficits). At times, he was able to
read short sentences slowly. Has speech apraxia.
.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 4 to 2mm and brisk. VFF to confrontation. Funduscopic
exam revealed no papilledema, exudates, or hemorrhages.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation reduced on right hemiface to pinprick, light
touch, cold. Left side intact.
VII: Mild facial assymmetry with right nasolabial fold
flattening. Subtle asyymetric smile.
VIII: Hearing decreased to finger rub on right compared to left
(chronic per patient's family).
IX, X: Palate elevates symmetrically.
XI: ___ shoulder shrug on right, ___ on left.
XII: Tongue protrudes in midline.
.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 0 0 0 0 0 0 0 3 0 0 0 0 0 0
.
-Sensory: Absent sensation for light touch, pinprick, cold and
vibration on the right hemibody. Intact on left side.
.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 2
R 3 3 3 2 2
Plantar response was flexor bilaterally.
.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally on left.
.
-Gait: unable to ambulate
=================
Physical Exam on Discharge: notable for
awake. alert. able to follow one-step midline and appendicular
commands. able to communicate in one to four-word answers.
unable to repeat even single words. difficulty naming both high
and low frequency objects. able to read one line phrases.
unable to write (right-handed).
.
Motor: There is an upper motor neuron right facial. Strength is
full in the left extremities. There is no spontaneous movement
or withdrawal from noxious stimulation in the right arm. There
is possible withdrawal (versus triple flexion) from noxious
stimulation at the great toe; the response is actually thought
to be more consistent with purposeful withdrawal as the leg
moves medially (rather than demonstrating triple flexion) with
noxious stimulation to the right lateral calf. The right
plantar response is extensor.
Pertinent Results:
Admission Labs:
GLUCOSE-115* UREA N-21* CREAT-0.8 SODIUM-139 POTASSIUM-4.0
CHLORIDE-104 TOTAL CO2-25 ANION GAP-14
WBC-7.5 RBC-4.52* HGB-13.1* HCT-39.1* MCV-87 MCH-29.0 MCHC-33.5
RDW-12.9
NEUTS-86.4* LYMPHS-9.2* MONOS-3.4 EOS-0.6 BASOS-0.5
PLT COUNT-170
___ PTT-24.0* ___
.
ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG
tricyclic-NEG
URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG
amphetmn-NEG mthdone-NEG
.
URINE COLOR-Straw APPEAR-Clear SP ___
URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG
BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG
URINE RBC-1 WBC-1 BACTERIA-NONE YEAST-NONE EPI-0
URINE MUCOUS-RARE
.
Modifiable Stroke Risk Factors:
%HbA1c-5.2 eAG-103
Triglyc-101 HDL-60 CHOL/HD-3.0 LDLcalc-102
.
Discharge Labs:
WBC-8.1 RBC-4.66 Hgb-13.6* Hct-39.8* MCV-85 MCH-29.2 MCHC-34.3
RDW-13.2 Plt ___
Glucose-108* UreaN-20 Creat-0.8 Na-138 K-3.7 Cl-104 HCO3-23
AnGap-15
Calcium-9.1 Phos-2.8 Mg-2.0
.
IMAGING:
.
CT head ___ 12:03pm:
IMPRESSION: Interval evolution of known left thalamic hemorrhage
with
slightly increased surrounding parenchymal edema. Similar
appearance of
hemorrhagic extension into the ventricle system with mild,
approximately 2 mm rightward shift of normally midline
structures. Slight asymmetric enlargement of the left lateral
ventricle appears similar to the prior examination.
Repeat CT head ___ 6:30pm:
IMPRESSION: Overall, no significant change from the study of
roughly six hours earlier, with:
1. Unchanged left thalamic hemorrhage with stable surrounding
edema and
minimal rightward shift of normally-midline structures.
2. Transependymal "dissection" of hemorrhage into the
ventricular system, as before, with no evidence of hydrocephalus
at this time.
CXR ___:
Heart size and mediastinum are unremarkable. Lungs are
essentially clear. No pleural effusion or pneumothorax
demonstrated.
.
MRI Head without Contrast (___):
IMPRESSION: Left thalamic hemorrhage, centered at the left
pulvinar as
described in detail above, relatively stable since the most
recent head CT
dated ___. A small amount of intraventricular
hemorrhage is
identified on the left occipital ventricular horn. Scattered
foci of high
signal intensity are visualized in the subcortical and
periventricular white matter, which are nonspecific and may
suggest chronic microvascular ischemic disease.
Brief Hospital Course:
___ year old right handed man with a history of hypertension and
remote prostate cancer who presented ___ with acute onset
right hemiparesis, hemibody sensory deficits and expressive
language deficits. He was found to have a left thalamic
hemorrhage with intraventricular extension on head CT. His
initial examination was siginificant for word finding
difficulties and confabulation, mild right facial weakness,
flaccid right arm, profoundly weak right leg with hemisensory
loss to all modalities on the right and hyperreflexia on the
right. Neurosurgery was consulted in the ED and did not feel
there was any indication for acute intervention at the time. The
most likely etiology of Mr. ___ hemorrhage is hypertension.
He was initially admitted to the neuro ICU for close monitoring
for any evidence of worsening edema, development of
hydrocephalus or further hemorrhage.
.
ICU COURSE:
.
Neuro: CT head on evening of ___ was stable. He was maintained
on Q1hr neurochecks with close BP monitoring with goal SBP <
160. Exam remained essentially unchanged the next am on ___,
still with fluent aphasia and flaccid R hemiparesis. MRI without
contrast was ordered. Aspirin was held. He was restarted on his
home Lisinopril 10mg daily for BP control and also given
labetalol IV prn to maintain SBP < 160. Lipid panel revealed
total cholesterol 182, LDL 102, HDL 60, ___ 101. HbA1c was 5.2%.
Pt passed speech and swallow eval and was started on a regular
diet. ___ were consulted.
.
CV:
Pt was maintained on telemetry monitoring. He was maintained on
labetalol prn to keep SBP < 160. He passed swallow eval and was
restarted on his home lisinopril on ___. Aspirin was held.
.
Endo:
HbA1c was 5.2%. He was maintained on fingersticks qACHS and
insulin sliding scale with goal of euglycemia.
.
FEN/GI:
Cleared for regular diet per speech. Restarted on home
omeprazole for GI prophylaxis.
.
Prophylaxis:
He was maintained on pneumo boots for DVT prophylaxis.
Subcutaneous heparin was held
.
Code Status: Full
.
Pt was transferred to the neurology step-down unit on ___.
.
FLOOR COURSE:
The pt has been stable on the floor since transfer from the ICU.
His VS remained stable, and clinically, his neurological exam
remains unchanged. ___ recommends rehab upon discharge w/ greater
than 3 hours of therapy per day.
Medications on Admission:
-lisinopril 10mg daily
-omeprazole 40mg ER daily
-aspirin 81mg daily
Discharge Medications:
1. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6
hours) as needed for pain, temp > 100.4.
3. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day: *this medication should be restarted on ___.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left thalamic hemorrhage with intraventricular extension likely
secondary to hypertension
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Mental Status: awake. alert. able to follow one-step midline
and appendicular commands. able to communicate in one-word
answers ('yes'). unable to repeat even single words.
difficulty naming both high and low frequency objects. able to
read one line phrases. unable to write (right-handed).
.
Motor: Strength is full in the left extremities. There is no
spontaneous movement or withdrawal from noxious stimulation in
the right arm. There is possible withdrawal (versus triple
flexion) from noxious stimulation at the great toe; the response
is actually thought to be more consistent with purposeful
withdrawal as the leg moves medially (rather than demonstrating
triple flexion) with noxious stimulation to the right lateral
calf. The right plantar response is extensor.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ on
___ with right sided weakness and difficulty speaking. You
were found to have bleeding in the left side of your brain,
likely due to high blood pressure. You were admitted to our ICU
and monitored closely, and then transferred to the neurology
floor on ___. An MRI of your brain showed left thalamic and
intraventricular hemorrhages (bleeds) in your brain.
We made the following changes to your medications:
- Your aspirin 81mg qd was held and will continue to be held
until ___
- You should also be started on heparin SQ 5000U TID starting
___
- Please also avoid NSAIDs (such as ibuprofen and aleve) to help
prevent further bleeding. In case of pain, you could try
tylenol.
- We recommend pneumoboots for deep vein thrombosis prophylaxis.
You will be discharged to ___ Rehab ___ for
rehabilitation services and further treatment.
If you experience any of the below listed danger signs, please
call your doctor or go to the nearest Emergency Department.
You will need to followup with Dr. ___ at the appointment
shown below. Also, please call registration at ___ to
update your insurance information and current PCP.
It was a pleasure taking care of you during your hospital stay.
Followup Instructions:
___
|
10097383-DS-10 | 10,097,383 | 25,378,217 | DS | 10 | 2139-04-02 00:00:00 | 2139-04-02 20:36:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: Mr. ___ is a ___ male w/ PMH of idiopathic
pancreatitis who presented to the ___ ED with epigastric/RUQ
pain following an admission 2 days prior to ___
for
acute pancreatitis, admitted for evaluation by ___ team.
Per the patient, he developed epigastric pain over the last two
days. He reports that it is squeezing in quality, worse with
drinking liquids, and radiating to the RUQ. He reports that he
was admitted to ___ for acute pancreatitis and was
discharged two days ago. He has been essentially NPO for the
last
few days. He reports normal bowel movement today. Given ongoing
pain, he presented to ___ where his LFT's were noted to
be elevated so he was transferred to ___ for further
evaluation
by the advanced endoscopy team.
Of note, the patient has had multiple admissions yearly for
acute
pancreatitis. No cause has been identified. Per the patient, he
has followed with Dr. ___ this in the past, although
there are no OMR notes from Dr. ___ I could see. Has
had
an ERCP many years ago which was normal, a cystic fibrosis
workup
was unrevealing. He reports that he drinks ___ beers/month and
denies any other drugs.
In the ___ ED, he had stable vitals and was afebrile. Labs
were
notable for lipase 127 (was 500 at ___ 57, AST 71,
INR
1.2, lactate 0.8. RUQUS showed mild dilatation of the main
pancreatic duct and Mild splenomegaly with Trace ascites. He was
given morphine 4 mg x1, Zofran 5 mg, IVF, dilaudid 1 mg x2
On arrival to the floor, the patient reports that his abdominal
pain continues to be severe and has not improved at all. He
lives
with an element of chronic pain but this is definitely more
severe than usual, up to close to a ___ when moving at all,
___ at rest.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
Idopathic recurrent acute pancreatitis
Hepatitis C
Question of prior opiate use
Tobacco abuse
Social History:
___
Family History:
Mother w/ recurrent pancreatitis due to
pancreatic dvisium
Physical Exam:
ADMISSION
VITALS: Afebrile and vital signs stable (see eFlowsheet)
GENERAL: Alert and in moderate distress with any movement
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft but with voluntary guarding, nondistended,
tender to palpation in epigastrium and RUQ. Normal BS
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
DISCHARGE
VS: ___ 0126 Temp: 98.3 PO BP: 125/78 HR: 53 RR: 18 O2 sat:
99% O2 delivery: RA Dyspnea: 0 RASS: 0 Pain Score: ___
Gen - supine in bed, comfortable appearing
Eyes - EOMI, anicteric
ENT - OP clear, MMM
Heart - RRR no mrg
Lungs - CTA bilaterally
Abd - soft, mild tenderness to deep palpation throughout; no
flank pain; normal bowel sounds
Ext - no edema
Skin - no rashes
Vasc - 2+ DP/radial pulses
Neuro - AOx3, moving all extremities
Psych - appropriate
Pertinent Results:
ADMISSION
___ 06:45PM BLOOD WBC-4.5 RBC-4.76 Hgb-14.0 Hct-39.6*
MCV-83 MCH-29.4 MCHC-35.4 RDW-12.8 RDWSD-38.8 Plt ___
___ 06:45PM BLOOD Glucose-86 UreaN-8 Creat-0.7 Na-139 K-4.2
Cl-102 HCO3-23 AnGap-14
___ 06:45PM BLOOD ALT-57* AST-71* AlkPhos-107 TotBili-0.5
___ 06:45PM BLOOD Lipase-127*
DISCHARGE
___ 06:09AM BLOOD WBC-4.3 RBC-4.63 Hgb-13.2* Hct-38.6*
MCV-83 MCH-28.5 MCHC-34.2 RDW-12.8 RDWSD-38.5 Plt ___
___ 06:09AM BLOOD Glucose-78 UreaN-8 Creat-0.8 Na-142 K-4.0
Cl-103 HCO3-25 AnGap-14
___ 06:09AM BLOOD ALT-52* AST-55* LD(LDH)-191 AlkPhos-99
TotBili-0.5
___ 06:09AM BLOOD Lipase-150*
RUQ US
1. No evidence of cholelithiasis or acute cholecystitis.
2. Mild dilatation of the main pancreatic duct.
3. Mild splenomegaly. Trace ascites.
Via ___ Records, scanned ___ Record
CT Abd/Pelvis w contrast ___
"Unremarkable liver gallbladder and spleen. Mildly dilated
pancreatic duct with a slightly heterogeneous pancreatic head.
Unremarkable adrenals and kidneys. Unremarkable stomach.
Markedly thick-walled second and third duodenal segments with
adjacent stranding and failr low density fluid that extends to
the adjacent pancreatic head and into the adjacent
retroperitoneum, mesentery, R paracolic gutter and pelvis.
Unremarkable mesenteric small bowel. Status post appendectomy.
Unremarkable large bowel.
...
Findings most likely represent a duodenitis quite possibly
secondary to pancreatitis."
Via ___ Records, scanned ___ MRCP ___
"Signal abnormality in the pancreas and edema in the
peripancreatic fascial planes suspicious for acute pancreatitis.
Dilation of the pancreatic duct may be related. A tiny focus of
low signal in the distal pancreatic duct may be artifactual but
raises the possibility of a tiny stone. No evidence of biliary
obstruction."
Brief Hospital Course:
___ year old male with past medical history of celiac disease,
chronic abdominal pain attributed to idiopathic pancreatitis,
recent hospitalization at ___ for acute
pancreatitis, admitted ___ with continued acute
pancreatitis, evaluated by advanced endoscopy service who
recommended endoscopic ultrasound in ___ weeks for evaluation
for underlying explanatory pathology, treated conservatively and
subsequently able to advance diet, discharged home
# Acute pancreatitis
# Chronic idiopathic pancreatitis
Patient with chronic abdominal pain symptoms attributed to
pancreatic pathology, with recent hospitalizations at ___
and ___ for acute pancreatitis, with
cross-sectional imaging consistent with peripancreatic edema
concerning for pancreatitis, who presented with ongoing
abdominal pain, OSH lipase of 550 (upper limit of normal for
their assay is 393), ___ lipase 150
(upper limit of normal for our assay is 60). RUQ ultrasound
showed mild dilatation of the main pancreatic duct. Patient was
seen by advanced endoscopy service who recommended patient
undergo an endoscopic ultrasound, but recommended waiting to
perform this until ___ weeks after the episode of acute
pancreatitis so as to best visualize area and identify any
potential underlying anatomic abnormalities. Patient grew very
upset upon hearing he would not be having an ERCP/EUS this
admission, and reported he was told by the referring ED that
this was the reason why he was being transferred to ___.
Following this conversation he requested to advance his diet and
be discharged home. IV pain medications were stopped, and he
tolerated clears, and then a regular diet. He asked about
opiate medications at home---he was advised that if he was still
having acute pain intense enough to require opiate pain
medications that this would be a sign he should stay in the
hospital. He reported feeling comfortable and that he was ready
for discharge home. Discharged with previously scheduled
follow-up with Dr. ___.
# Chronic Hepatitis C
# Abnormal LFTs
Patient with reported history of chronic hep C, noted to have
mild transaminitis; this admission without elevation in
bilirubin or alk phos. Remained stable during this brief
admission--would consider check at follow-up to ensure
stability. Consider referral to hepatologist for additional
testing and treatment. Discharge ALT 52 AST 55 AP 99 Tbili 0.5.
# Pancreatic insufficiency
Continued Creon
# GERD
Continued PPI
Transitional issues
- Discharged home
- Consider repeat LFTs as above
- Has previously scheduled appointment with Dr. ___ on
___ @ 09:20a;
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Creon 12 1 CAP PO TID W/MEALS
2. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Creon 12 1 CAP PO TID W/MEALS
2. Omeprazole 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
# Acute epigastric abdominal pain secondary to acute
pancreatitis
# Abnormal LFTs
# Pancreatic insufficiency
# GERD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___:
It was a pleasure caring for you at ___. You were admitted
with abdominal pain. You were seen by GI specialists who
reviewed your recent blood tests and imaging studies. They
think you had inflammation of the pancreas ("pancreatitis").
They recommended treatment with bowel rest, IV fluids and pain
medications. They recommended an endoscopic ultrasound as an
outpatient after you recover from the pancreatitis.
You improved and were able to tolerate a regular diet. You are
now able be discharged home.
Followup Instructions:
___
|
10097383-DS-12 | 10,097,383 | 22,623,208 | DS | 12 | 2139-12-23 00:00:00 | 2139-12-23 21:27:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old M w/ hx of idiopathic recurrent
pancreatitis ___ episodes since ___ y.o.), celiac disease, and
remote h/o hep C who is presenting with acute on chronic
abdominal pain for ___ days.
Patient states that he has chronic abdominal pain that is fairly
mild, ___ in intensity, and described as "nagging" in the
epigastrium. This has been present since the Pt was ___ years
old
to some degree, when his pancreatitis first started; however, it
has been constant for the past year. Pt generally manages this
chronic pain with OTC ibuprofen or the occasional 5mg oxycodone
BID-TID:PRN that his primary care prescribes him.
Over the past ___ days, the patient's pain has risen acutely to
a
___ in intensity. It is a similar pain character, with
additional "sharp/acidic" components. It radiates to the back
and RLQ/R flank. This pain is intermittent, made worse with
deep
breathing and any food/drink (generally 10 minutes or so after
eating). It has not been relieved by home Tylenol or ibuprofen.
The patient has decreased his PO intake over the past few days
to
just sips of water, because food has so reliably made his pain
worse; in spite of this, his pain persists.
Patient was trying to hold out until his follow-up with General
Surgery on ___ (with Dr. ___ for discussion of surgical
management of his ongoing pancreatitis. However, his pain
became
more severe - and he also began to notice other symptoms
(including nausea, two episodes of nonbloody clear vomiting, and
___ stools) that prompted him to present earlier. He
called his primary gastroenterologist's office (Dr. ___,
who
encouraged him to come to ___ for further evaluation by his
primary teams.
Of note, the patient has had an extensive workup for the cause
of
his pancreatitis in the past including genetic testing, IgG
subclasses, sweat testing (see outpatient GI notes) which have
thus far been unrevealing. During prior admissions for acute on
chronic pancreatitis, he responded well to IV Zofran and
Dilaudid
(he occasionally takes home oxycodone for pain as discussed
above).
Past Medical History:
Celiac disease
Recurrent idiopathic pancreatitis s/p multiple ERCPs, stent
exchanges; being considered for proactive Whipple with General
Surgery
Remote hepatitis C (with spontaneous clearance per Pt, never
treated)
Remote OUD, no longer using IVDU and taking only prescribed
opiates for pain
Status post appendectomy
Social History:
___
Family History:
Mother with pancreas divisum and acute pancreatitis, for which
she underwent underwent modified whipple and had great
symptomatic improvement.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: T 97.2 BP 136/77 HR 62 RR 18 O2 95% on RA
GENERAL: Alert and interactive Caucasian male, ambulatory from
stretcher to bed. Pleasant, cooperative, in no acute distress.
HEENT: Sclerae anicteric, MMM.
CARDIAC: Regular rate and rhythm, normal S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No dullness to percussion bilaterally.
BACK: Mild pain with CVA percussion bilaterally, which Pt
endorses as pain that radiates to his abdomen.
ABDOMEN: NABS. Abdomen is soft, non distended, tender mildly in
the lower quadrants but worst in the epigastrium > RUQ with
rebound tenderness in the epigastrium.
EXTREMITIES: No clubbing, cyanosis, or edema.
SKIN: Warm. No jaundice.
NEUROLOGIC: A&O x3, moves all four extremities with purpose. No
asterixis.
DISCHARGE PHYSICAL EXAM:
**VS: BP 124/68 T 97.4 HR 52 RR 18 O2Sat 97 RA
GENERAL: NAD
HEENT: AT/NC, anicteric sclera, MMM
NECK: supple, no LAD
CV: RRR, S1/S2, no murmurs, gallops, or rubs
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
GI: abdomen soft, nondistended, tender most in epigastric and
RUQ
regions. Pain on palpation improved from yesterday. No
rebound/guarding.
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ radial pulses bilaterally
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric
DERM: Warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS:
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
___ 09:00PM BLOOD WBC-6.1 RBC-4.90 Hgb-13.9 Hct-40.1 MCV-82
MCH-28.4 MCHC-34.7 RDW-13.3 RDWSD-39.4 Plt ___
___ 09:00PM BLOOD Neuts-62.8 ___ Monos-7.1 Eos-3.3
Baso-0.5 Im ___ AbsNeut-3.83 AbsLymp-1.59 AbsMono-0.43
AbsEos-0.20 AbsBaso-0.03
___ 05:33PM BLOOD Glucose-117* UreaN-10 Creat-0.8 Na-140
K-3.9 Cl-106 HCO3-22 AnGap-12
___ 05:33PM BLOOD ALT-41* AST-31 AlkPhos-113 Amylase-27
TotBili-0.3
___ 05:33PM BLOOD Lipase-9
___ 09:00PM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG HAV Ab-POS*
IgM HAV-NEG
___ 07:27AM BLOOD HIV Ab-NEG
___ 07:27AM BLOOD HCV VL-NOT DETECT
DISCHARGE LABS:
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
___ 07:57AM BLOOD WBC-6.1 RBC-5.36 Hgb-14.9 Hct-43.5
MCV-81* MCH-27.8 MCHC-34.3 RDW-13.1 RDWSD-38.2 Plt ___
___ 07:57AM BLOOD Glucose-91 UreaN-5* Creat-0.9 Na-145
K-4.1 Cl-104 HCO3-28 AnGap-13
___ 07:57AM BLOOD ALT-34 AST-22 LD(LDH)-167 AlkPhos-120
TotBili-0.4
___ 07:57AM BLOOD Calcium-9.6 Phos-3.9 Mg-1.9
MICROBIOLOGY:
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
___ BLOOD CULTURE NGTD
___ URINE CULTURE No growth
IMAGING:
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
___
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The
contour of
the liver is smooth. There is no focal liver mass. The main
portal vein is
patent with hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation.
CHD: 2 mm
GALLBLADDER: There is no evidence of stones or gallbladder wall
thickening.
PANCREAS: There is equivocal peripancreatic edema. Pancreas is
not fully
assessed due to overlying bowel gas.
SPLEEN: Normal echogenicity.
Spleen length: 13 cm, borderline in size.
KIDNEYS: Normal cortical echogenicity and corticomedullary
differentiation is
seen bilaterally. There is no evidence of masses, stones, or
hydronephrosis
in the kidneys.
Right kidney: 11.0 cm
Left kidney: 11.2 cm
RETROPERITONEUM: The visualized portions of aorta and IVC are
within normal
limits.
IMPRESSION:
Equivocal peripancreatic edema. Normal gallbladder. No biliary
dilatation.
___ ABDOMEN W&W/O C & RECON
1. No evidence of acute pancreatitis.
2. Mild unchanged main pancreatic ductal dilation measuring up
to 4 mm in
diameter without an obstructing process identified.
3. Nonspecific prominence of multiple retroperitoneal and
mesenteric lymph
nodes measuring up to 1 cm.
Brief Hospital Course:
SUMMARY:
=========================================
Mr. ___ is a ___ with hx chronic pancreatitis and recurrent
flares since age ___, who presented with acute on chronic
epigastric pain radiating to the RUQ, felt to be related to his
chronic pancreatitis.
ACUTE ISSUES:
=========================================
# Epigastric pain
# Chronic Pancreatitis
The patient presented with ___ days of worsening epigastric, RUQ
pain, and acholic stools. Lipase was not elevated. RUQUS showed
no evidence of cholelithiasis or biliary dilatation. CTA of the
abdomen additionally showed no evidence of acute pancreatitis,
no biliary obstruction, and chronic pancreatic ductal dilatation
up to 4mm. He was evaluated by GI as well as ___ Surgery.
His pain was treated with APAP, ketorolac, oxycodone up to 15mg
Q4H, and IV hydromorphone up to 1mg Q3H PRN for breakthrough
pain. This regimen was weaned over the hospital course and he
was discharged on oxycodone taper (15 5mg tabs) and APAP PRN. At
time of discharge he was tolerating a regular diet with no
issues. He was also started on gabapentin 300mg TID for his
chronic pancreatic pain. Notably, records from ___ state that
the patient is heterozygous for N291 mutation in cationic
trypsinogen (T PRSS1).
# Constipation
The patient was noted to have last BM several days prior to
admission, likely secondary to narcotics and decreased PO
intake. He was started on a bowel regimen including senna,
bisacodyl, polyethylene glycol. He was discharged with plan to
continue senna, polyethylene glycol as needed.
CHRONIC ISSUES:
=========================================
# Celiac disease
Repeat Ttg-IgA was sent during this admission. He was maintained
on gluten-free diet.
# History of HCV
Unclear history. Per patient, he acquired HCV in the past in the
setting of IVDU but spontaneously cleared. HCV VL during this
admission was negative.
TRANSITIONAL ISSUES:
=========================================
[] Plan to follow up with ___ Surgery on ___ for
further discussion of surgical intervention for his chronic
pancreatitis
[] Continue to monitor chronic abdominal pain. He was discharged
on new medication of gabapentin 300mg TID which could be
uptitrated as needed in addition to other neuromodulators e.g.
duloxetine for his presumed hereditary pancreatitis
[] Patient is hepatitis A immune but hepatitis B non-immune.
Should get vaccinated in setting of history of HCV.
[] The patient's genetic testing reports from ___
___ were requested through medical records, but had not
arrived by the time of patient discharge.
MEDICATION CHANGES:
=========================================
- Started gabapentin 300mg TID
- Started senna and polyethylene glycol PRN
- Prescribed 3-day oxycodone taper, total of 15 5mg tabs
CODE STATUS: Full code
This patient was prescribed, or continued on, an opioid pain
medication at the time of discharge (please see the attached
medication list for details). As part of our safe opioid
prescribing process, all patients are provided with an opioid
risks and treatment resource education sheet and encouraged to
discuss this therapy with their outpatient providers to
determine if opioid pain medication is still indicated.
[x]>30 minutes spent on discharge planning and care coordination
on day of discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 20 mg PO DAILY
2. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild
3. Creon 12 3 CAP PO TID W/MEALS
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Gabapentin 300 mg PO TID
RX *gabapentin 300 mg 1 capsule(s) by mouth three times a day
Disp #*90 Capsule Refills:*0
3. OxyCODONE (Immediate Release) 15 mg PO Q4H:PRN Pain -
Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *oxycodone [Oxaydo] 5 mg 1 tablet(s) by mouth every six (6)
hours Disp #*15 Tablet Refills:*0
4. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
RX *polyethylene glycol 3350 [Miralax] 17 gram/dose 1 dose by
mouth once daily Refills:*0
5. Creon 12 3 CAP PO TID W/MEALS
6. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild
7. Omeprazole 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
# Chronic pancreatitis flare
SECONDARY:
# Hereditary chronic pancreatitis
# Celiac disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You had worse abdominal pain than usual
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were given pain medications for the abdominal pain
- You were given intravenous fluids
- You had a CT scan of the belly done which did not show acute
pancreatitis or any other complications
- You were seen by Gastroenterologists and Surgery
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your appointments
including with Surgery
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10097612-DS-14 | 10,097,612 | 29,104,091 | DS | 14 | 2156-10-24 00:00:00 | 2156-10-25 11:31:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Cardiac catherization ___
History of Present Illness:
___ who has not seen a physician in over ___ years and no known
heart disease, presents with one month of progressive chest
pressure and dyspnea on exertion. Symptoms have been ongoing
for past month, and patient states he can now walk 100 feet
without getting extremely winded and feeling like an elephant
was sitting on his chest. Patient also noticed significant leg
swelling over the past few months. He attributed his symptoms
to a viral illness, after speaking with his sister-in-law, who
is a ___, and told him this ___ has been particularly bad
for viral respiratory infections.
Today, while at work, a co-worker noticed that he did not look
well. He was panting, pale and diaphoretic after walking, so a
facilities manager took him to the Emergency Room for
evaluation.
In the ED, initial vitals were 96.4 101 136/86 20 96%. Labs and
imaging significant for elevated BNP, lactate 3.2, trop <0.01.
EKG showed new LBBB. CXR showed cardiomegaly, some fluid but not
drastic, no clear pna. Bedside echo did not showed any
pericardial effusion. Patient given aspirin 325 mg po x 1. He
was unable to urinate after 30 minutes of trying, so a foley
catheter was placed. Vitals on transfer were : 97.8, 92,
114/68, 24, 98 2L.
On arrival to the floor, patient appeared comfortable and was
breathing comfortably on 2L. He states he current chest
pressure or shortness of breath.
REVIEW OF SYSTEMS
He denies recent chest pressure or shortness of breath that did
not resolve with rest, nausea, diaphoresis, or severe chest
pain. He does not remember any one day in the past few months
where he felt particularly bad. He denies orthopnea or PND.
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, but does not walk far. All of
the other review of systems were negative.
Past Medical History:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS:
+Hypertension (per OMR note in ___
2. CARDIAC HISTORY:
None
3. OTHER PAST MEDICAL HISTORY:
BPH (per OMR note in ___
Social History:
___
Family History:
Father had ___ MIs in his ___. Mother had no medical problems.
Sister died of ___.
Physical Exam:
PHYSICAL EXAMINATION ON ADMISSION:
VS- T=98.1 BP=134/93 HR=52 RR=18 O2 sat=94% on 2L NC
GENERAL- Obese man in NAD. Oriented x3. Mood, affect
appropriate.
HEENT- NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa.
NECK- Supple with JVP of 14 cm.
CARDIAC- RRR, normal S1, split S2. No m/r/g. No S3 or S4.
LUNGS- Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABDOMEN- Soft, obese, NT/ND. No HSM or tenderness.
EXTREMITIES- 2+ lower exxtremity edema to mid-calves. area of
skin breakdown in right shin that does not appear to be
infected.
PHYSICAL EXAMINATION ON DISCHARGE:
VS- T 98.0 BP 111-126/72-88 HR ___ RR 18 O2sat 97(RA)
Wt 131.3kg (down from 137.6kg on admission)
GENERAL- Obese man in NAD. Oriented x3. Mood, affect
appropriate.
HEENT- NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa.
NECK- Supple with JVP of 10 cm.
CARDIAC- RRR, normal S1, S2. No m/r/g. +faint s3, +s4.
LUNGS- Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABDOMEN- Soft, obese, NT/ND. No HSM or tenderness.
EXTREMITIES- 1+ or trace lower extremity edema to shins, R>L
now.
Pertinent Results:
Labs on Admission:
___ 10:53AM BLOOD WBC-7.1 RBC-4.96 Hgb-15.1 Hct-47.9
MCV-97# MCH-30.5 MCHC-31.5 RDW-15.2 Plt ___
___ 10:53AM BLOOD Neuts-75.0* ___ Monos-4.1 Eos-0.7
Baso-0.6
___ 10:53AM BLOOD ___ PTT-29.0 ___
___ 10:53AM BLOOD Glucose-99 UreaN-26* Creat-1.2 Na-142
K-4.0 Cl-106 HCO3-23 AnGap-17
___ 10:53AM BLOOD Calcium-9.3 Phos-4.7*# Mg-2.0
Cardiac Biomarkers:
___ 10:53AM BLOOD ___
___ 10:53AM BLOOD cTropnT-<0.01
___ 07:43PM BLOOD CK(CPK)-55
___ 07:43PM BLOOD CK-MB-4 cTropnT-<0.01
___ 06:57AM BLOOD CK-MB-3 cTropnT-<0.01 ___
___ 06:57AM BLOOD CK(CPK)-42*
Pertinent Labs:
___ 07:43PM BLOOD Cholest-134
___ 04:15PM BLOOD Iron-38*
___ 07:35AM BLOOD Albumin-3.2*
___ 04:15PM BLOOD calTIBC-239* Ferritn-187 TRF-184*
___ 07:43PM BLOOD %HbA1c-5.5 eAG-111
___ 07:43PM BLOOD HDL-31 CHOL/HD-4.3
___ 04:15PM BLOOD TSH-1.8
___ 04:15PM BLOOD HIV Ab-NEGATIVE
___ 06:34AM BLOOD VITAMIN B1-PND
Labs on Discharge:
___ 07:35AM BLOOD WBC-6.0 RBC-4.57* Hgb-14.0 Hct-43.8
MCV-96 MCH-30.7 MCHC-32.0 RDW-14.9 Plt ___
___ 01:05PM BLOOD Na-139 K-4.3 Cl-98
___ 07:35AM BLOOD ALT-23 AST-22 AlkPhos-51 TotBili-1.4
Chest Xray ___:
FINDINGS: The heart is moderately enlarged. There is mild
prominence of pulmonary vascularity and interstitium without
frank pulmonary edema. Patchy opacity in the lingula is linear
and suggests atelectasis. Small bilateral pleural effusions are
suspected. The lungs are hyperinflated. There is a mild lower
thoracic wedge compression deformity that appears chronic and
correlates with the prior CT findings. Mild degenerative
changes involve the right shoulder.
IMPRESSION: Moderate cardiomegaly and findings suggesting mild
vascular congestion.
RHC/LHC ___:
- clean coronary artery
- PCWP 30 mmHg
- PASP 53 mmHg
TTE ___:
IMPRESSION: Biatrial enlargement. Mildly dilated left ventricle
with mild symmetric left ventricular hypertrophy with severe
global left ventricular systolic dysfunction/dyskinesis.
Increased left ventricular filling pressure. Dilated,
hypokinetic right ventricle. Mildly dilated aortic root. There
is the suggestion of a moderately thickened, functionally
bicuspid aortic valve. Aortic stenosis may be present, but in
the setting of extensive calcification and markedly depressed
left ventricular systolic function its severity cannot be
quantitatively determined, but is unlikely to be severe. Mild
aortic regurgitation. Mild mitral regurgitation. Borderline
pulmonary artery systolic hypertension.
EKG ___:
Sinus rhythm with sinus arrhythmia. Left bundle branch block.
Since the
previous tracing of ___, there are probably fewer atrial
premature beats on the present tracing.
Microbiology:
___ Blood culture - final no growth
___ Urine culture - final no growth
Brief Hospital Course:
PRIMARY REASON FOR ADMISSION:
Mr. ___ is a ___ who has not seen a physician in over ___ years
and no diagnosis of cardiac disease, presents with one month of
progressive chest pressure and dyspnea on exertion, found to
have systolic CHF with EF 15%.
ACTIVE DIAGNOSES:
# New Diagnosis of Systolic Congestive Heart Failure (EF 15%):
EF 15% on TTE this admission, last TTE in ___ was normal.
There is no evidence of ischemic cardiomyopathy on LHC. Current
workup is notable for no HIV, normal TSH, normal iron levels.
Thiamine level to assess for beriberi is pending. Most likely
EtOH induced cardiomyopathy. Patient states he drinks ___ cans
beer/night, ___ on the weekend, margaritas when he goes
out to restaurants on the weekend, and 2 six packs/weekend.
LFTs are unremarkable. He is not anemic, no macrocytosis. He
was initially aggresively diuresed with IV lasix 20mg bid for
two days, was -2.5 to 3.5L every day. He was then switched to
lasix 40mg PO daily, when he started to become alkalotic with
diuresis. By discharge, his lower extremity pitting edema had
decreased from 3+ to mid-thights to 1+ to mid-shins. He was
started on carvedilol 3.125 daily and lisinopril 10mg daily.
Prior to discharge, he was also started on spironolactone 12.5mg
daily.
# Hyperkalemia: Patient was hyperkalemic to 5.5 in the morning
on the day of discharge. This was the first time he has been
hyperkalemic during admission, likely related to increasing his
lisinopril from 5 to 10mg, and diuresing less aggressively.
Repeat K+ in afternoon was normal. Patient was then started on
low dose spironolactone on discharge for mortality benefit for
___. He will need to get his K rechecked at his next PCP
___.
# Stable Angina: Patient presented withs ymptoms of chest
pressure on exertion, always resolves with rest. This is likely
secondary to CHF, as patient was found to have clean coronaries
on left heart catheteruzation. Cardiac enzymes negative x3.
# Elevated Lactate: Lactate was elevated on admission, likely
related to decreased renal clearance secondary to low forward
flow. Resolved with diuresis.
==================================
TRANSITIONAL ISSUES:
- Please follow up on pending thiamine level at discharge. This
was ordered to assess for beriberi as a cause of new
cardiomyopathy.
- Please follow up on patient's K during next PCP ___
few days after discharge, because patient was just started on
lisinopril and spironolactone.
Medications on Admission:
none
Discharge Medications:
1. Carvedilol 3.125 mg PO BID
please hold for sbp<100, hr<55
RX *carvedilol 3.125 mg twice a day Disp #*60 Tablet Refills:*0
2. Cyanocobalamin 50 mcg PO DAILY
RX *Vitamin B-12 50 mcg once a day Disp #*30 Tablet Refills:*0
3. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg once a day Disp #*30 Tablet Refills:*0
4. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg once a day Disp #*30 Tablet Refills:*0
5. Lisinopril 10 mg PO DAILY
please hold for sbp<100
RX *lisinopril 10 mg once a day Disp #*30 Tablet Refills:*0
6. Multivitamins 1 TAB PO DAILY
RX *Daily Multiple once a day Disp #*30 Tablet Refills:*0
7. Spironolactone 12.5 mg PO DAILY
RX *Aldactone 25 mg once a day Disp #*30 Tablet Refills:*0
8. Thiamine 100 mg PO DAILY
RX *thiamine HCl 100 mg once a day Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Systolic 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 taking care of you at ___
___. You were admitted with chest pain and shortness
of breath after walking, as well as swelling in your legs. We
diagnosed you with congestive heart failure based on an
echocardiogram (ultrasound of your heart) that found your heart
does not squeeze that well. We started you on some medications
and helped you urinate more with a medication called lasix. We
think you have lost most of the extra fluid on your body, and
your breathing and chest pain are much improved. We think you
are now safe to go home. You should follow up with your new
primary care doctor and cardiologist to monitor your heart, and
you should also stop drinking alcohol, because this is likely
reponsible for your heart condition.
Please make the following changes to your medications:
- Please START taking Carvedilol, Lisinopril, and Spironolactone
for your heart failure
- Please START taking Vitamin B12 (cyanocobalamine), Vitamin B1
(thiamine), folate, and a multivitamin every day for nutritional
supplementation.
- Please take Lasix 40mg every day to keep fluid from
accumulating in your legs and lungs
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
10097612-DS-16 | 10,097,612 | 26,618,472 | DS | 16 | 2159-05-25 00:00:00 | 2159-05-25 16:43:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ with PMHx significant for HTN, BPH,
obesity, h/o DVT, aortic insufficiency, non-ischemic
cardiomyopathy with EF 15% who presented from PCP visit with
asymptomatic hypotension, BP 77/51. Guaiac negative on exam.
Recent labs apparently show new anemia from ___ to
___ from 14.9 to 11.9. Med rec done on admission show
patient still lisinoril and spironolatone though it had been on
hold for an elevated creatinine since the ___, but on
PCP visit on ___, PCP was concerned patient was still
taking them accidentally. Also brings in an empty furosemide
bottle, which he states he stopped taking a few weeks ago.
However patient also on Torsemide.
The patient denies chest pain, no shortness of breath, no
increased swelling in his lower extremities. No abdominal pain,
no nausea or vomiting. Patient denies dizziness.
In the ED initial vitals were: 97.1 86 96/54 16 98%
Labs were notable for: ___: 11184, Cr: 1.7
EKG was reportedly significant for sinus rhythem with Left
bundle branch block and left axis deviation
He was given 1.5L on Normal Saline and sent to the floor
On the floor, vitals: 97.9 ___ 20 99% on RA
Past Medical History:
Non-ischemic cardiomyopathy (EF 15%)
Left bundle branch block
Hypertension
Aortic insufficiency
Colonic Polyps
BPH
H/o DVT
Osteoporosis
Social History:
___
Family History:
Father ___ myocardial infarction, first at ___
Sister ___ disease
Physical Exam:
Admission exam
VS: T= 97.9 BP= 101/72 HR= 84 RR= 20 O2 sat= 99% on RA
Weight : 226 Ibs (dry weight ~218 Ibs per patient)
GENERAL: WDWN man 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 ~3cm from clavicle at 45 degrees.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2 and S3. No murmurs. No thrills, lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, minor to no
crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas
Discharge exam
VS: 98.2, 93-120/57-83, 67, 16, 95-96% RA
Weight: 102.9kg ___ (dry weight ~220Ibs/100kg per patient)
I/O: ___
GENERAL: WDWN man 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 ~3cm from clavicle at 45 degrees.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, and split S2. No murmurs. No thrills,
lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, minor to no
crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas
Pertinent Results:
Admission labs
___ 01:47PM BLOOD WBC-6.0 RBC-3.94* Hgb-11.9* Hct-36.3*
MCV-92 MCH-30.3 MCHC-32.9 RDW-15.0 Plt ___
___ 01:47PM BLOOD ___ PTT-24.8* ___
___ 01:47PM BLOOD Glucose-104* UreaN-43* Creat-1.7* Na-138
K-4.3 Cl-102 HCO3-26 AnGap-14
___ 01:47PM BLOOD Iron-66
___ 01:47PM BLOOD calTIBC-251* VitB12-807 Ferritn-181
TRF-193*
___ 02:00PM BLOOD Lactate-1.8
Discharge labs
___ 07:57AM BLOOD WBC-5.4 RBC-3.99* Hgb-12.4* Hct-37.0*
MCV-93 MCH-31.1 MCHC-33.5 RDW-14.9 Plt ___
___ 01:47PM BLOOD Neuts-58.4 ___ Monos-5.7 Eos-2.2
Baso-0.4
___ 07:57AM BLOOD Plt ___
___ 07:57AM BLOOD Glucose-88 UreaN-25* Creat-1.0 Na-138
K-4.3 Cl-104 HCO3-25 AnGap-13
___ 07:57AM BLOOD Calcium-9.9 Phos-3.2 Mg-2.3
Imaging
Chest xray ___
IMPRESSION:
Right costophrenic angle not completely included on the image;
given this, no pleural effusion seen. Persistent enlargement of
the cardiac silhouette without overt pulmonary edema.
Brief Hospital Course:
___ y/o M with PMHx significant for HTN, BPH, obesity, h/o DVT,
aortic insufficiency, non-ischemic cardiomyopathy with EF 15%
who initially presented with hypotension due to his medications
and taking furosemide with torsemide when asked to stop it.
# Hypotension: Patient was given 1.5L of NS and recovered from
___ to 100s/60s (baseline). His diuretics were stopped
briefly and he was briefly restarted on his Torsemide at a lower
dose of 20mg from 40mg. Lisinopril was also decreased from 5mg
to 2.5mg and Spironolactone was stopped. No evidence of bleed or
that hypotension is due to blood loss despite anemia. Was guaiac
negative in clinic and anemia work up showed anemia of chronic
disease.
# ___: Cr of 1.7 on admission from baseline normal of 1.0. Most
likely due to his overdiuresis and etiology is pre-renal.
Improved to 1.0 by discharge.
# Acute sCHF: Last echo from ___ showed ejection fraction of
20%. Patient reports no change in weight or increased weight.
Plan from outpatient plan was to get a cardiac MRI and plan for
BiV placement. However insurance approval and financial
limitations are making this work up pending in the outpatient.
Patient will follow up with cardiologists in outpatient..
# Anemia: Etiology unclear. Recent labs apparently show new
anemia from ___ to ___ from 14.9 to 11.9
without evidence of bleed. Hemolysis workup showed amemia of
chronic disease.
## TRANSITIONAL ISSUES
==================================
- Torsemide decreased from 40mg to 20mg daily
- Lisinopril decreased from 5mg to 2.5mg
- Spironolactone stopped.
- Adjust antihypertensive meds or restart them if patient
becomes hypertensive in the outpatient setting
- Patient has dilated ascending aorta and will need monitoring
of this
- Frequent check in with patient about which meds he's taking
vrs prescribed. (rejected ___ services)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 25 mg PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. Lisinopril 5 mg PO DAILY
4. Spironolactone 12.5 mg PO DAILY
5. Torsemide 40 mg PO DAILY
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth Daily Disp #*60 Tablet
Refills:*1
2. Torsemide 20 mg PO DAILY
RX *torsemide 20 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*1
3. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth Daily Disp
#*30 Tablet Refills:*1
4. Lisinopril 2.5 mg PO DAILY
RX *lisinopril 2.5 mg 1 tablet(s) by mouth Daily Disp #*30
Tablet Refills:*1
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Hypotension
Acute Systolic Heart failure
Secondary Diagnosis:
Acute Kidney injury
Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
You were admitted due to having low blood pressure. You were
treated and improved. This was due to you taking one of your
medications which was stopped, called furosemide.
We were hoping to have a visiting nurse come by your house to
help educate you about your medications but you refused this.
Please DO NOT take furosemide and torsemide at the same time.
Take ONLY TORSEMIDE 20mg Daily.
We are writing new scripts for you with all your medications you
should be taking. Please don't take any of your old medications.
It was a pleasure being part of your care
Your ___ team
Followup Instructions:
___
|
10097612-DS-18 | 10,097,612 | 21,981,172 | DS | 18 | 2159-11-27 00:00:00 | 2159-11-30 14:11:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Beta-Blockers (Beta-Adrenergic Blocking Agts) / ACE Inhibitors
Attending: ___
Chief Complaint:
Worsening lower extremity edema
Major Surgical or Invasive Procedure:
Cardioversion ___
History of Present Illness:
___ yo M with a history of NICMP (EF 20%), BAV c/b moderate AS
___ 1.0), HTN, obesity, AF s/p unsuccessful ___ now in NSR on
amiodarone and digoxin who presents with worsening ___ edema and
worsening renal failure. Mr. ___ only complains of worsening
edema. He denies any change to his diet, states he eats a low
salt diet and monitors his intake. He is adherent with his
torsemide and continues to make good amounts of urine. He denies
any shortness of breath and continues to walk with a cane. He
denies any PND and sleeps with one pillow, flat at night. He
denies any early satiey or abdominal pain. He does not have any
chest pain.
In the ED, initial vitals were 97.8 62 97/59 18 100%. He was
admitted to medicine for further management.
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. S/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 chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
palpitations, syncope or presyncope.
Of note, recently hospitalized from ___ with a
hospitalization complicated by new onset atrial fibrillation
causing cardiogenic shock. He was in the CCU and required
dopamine and dobutamine at different points for inotropic
support. He was also diuresed with lasix gtt and placed on
nitroprusside gtt for afterload reduction. His
anti-hypertensives were downtitrated due to persistent
hypotension. For his new onset atrial fibrillation, he was
cardioverted to NSR but reverted back into afib. He was
discharged on digoxin and amiodarone for control. He was
anticoagulated with warfarin. This hospitalization was also
complicated by acute kidney injury from poor forward flow from
decompensated CHF. His creatinine peaked at His weight at
discharge was 85.3kg and he was on torsemide 40mg PO daily.
Past Medical History:
Cardiogenic Shock in ___ requiring dobutamine/dopamine and
lasix gtt
Non-ischemic cardiomyopathy (EF 15%)
Atrial fibrillation
Aortic stenosis
Left bundle branch block
Hypertension
Aortic insufficiency
Colonic Polyps
BPH
H/o DVT
Osteoporosis
Social History:
___
Family History:
Father ___ myocardial infarction, first at ___
Sister ___ disease
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION: Wegith 84.4gkg at time of
transfer ___
Vitals: 97.7 ___ 62 18 98%RA weight: 88.68 kg (at discharge
85.3kg ___
General: NAD, alert and oriented to name, date, hospital
HEENT: mildly icteric sclera, EOMI PERRL
Neck: JVP elevated to chin at 45 degrees in bed
CV: RRR, ___ SEM @ RUSB, displaced inferiorly PMI
Lungs: rales bilaterally at based
Abdomen: soft, NT/ND
GU: no foley, deferred
Extr: +1 radial pulses, dopplerable ___ pulses, warm with
pitting edema to posterior thighs
Neuro: CN II-XII intact
Skin: multiple ecchymosis on skin
DISCHARGE PHYSICAL EXAM
VS: Tm 97.8 BP 97-132/60s-70s HR ___ RR ___ RA
WT: 80.7 kg
I/O since ___
I/O over 24H: ___
GENERAL: lying in bed; appears comfortable and in a pleasant
mood.
HEENT: No scleral icterus.
CARDIAC: regular pulse, normal S1, S2; no murmur appreciated.
LUNGS: Faint bibasilar crackles.
ABDOMEN: soft, nontender, nondistended.
EXTREMITIES: R arm in sling; B pedal pulses 2+. 2+ Pitting edema
bilaterally up to mid shin.
Pertinent Results:
ADMISSION LABS
==============
___ 09:10PM BLOOD WBC-5.1 RBC-3.57* Hgb-11.0* Hct-33.3*
MCV-93 MCH-30.8 MCHC-33.0 RDW-18.8* RDWSD-61.7* Plt ___
___ 09:10PM BLOOD Neuts-70.9 ___ Monos-6.2 Eos-0.8*
Baso-0.4 Im ___ AbsNeut-3.64 AbsLymp-1.08* AbsMono-0.32
AbsEos-0.04 AbsBaso-0.02
___ 09:15AM BLOOD ___ PTT-50.0* ___
___ 09:10PM BLOOD Glucose-66* UreaN-45* Creat-1.7* Na-135
K-3.7 Cl-91* HCO3-24 AnGap-24*
___ 09:10PM BLOOD ALT-26 AST-57* AlkPhos-55 TotBili-2.3*
DirBili-0.8* IndBili-1.5
___ 09:10PM BLOOD cTropnT-0.03*
___ 09:10PM BLOOD Albumin-3.6 Calcium-9.7 Phos-3.6 Mg-2.2
PERTINENT AND DISCHARGE LABS
============================
___ 06:05AM BLOOD WBC-4.0 RBC-3.43* Hgb-10.6* Hct-33.5*
MCV-98 MCH-30.9 MCHC-31.6* RDW-21.9* RDWSD-76.3* Plt ___
___ 06:05AM BLOOD Plt ___
___ 06:05AM BLOOD Glucose-70 UreaN-17 Creat-1.0 Na-138
K-3.7 Cl-99 HCO3-29 AnGap-14
___ 06:05AM BLOOD ALT-169* AST-44* AlkPhos-109 TotBili-1.8*
___ 06:05AM BLOOD Calcium-9.1 Phos-3.0 Mg-2.1
___ 06:05AM BLOOD Digoxin-1.2
IMAGING
========
___ CXR: "IMPRESSION:
Moderate cardiomegaly increased from ___, with increased mild
interstitial
edema. No large pleural effusion."
___: cardiac cath: "impressions: moderate pulmonary artery
hypertension with a mean PAP 36 mmHg. There was elevation of the
right and left heart filling pressures."
___ shoulder xray: "FINDINGS:
There is deformity of the right proximal humerus with a surgical
neck of
humerus fracture. This is age indeterminate as the margins
appear somewhat
ill-defined and there is likely some callus formation. The
fracture line
appears to extend through the greater tuberosity. There is mild
impaction of
the fracture. Inferior subluxation of the humeral head relative
to the
glenoid. A linear lucency through the glenoid is likely related
to
degenerative change as there is moderate degenerative change at
the
glenohumeral joint although a fracture cannot be excluded."
Brief Hospital Course:
Pt. was admitted and diuresed. After addition of ACEi and CCB
as well as significant diuresis, he became hypotensive and was
transferred to CCU on ___ for asymptomatic hypotension, with
SBP in the low ___. He had a PAC placed, which showed a PCWP of
23 and CVP of 4, with CI 2.2. He was briefly trialed on
dobutamine, without improvement of hemodynamics. His hypotension
was ultimately attributed to diuresis, since patient was
actually ~1kg below previous discharge weight. He was given
500cc NS with resolution of hypotension. He again became
hypotensive after a dose of captopril, so all antihypertensives
were discontinued. He was transferred to the floor on ___. He
returned to the unit in the afternoon of ___ for hypotension
and elevated lactate. Hypotesnion thought likely due to
hypovolemia in setting of overdiuresis. He was given IVF total
750cc with subsequent reduction in lactate and increase in UOP.
He was also started on nitro gtt for afterload reduction and on
dobutamine at 2.5cc/hr. Nitro gtt discontinued on ___. Patient
also with ___, shock liver, and INR of 5.5, all likely ___ shock
physiology. BUN/Ct, LFTs, and INR improved with volume
resuscitation. For Afib, he was continued on home digoxin and
amiodarone. His home beta blocker was held in light of
hypotension. He was briefly on the floor, but on ___ he again
returned to ___ for concern for cardiogenic shock in setting of
cold extremities, low urine output, and rising lactate. Of
note, patient had not received hydralazine or isordil as they
were ordered to be held for SBP<110. Hydralazine then increased
to 30 mg, isordil to 20 mg, and on transfer to CCU, patient
stable w/ warm extremities. On exam, patient appeared volume
overloaded (1.2 kg up since leaving CCU) so given lasix 40 mg IV
x 1 with good effect.
Patient came back to the floor ___. His hydralazine and isordil
doses were increased. Restarted on home torsemide. Since then,
the patient has been improving. He underwent cardioversion for
his Afib on ___, the procedure was successful and he is in
sinus rhythm. We have held warfarin the past night ___
because INR was 4.3. ON discharge, INR 4.2. He was euvolemic
with plans for BiV pacing as outpatient now that sinus rhythm
restored.
Of note, patient also has a stable R humerus fracture that will
need f/u with orthopedic surgery. Pt has been in sling and
stable this admission.
Transitional care:
- Plan for BiV pacing now that sinus rhythm established.
- Pt. should continue anticoagulation indefinitely.
- Continue to f/u INR and digoxin levels and adjust meds
respectively.
- Warfarin administration: Do NOT take warfarin tonight ___.
Continue on ___. Rehab should monitor INR and redose
warfarin appropriately with goal INR ___.
- Given right humerous fracture, pt. should keep arm in sling
and remain non-weight bearing in that limb.
- Code status: FULL
- Health care proxy: ___, niece, ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Digoxin 0.125 mg PO EVERY OTHER DAY
2. Amiodarone 200 mg PO DAILY
3. Warfarin 3 mg PO DAILY16
4. HydrALAzine 10 mg PO Q8H
5. Torsemide 20 mg PO DAILY
6. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
7. Potassium Chloride 20 mEq PO DAILY
8. FoLIC Acid 1 mg PO DAILY
9. Thiamine 100 mg PO DAILY
10. Vitamin D 1000 UNIT PO DAILY
The Preadmission Medication list is accurate and complete.
1. Digoxin 0.125 mg PO EVERY OTHER DAY
2. Amiodarone 200 mg PO DAILY
3. Warfarin 3 mg PO DAILY16
4. HydrALAzine 10 mg PO Q8H
5. Torsemide 20 mg PO DAILY
6. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
7. Potassium Chloride 20 mEq PO DAILY
8. FoLIC Acid 1 mg PO DAILY
9. Thiamine 100 mg PO DAILY
10. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Amiodarone 200 mg PO DAILY
2. Digoxin 0.125 mg PO EVERY OTHER DAY
3. Thiamine 100 mg PO DAILY
4. Torsemide 20 mg PO DAILY
5. FoLIC Acid 1 mg PO DAILY
6. Warfarin 3 mg PO DAILY16
7. Vitamin D 1000 UNIT PO DAILY
8. HydrALAzine 30 mg PO Q8H
9. Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY
10. Docusate Sodium 100 mg PO BID
11. Senna 17.2 mg PO HS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES
=================
# NICMP with subacute exacerbation
# Atrial fibrillation
# Cardiogenic Shock, resolved.
# Acute Kideny Injury
SECONDARY DIAGNOSES
===================
# Hyperbilirubinemia
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 meeting you and caring for you while you were
at ___. You were admitted to us
with worsening leg swelling. Upon presentation you had a lot of
excess fluid on your body as a result of heart failure. You were
given medications to help you urinate out the excess fluid.
However, during this process your blood pressure dropped and you
ended up in the intensive care unit a few times. Your blood
pressures recovered and you lost the excess fluid with
improvement of your leg swelling. You underwent a cardioversion
for your atrial fibrillation on ___, and are now in a
regular sinus rhythm. It is very important you continue to
maintain a low salt diet and take your medication to ensure you
don't have too much extra fluid in your body. Weigh yourself
every morning, call MD if weight goes up more than 3 lbs.
Sincerely,
Your ___ care team
Followup Instructions:
___
|
10098553-DS-11 | 10,098,553 | 24,711,357 | DS | 11 | 2156-03-10 00:00:00 | 2156-03-10 18:18:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bactrim
Attending: ___.
Chief Complaint:
Hematemesis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a ___ with PMHx of papillary thyroid carcinoma with
two positive lymph nodes status post thyroidectomy in ___ who
presents from ___ clinic with complaints of hematemesis.
.
Patient presented from ___ clinic complaining of acute
development of nausea and heartburn symptoms the night prior to
presentation. In clinic, the patient was found to be
tachycardic, though orthostatics were negative. From ___ clinic,
the patient was referred to the ED for further evaluation.
.
Patient reports waking up at 3AM night prior to presentation
with severe heart burn and feeling constipated. The patient also
felt nauseous. At 6AM on the morning prior to presentation, the
patient vomited. She reports that initially her vomit appeared
like the food she was eating and brown. Following the brown
material, she passed one red glob and then resumed vomitting
brown material. In total, she vomited two globs of blood. She
denies the appearance of coffee grounds in her vomit. She also
denies liquid blood. She has not used any medications for her
symptoms. She drank 1 cup of soda water, which she reports
burning when going down. She has not had other vomiting since
the episodes this morning. She denies melena, hematochezia, and
BRBPR; she also denies hemoptysis, epitaxis, or oral ulcers. She
reports a history of hemorrhoids. She reports loose stools this
AM, but has not had BMs since this AM.
.
Of note, the patient reports that her sons are ill with
gastrointestinal illness associated with vomiting and diarrhea.
The patient typically does not have heartburn, only noticing
symptoms of heartburn during his last pregnancy. She takes no
medications for symptoms of reflex.
.
In the ED, initial vitals: 96.8 127 116/89 16 100%. The patient
was guiaic negative per report in the ED. An NGT was placed in
the ED, and NG lavage showed no frank blood. Per report, the
patient's NG lavage was hemocult positive but gastrocult
negative. HCT was stable. In the ED, the patient recieved
pantoprazole 40mg IV, 2mg Morphine, 2mg Ondansetron, and 2mg
Lorazepam. In the ED, the patient had no further episodes of
emesis.
.
Currently, the patient is lying in bed in NAD. She is currently
denying abdominal pain and nasuea. She reports some
lightheadedness while going from a sitting to standing position.
.
ROS:
(+): per HPI.
(-): Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, shortness
of breath, chest pain, abdominal pain, dysuria, hematuria.
Past Medical History:
PAST SURGICAL HISTORY: (per ___ records and confirmed w/ patient
at bedside)
1. s/p thyroidectomy for papillary thyroid carcinoma on
___ with metastatic papillary carcinoma and two lymph
nodes.
2. s/p cesarean section ___ years ago.
3. s/p excision of dysplastic nevus in ___ for mid low
back.
4. s/p skin biopsy central back showing dysplastic
nevus.
5. s/p skin biopsy, left lateral back dysplastic nevus
___.
.
MEDICAL:
1. h/o labile blood pressure, question white-coat hypertension.
2. Thyroid cancer, papillary with two positive lymph nodes,
___.
3. anxiety treated with low-dose sertraline and lorazepam in
the past.
4. h/o migraine headaches, especially with the second
pregnancy.
5. Allergic rhinitis.
Social History:
___
Family History:
--Father: Living, age ___, hypertension, hypothyroid.
--Mother: Living, age ___, hyperlipidemia, hypothyroidism,
precancerous colon polyp at age ___.
--Two sisters___, ___, alive and well.
--One brother, age ___, alive and well.
--___ son, alive.
--One half month old baby son, alive and well.
--Maternal grandfather and paternal grandfather both died in
their ___ of MI.
--Family history negative for breast cancer or diabetes.
Physical Exam:
Admission physical exam:
VS - Temp 100.3 F, BP 104/68, HR 113, R 16, O2-sat 99% RA
GENERAL - Woman in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, dryMM, OP clear
without evidence of exudate or erythema.
NECK - supple, no JVD, no cervical LAD, scar overlying most
inferior aspect of the neck
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - Tachycardia, ___ systolic ejection mumur best
appreciated at the RUSB and LUSB, nl S1-S2
ABDOMEN - NABS+, soft/ND, epigastric tenderness upon palpation,
otherwise no TTP, 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.
.
Discharge physical exam:
Pertinent Results:
Admission labs:
___ 11:30AM BLOOD WBC-10.0 RBC-4.86 Hgb-14.6 Hct-42.0
MCV-86 MCH-30.0 MCHC-34.7 RDW-12.4 Plt ___
___ 11:30AM BLOOD Glucose-109* UreaN-18 Creat-0.7 Na-137
K-4.0 Cl-102 HCO3-24 AnGap-15
___ 11:30AM BLOOD ALT-10 AST-15 AlkPhos-75 TotBili-0.5
___ 11:30AM BLOOD Lipase-25
___ 11:30AM BLOOD Albumin-4.8
Microbiology:
___:40 am BLOOD CULTURE
Blood Culture, Routine (Pending):
___ 1:23 am BLOOD CULTURE
Blood Culture, Routine (Pending):
___ 6:20 am SEROLOGY/BLOOD
HELICOBACTER PYLORI ANTIBODY TEST (Pending):
Discharge labs:
___ 06:20AM BLOOD WBC-3.9*# RBC-3.80* Hgb-11.4*# Hct-32.9*
MCV-87 MCH-30.0 MCHC-34.6 RDW-12.5 Plt ___
___ 06:20AM BLOOD Glucose-77 UreaN-9 Creat-0.6 Na-137 K-3.5
Cl-109* HCO3-21* AnGap-11
___ 11:30AM BLOOD TSH-<0.02*
___ 11:30AM BLOOD Free T4-1.8*
Imaging:
Chest X-ray (PA and Lateral)
FINDINGS: The cardiomediastinal and hilar contours are normal.
The lungs are clear. There is no pleural effusion or
pneumothorax. There is no evidence of pneumomediastinum or
subdiaphragmatic free air.
IMPRESSION: No acute cardiopulmonary process. No evidence of
pneumomediastinum or free air beneath the diaphragms.
Brief Hospital Course:
# Likely ___ Tear: Patient presenting with vomiting
associated with 2 blood clots. In emergency department, the
patient was started on IV pantoprazole. The patient's hematocrit
was trended during the admission; her hematocrit was noted to
have fallen, but the patient's hematocrit remained stable at 32
and asymptomatic. The patient's diet was advanced. H. pylori
serology was sent, which was pending on day of discharge. The
patient was also started on ranitidine 300mg for 7 days. Given
that the patient is currently breastfeeding, the lactation
consultants were contacted and confirmed that maternal
ranitidine would not be expected to cause any adverse effects in
breastfed infants.
OUTPATIENT ISSUES: Follow-up of pending H. pylori serology.
Continuation of Ranitidine for 7 days.
.
# Viral gastroenteritis: Patient with a history of sick
contacts- sons who have recently had diarrhea illnesses. Patient
herself presented with nausea, vomiting, and loose stools, and
during admission, she has developed a fever. The patient was not
started on antibiotics. She was maintained on contact
precautions through the admission. The patient's symptoms of
nausea and vomiting resolved on day of discharge. The patient
was able to tolerate an oral diet on day of discharge.
.
# Tachycardia: Patient initially presented to the emergency
department with heart rate in 120s. She received IV fluid
boluses in the emergency department. The patient also received
1L NS bolus on the floor and continuous IV fluids. Her heart
rate improved on hospital day 2. Elevated heart rate was thought
to be due loss of volume secondary to vomiting. Thyroid function
tests were done during this hospitalization, with her free T4
slightly elevated, but not elevated enough to thought to
contribute to patient's tachycardia. The patient also had
orthostatics done which were negative.
.
# Anxiety: Patient had 0.5-1mg available as needed for symptoms
of anxiety.
OUTPATIENT ISSUES: Follow-up with primary care physician
regarding symptoms of anxiety and starting pharmacological
therapy for management of symptoms of anxiety.
.
# Hypothyroidism: Patient status post thyroidectomy for
papillary thyroid cancer. Home dose of levothyroxine was
continued through the admission. The patient's TSH and free T4
were checked during the admission. The patient's free T4 was
slightly elevated. No changes were made to the patient's
levothyroxine dose during the hospitalization.
OUTPATIENT ISSUES: Follow-up of thyroid function tests as an
outpatient with Primary care physician.
.
# Allergic rhinitis: Fluticasone nasal spray is used by the
patient on an as needed basis at home. The patient did not use
any during the hospitalization.
Medications on Admission:
--Levothyroxine 150mcg qDay
--Women's One-a-Day multivitamin daily
--Vitamin D 1000 units a day
--Fluticasone Nasal spray PRN.
Discharge Medications:
1. levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. ranitidine HCl 150 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
3. fluticasone 50 mcg/actuation Spray, Suspension Sig: One (1)
spray Nasal twice a day as needed for congestion.
4. One-A-Day Womens Formula ___ mg Tablet Sig: One (1) Tablet
PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
___ Tear
SECONDARY DIAGNOSIS:
Viral gastroenteritis
Hypothyroidism
Anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you during your hospitalization
at ___.
You were hospitalized because of blood associated with vomiting
thought to be due to a small tear in your esophagus. You were
observed overnight, and your blood levels were trended given the
blood associated with vomiting. You were hydrated with IV
fluids, and you tolerated an oral diet.
If you have any symptoms that concern you, call the Health Care
Associates Clinic at ___ and ask to make an appointment
with your primary care physician or the next available provider.
Please take all medications as instructed. Please note the
following medication changes:
1. *ADDED* Ranitidine 300mg daily for 7 more days. You are
being provided a prescription, though you can also buy this
medication over the counter.
Please keep all follow-up appointment; your upcoming follow-up
appointments are listed below.
Followup Instructions:
___
|
10098672-DS-4 | 10,098,672 | 21,259,834 | DS | 4 | 2141-04-17 00:00:00 | 2141-04-18 16:39:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fever noted in clinic, patient without complaint
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old man with history of Crohn's disease s/p multiple
bowel resections complicated by short gut syndrome on chronic
TPN who is admitted for fevers. The patient was seen in GI
clinic today, where he was noted to have a fever to 102 and was
sent to the emergency room for evaluation. The patient states
he has not been feeling f/c/s recently. He does not some fatique
over the past few weeks, but otherwise no cough, sob, cp,
dysuria, increased ostomy, change in ostomy output.
A full ROS is notable only for left side/lower back pain that is
mostly when he reaches for objects. This pain has been
intermittent over the past few days. The patient has had muscle
pains in the past, and he states that this pain feels similar,
though it is particularly bad.
Of note, the patient was recently treated at an OSH for strep
viridans bacteremia and possible fungemia.
ED Course: initial vitals 99.8 97 135/63 18 96%/RA. The patient
had blood cultures drawn, all PICC lines pulled, was given IV
Vancomycin, and had a CT scan notable only for enlarged
splenomegally.
.
Currently, the patient is comfortable with the exception of his
back/side pain.
.
He denies new rashes, headaches, incontinence, weakness, gait
instability.
Past Medical History:
Crohn's disease s/p colectomy and multiple small bowel
resections.
IDDM c/b severe neuropathy and nephropathy
Stage III CKD (baseline Cr 1.5-2)
nephrolithiasis
hyperlipidemia
anxiety w/ panic attacks
gout
Lyme disease
Social History:
___
Family History:
He denies any family history of Crohn's disease or ulcerative
colitis. He denies any family history of colon cancer but
reports relatives with colon polyps. He has multiple family
members with diabetes and coronary artery disease, and his
father died from complications of end-stage renal disease
requiring dialysis.
Physical Exam:
Admission:
VS - 98 139/83 81 100%RA
GENERAL - Pleasant man, sleepy but NAD
HEENT - MMM, no LAD, OP clear
Chest - RRR, no excess sounds
Lungs - clear bilaterally
abdomen - tenderness LLQ, no rebound
Ext - no stigmata of endocarditis
back - tender over lateral lower back, no tenderness over
vertebrae
Neuro - AAO x3, ___ strength b/l upper and lower extremities
Discharge:
VS - Tm 98, 128/73 63 99%RA
GENERAL - Pleasant man in NAD
HEENT - MMM, no LAD, OP clear
Chest - RRR, no excess sounds
Lungs - clear bilaterally
abdomen - non-tender, non-distended
Ext - no stigmata of endocarditis
back - tender over lateral lower back, no tenderness over
vertebrae
Neuro - AAO x3, CN II-XII intact, ___ strength b/l upper and
lower extremities
Pertinent Results:
Adm:
___ 12:40PM BLOOD WBC-6.3# RBC-3.53* Hgb-9.7* Hct-29.1*
MCV-83 MCH-27.6 MCHC-33.5 RDW-18.5* Plt ___
___ 12:40PM BLOOD Neuts-77.3* ___ Monos-2.6 Eos-0.3
Baso-0.2
___ 12:40PM BLOOD Hypochr-1+ Anisocy-2+ Poiklo-1+
Macrocy-NORMAL Microcy-1+ Polychr-1+ Ovalocy-1+
Schisto-OCCASIONAL Tear Dr-OCCASIONAL
___ 12:40PM BLOOD Glucose-158* UreaN-44* Creat-1.7* Na-136
K-4.0 Cl-99 HCO3-25 AnGap-16
___ 07:55AM BLOOD ALT-14 AST-30 AlkPhos-98 TotBili-0.6
___ 12:48PM BLOOD Lactate-1.2
___ 04:20PM URINE Color-Yellow Appear-Clear Sp ___
___ 04:20PM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 04:20PM URINE RBC-4* WBC-1 Bacteri-NONE Yeast-NONE
Epi-0
Micro:
___ BCx: ___ PARAPSILOSIS from multiple bottles
___ UCx: <10,000 organisms/ml
___ PICC tip cx: No Growth
___ BCx: NGTD
___ BCx: NGTD
___ BCx: NGTD
Reports:
___ CXR: IMPRESSION: Increased cardiomegaly since the prior
study of ___. Otherwise, no acute intrathoracic
process.
___ CT abd/pelvis: No evidence of obstruction. Increased
splenomegaly since ___ now measuring 17cm, prior 14cm.
Otherwise no other acute findings.
___ TTE: The left atrium is normal in size. No atrial septal
defect is seen by 2D or color Doppler. Left ventricular wall
thicknesses are normal. The left ventricular cavity is
moderately dilated. There is mild regional left ventricular
systolic dysfunction with mild inferior and infero-lateral
hypokinesis suggested. There is no ventricular septal defect.
Right ventricular chamber size and free wall motion are normal.
The aortic root is mildly dilated at the sinus level. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. No
masses or vegetations are seen on the aortic valve. The mitral
valve leaflets are mildly thickened. No mass or vegetation is
seen on the mitral valve. An eccentric, posteriorly directed jet
of mild (1+) mitral regurgitation is seen. The left ventricular
inflow pattern suggests impaired relaxation. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.
IMPRESION: No valvular vegetations. CAD suggested.
___ MRI back: IMPRESSION: No evidence of epidural abscess or
discitis/osteomyelitis
.
___ Chest X-ray:
IMPRESSION:
1. Interval PICC placement, tip is in the mid-to-lower SVC.
2. No acute chest abnormality.
Discharge:
___ 07:55AM BLOOD WBC-11.4*# RBC-4.54*# Hgb-12.0*
Hct-38.5*# MCV-85 MCH-26.5* MCHC-31.3 RDW-18.1* Plt ___
___ 07:55AM BLOOD Glucose-102* UreaN-36* Creat-1.7* Na-141
K-4.7 Cl-105 HCO3-26 AnGap-15
Brief Hospital Course:
SUMMARY: ___ year old man with history of Crohn's disease s/p
multiple bowel resections complicated by short gut syndrome on
chronic TPN who is admitted for fevers, found to have high grade
yeast fungemia.
.
# Fungemia: Most likely source is line infection secondary to
chronic TPN. His PICC line was pulled, the patient was started
on micafungin. After 48 hours of negative cultures, a double
lumen PICC line was placed. Infectious disease recommended a 2
week course of micafungin, with plans to follow-up
sensitivities. Ophthalmology did not see evidence of eye
involvement, and a TTE did not show evidence of endocarditis.
The patient will complete a course of micafungin and at that
time consideration of a tunneled line will take place. Dr. ___
will work with the patient and IV team to arrange this.
.
# Back pain: The patient did have back spasms, which was
evaluated with an MRI (without gadolinium as the patient could
not tolerate longer in the machine). This did not show evidence
of infection. He should have a repeat MRI with gadolinium
within two weeks of discharge. He was treated with a lidocaine
patch and oxycodone
.
# CAD: Patient has likely chronic CAD based on TTE and EKG
consistent with inferior wall hypokinesis. Dr. ___ was
contacted and felt the patient was ok for primary ASA
prophylaxis from a gastroenterology standpoint. THe patient
preferred to see a cardiologist as an outpatient closer to his
home and not at ___.
.
# Crohn's Disease: C/b short gut syndrome. TPN held. THe
patient became hemoconcentrated on the day of discharge, and was
given 1L IVF. Plan to restart TPN with home infusion company.
Continued budesonide, cholestyramine, codeine, loperamide,
ursodiol and vitamin D.
.
# CKD: Remained at recent baseline Cr of 1.5-1.7
.
# Diabetes: Intially held lantus given the patient was not using
TPN, however he became hyperglycemic so this was restarted.
#HTN: Continued hydralazine, carvedilol
#GERD: Continued ranitidine and omeprazole
#HL: Continued atorvastatin 10mg daily, ezetimibe, gemfibrozil
#Depression: Continued duloxetine
#Gout: Chronic, continued allopurinol
.
====
TRANSITIONAL ISSUES:
-Infectious disease to follow-up ___ sensitivity, and
contact the patient if the organism is not sensitive to
micafungin.
-If fungemia recurs, will need repeat TEE
-Tunneled PICC line consideration after 2 week course of
micafungin
-Patient needs cardiology referral (prefers to be seen close to
home, not ___
-Will need MRI of the thoracic and lumbar spine with gadolinium
within the next two weeks (prior to stopping micafungin) to
definitively rule out osteomyelitis.
-Blood cultures to be drawn 1 week after discharge, with the
results sent to the infectious disease team (Dr. ___ Dr.
___
Medications on Admission:
verified with pharmacy
-allopurinol ___ mg Tablet 1 Tablet(s) by mouth once a day
-atorvastatin [Lipitor] 10 mg Tablet 1 Tablet(s) by mouth once a
day
-budesonide 3 mg Capsule, Delayed & Ext.Release 3 Capsule(s) by
mouth DAILY
-hydralazine 25mg TID
-carvedilol 6.25mg BID
-cholestyramine (with sugar) 4 gram Packet 1 packet by mouth
twice daily
-codeine sulfate 60mg QID
-duloxetine [Cymbalta] 60 mg Capsule, Delayed Release(E.C.)
1 Capsule(s) by mouth twice a day
-ezetimibe [Zetia] 10 mg Tablet 1 Tablet(s) by mouth once a day
-fentanyl 50 mcg/hour Patch 72 hr 1 patch topical Q72 hours
-gabapentin 300 mg Capsule 1 Capsule(s) by mouth 12 hours
-gemfibrozil 600 mg Tablet 1 Tablet(s) by mouth once a day
-omeprazole 20 mg Capsule (E.C.) 1 Capsule(s) by mouth twice a
day
-ranitidine 150 mg Capsule BID
-loperamide 2mg, 4tab in AM 4tabs in evening
-ursodiol 300mg BID
-vit d ___ daily
-Lantus insulin pen, 17u qhs
-humalog sliding scale
Discharge Medications:
1. allopurinol ___ mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. budesonide 3 mg Capsule, Delayed & Ext.Release Sig: Three (3)
Capsule, Delayed & Ext.Release PO DAILY (Daily).
4. hydralazine 25 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
5. carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
6. cholestyramine (with sugar) 4 gram Packet Sig: One (1) Packet
PO BID (2 times a day).
7. codeine sulfate 30 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
8. duloxetine 60 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
9. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
11. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H
(every 12 hours).
12. gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
14. ranitidine HCl 150 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
15. loperamide 2 mg Capsule Sig: Four (4) Capsule PO BID (2
times a day).
16. ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
17. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
18. micafungin 100 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours) for 11 days: Course to
complete on ___.
Disp:*11 Recon Soln(s)* Refills:*0*
19. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
Disp:*10 Adhesive Patch, Medicated(s)* Refills:*0*
20. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
21. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*10 Tablet(s)* Refills:*0*
22. insulin glargine 100 unit/mL Solution Sig: Seventeen (17)
units Subcutaneous once a day.
23. MRI with gadolinium
Please have an MRI with gadolinium of the thoracic and lumbar
spine within 10 days of discharge
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Fungemia
Secondary:
Crohn's disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted after being noted to have a fever in
___ clinic. We felt this was most likely related
to an infection of your PICC line, and so this line was removed.
You also had yeast in your blood, which likely caused the
fever. We are treating you with a medicine to kill the yeast.
It will be VERY important for you to take good care of your new
PICC line. This means wearing gloves, sterilizing the line
before using, keeping your ostomy supplies separate from your
PICC line supplies, and following the instructions of the nurses
who help with your TPN. This will help prevent future infections
which could make you very, very sick.
You also had some findings on the ultrasound of your heart and
your EKG that require that you follow-up with a cardiology
doctor as an outpatient. You should speak with your primary care
doctor regarding this, as you may need a "stress test" to
evaluate your heart.
Please note the following medication changes:
-Please take ranitidine, 300mg, at night (this is a change from
taking 150mg in the morning and 150mg in the evening)
-Please START Micafungin IV daily until ___. The
infectious disease doctors ___ be following the data from your
blood culture to make sure that this medication effectively
treats your infection. If it does not, you may hear from them
about starting a different medication
-Please START Lidocaine patch for your back pain
-Please START Aspirin once daily (81mg) for your heart
-Please START oxycodone for back pain. This medication can be
dangerous with your fentanyl patch, and you should be very
careful to not drink alcohol or drive when using this
medication. If you are feeling more sleepy or confused than
usual, you should also not use this medication.
Followup Instructions:
___
|
10098672-DS-8 | 10,098,672 | 21,229,395 | DS | 8 | 2142-05-23 00:00:00 | 2142-05-23 13:49:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
aspirin / sucrose / Equal sweetener
Attending: ___.
Chief Complaint:
HOSPITAL MEDICINE ___ ADMISSION NOTE
time pt seen & examined: 7:40am
CC: generalized weakness, abdominal pain, nausea, ___
PCP: ___
___ Surgical or Invasive Procedure:
Foley placement
History of Present Illness:
___ man whose PMH includes DM II, CKD stage III, fistulizing
Crohn's disease c/b multiple SBOs ___ years ago, s/p
proctocolectomy with end ileostomy, and short gut syndrome,
TPN-dependent. Crohn's disease had been relatively quiescent
until he started smoking again a few years ago. Admitted in
___ with Crohn's exacerbation, at which time biologic agents
such as anti-TNF were being considered. However, a highly
atypical prostate nodule was seen on MR, and biopsy was
recommended prior to proceeding with biologic therapy, given
risk of malignancy. He underwent prostate biopsy, which showed
HGPIN. Urology recommended prostatectomy, and he underwent
radical retropubic prostatectomy with pelvic lymphadenectomy on
___.
He was discharged home with indwelling Foley on ___ and felt
unwell the following day. He felt tired and weak, stayed in bed,
"lost a whole day." Poor appetite with occ N/V, too weak to
connect himself to TPN for several days. He developed worsening
lower abdominal pain, different from Crohn's pain, as well as
headache. Denies F/C, SOB, CP or cough. Frequency of loose,
brown BMs increased over last few days bc unable to take his
meds (loperamide, hyoscyamine) but no blood. Pt feels worse than
he has felt in a long time.
ROS otherwise noncontributory.
In the ED: Tm 98.5 70-80s 140s/70s 18 98% RA. WBC 8.8K, BUN 47,
Creat 2.7 (baseline 1.5). UA with marked pyuria, hematuria,
+leuk, mod bacteria, trace ketones. Noncontrast CT scan
abd/pelvis showed postsurgical changes without discrete fluid
collection. He was given empiric ciprofloxacin 400mg IV, several
doses dilaudid 1mg IV for pain, zofran for nausea, and 2L NS.
Urology was consulted and found no acute surgical issues,
recommended maintaining Foley in place until scheduled removal
___. Admitted to ___ for ___ on CKD.
Currently he remains very uncomfortable due to abd pain,
malaise, fatigue. Tolerating small amounts liquids.
Past Medical History:
# Crohn's disease s/p proctocolectomy with end ileostomy and
multiple small bowel resections
# short gut syndrome, TPN-dependent
# iron deficiency anemia
# vitamin D deficiency
# DMII c/b severe BLE neuropathy and nephropathy
# Stage III CKD (baseline Cr 1.5-2)
# nephrolithiasis
# hyperlipidemia
# anxiety w/ panic attacks
# gout
# Lyme disease
Social History:
___
Family History:
significant for DM, CAD in multiple members
father with ESRD
No history of IBD or colon cancer
Physical Exam:
Admission Exam:
VS: 99.1 146/73 80 95% RA
GEN: NAD, chronically ill-appearing, uncomfortable
EYES: conjunctiva clear anicteric
ENT: dry mucous membranes
NECK: supple
CV: RRR s1s2
PULM: CTA
GI: normal BS, ND, soft, mild diffuse lower tenderness;
suprapubic surgical scar with mild surrounding erythema, one
proximal staple missing with ~5mm superficial wound dehiscence;
ostomy bag in place
EXT: warm, no edema
SKIN: no rashes
NEURO: alert, oriented x 3, answers ? appropriately, follows
commands
PSYCH: appropriate, flat affect
ACCESS: right port site C/D/I
FOLEY: present
.
Discharge Exam:
AVSS
Line: slightly pink, non-tender, no discharge
GI: (unchanged) normal BS, ND, soft, mild diffuse lower
tenderness; suprapubic surgical scar with mild surrounding
erythema, one proximal staple missing with ~5mm superficial
wound dehiscence; ostomy bag in place
Foley
Pertinent Results:
CBC:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
___ 05:22 11.2* 3.52* 10.2* 29.9* 85 29.0 34.1 16.1*
396
Source: Line-___
___ 07:35 12.8* 3.85* 11.0* 33.2* 86 28.5 33.1 16.2*
475*
___ 08:15 12.6* 3.83* 10.9* 32.6* 85 28.4 33.3 16.1*
451*
___ 10:50 10.5 3.62* 10.5* 30.8* 85 29.1 34.2 15.6*
360
___ 05:30 7.1 3.34* 9.5* 28.1* 84 28.5 33.9 15.4 292
Source: Line-tunnelled line
___ 08:00 6.7 3.43* 9.5* 28.3* 82 27.8 33.7 15.5 306
___ 06:45 5.8 3.22* 8.9* 26.8* 83 27.5 33.0 15.5 265
___ 17:18 8.8 3.54* 10.1* 30.0* 85 28.4 33.6 15.8* 312
.
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
___ 05:22 55*1 54* 1.8* 140 4.3 111* 20* 13
Source: ___
___ 07:35 971 54* 2.1* 138 4.8 106 20* 17
___ 08:15 911 50* 2.2* 141 4.7 109* 21* 16
___ 10:50 208*1 39* 2.0* 1352 4.82 1062 22 12
LIPEMIC SPECIMEN
___ 05:30 142*1 35* 2.0* 141 4.5 ___
Source: Line-tunnelled line
___ 08:00 176*1 37* 2.1* 138 4.2 ___
___ 06:45 232*1 37* 2.3* 137 4.2 ___
___ 17:18 266*1 47* 2.7* 137 4.4 96 26 19
.
LIPID/CHOLESTEROL Cholest Triglyc
___ 08:00 361*1
___ 06:45 357*1
.
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
___ 17:18 22 39 92 0.5
.
CT Abdomen and Pelvis: ___
HISTORY: Bilateral lower quadrant abdominal pain after surgery
for prostate
cancer (per the ___ medical record surgery was ___.
Evaluate for
intra-abdominal abscess or worsening Crohn's disease.
TECHNIQUE: MDCT-axial images were acquired from the dome of the
liver to the
pubic symphysis without the administration of IV contrast given
renal
insufficiency. Oral contrast was administered. Coronal and
sagittal
reformations were provided and reviewed.
DLP: 842.42 mGy/cm.
COMPARISON: CT abdomen pelvis ___.
FINDINGS:
Abdomen: The imaged lung bases show mild bronchiectasis at the
left lung
base. There is no pleural effusion or pneumothorax. The heart
is normal in
size and there is no pericardial effusion.
Evaluation of the intra-abdominal contents is limited by lack of
intravenous
contrast. Within this limitation the pancreas and adrenal
glands are
unremarkable. The spleen is enlarged, measuring 14.9 cm in the
craniocaudal
dimension, decreased from 17 cm. The gallbladder is surgically
absent.
Hypodensities within the liver likely reflect focal fat (2:19,
26). A 4.8 cm
simple cyst within the right kidney is unchanged. There is no
definte
solid-appearing lesion within the left kidney seen on this
study. Otherwise,
there is no hydronephrosis or nephrolithiasis. There is no
retroperitoneal or
mesenteric lymphadenopathy. Dense calcifications are seen at
the origin of
the superior mesenteric artery and left renal artery.
The stomach is normal. Contrast has progressed to the
ileostomy. There is no
bowel wall thickening or evidence for obstruction. The patient
is status post
a total proctocolectomy. There is no extraluminal contrast,
free fluid or
free air.
Pelvis: A 2.9 x 2.7 cm fluid collection anterior to the aortic
bifurcation is
unchanged from ___. There are extensive postsurgical changes
within the
pelvis, including stranding, clips and air (2:80). There is no
discrete fluid
collection. A Foley catheter and air are seen within the
bladder. There is
no pelvic lymphadenopathy.
Bones: There are no concerning sclerotic foci.
IMPRESSION:
1. Postsurgical changes in the pelvis from recent
prostatectomy. The absence
of contrast limits the evaluation for abscess, however, there is
no new
discrete fluid collection.
2. Decrease in size of splenomegaly.
.
Cystogram ___
FINDINGS: Scout radiographs demonstrate multiple surgical clips
in the pelvis
and Foley catheter in situ. The bladder was slowly filled with
water soluble
contrast. Oblique and lateral views reveal extravasation of
contrast from the
posterior base of the bladder. A track of contrast
approximately 1 cm in
width connects the base of the bladder to a 5.8 x 1.7 cm
collection in the
presacral space.
IMPRESSION: Urine leak from the posterior base of the bladder
communicates
with a 5.8 x 1.___LOOD CX (___) 1 of 2: gram positive cocci in pairs and chains
Brief Hospital Course:
___ with long standing Crohns on TPN, recent prostatectomy,
presents with malasie and weakness and found to have klebsiella
and proteus UTI in the setting of a post-surgical urinary leak.
ACTIVE ISSUES:
# Prostate CA s/p Prostatectomy with Urinary Leak: The patient
presented with malaise and weakness in the setting of a UTI (see
below). During the admission Urology was consulted and upon
urostogram evaluation was found to have a urinary leak. A foley
was placed. The patient will f/u in ___ clinic this week.
.
# Klebsiella and Proteus UTI: Secondary to recent prostatectomy
with indwelling Foley; No evidence pyelonephritis on
non-contrast CT but some systemic symptoms concerning. The
klebsiella dn proteus were pan-sensistive (with exception to
nitrofurantoin). The patient was treated for 7 days while in
house (first via IV and then switched to PO) with instruutions
to continue the antobiotics through urology follow-up this week.
.
# Malaise and Wakness: Presnted with with marked hypovolemia,
UTI. Improved with IVF and antibiotoics.
.
# Strep Viridans Bacteremia: In ___ bottles out of one culture.
No evidence of line infection or clinical signs of endocarditis.
The patient received 3 days of CTX but this was discontinued
when the bacteremia was considered to be contaminant.
.
# ___: Patient with ___ (Cr up to 2.2 from 1.5) that was likel
yprerenal secondary to marked hypovolemia due to poor po intake
and lack of TPN. The patient should resume his home TPN and IVF
while at home.
.
# Abdominal Pain: Thought to be secondary to urinary leak.
Clinically stable. The patient was provided a script for 60 x
10mg Oxycodone pills and instructed not to drive or operate
machinery on the medication.
.
CHRONIC ISSUES:
# Crohn's disease w short gut syndrome: Recently increased
diarrhea likely secondary to inability to take antimotility
agents, less likely evolving Crohn's flare. Restarted on home
meds.
.
# Chronic neuropathic pain: at baseline but pt reports
difficulty obtaining Fentanyl patches due to inadequate drug
coverage by his insurance plan
.
TRANSITIONAL ISSUES:
- The patient will f/u with urology this week for repeat
cystogram to check for resolution of urinary leak. The patient
remains on ciprofloxacin (for 5 more days through the
appointment) at which time is should be determined if the abx
should be continued going forth.
- The patient was sent out with a medication supply list for
Ethanol Locks at 70% instead of the previously prescribed 10%
(per ___ RN).
- Blood cultures were pending at d/c
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q6H:PRN fever, pain
2. Carvedilol 6.25 mg PO BID
3. Cholestyramine 4 gm PO BID
4. Gabapentin 300 mg PO BID
5. PredniSONE 10 mg PO DAILY
6. Ranitidine 150 mg PO DAILY
7. Hyoscyamine SO4 (Time Release) 0.375 mg PO BID:PRN abdominal
pain
8. Fentanyl Patch 50 mcg/h TD Q72H
9. Pantoprazole 40 mg PO Q24H
10. Gemfibrozil 600 mg PO DAILY
11. Duloxetine 60 mg PO BID
12. Multivitamins 1 TAB PO DAILY
13. Erythromycin 0.5% Ophth Oint 0.5 in RIGHT EYE TID eye pain
14. Ethanol 10% Catheter DWELL 2 mL DWELL BID
15. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
16. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
17. LOPERamide 2 mg PO QID:PRN diarrhea
18. Codeine Sulfate 60 mg PO Q6H:PRN diarrhea
pre-admission medication
19. Ciprofloxacin HCl 500 mg PO Q12H
start one day before planned foley removal
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN fever, pain
2. Carvedilol 6.25 mg PO BID
3. Cholestyramine 4 gm PO BID
4. Ethanol 70% Catheter DWELL (Tunneled Access Line) 2 mL DWELL
DAILY
5. Fentanyl Patch 50 mcg/h TD Q72H
6. Gabapentin 300 mg PO BID
7. Gemfibrozil 600 mg PO DAILY
8. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
9. Hyoscyamine SO4 (Time Release) 0.375 mg PO BID:PRN abdominal
pain
10. LOPERamide 2 mg PO QID:PRN diarrhea
11. Pantoprazole 40 mg PO Q24H
12. PredniSONE 10 mg PO DAILY
13. Ranitidine 150 mg PO DAILY
14. Bacitracin Ointment 1 Appl TP TID
RX *bacitracin zinc [Antibiotic (bacitracin zinc)] 500 unit/gram
Apply three times a day Disp #*1 Tube Refills:*0
15. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
16. Erythromycin 0.5% Ophth Oint 0.5 in RIGHT EYE TID eye pain
17. Multivitamins 1 TAB PO DAILY
18. Ethanol Locks
Ethanol 70% Catheter DWELL (Tunneled Access Line) 2 mL DWELL
DAILY
FOR PORT2 #1&2 Ethanol 70% Catheter DWELL (Tunneled Access Line)
2 mL DWELL DAILY per lumen Not for IV use. To be instilled into
central catheter port for local dwell. 2hr dwell.
19. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 10 mg 1 tablet(s) by mouth every four (4) hours
Disp #*60 Tablet Refills:*0
20. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth twice a
day Disp #*10 Tablet Refills:*0
21. Codeine Sulfate 60 mg PO Q6H:PRN diarrhea
22. Duloxetine 60 mg PO BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis
- Urethral leak secondary to prostate surgery
- Acute Kidney Injury
- Proteus and Kidney Bacterial Infection
- Strep Viridans Bacteremia (Contaminant)
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 fever and kidney injury
and were found to have a urinary leak from your prostate
surgery. We placed a foley catheter and you will follow-up on
___ in ___ clinic. You were also treated for a urinary
tract infection.
Followup Instructions:
___
|
10098993-DS-42 | 10,098,993 | 21,687,208 | DS | 42 | 2166-02-21 00:00:00 | 2166-02-21 15:41:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Vancomycin
Attending: ___.
Chief Complaint:
Chest pain, dark stools
Major Surgical or Invasive Procedure:
Endoscopy
History of Present Illness:
___ yo female with significant history of coronary artery disease
s/p CABG, ischemic cardiomyopathy s/p BiV-ICD placement and
ventricular tachycardia who presents with acute onset of likely
GI bleed and left-sided chest pain. The pain was located under
her left breast radiating to her back that awoke her from sleep
around 3 AM on the day of admission, ___ in severity. She
reports taking a few nitroglycerin tablets with some relief in
her pain. The pain was reported as being constant in nature as
achey in character. She also reports that she had significant
dyspnea on exertion this morning, upon walking to the bathroom,
which is not typical for her, no shortness of breath at rest. At
baseline, she can walk less than a city block without stopping
for rest. She received nitroglycerin and aspirin prehospital.
She reports no fever or chills, no cough. On further questioning
the patient does report having some dark stool intermittently
for the last month or so.
.
In the ED, initial VS were pain ___, T 97.2, P 64, BP 163/64, R
16, Sat 97%. On physical exam, patient had guaiac positive black
stool. ECG reportedly showed paced rhythm, with LAD, RBBB, new
ST depressions in V3 and V5, as well as new TWF in V3. Labs were
significant for hematocrit of 25 from baseline 34. Troponin was
noted to 0.04, which is below her baseline. In addition,
potassium was elevated at 5.5, creatinine elevated at 1.8 from
baseline of 1.5, and INR was 1.3. Patient was administered
full-dose aspirin and started on a nitroglycerin gtt. GI was
consulted for GI bleed, and recommended protonix bolus and gtt,
transfusion of 2 units PRBCs and possible EGD on ___.
Transfusion has not started at the time of transfer. Chest X-ray
was performed and showed no acute cardiopulmonary process.
Patient was chest pain free at the time of transfer. Peripheral
line and EJ line was placed in ED.
.
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 paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, syncope or
presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: + Diabetes, + Dyslipidemia, +
Hypertension
2. CARDIAC HISTORY:
- CAD status post inferoposterior wall MI, CABG in ___
(LIMA-LAD, SVG-OM, SVG-PDA, known SVG to PDA stenosis)--> Taxus
stent to SVG - PDA in ___ stenting of anterograde limb
of PDA in ___. Demonstration of SVGSVG-rPDA
demonstrated 40%ostial lesion consistent with in-stent
restenosis.
- Permanent atrial fibrillation
- Ischemic CM, EF 22% on PMIBI ___. ___ Class III.
- ___ Biventricular ICD implant ___ Cognis).
- ___ LV lead revision
- Ventricular tachycardia status post ICD placement; generator
change 6.05
3. OTHER PAST MEDICAL HISTORY:
- Hypertension/LVH.
- Type 2 diabetes (HbA1c 7.5 in 6.10), followed at the ___
by ___.
- Mild AS/AR.
- Hypothyroidism
- Irritable bowel syndrome/diverticulosis
- Chronic kidney disease
- Anemia
- Arthritis
- Breast CA, s/p R mastectomy and XRT ___
- Gastritis on EGD, w/ hiatal hernia
- diverticulosis
Social History:
___
Family History:
Mother died at ___ of an MI, also had a stroke. Brother died of
MI at ___; sister died of MI in her ___, another brother died of
congenital heart defect at ___(valve). Father died at ___.
Children both have diabetes.
Physical Exam:
ADMISSION PHYSICAL EXAM:
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVD at level of the jaw.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
NEURO: AAOx3, CNII-XII intact, ___ strength biceps, triceps,
wrist, knee/hip flexors/extensors, 2+ reflexes biceps,
brachioradialis, patellar, ankle.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
.
DISCHARGE PHYSICAL EXAM:
Vitals - Tm/Tc 97.8 HR 59-66 BP 110-125/55-64 RR ___ 02 sat
100% RA
In/Out: Last 24H: -300, Last 8H: ___
Weight: 67.9 (up 0.2 kg from yesterday)
Tele: paced
___: 129
GENERAL: ___ yo female in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: Conjunctiva pink with injection on right side only that
extends to lower eyelid, no pallor or cyanosis of the oral
mucosa.
NECK: Supple with JVD at 3cm above clavicle
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RRR, normal S1, S2. Systolic mumur ___ in RUSB. Murmur
radiating to bilateral carotids. No thrills, lifts.
LUNGS: CTAB no w/r/r
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: 2+ ___, no pedal edema
GAIT: in bed, awaiting ___ to see. ambulated with ___ using
walker, steady on feet
Pertinent Results:
ADMISSION LABS:
WBC-5.0 RBC-2.76*# Hgb-8.2*# Hct-0*# MCV-90 MCH-29.9 MCHC-33.1
RDW-13.4 Plt ___
Neuts-63.9 ___ Monos-7.3 Eos-3.4 Baso-0.8
___ PTT-57.0* ___
Glucose-161* UreaN-65* Creat-1.8* Na-135 K-6.7* Cl-103 HCO3-22
AnGap-17
CK-MB-4
.
CHEST X-RAY (___): Compared with prior, there has been no
significant interval change. The lungs remain clear. There is no
pleural effusion. There is no pulmonary vascular engorgement.
Cardiac silhouette is enlarged, but stable in configuration.
Biventricular pacing device again seen with multiple leads in
stable positions. Atherosclerotic calcifications seen throughout
the aorta. Median sternotomy wires and mediastinal clips again
noted.
IMPRESSION: No acute cardiopulmonary process.
.
DC LABS:
___ 06:30AM BLOOD WBC-6.5 RBC-3.38* Hgb-10.3* Hct-30.1*
MCV-89 MCH-30.4 MCHC-34.2 RDW-13.7 Plt ___
___ 06:30AM BLOOD Glucose-104* UreaN-47* Creat-2.2* Na-137
K-4.6 Cl-101 HCO3-30 AnGap-11
___ 06:30AM BLOOD Calcium-10.4* Phos-3.5 Mg-2.6
.
ENDOSCOPY ___:
Impression: Irregular z-line.
Abnormal mucosa in the esophagus (biopsy)
Slightly thickened gastric folds.
Polyp in the first part of the duodenum (biopsy)
Otherwise normal EGD to third part of the duodenum
Recommendations: Follow-up biopsy results. If duodenal polyp is
adenomatous, may need repeat endoscopy.
The findings do not account for the symptoms
Brief Hospital Course:
Ms. ___ is a ___ year old woman with significant history of
coronary artery disease s/p CABG, ischemic cardiomyopathy s/p
BiV-ICD placement and ventricular tachycardia who presented with
acute onset of likely GI bleed with resultant
exertionalleft-sided chest pain. She underwent an endoscopy
which didnt show any active signs of bleeding and was dc/ed to
___ d/t orthostatic hypotension.
.
# Gastrointestinal bleed: Ms. ___ experienced a hematocrit drop
from baseline of 34 to 24 in setting of guaiac positive dark
stool. Differential diagnosis for upper GI bleed included
bleeding ulcer, gastritis, or variceal bleed. She has history of
gastritis on previous EGD and diverticulosis on prior
colonoscopy. On admission, Ms. ___ was started on a protonix
drip, and GI was consulted who performed EGD on ___ which
demonstrated no acitve site of bleeding and no lesion that may
have been responsible for the GIB. Ms. ___ recieved 3 units of
blood on the first day of admission which resulted in resolution
of her chest pain.
.
# Chest pain: Ms. ___ experienced left-sided chest pain which is
similar to her prior anginal symptoms. There were no discernible
EKG changes but these are difficult to interpret in the setting
of BiV pacing. Her MB was flat and troponins were less than
baseline (normally elevated secondary to CKD). Patient received
full-dose aspirin and was initiated on a nitroglycerin gtt in
the ED with resolution of her pain. Pain did not recur after
weaning the nitroglycerin drip and receiving 3 units of PRBCs
until 2 days later on ___. Beta blockade and lisinopril were
initially held but were restarted at lower dose on ___.
Lisinopril however was held at the time of dc due to a Cr bump.
.
# Ischemic cardiomyopathy: Ms. ___ furosemide and
spironolactone were initially held given concern for GI bleed.
Before d/c her Cr was high so lasix and lisinopril were held.
.
# Atrial fibrillation: CHADS2 score of 4. Ms. ___ states that
her physicians told her to stop dabigatran several months ago
and according to GI note from ___ her dabigatran had already
been stopped. Her outpatient cardiologist, Dr. ___, was
contacted and an appt was set up. On discharge, she was
prescribed dabigatran 75 BID and set up with outpt f/up.
.
# Type 2 diabetes mellitus: Home lantus and a sliding scale were
continued in lieu of her januvia and sulfonyluea.
.
# Hypothyroidism: Continued home levothyroxine
.
TRANSITIONAL ISSUES: The pt developed some orthostatic
hypotension just before the time of discharge and her Cr spiked,
likely in the setting of being NPO for a long period and getting
lisinopril and lasix. These meds were held at the time of dc and
she will need a CHEM 7 before these meds can be restarted.
Medications on Admission:
Metoprolol succinate 200 mg PO daily
Lisinopril 10 mg PO daily
Furosemide 40 mg PO daily
Aspirin 81 mg PO daily
Isosorbide mononitrate 30 mg PO daily
Rosuvastatin 20 mg PO daily
Levothyroxine 0.1 mcg PO daily
Omeprazole 20 mg PO daily
Insulin glargine 16 units PO QAM
Insulin Humalog per sliding scale patient only takes when BS>400
Januvia 50 mg PO PO daily
Glipizide 2mg BID
Ferrous sulfate 325 mg PO daily
Vitamin B6 100 mg PO daily
Vitamin B12 100 mcg PO daily
Doxercalciferol
Multivitamin 1 tab PO daily
Loperamide PO PRN
Discharge Medications:
1. Outpatient Lab Work
Please have your labs drawn at rehab ___ and have those
results faxed to your PCP: Dr. ___ ___
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
4. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
7. Januvia 50 mg Tablet Sig: One (1) Tablet PO once a day.
8. glipizide 5 mg Tablet Sig: 0.5 Tablet PO twice a day.
9. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1)
Tablet PO once a day.
10. Vitamin B-6 100 mg Tablet Sig: One (1) Tablet PO once a day.
11. multivitamin Tablet Sig: One (1) Tablet PO once a day.
12. insulin glargine 100 unit/mL Cartridge Sig: Sixteen (16)
units Subcutaneous qAM.
13. Toprol XL 200 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO once a day.
14. Vitamin B-12 500 mcg Tablet Sig: One (1) Tablet PO once a
day.
15. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tab
Sublingual Q 5 minutes x3 as needed for chest pain: take as
directed.
16. Pradaxa 75 mg Capsule Sig: One (1) Capsule PO twice a day.
17. Hectorol 0.5 mcg Capsule Sig: Two (2) Capsule PO twice a
day.
18. Fish Oil 1,000 mg Capsule Sig: One (1) Capsule PO once a
day.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Blood loss from unknown source (likely GI)
Chest pain from blood loss
Secondary diagnosis:
Coronary artery disease
Cardiomyopathy (weak heart muscle)
Hypertension
Diabetes
Chronic kidney disease
Atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___. You were admitted
to the hospital for chest pain and dark stools. You met with the
GI doctors, and an EGD scope procedure was performed. You also
had a biopsy done, the results of which are pending on
discharge. Your bleeding stopped after 3 units of blood, and
your blood counts remained stable. Your chest pain was felt to
be related to the bleeding, and this improved.
.
You had mild worsening of your kidney function, which was likely
related to dehydration. This improved with IV fluids. You will
require a repeat blood test to ensure that your blood counts and
kidney function are stable. You should have this test done on
___, if the kidneys look better, we will restart you on your
lasix and lisinopril.
.
MEDICATION CHANGES:
- INCREASE omeprazole to 20 mg twice a day
- HOLD your Lasix (Furosemide)
- HOLD your Lisinopril
*if your kidney function is improving on ___, please
resume both Lasix 40mg daily and Lisinopril 10mg daily
For your heart failure diagnosis: Weigh yourself every morning,
call MD if weight goes up more than 3 lbs in 2 days or 5 lbs in
3 days, follow a low salt diet and restrict your fluids to 1500
ml/ day.
Please have your hematocrit and BMP drawn on ___
Followup Instructions:
___
|
10099104-DS-16 | 10,099,104 | 28,798,348 | DS | 16 | 2180-11-19 00:00:00 | 2180-11-19 18:17:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / aspirin / tamsulosin
Attending: ___
Chief Complaint:
Fever, Lower ABD Pain, Weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old male with PMH of HTN, T2DM, Bell's
Palsy (R), colon cancer a/p colectomy and new diagnosis of
acontractile bladder presenting to the ED with fevers, nausea,
vomiting, and lethargy.
Patient reports that over the past 24 hours he started to feel
unwell and developed fevers, chills, weakness, malaise, and
decreased appetite. He reports that he has been taking in a good
amount of fluid PO but minimal solid food. His family noticed an
acute change in him at dinner today when he hung his head in his
lap and began vomiting. At this point he was unable to ambulate
without assistance and his family called EMS to bring him to the
hospital.
Of note patient is followed by urology for a new diagnosis of
underactive detrusor muscle/acontractile bladder. He was seen on
___ by an NP to have his Foley exchanged.
- In the ED, initial vitals were:
- P 4, T 101.4, HR 84, BP 112/60, RR 16, SpO2 96%
- Exam was notable for:
- Gen: Elderly male in NAD
- CV: RRR no m/g/r.
- Pulm: CTAB
- Abd: Soft, NT, ND. (+) CVAT
- Rectal: Non-tender prostate
- Extr: No ___ edema. 2+ DP pulses.
- Labs were notable for:
8.9 133|103| 34
28.3>----<113 ------------<164
27.0 4.0| 20| 1.5
- ___ 13.6, PTT 27.2, INR 1.3
- Ca 8.9, Mg 1.5, P 2.3
- Trop-T 0.02
- Lactate 1.3
- UA with large leuk, positive nitrate, 97 WBC, few bacteria,
30 protein
- Studies were notable for:
- CXR: No signs of pneumonia.
- The patient was given:
- CTX 1 gm
- 1L NS
On arrival to the floor, reports that he is still not feeling
well but denies any nausea at this time. Endorses some bladder
discomfort.
REVIEW OF SYSTEMS:
==================
Per HPI, otherwise, 10-point review of systems was within normal
limits.
Past Medical History:
ADULT-ONSET TYPE 2 DIABETES MELLITUS WITH NEUROLOGICAL
MANIFESTATIONS
BELL'S PALSY
CATARACT
COLON CANCER
GLAUCOMA
HEARING LOSS
HYPERCHOLESTEROLEMIA
HYPERTENSION
SYMPTOM, MEMORY LOSS
DIABETES MELLITUS
Social History:
___
Family History:
Mother ___
Father ___
Comments: siblings also have hearing loss, cataracts, and
glaucoma 4 (including himself) are living out of 9
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS:
24 HR Data (last updated ___ @ 222)
Temp: 98.0 (Tm 98.0), BP: 161/47, HR: 104, RR: 18, O2 sat:
96%, O2 delivery: Ra
GENERAL: NAD. Right sided facial droop ___ Bell's palsy.
HEENT: PERRL, EOMI. MMM.
CARDIAC: RRR no m/r/g
LUNGS: CTAB no r/r/w
BACK: Positive CVA tenderness
ABDOMEN: Soft, NT, ND, +BS
EXTREMITIES: No clubbing, cyanosis, or edema.
SKIN: Warm. No rashes.
NEUROLOGIC: AOx3. Right sided facial droop ___ Bell's palsy
DISCHARGE PHYSICAL EXAM:
24 HR Data (last updated ___ @ 803)
Temp: 97.8 (Tm 99.0), BP: 128/53 (120-145/53-64), HR: 73
(73-81), RR: 18 (___), O2 sat: 98% (97-98), O2 delivery: Ra
GENERAL: NAD. Right sided facial droop ___ Bell's palsy.
CARDIAC: RRR no m/r/g
LUNGS: CTAB no r/r/w
BACK: No CVA tenderness
ABDOMEN: Soft, NT, ND, +BS
EXTREMITIES: No clubbing, cyanosis, or edema.
SKIN: Warm. No rashes.
NEUROLOGIC: AOx3. Right sided facial droop ___ Bell's palsy
Pertinent Results:
ADMISSION LABS
===============
___ 09:45PM BLOOD WBC-28.3* RBC-2.60* Hgb-8.9* Hct-27.0*
MCV-104* MCH-34.2* MCHC-33.0 RDW-14.9 RDWSD-55.9* Plt ___
___ 09:45PM BLOOD Neuts-90.4* Lymphs-2.6* Monos-5.8
Eos-0.0* Baso-0.2 Im ___ AbsNeut-25.59* AbsLymp-0.74*
AbsMono-1.64* AbsEos-0.00* AbsBaso-0.06
___ 09:45PM BLOOD ___ PTT-27.2 ___
___ 09:45PM BLOOD Glucose-164* UreaN-34* Creat-1.5* Na-133*
K-4.0 Cl-103 HCO3-20* AnGap-10
___ 09:45PM BLOOD Calcium-8.9 Phos-2.3* Mg-1.5*
___ 07:26AM BLOOD Albumin-3.3*
___ 07:26AM BLOOD ALT-10 AST-14 LD(LDH)-244 AlkPhos-57
TotBili-0.4
___ 10:04PM BLOOD Lactate-1.3
___ 09:45PM URINE Color-Straw Appear-Clear Sp ___
___ 09:45PM URINE Blood-SM* Nitrite-POS* Protein-30*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG*
___ 09:45PM URINE RBC-0 WBC-97* Bacteri-FEW* Yeast-NONE
Epi-0
MICRO
=====
___ 9:45 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
PSEUDOMONAS AERUGINOSA. >100,000 CFU/mL.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 2 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ 8 I
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S
PERTINENT STUDIES
=================
CHEST XRAY ___
FINDINGS:
AP upright and lateral views of the chest provided. Overlying
EKG leads are present. Slightly increased interstitial opacity
at the lung bases may reflect areas of fibrosis. No large
effusion or pneumothorax. No signs of pneumonia or edema.
Cardiomediastinal silhouette is normal. Bony structures are
intact
IMPRESSION:
No signs of pneumonia.
DISCHARGE LABS
===============
___ 12:40PM BLOOD WBC-8.2 RBC-2.55* Hgb-8.6* Hct-26.9*
MCV-106* MCH-33.7* MCHC-32.0 RDW-14.8 RDWSD-57.2* Plt ___
___ 05:45AM BLOOD Glucose-192* UreaN-35* Creat-1.3* Na-141
K-4.5 Cl-103 HCO3-23 AnGap-15
___ 05:45AM BLOOD Calcium-8.4 Phos-3.1 Mg-1.7
Brief Hospital Course:
SUMMARY STATEMENT:
====================
The patient is a ___ man with a history of hypertension,
diabetes, right-sided Bell's palsy, and recently diagnosed
neurogenic bladder with chronic Foley who presents with fevers,
fatigue, nausea, vomiting, lethargy found to have pseudomonal
UTI. He was given IV fluids and started on IV ceftriaxone until
urine culture grew pansensitive Pseudomonas at which point he
was switched to oral ciprofloxacin. He had his Foley exchanged.
He is discharged home on a 7-day course of oral Cipro Floxin.
TRANSITIONAL ISSUES:
====================
[] 7-day course of ciprofloxacin to end ___
[] Patient complained of a bubbling feeling in his stomach on
discharge. He also reported some mild diarrhea on discharge.
Recommend following this up at outpatient primary care
appointment to ensure resolution.
[] ___ was held this admission due to concern for infection
and sepsis. Recommend restarting as outpatient if necessary from
a hypertension standpoint.
[] Patient was offered MOLST this admission but did not complete
it. Recommend following up as an outpatient to see if he wants
to complete it.
ACTIVE ISSUES:
==============
#Pseudomonas urinary tract infection
Patient presented complaining of fevers, fatigue, nausea and
vomiting, and lethargy. He has a recent diagnosis of neurogenic
bladder and has an indwelling Foley at home. On admission his UA
indicated UTI and urine culture ultimately grew pansensitive
Pseudomonas. He was given IV fluids in the emergency department.
He was treated with IV ceftriaxone for 3 days with improvement
in symptoms, once cultures finalized he was switched to oral
ciprofloxacin for appropriate pseudomonal coverage. He had a
leukocytosis on admission which improved significantly with
antibiosis. He will continue this course for a total of 7 days,
the final day will be ___.
#Acute kidney injury
Likely due to combination of urinary tract infection and
hemodynamic insult. His creatinine improved with IV fluids.
#Nonspecific GI complaints
Patient complained of several days prior to admission of loose
stools. He also complained of a bubbling feeling in his stomach.
He was discharged with a prescription for bowel regimen to take
as needed and should have this issue followed up in primary care
clinic.
CHRONIC ISSUES:
===============
#HTN
Creatinine about at baseline. Held home losartan due to concern
for sepsis physiology. This should be restarted as an
outpatient.
#DM
Hold home glipizide in setting of infection which was restarted
on discharge.
#Hyperlipidemia
Continued simvastatin
# CODE: DNR/DNI (needs MOLST)
# CONTACT:
Name of health care proxy: ___
Relationship: wife
Phone number: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. GlipiZIDE 5 mg PO BID
2. Losartan Potassium 50 mg PO DAILY
3. Simvastatin 40 mg PO QPM
4. Vitamin D 1000 UNIT PO DAILY
5. Tamsulosin 0.4 mg PO QHS
Discharge Medications:
1. Ciprofloxacin HCl 250 mg PO Q24H Duration: 7 Days
RX *ciprofloxacin HCl 250 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*11 Tablet Refills:*0
2. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
RX *polyethylene glycol 3350 17 gram/dose 1 dose by mouth once a
day Refills:*0
3. Senna 8.6 mg PO BID:PRN Constipation - First Line
RX *sennosides 8.6 mg 1 ml by mouth twice a day Disp #*60 Tablet
Refills:*0
4. GlipiZIDE 5 mg PO BID
5. Simvastatin 40 mg PO QPM
6. Tamsulosin 0.4 mg PO QHS
7. Vitamin D 1000 UNIT PO DAILY
8. HELD- Losartan Potassium 50 mg PO DAILY This medication was
held. Do not restart Losartan Potassium until follow-up with PCP
___:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Pseudomonas urinary tract infection
Acute kidney injury on chronic kidney disease
Neurogenic bladder
SECONDARY DIAGNOSES:
Bell's palsy
Hypertension
Diabetes mellitus type 2
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 had fatigue,
abdominal pain, weakness, and fever.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
- In the hospital, you were found to have a urinary tract
infection. You were given IV fluids and started on IV
antibiotics and your Foley was replaced. Your symptoms improved
and you are discharged on a course of oral antibiotics.
-You had some abdominal pain that persisted on discharge. You
should speak with your primary care doctor about finding out why
you may be having this.
WHAT SHOULD I DO WHEN I GO HOME?
- Please take all of your medications exactly as prescribed and
attend all of your follow-up appointments listed below.
We wish you the ___!
Your ___ Care Team
Followup Instructions:
___
|
10099480-DS-11 | 10,099,480 | 26,044,496 | DS | 11 | 2175-07-11 00:00:00 | 2175-07-11 20:58:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
amiodarone / Prilosec
Attending: ___.
Major Surgical or Invasive Procedure:
___ RHC
attach
Pertinent Results:
ADMISSION LABS
=========================
___ 05:07PM cTropnT-0.27*
___ 05:07PM DIGOXIN-0.6
___ 05:07PM ___ PTT-30.4 ___
___ 04:36PM ___ PO2-33* PCO2-47* PH-7.44 TOTAL
CO2-33* BASE XS-6 COMMENTS-GREEN TOP
___ 04:36PM O2 SAT-54
___ 04:32PM GLUCOSE-302* UREA N-35* CREAT-1.5* SODIUM-139
POTASSIUM-4.0 CHLORIDE-96 TOTAL CO2-29 ANION GAP-14
___ 04:32PM estGFR-Using this
___ 04:32PM WBC-5.5 RBC-4.25* HGB-12.8* HCT-40.2 MCV-95
MCH-30.1 MCHC-31.8* RDW-13.2 RDWSD-45.0
___ 04:32PM NEUTS-58.7 ___ MONOS-9.5 EOS-1.1
BASOS-0.4 IM ___ AbsNeut-3.20 AbsLymp-1.64 AbsMono-0.52
AbsEos-0.06 AbsBaso-0.02
___ 04:32PM PLT COUNT-209
DISCHARGE LABS
=========================
___ 06:44AM BLOOD WBC-6.2 RBC-4.30* Hgb-13.0* Hct-41.2
MCV-96 MCH-30.2 MCHC-31.6* RDW-13.3 RDWSD-46.9* Plt ___
___ 06:25AM BLOOD Glucose-103* UreaN-31* Creat-1.3* Na-144
K-4.4 Cl-103 HCO3-28 AnGap-13
___ 06:25AM BLOOD Phos-3.3 Mg-2.2
IMAGING
=========================
___ CXR
FINDINGS:
___ catheter has been placed via a right internal jugular
venous
approach. The catheter projects tip projects 2.5 cm lateral to
the right
mediastinal border, probably in the basilar trunk of the right
lower lobe
pulmonary artery. Dual lead pacemaker/ICD device appears
unchanged. Trace pleural effusions are likely. There is no
pneumothorax. Moderate to severe pulmonary edema has
substantially worsened since the prior day.
IMPRESSION: ___ catheter likely terminating in the
basilar right lower lobe pulmonary artery.
___ TTE:
The inferior vena cava diameter is normal. The left ventricle
has a normal cavity size. There are
moderate to extensive areas of severe regional left ventricular
systolic dysfunction with near akinesis of
the distal ___ of the ventricle (see schematic) and mild
global hypokinesis of the remaining segments.
The visually estimated left ventricular ejection fraction is
<=30%. The right ventricle has depressed
free wall motion. There is no pericardial effusion.
IMPRESSION: Normal left ventricular cavity size with severe
systolic dysfunction. Right
ventricular free wall hypyokinesis. No pericardial effusion.
CXR ___
IMPRESSION: In comparison with the earlier study of this date,
there is little change in the appearance of the ___
catheter tip which again appears in the right pulmonary artery
at the mediastinal border.
The lungs are essentially clear and there is no vascular
congestion.
Brief Hospital Course:
BRIEF HOSPITAL COURSE
=====================
Mr. ___ is a ___ with CAD s/p PCI to proximal LAD ___, HTN,
HLD, DM2, paroxysmal atrial fibrillation on Xarelto, mild aortic
stenosis, and SSS s/p dual chamber pacemaker (___) with
recent admission for influenza found to have HFrEF, who now
presented with episodes of somnolence at home. He was found to
be in cardiogenic shock, underwent RHC with leave in ___ for
medication titration. He was diuresed with maximum 80mg IV Lasix
until euvolemic and then started on po Lasix 20 mg three times
per week for maintenance and started on Dofetilide to help
control his atrial fibrillation. Etiology of his decompensation
possibly in the setting of poorly controlled atrial
fibrillation, influenza virus infection, and inability to
tolerate ___ medical therapy instated during his
last hospital admission.
TRANSITIONAL ISSUES
===================
Discharge Weight: 168 lbs
Discharge Cr: 1.3
Discharge diuretic: Lasix 20mg three times weekly
(___)
[ ] Because he presented with hypotension, we stopped his home
losartan 25mg PO daily and imdur 30mg PO daily. We started
lisinopril 5mg daily for afterload reduction in the setting of
HFreF, which he tolerated well without hypotension.
[ ] We reduced his home metoprolol succinate from 37.5mg BID to
25mg PO BID
[ ] His statin was initially held due to transaminitis from
congestive hepatopathy. Although his LFTs have normalized, we
are holding his statin at discharge, since due to his age, he
may not benefit from taking a statin based on Beer's criteria.
[ ] He was started on dofetilide during this admission for
rhythm control in atrial fibrillation. He had daily ECGs to
monitor his QTc.
[ ] For diuresis, patient will be discharged on 20mg Lasix three
times weekly (___).
ACUTE ISSUES
============
# Acute HFrEF
He has a prior history of HFpEF and a recent admission for
influenza, at which point he was found to have new HFrEF which
was thought to be due to flu versus uncontrolled atrial
fibrillation. On arrival to ___ this admission, he was found
to be cool and somnolent which was concerning for cardiogenic
shock. A TTE was repeated on this admission, which showed an EF
30%, normal left ventricular cavity size with severe systolic
dysfunction, right ventricular free wall hypyokinesis, similar
study to prior on last recent admission this month. RHC was done
___ with leave in ___, with a CO 3.59 and cardiac index 1.79.
He was diuresed with a maximum 80mg IV Lasix, and re-started him
on lasix 20mg PO three times per week. We stopped his losartan
and imdur in the setting of his hypotension. We initially
managed afterload with captopril, but switched to 5mg lisinopril
daily. Metoprolol succinate was initially held due to RHC
indicating poor cardiac output, but was eventually restarted at
a lower dose of 25mg bid compared to his home dose of 37.5mg
bid. At discharge he was euvolemic and tolerating ___
medical therapy with a reduced dose of beta-blocker and
afterload reduction with lisinopril 5mg daily.
Pre-load: lasix 20mg three times weekly
(___)
Afterload: Lisinopril 5mg daily
NHBK: metoprolol succinate 25mg bid
# Atrial fibrillation
During the hospitalization, his heart rate would spike up to
130-150s resulting in lower blood pressure. He was already on
37.5mg metoprolol succinate bid, and 0.125mg digoxin daily at
home. He was loaded on dofetilide during this admission and his
heart rates have been well-controlled ___ with an atrial paced
rhythm. He had daily ECG to monitor his QTc. He will be
discharged on 125mcg bid of Dofetilide. He was continued on
rivaroxaban for anticoagulation and his metoprolol was decreased
to 25mg bid due to low cardiac output. He was continued on
0.125mg daily digoxin. His digoxin level was 0.5 on ___.
Rate: metoprolol succinate 25mg bid, digoxin 0.125mg daily
Rhythm: dofetilide 125mcg bid
Anticoagulation: Rivaroxaban 15mg PO daily
#Transaminitis:
He presented with transaminitis, with initial ALT and AST 160
and 72. Likely congestive hepatopathy, as his LFTs normalized
after diuresis.
CHRONIC ISSUES
==============
# CAD s/p PCI
Continued home Plavix, deferred restarting statin despite normal
LFTs given his age.
# Type 2 Diabetes
He has a longstanding history of diabetes most recent A1c 8.4 in
___. His diabetes is complicated by peripheral neuropathy
and autonomic instability which may be contributing to his
symptoms as above. He is followed closely by Dr. ___
endocrinology who has continued to help titrate his insulin
regimen as an outpatient. He was continued on his home insulin
regimen during this admission.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Clopidogrel 75 mg PO DAILY
2. Digoxin 0.125 mg PO DAILY
3. Metoprolol Succinate XL 37.5 mg PO BID
4. Rivaroxaban 15 mg PO DAILY
5. Losartan Potassium 25 mg PO DAILY
6. Multivitamins W/minerals 1 TAB PO DAILY
7. Atorvastatin 40 mg PO QPM
8. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
9. Furosemide 20 mg PO DAILY
10. Glargine 10 Units Bedtime
Humalog 2 Units Breakfast
Humalog 2 Units Lunch
Humalog 2 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Dofetilide 125 mcg PO Q12H
2. Lisinopril 5 mg PO DAILY
3. Furosemide 20 mg PO 3X/WEEK (___)
4. Glargine 10 Units Bedtime
Humalog 4 Units Breakfast
Humalog 4 Units Lunch
Humalog 4 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
5. Metoprolol Succinate XL 25 mg PO BID
6. Rivaroxaban 15 mg PO DINNER
7. Clopidogrel 75 mg PO DAILY
8. Digoxin 0.125 mg PO DAILY
9. Multivitamins W/minerals 1 TAB PO DAILY
Spirinolactone was not prescribed due to labile renal function.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
ACUTE HEART FAILURE WITH REDUCED EJECTION FRACTION COMPLICATED
BY CARDIOGENIC SHOCK
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 our pleasure to care for you at ___. You came to the
hospital because you were feeling very fatigued at home.
WHAT HAPPENED?
- We found that your heart still was not pumping well.
- We did a procedure called a right heart catheterization and
placed a Swan-Ganz catheter to measure the pressures in your
heart.
- We adjusted your medications and started a new medicine called
Dofetilide for atrial fibrillation.
WHAT SHOULD YOU DO AT HOME?
- Please weigh yourself every morning and call the cardiologist
if your weight goes up more than 3 lbs in one day.
- Your discharge weight is 168 lb.
- Please take the medications listed below and follow up with
the appointments listed below.
We wish you the best!
Sincerely,
Your care team at ___
Followup Instructions:
___
|
10099592-DS-16 | 10,099,592 | 26,871,521 | DS | 16 | 2137-08-04 00:00:00 | 2137-08-07 09:38:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
nausea/ admitted for acute renal failure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo female with h/o DM, rheumatoid arthritis, HTN, ___ body
dementia and GI bleed in ___, recently discharged within past
week for GI bleed, who presents with vomiting x1 this AM, mild
abdominal pain and blood in urine x1 today. History is
difficult to elicit from patient, and message was left with son
who lives with her. Patient does report some diffuse abdominal
pain, not localizable, and not sharp. She reports the pain as
similar to her pain when she was admitted for a likely
diverticular bleed over a week ago. The pain started after
eating fried chicken yesterday. Patient states that moving
makes the pain worse, and she has not taken anything to make it
better. She also endorses feeling unwell and not having a bowel
movement for the pat 2 days (normal for her is 2x day) and
sitting in her bed, moving around somewhat, over the weekend.
In the ED, initial vs were: ___ 52 199/86 16 100% RA.
Patient was given 1L IV fluids and zofran x1. She was found to
have an elevated creatinine of 1.7 on laboratory analysis.
Vitals on transfer were: 98.1, 141/71, 60, 16, 100%RA
On the floor, patient continues to feel nauseaus, although is
asking to eat dinner. She is somewhat forgetful, although is
able to recall her children's phone numbers. Patient states
that she is able to get out of a chair without difficulty,
although has some subjective weakness.
Review of sytems:
(+) Per HPI including subjective fever, chills, night sweats,
recent weight gain. Endorses headache, sinus tenderness,
rhinorrhea, cough, chest pain from the cough, nausea, vomiting,
blood in her urine,
(-) for shortness of breath. Denied chest tightness/
palpitations. Denied diarrhea. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.
Past Medical History:
- past GI bleed in ___ and again ___- attributed to
diverticular bleed vs internal hemorrhoids
- Diabetes Type II
- Rheumatoid Arthritis - h/o signficant NSAID use in past
- Hypertension
- Hyperlipidemia
- ___ Body Dementia
- Internal hemorrhoids
- Hysterectomy
- Right knee arthroscopy
- Right breast lumpectomy
Social History:
___
Family History:
Non-contributory
Physical Exam:
Admission:
Vitals: T:98.2 BP:155/82 P:91 O2: 99%, ___ 114
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally with trace crackles at
the bases, no wheezes, ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, tender in periulbilical area, 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:
Vitals: 97.5-98.3, 112-139/62-79, 49-61, 99-100%
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, ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, tender in periulbilical area, 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
Pertinent Results:
___ 09:40AM BLOOD WBC-10.1 RBC-3.26* Hgb-9.7* Hct-29.6*
MCV-91 MCH-29.8 MCHC-32.9 RDW-15.2 Plt ___
___ 07:20AM BLOOD WBC-8.8 RBC-2.87* Hgb-8.7* Hct-26.4*
MCV-92 MCH-30.4 MCHC-33.1 RDW-15.8* Plt ___
___ 07:10AM BLOOD WBC-9.8 RBC-2.77* Hgb-8.5* Hct-26.3*
MCV-95 MCH-30.8 MCHC-32.5 RDW-15.8* Plt ___
___ 07:45AM BLOOD WBC-6.6 RBC-2.39* Hgb-7.8* Hct-22.7*
MCV-95 MCH-32.7* MCHC-34.4 RDW-15.3 Plt ___
___ 01:20PM BLOOD WBC-7.3 RBC-2.66* Hgb-8.6* Hct-25.4*
MCV-95 MCH-32.3* MCHC-33.9 RDW-15.3 Plt ___
___ 04:10PM BLOOD WBC-6.8 RBC-2.52* Hgb-7.6* Hct-23.9*
MCV-95 MCH-30.3 MCHC-32.0 RDW-15.4 Plt ___
___ 07:05AM BLOOD WBC-7.7 RBC-2.52* Hgb-7.9* Hct-24.1*
MCV-96 MCH-31.4 MCHC-32.8 RDW-15.9* Plt ___
___ 01:45PM BLOOD Hct-25.0*
___ 09:40AM BLOOD Neuts-49* Bands-4 ___ Monos-14*
Eos-3 Baso-1 ___ Myelos-0 NRBC-1*
___ 07:20AM BLOOD Neuts-59.2 ___ Monos-7.1 Eos-2.1
Baso-0.8
___ 07:20AM BLOOD Hypochr-3+ Anisocy-2+ Poiklo-1+
Macrocy-1+ Microcy-NORMAL Polychr-1+ Spheroc-OCCASIONAL
Ovalocy-OCCASIONAL Burr-OCCASIONAL
___ 01:45PM BLOOD CD55-DONE CD59-DONE
___ 04:10PM BLOOD Ret Aut-3.3*
___ 01:45PM BLOOD IPT-DONE
___ 09:40AM BLOOD Glucose-120* UreaN-25* Creat-1.7* Na-143
K-3.7 Cl-106 HCO3-26 AnGap-15
___ 07:15PM BLOOD Glucose-123* UreaN-23* Creat-1.5* Na-144
K-3.3 Cl-109* HCO3-25 AnGap-13
___ 07:20AM BLOOD Glucose-162* UreaN-20 Creat-1.6* Na-140
K-3.4 Cl-106 HCO3-23 AnGap-14
___ 07:10AM BLOOD Glucose-100 UreaN-16 Creat-1.7* Na-141
K-3.6 Cl-108 HCO3-24 AnGap-13
___ 07:45AM BLOOD Glucose-100 UreaN-19 Creat-1.9* Na-143
K-3.5 Cl-110* HCO3-25 AnGap-12
___ 04:10PM BLOOD Glucose-81 UreaN-19 Creat-1.8* Na-141
K-3.5 Cl-109* HCO3-25 AnGap-11
___:05AM BLOOD Glucose-100 UreaN-18 Creat-1.7* Na-141
K-3.7 Cl-110* HCO3-23 AnGap-12
___ 09:40AM BLOOD ALT-12 AST-42* CK(CPK)-302* AlkPhos-66
TotBili-1.4
___ 07:15PM BLOOD ALT-14 AST-41* CK(CPK)-277* AlkPhos-58
TotBili-1.2
___ 07:20AM BLOOD ALT-12 AST-48* CK(CPK)-306*
___ 04:15PM BLOOD LD(LDH)-1150*
___ 07:10AM BLOOD LD(___)-1541* TotBili-0.9 DirBili-0.2
IndBili-0.7
___ 09:40AM BLOOD cTropnT-0.01
___ 07:15PM BLOOD CK-MB-2 cTropnT-<0.01
___ 07:20AM BLOOD cTropnT-0.02*
___ 07:20AM BLOOD Calcium-8.4 Phos-2.6* Mg-1.7
___ 07:10AM BLOOD Calcium-8.6 Phos-2.8 Mg-2.3
___ 07:05AM BLOOD Calcium-8.5 Phos-2.6* Mg-2.2
___ 04:15PM BLOOD VitB12-627 Folate-17.9 Hapto-<5*
___ 04:15PM BLOOD Homocys-12.3
___ 07:45AM BLOOD ERYTHROPOIETIN-PND
___ 07:45AM BLOOD METHYLMALONIC ACID-PND
___ 11:35AM URINE Color-RED Appear-Hazy Sp ___
___ 11:35AM URINE Blood-LG Nitrite-NEG Protein-100
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM
___ 11:35AM URINE RBC-0 WBC-2 Bacteri-FEW Yeast-NONE Epi-3
___ 11:35AM URINE CastHy-2*
___ 07:46AM URINE Color-Red Appear-Hazy Sp ___
___ 07:46AM URINE Blood-LG Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-SM
___ 07:46AM URINE RBC-2 WBC-25* Bacteri-FEW Yeast-NONE
Epi-3
___ 11:21AM URINE Color-Yellow Appear-Hazy Sp ___
___ 11:21AM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-4* pH-6.5 Leuks-TR
___ 11:21AM URINE RBC-1 WBC-11* Bacteri-FEW Yeast-NONE
Epi-3 TransE-<1
___ 11:21AM URINE Hemosid-NEGATIVE
___ 08:28PM URINE Hours-RANDOM Creat-69 Na-168 K-22 Cl-165
___ 08:28PM URINE Osmolal-570
___ 11:35 am URINE Site: CLEAN CATCH
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ 7:20 am BLOOD CULTURE
Blood Culture, Routine (Pending):
ECG Study Date of ___ 5:51:58 ___
Sinus bradycardia. Left ventricular hypertrophy. Q-T interval
prolongation. Compared to the previous tracing of ___ no
diagnostic interim change.
CT ABD & PELVIS W/O CONTRAST Study Date of ___ 12:13 ___
FINDINGS: LUNG BASES: There is a small nodule in the right
middle lobe on
series 2 image 1 measuring approximately 5 mm stable from ___
CT. An area of subsegmental atelectasis is seen in the inferior
lingula.
ABDOMEN: Non-contrast evaluation does limit evaluation of solid
organs.
Multiple hepatic and splenic calcified granulomas are noted.
Multiple
calcified stones are seen layering within the gallbladder lumen.
There is no evidence of choledocholithiasis. Adrenal glands are
normal bilaterally. The pancreas and kidneys appear normal. No
hydronephrosis. Tiny calcific
densities in the renal hilum bilaterally likely reflect vascular
calcification. Abdominal aorta is normal in course and caliber
with faint
minimal atherosclerotic calcification. No retroperitoneal
lymphadenopathy.
The stomach is decompressed. Duodenum appears normal.
PELVIS: Loops of small bowel demonstrate no signs of ileus or
obstruction. No appendix is visualized. The colon is notable
for diverticulosis but no signs of diverticulitis. No free
pelvic fluid. Uterus appears surgically absent. No adnexal
masses. Urinary bladder is minimally distended. No free pelvic
fluid.
BONES: Unremarkable.
IMPRESSION:
1. Gallstones without definite signs of cholecystitis.
2. No hydronephrosis or kidney stone.
3. 5-mm nodule in the right middle lobe stable from ___
requiring no further workup.
4. Diverticulosis without diverticulitis.
Brief Hospital Course:
___ yo female with h/o DM, rheumatoid arthritis, HTN, ___ body
dementia and GI bleed in ___, recently discharged within past
week for GI bleed, who presents with vomiting x1 this AM, mild
abdominal pain and blood in urine x1 today.
#Hemolytic anemia based on falling crit, Haptoglobin <5 and LDH
>1000. No schistocytes on smear. Likely secondary to delayed
reaction to transfusion. Also possible but less likely is PNH,
autoimmune hemolytic anemia. This is in the context of a
history of gastrointestinal bleeding: (Patient admitted earlier
this month for likely diverticular bleed. Endoscopy and
colonoscopy without clear source of bleed, presumed diverticular
bleed which resolved. Capsule endoscopy negative for bleeding.
Patient got O+ blood ___ and ___. With respect to the GI
bleed, we continued home omeprazole 20mg qd. With respect to
the hemolytic anemia: Coombs test negative, repeated negative by
blood bank with elute. B12 and Folate within normal limits,
methylmalonic and epo pending.
-Patient to follow up with the hematology team as an outpatient.
#Initial Abdominal Pain: Likely secondary to viral etiology.
Resolved with keeping patient NPO and time. Patient initially
presented with an isolated rise in AST with large blood in urine
and no RBCs and elevated CK now with ARF. We initially were
concerned for statin induced myositis (although patient with
normal CK). Also possible is ulcer/ gastritis (recent EGD was
unremarkable). CT scan ruled out SBO, acute cholecystitis,
other catastrophic intraabdominal process. Troponins negative
x2, 0.02 on third set. Patient with 2 bowel movements ___ and
resolution of abdominal pain. Her main symptom was spitting up
clear sputum, which also resolved with time. Patient was
evaluated with speech and swallow who deemed no difficulty
swallowing. We continued to hold simvastatin 20mg daily (not
for concern not of active myositis, but for concern of
potentially tipping over renal function given hemolysis above if
any myoglobinuria induced). At discharge, patient was able to
eat PO without difficulty.
#Acute Renal failure: Likely secondary to hemoglobinuria/
hemoglobin intrinsically damaging kidneys. Creatinine baseline
approximately 1.2-1.4 for the past ___ years. FeNa 2.54
inconsistent with prerenal disorder. We continued to hold
losartan and HCTZ and gave small NS boluses with improving trend
of creatinine.
#Hypertension: Patient initially presented with elevated SBP to
199. To avoid renal damage, we chose labetalol 100mg BID which
was frequently held due to bradycardia. At discharge, we held
hydrochlorothiazide 25 mg daily and losartan 50 mg daily which
can be restarted pending resolution of renal function
#Diabetes Mellitus type 2, A1C 6.8 from ___. Controlled,
without complications:
had previously taken metformin, however not on any meds
currently. Was on ISS while in house.
#Dementia, ___ body: still living in her own apartment,
independent with some ADLs. Continued donepezil and sertraline
25 mg daily
#Glaucoma: we continued timolol maleate 0.5 % Drops Sig: One (1)
Drop Ophthalmic BID
(2 times a day).
#Allergic rhinitis: Not active we held fluticasone 50
mcg/Actuation Spray, Suspension Sig: Two (2) Spray Nasal DAILY
(Daily)
#Transitional:
-We held simvastatin at discharge not for concern for active
rhabdo/myositis but rather for concern of the possibility of it
happening and the little reserve the patient has given her
active hemoglobin sediment in her urine. This can be restarted
at follow up along with HCTZ and losartan pending renal
function.
-Follow up with hematology team for consideration of PNH causing
hemolytic anemia. MMA and epo pending at time of discharge.
Medications on Admission:
1. donepezil 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. timolol maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic BID
(2 times a day).
3. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. sertraline 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
5. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily). (Not taking)
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
7. hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
8. losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Medications:
1. donepezil 10 mg Tablet Sig: One (1) Tablet PO once a day.
2. timolol maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic BID
(2 times a day).
3. sertraline 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
sprays Nasal once a day.
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Delayed transfusion reaction/ hemolytic anemia, viral
gastroenteritis, ___ Body dementia,
Secondary: History of GI bleeds, Rheumatoid Arthritis,
Hypertension, Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was our pleasure to care for you at ___. You were admitted
for abdominal pain. We found on examination and by scanning
that you likely had a viral infection which was causing you
abdominal pain and to spit up sputum. We also found that you
were popping your blood cells in your vessles likely due to an
antibody in blood, which we were able to manage conservatively.
We made the following changes to your medications:
Please STOP simvastatin until told to start it by your PCP
___ STOP losartan
Please STOP hydrochlorothiazide
Followup Instructions:
___
|
10099592-DS-18 | 10,099,592 | 21,483,421 | DS | 18 | 2138-02-06 00:00:00 | 2138-02-06 11:57:00 |
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 hip pain and lower back pain ___ fall.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mrs. ___ is an ___ year-old female who presents with left hip
pain and lower back pain after sustaining a suspected mechanical
fall. She was in her bathroom when she fell. She was unable to
get up, and pressed her lifeline
button. EMS had to break the door to get to her. She could not
get up, and complained of left hip and lower back pain, but had
no other complaints. Upon arrival to the ED she was triggered
for bradycardia. She is unsure of how she fell, but she denies
any headstrike loss of consciousness, neurological deficits,
chest pain, shortness of breath, headache, or any other pain or
symptoms. She fell in ___, and was admitted to ___
with a non-displaced fracture of the left medial superior pubic
ramus. She was
discharged to a rehab facility at the end ___ with physical
therapy.
Past Medical History:
Anemia- Patient developed hemolytic anemia following a
hospitalization for a GI bleed and 2unit PRBC transfusion in ___. Workup was negative for delayed transfusion reaction; ddx
included PNH. Hemolysis labs were sent which revealed
haptoglobin less than 5 and elevated LDH 1541. DAT was
negative. Antibody screen negative. Anemia subsequently
resolved; hematology consult did not see anything notable on
peripheral smear.
DM- Per patient is on oral hypoglycemics, name unknown
GI ___ hemorrhoids in ___, and possible diverticular
bleed (vs hemorrhoids) in ___ that required a 2u PRBC
transfusion.
Glaucoma- On Timolol eye gtt
Hyperlipidemia- Was on statins, d/c'd a few months ago when
patient had acute kidney injury, unsure if patient is taking
them
Hypertension- unsure of what meds patient is on, has been on
Losartan and HCTZ that were held in the past secondary to renal
injury.
___ Body Disease- Moderate dementia, able to perform most ADLs.
Orthopedic Issues- She has had a history of numerous orthopedic
problems, including trochanteric bursitis, bilateral shoulder
pain, knee pain, elbow epicondylitis, plantar fasciitis, and
right gluteal pain. She has recently had continued right upper
arm pain and right gluteal pain. She has attended P.T.
for the gluteal pain.
Sleep Apnea- non-adherent with CPAP per PCP documentation
___ R TKR ___, ___ TAH
Social History:
___
Family History:
Non-contributory
Physical Exam:
On admission:
Temp: 97,4 HR: 44 BP: 146/114 Resp: 22 O(2)Sat: 100 Normal
Constitutional: No acute distress.
HEENT: Cataracts bilaterally. , Normocephalic, atraumatic
Oropharynx within normal limits. C-spine nontender.
Chest: Right upper chest wall tenderness.
Cardiovascular: Bradycardic, sinus rhythm.
Abdominal: Soft, diffuse tenderness
GU/Flank: Left hip tenderness.
Extr/Back: No cyanosis, clubbing or edema.; diffuse back
midline tenderness
Skin: Warm and dry
Neuro: Speech fluent. Moves all extremities.
Psych: Normal mentation
On discharge:
Vitals: Temp 98.7 po, HR 53, SBP 151/85, RR 18, sat 99% on room
air.
Neuro: AAO x 3. NAD.
Card: S1, S2. RRR. No m/r/g.
Pulm: Clear bilaterally full lung fields (anteriorly).
GI: Active BS. Soft, tender to palpation.
GU: Foley catheter draining clear yellow urine.
Extrem: Warm, well perfused. Pulses 2+ throughout.
Pertinent Results:
___ 07:55PM BLOOD WBC-7.8 RBC-3.72* Hgb-11.6* Hct-35.5*
MCV-96 MCH-31.3 MCHC-32.7 RDW-15.2 Plt ___
___ 07:55PM BLOOD Neuts-56.4 ___ Monos-5.9 Eos-2.2
Baso-0.6
___ 07:55PM BLOOD ___ PTT-28.3 ___
___ 07:55PM BLOOD Plt ___
___ 07:55PM BLOOD Glucose-136* UreaN-25* Creat-1.7* Na-139
K-5.1 Cl-101 HCO3-27 AnGap-16
___ 07:55PM BLOOD CK(CPK)-183
___ 07:55PM BLOOD cTropnT-<0.01
___ 06:25AM BLOOD Calcium-9.2 Phos-3.4 Mg-2.0
___ 06:40AM BLOOD WBC-6.9 RBC-3.63* Hgb-11.2* Hct-34.8*
MCV-96 MCH-30.9 MCHC-32.2 RDW-15.0 Plt ___
___ 06:40AM BLOOD Plt ___
___ 06:40AM BLOOD Glucose-116* UreaN-14 Creat-1.3* Na-138
K-3.6 Cl-99 HCO3-28 AnGap-15
___ 06:40AM BLOOD Calcium-9.1 Phos-3.5 Mg-1.9
Imaging:
___ CT chest, abdomen and pelvis with contrast
1. Minimally displaced fracture of the anterosuperior endplate
of the T11 vertebral body. This involves only the anterior
column. Additionally, there are minimally displaced fractures
of the left twelfth rib, nondisplaced fracture of the left
eleventh rib and left transverse processes at L1, L2, and L3.
2. Remote left inferior pubic ramus fracture with signs of
interval healing.
___ ECG
Sinus bradycardia. Leftward axis. Non-diagnostic Q waves in high
lateral
leads. Delayed R wave transition. Diffuse non-specific ST
segment changes. Left ventricular hypertrophy. Compared to the
previous tracing of ___ the Q-T interval has normalized and
baseline artifact is no longer appreciated.
___ Carotid series
PENDING
Brief Hospital Course:
Mrs. ___ was admitted to ___
on ___ after falling while using her ___. Patient
states she was using her ___ to go to the bathroom when she
suddenly fell. She doesn't remember the incident and woke up
already on the ground. At that time, she had left-sided pain.
She denied lightheadedness or dizziness. She then used life-line
to call for help and was brought by ambulance. In the ED, she
was triggered for bradycardia w/ HR of 44.
Mrs. ___ injuries include a new minimally displaced
fracture of left 12 rib and non-displaced fracture left 11 rib
and a posterior left flank subcutaneous hematoma and contusion.
She suffered no other intracranial or intrabdominal trauma. She
was transferred to the inpatient floor under the ACS service for
further management and observation.
As there was some concern for potential syncope, the patient was
ordered for an ECG, carotid ultrasound and echocardiogram. The
ECG showed bradycardia in the ___ with non-specific t-wave
changes. There was no acute change from prior exam. At the
time of discharge, the patient's carotid exam was pending. The
echocardigram was not completed prior to discharge. An
echocardiogram was completed immediately prior to her discharge.
The patient's acute pain was treated with intermittent boluses
of fentanyl, but was soon started on oral non-narcotic
analgesics (tramadol, acetaminophen). As she was having a fair
amount of pain on exam, a prescription for PRN oxycodone was
provided at time of discharge. She was resumed on her home
medication regimen. Physical therapy was consulted as well.
Their recommendations were that the patient be discharged to an
acute care rehabiliation center due to poor conditioning and her
significant history of falls.
At the time of discharge, Mrs. ___ was hemodynamically stable
and afebrile. Discharge instructions were provided by myself
and the bedside RN. A follow up appointment has been made with
the ACS service. We have recommended that the patient follow up
with her PCP regarding her bradycardia. The patient is awaiting
transport to the skilled nursing facility.
Medications on Admission:
Donepezil 10', cozaar 50', alendronate 35qweek, HCTZ 25',
sertraline 25', simvastatin 20', timolol maleate 0.5% eye drops,
tramadol 50'''' prn.
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Docusate Sodium 100 mg PO BID
3. Donepezil 10 mg PO HS
4. Hydrochlorothiazide 25 mg PO DAILY
Hold for SBP<110
5. Losartan Potassium 50 mg PO DAILY
Hold for SBP<110
6. Senna 1 TAB PO BID:PRN constipation
7. Sertraline 25 mg PO DAILY
8. Simvastatin 20 mg PO DAILY
9. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
10. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
11. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*25 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Rib fractures, left flank hematoma, vertebral body fracture.
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid ___
or cane).
Discharge Instructions:
You were admitted to ___ on
___ after you fell using your ___. You sustained rib
fractures which can cause severe pain and subsequently cause you
to take shallow breaths because of the pain.
You also sustained a blood clot formation in your left side as
well as a fracture of one of you vertebrae (back bones). For
both of those conditions, there was no surgical or medical
intervention required.
We have made an appointment for you to follow up with the
ACS/Trauma doctors regarding your ___ fractures. We recommend
that you also follow up with your PCP because of your low heart
rate (bradycardia). Because you may have lost consciousness due
to "passing out", we ordered an ECG, cartoid duplex ultrasound
and an echocardiogram. Your ECG was stable from prior and the
test results of your carotid ultrasound were pending at the time
of discharge. Please follow up with your PCP to have an
echocardiogram completed.
Further Directions:
You should take your pain medicine as 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.
Do NOT smoke.
Return to the ED right away for any acute shortness of breath,
increased pain or crackling sensation around your rips
(crepitus).
Followup Instructions:
___
|
10099652-DS-11 | 10,099,652 | 28,009,527 | DS | 11 | 2184-11-10 00:00:00 | 2184-11-25 19:12:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
morphine / codeine / Demerol / Vicodin
Attending: ___.
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
___ Cariac Catheterization
___ EP Study + PPM placement
History of Present Illness:
Ms, ___ is a ___ year old F with PMH of osteoarthritis, renal
cell carcinoma, and GERD who presents with complaint of two
weeks of slowly progressive dyspnea on exertion. It has now
progressed to the point where she is unable to walk up ramp at
DMV without significant dyspnea. She also reports a single event
last evening of mid-chest tightness which was non-exertional and
lasted ___ minutes before resolving spontaneously. She denies
fever/chills, cough, weight gain, edema, SOB at rest, nausea,
diaphoresis, orthopnea, or PND.
Of note, per PCP records pt has been under a lot of stress
recently and has been gaining weight. Pt husband bought her some
diet pills(white kidney bean extract) which she reported then
resulted in an infection in her tooth and arthritis in her
ankle. She saw the dentist placed her on Amoxicilioin for a
tooth infection on ___. About two weeks ago, she started noting
progressive dysopnea with relatively mild exertion, e.g. walking
up the ramp into the DMV.
In the ED intial vitals were: 98.3 90 171/89 20 98%
Exam was notable for: trace bibasilar crackles, irregular S1 and
S2. LEs with 1+ edema to ankles
Labs were notable for: proBNP: 428, Trop-T: <0.01, normal CBC,
chem-7, D-Dimer: 754, negative UA.
ECG: SR, LBBB (old), multifocal PVCs with occ bigeminy, Mobitz
II
CXR showed: Opacities at the left lung base, probably compatible
with atelectasis.
She had a Bedside echo which showed: trace effusion, LVEF ~50%,
c/f basilar septal hypokinesis (RCA), LV dilatation, no RV
dilatation.
She had a CTA chest which was negative for PE.
Patient was given: Aspirin and 10mg IV hydralazine
Pt was seen by cardiology in the ED who recommended admission
for for w/u, and nuclear stress on ___.
Vitals on transfer: 92 170/82 18 96% RA
On the floor patient reports that she feels fine. She does not
have dyspnea at rest. She denies orthopnea or PND. No chest pain
at this time. She reports that she has been under a lot of
stress lately.
ROS: On review of systems, s/he denies any prior history of
stroke, TIA, deep venous thrombosis, pulmonary embolism,
bleeding at the time of surgery, myalgias, joint pains, cough,
hemoptysis, black stools or red stools. S/he denies recent
fevers, chills or rigors. S/he denies exertional buttock or calf
pain. All of the other review of systems were negative.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
s/p left partial nephrectomy around ___ ___s for renal cell
carcinoma (found via microscopic hematuria)
Bilateral knee replacements at NEBaptist ___
LLE varicose vein surgeries yrs ago at ___ Osteoarthritis, knees
and ankles
GERD
Urinary incontinence
S/P hysterectomy age ___ - ?endometrial cancer
Diverticulosis
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death. mother lived to ___, had ___
dz(chronic skin condition)
sister has ___ son has "calcium deposits near/around his
heart"
Physical Exam:
ADMISSION
VS: T=97.7 BP=113/74 HR=68 RR=18 O2 sat=98%RA
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 without elevated JVP.
CARDIAC: RRR, normal S1, S2. No m/r/g. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: trace pedal edema. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: 2+ radial and DP
LABS: Reviewed see below
DISCHARGE
VS: 98.2 101-160/56-70 ___ 18 95%RA
GENERAL: WDWN female in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. Conjunctiva were pink, no pallor
or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple, elevated JVP 1 cm above clavicle +hepatojugular
reflex
CARDIAC: RRR, normal S1, S2. No m/r/g. No S3 or S4.
LUNGS: CTAB, no crackles, wheezes or rhonchi.
EXTREMITIES: 1+ non-pitting edema b/l.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: 2+ radial and DP
Pertinent Results:
ADMISSION
___ 04:19PM BLOOD D-Dimer-754*
___ 04:19PM BLOOD WBC-8.5 RBC-4.46 Hgb-14.4 Hct-42.9 MCV-96
MCH-32.4* MCHC-33.7 RDW-13.7 Plt ___
___ 04:19PM BLOOD Neuts-55.8 ___ Monos-4.0 Eos-2.0
Baso-0.9
___ 04:19PM BLOOD Plt ___
___ 04:19PM BLOOD Glucose-95 UreaN-18 Creat-0.9 Na-143
K-3.5 Cl-103 HCO3-29 AnGap-15
___ 04:19PM BLOOD cTropnT-<0.01 proBNP-428
___ 11:53PM BLOOD cTropnT-<0.01
___ 06:15AM BLOOD CK-MB-3 cTropnT-<0.01
DISCHARGE
___ 06:45PM BLOOD cTropnT-<0.01
___ 06:15AM BLOOD Calcium-9.4 Phos-4.8* Mg-2.1
___ 06:15AM BLOOD Calcium-9.3 Phos-3.7 Mg-2.1
___ 06:15AM BLOOD WBC-6.5 RBC-4.22 Hgb-13.7 Hct-40.4 MCV-96
MCH-32.6* MCHC-34.1 RDW-13.6 Plt ___
___ 06:15AM BLOOD Plt ___
___ 06:15AM BLOOD ___
___ 06:15AM BLOOD Glucose-99 UreaN-26* Creat-0.9 Na-143
K-4.6 Cl-106 HCO3-28 AnGap-14
MICROBIOLOGY
___ 04:19PM URINE Color-Straw Appear-Clear Sp ___
___ 04:19PM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 04:19PM URINE RBC-1 WBC-2 Bacteri-FEW Yeast-NONE Epi-<1
___:19PM URINE Mucous-RARE
ECG
___
Sinus rhythm with a blocked atrial premature beat. Left
bundle-branch
block. No previous tracing available for comparison.
___
Sinus bradycardia. Prolonged Q-T interval. Anterior ST-T wave
changes raise concern for ischemia. Clinical correlation is
suggested.
STUDIES:
___
CXR IMPRESSION:
Opacities at the left lung base, probably compatible with
atelectasis.
Infectious process is not excluded, however.
CTA IMPRESSION:
1. No evidence of pulmonary embolism.
2. Mild mosaic attenuation pattern, most often due to air
trapping associated
with small airways disease, versus slight vascular congestion.
3. Patchy peripheral opacities in the right upper lobe,
possibly atelectasis;
pneumonia hard to exclude but seems less likely. Although less
common,
organizing and eosinophilic forms of pneumonitis can also
present as
peripheral opacities; focal edema could also be considered.
4. Small perifissural nodule measuring 3-4 mm and mildly
enlarged lymph node,
probably reactive. However, follow-up surveillance of the
findings is
suggested in six months with chest CT.
5. Mild dilatation of the right pulmonary artery.
___
ECHO IMPRESSION:
Mild-moderate regional systolic dysfunction (LAD territory) in
association with LBBB-related dyssynchrony. Mild-moderate mitral
regurgitation. Mild pulmonary artery systolic hypertension.
___
Cath Report:
Coronary angiography: Co-dominant (right >left).
LMCA (JL4 selective in the CX): The LMCA had minimal luminal
irregularities.
LAD: The LAD had mild plaquing and gave off a large ___
septal.
The remainder of the LAD proper had few septal branches. There
was mild plaquing to 30% in the mid LAD after S1. There was a
very long but high D1. S2 had mild origin disease. Flow into the
LAD was slow, partly due to selective engagement in the LCX, but
also likely from some intramyocardial dysfunction.
LCX: There was a mild ostial LCX lesion. (~20%). The LCX had
minimal luminal irregularities and supplied a modest caliber
OM1,
a small OM2, large tortuous LPL1-LP3 branches, a small LPL4,
along with a short small LPDA. The flow in the CX was slow,
consistent with microvascular dysfunction.
RCA: The RCA had diffuse disease throughout to 40%
proximal-mid
vessel. The modest caliber RPDA had mild origin and moderate
(~50-60%) disease mid RPDA. Flow in the RCA was slow, consistent
with microvascular dysfunction.
Assessment & Recommendations
1. Moderate single vessel angiographically-apparent obstructive
CAD, but diffuse atherosclerosis and evidence of disuse
microvascular dysfunction .
2. Systemic systolic arterial hypertension.
3. Mild left ventricular diastolic heart failure.
4. No tight LAD lesions seen. ? LVSD related to dys-synchrony.
5. Reiforce primary preventative measures against CAD and
secondary preventatitve mreasures against LVSD and HTN.
6. Additional plans per the ___ and EP Services
7. Routine post-TR Band care.
___
EP STUDY + ___ Placement
(SEE EP NOTE DATED ___ for full details)
___
CXR IMPRESSION:
As compared to the previous radiograph, the patient has received
a left
pectoral pacemaker. The course of the pacemaker leads is
unremarkable, 1 lead
projects over the right atrium and 1 over the right ventricle.
There is no
pneumothorax. No pleural effusions. No pulmonary edema. The
known left
basal atelectasis is completely unchanged.
Brief Hospital Course:
___ year old F with PMH of osteoarthritis, renal cell carcinoma,
GERD, no previously known cardiac disease presented with
complaint of ___ days of slowly progressive dyspnea on exertion
with VSS. She had negative troponin x1 and relatively low BNP.
CXR did not show PNA or pleural effusion. She had negative CTA
chest which ruled out PE. She was incidentally found to have new
Mobitz II on one EKG although not present on repeat ECG. ECHO
once admitted showed EF 40-45% with regional hypokinesis of the
LV. Given the territorial nature of her dysfunction, suspected
ischemic source due to possible silent MI. Underwent
catheterization which showed mild-moderate occlusions but no
intervenable lesions, as well as, LV diastolic dysfunction.
Patient recovered well from procedure. While waiting for EP
study, interval EKG showed reversal of LBBB with T wave memory.
Patient underwent EP study which showed poor conduction below
below AV node (final and patient recieved ___ DUAL CHAMBER
PACEMAKER. Patient recovered well, follow-up X-ray confirmed
correct placement of leads, and patient was discharged to
follow-up with PCP and Dr. ___.
TRANSITIONAL ISSUES
-INCIDENTALLY FOUND ON CTA: "Small perifissural nodule measuring
3-4 mm and mildly enlarged lymph node, probably reactive.
However, follow-up surveillance of the findings is suggested in
six months with chest CT."
-Lyme serologies still pending, unlikely to be positive but
should be follow-up up by outpatient provider given potentially
reversibly cause of heart block
-Patient will follow-up for a Device Check in one week
-Started on multiple new medications, new regimen given to
patient and in discharge summary
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Celebrex ___ mg oral daily
2. Omeprazole 20 mg PO BID
3. Fish Oil (Omega 3) 1000 mg PO DAILY
4. Vitamin D 1000 UNIT PO DAILY
5. Vitamin E 400 UNIT PO DAILY
6. Vesicare (solifenacin) 10 mg oral Daily
Discharge Medications:
1. Fish Oil (Omega 3) 1000 mg PO DAILY
2. Omeprazole 20 mg PO BID
3. Vitamin D 1000 UNIT PO DAILY
4. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
5. Atorvastatin 40 mg PO DAILY
RX *atorvastatin 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
6. Lisinopril 10 mg PO DAILY
RX *lisinopril 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
7. Metoprolol Succinate XL 12.5 mg PO DAILY
RX *metoprolol succinate 25 mg one half tablet(s) by mouth daily
Disp #*30 Tablet Refills:*0
8. Cephalexin 500 mg PO Q6H Duration: 2 Days
Please continue up to and on ___ for a total of 3 days of
antibiotic coverage
RX *cephalexin 500 mg 1 capsule(s) by mouth q 6 hours Disp #*10
Capsule Refills:*0
9. Celecoxib 200 mg ORAL DAILY
10. Vesicare (solifenacin) 10 mg oral Daily
11. Vitamin E 400 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Acute systolic and diastolic heart failure, compensated
Mobitz II second degree heart block s/p EP study + PPM placement
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ was a pleasure treating you at ___
___. You were admitted for concern of your difficulty
breathing. While you were admitted, your underwent an
ECHOcardiogram of your heart which showed that your heart wasn't
pumping as well as it should, which likely caused your
difficulty breathing. You underwent cardiac catheterization
which showed no major blockages of the vessels of your heart.
You also underwent multiple electrocardiograms (EKGs) which
raised concern about possibly missing a beat or two which could
have progressed to a bigger problem. You underwent an
electrophysiologic study or a study to examine how your heart
was sending signals to generate beats. This study showed some
problems with conduction of signals in a certain area of the
heart. A pacemaker was placed to help prevent problems from
developing from this issue. You were discharged to follow-up
with your PCP and your new Cardiologist Dr. ___
cardiologist who saw you daily in the hospital). Its important
that you keep your visits as scheduled.
Wishing you the best of health,
Your ___ team
Followup Instructions:
___
|
10099869-DS-3 | 10,099,869 | 21,026,790 | DS | 3 | 2185-01-16 00:00:00 | 2185-01-16 16:17:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest pain, shortness of breath
Major Surgical ___ Invasive Procedure:
None
History of Present Illness:
Patient is a ___ y/o male with little past medical history who
suffered a motorcycle accident on ___. He "flipped" on his
motorcycle, and was transferred to ___ for right tib/fib
fracture, fractured right sided ribs (with pneumothorax) and
right scapular fracture. He underwent debridement followed by
placement of gastrocnemius flap and was transferred to rehab on
___, where he remains non weight bearing on the right leg and
with the leg immobilized. He had an ultrasound on ___ for
unclear reasons (he had no pain, had decreased swelling on the
right leg) and was found to have a partial thrombosis ___ the
common femoral vein on the right and was started on systemic
anticoagulation with lovenox twice a day and then Coumadin was
started. He tells me that no lovenox doses were missed. He
experienced a syncopal episode at his rehab on ___ - after
his first long, warm shower. His wife caught him so there was
no head strike. He did have urinary incontinence with this
episode. He felt like he was about "to pass out" on ___
when ___ rehab. He felt clammy, sweaty so he was sent to ___
___. While there he developed right sided chest
pain and shortness of breath so they did a PE CT and found a RLL
PE with ? of pulmonary infarction so he was sent to ___. Of
note, INR was 2.4 at ___.
At present he states that the right sided chest pain that he
experienced ___ the ED is largely gone, as is his shortness of
breath. No fevers/chills/n/v/constipation. He has no prior
history of syncope. He is presently non weight bearing on the
right leg and participates ___ three one hour sessions of ___
daily. He is eating well and has gained about 20 lbs ___ rehab.
Per rehab records:
___ - d/c prophylactic lovenox (40mg sc daily)
___ - started 80 mg sc bid after found to have right ___ DVT
- and has remained on this dose until ___. His weight is
closer to 100 kg
Coumadin started on ___ INR ___ INR 1.8
___ INR 1.3
___ INR 1.5
___ INR 1.8
___ INR 2.1
Past Medical History:
None
Social History:
___
Family History:
No history of blood clots.
Physical Exam:
Gen: Well developed male, pleasant, NAD
Lung: CTA B
CV: RRR
Abd: Nabs, soft
Ext: no edema on LLE; on right ___, he had bandages and
immobilizer ___ place; ortho staff removed bandages; has
desquamations on anterior right thigh at area of skin grafting
On RLE over shin there is signifant swelling, and scant drainage
at borders of skin graft that was placed
Neuro: CN ___ grossly intact
Psych: Normal affect.
On Discharge
VSS
Gen: HE appears well
Right ___ + atrophy noted right lateral thigh, area of
desquamation from graft, + large flap on anterior shin, sutures
___ place, no fluctuance, drain ___ place.
Pertinent Results:
___ 02:26AM BLOOD WBC-11.9* RBC-4.18*# Hgb-10.8*#
Hct-35.0*# MCV-84 MCH-25.8* MCHC-30.9* RDW-15.5 RDWSD-47.4* Plt
___
___ 02:26AM BLOOD Neuts-77.3* Lymphs-13.4* Monos-7.7
Eos-0.7* Baso-0.4 Im ___ AbsNeut-9.19* AbsLymp-1.59
AbsMono-0.92* AbsEos-0.08 AbsBaso-0.05
___ 02:26AM BLOOD Glucose-114* UreaN-12 Creat-0.7 Na-133
K-4.5 Cl-98 HCO3-23 AnGap-17
___ 02:26AM BLOOD cTropnT-<0.01 proBNP-30
___:
"Findings positive for pulmonary embolus ___ the right lower lobe
pulmonary artery. Rounded area of increased density ___ the
right lower lob posterior laterally near the diaphragm which
could be due to pulmonary infarct ___ infiltrate".
INR at ___ was 2.4
EKG: Sinus tachycardia
U/S
COMPARISON: Right lower extremity deep vein ultrasound dated ___.
FINDINGS:
There is normal compressibility and flow of the right common
femoral, femoral, and popliteal veins. The right calf veins
were not evaluated secondary to bandaging, skin graft, and
possible open wounds.
There is normal respiratory variation ___ the common femoral
veins bilaterally. No evidence of medial popliteal fossa (___)
cyst.
IMPRESSION:
No evidence of deep venous thrombosis ___ the right common
femoral, femoral, and popliteal veins. Calf veins not imaged
secondary to bandaging and skin graft.
CT lower extremity
There is a comminuted fracture of the right tibia and fibula,
now post ORIF. The cortical plates create significant beam
hardening artifact largely obscuring the surrounding soft
tissues, particularly anteriorly. Within these limits, no rim
enhancing fluid collection to suggest abscess is identified.
There is soft tissue density anteriorly compatible with the skin
flap. Extensive edema is noted ___ the subcutaneous soft
tissues. Vessels appear grossly patent. There is a small knee
joint effusion, with tiny locules of air likely related to
recent surgery.
IMPRESSION:
1. Examination limited by streak artifact from extensive
orthopedic hardware. Within these limitations, no focal fluid
collection is detected.
2. Post ORIF of comminuted right tibial and fibular fractures.
3. Small knee joint effusion, with tiny locules of air likely
related to
recent surgery.
Discharge Labs
___ 05:47AM BLOOD WBC-4.7 RBC-3.43* Hgb-8.4* Hct-28.1*
MCV-82 MCH-24.5* MCHC-29.9* RDW-15.5 RDWSD-46.3 Plt ___
___ 06:00AM BLOOD ___ PTT-96.8* ___
___ 05:46PM BLOOD Vanco-13.5
MICROBIOLOGY
___ 3:34 pm TISSUE Site: TIBIA RIGHT TIBIA.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS.
Reported to and read back by ___ @ ___ ON
___.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS.
Reported to and read back by ___ @ ___ ON
___.
TISSUE (Final ___:
STAPH AUREUS COAG +. SPARSE GROWTH.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
ENTEROBACTER CANCEROGENUS. 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.
Ertapenem Susceptibility testing requested by ___.
___ ___
___. SENSITIVE TO Ertapenem.
Ertapenem sensitivity testing performed by ___.
MIXED BACTERIAL FLORA.
Due to mixed bacterial types [>=3] an abbreviated
workup is
performed; all organisms will be identified and
reported but only
select isolates will have sensitivities performed.
ENTEROCOCCUS SP.. SPARSE GROWTH.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
| ENTEROBACTER
CANCEROGENUS
| | ENTEROCOCCUS
SP.
| | |
AMPICILLIN------------ <=2 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- <=0.25 S
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- R
GENTAMICIN------------ <=0.5 S <=1 S
LEVOFLOXACIN---------- 0.25 S
MEROPENEM------------- <=0.25 S
OXACILLIN------------- 0.5 S
PENICILLIN G---------- 2 S
PIPERACILLIN/TAZO----- <=4 S
TETRACYCLINE---------- <=1 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S <=1 S
VANCOMYCIN------------ 2 S
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
Brief Hospital Course:
Patient is a ___ y/o male with recent leg immobilization after
motorcycle accident of ___, s/p Tib/fib fracture, now with
cement spacer, admitted after near syncope event at rehab. He
had been on Coumadin and lovenox for a DVT, but developed chest
pain and shortness of breath while ___ the ED and the CT scan
showed acute right sided pulmonary embolism, with question of
infarction, despite being on anticoagulation. He was
incidentally found to have an infection under his flap on the
right leg based on the physical exam performed by plastic
surgery.
# Pulmonary Embolism: Hematology was consulted - the patient
was taking lovenox 80 mg sc bid at rehab, and his weight based
dose is 100 mg sc/bid based on his weight. He has also had some
recent subtherapeutic INRs. It was felt that the development of
acute pulmonary embolism ___ the setting of a previously seen DVT
no longer visualized, was due to embolization and suboptimal
anticoagulation rather than warfarin failure. He was countinued
on warfarin and bridged to a therapeutic INR with a heparin drip
___ the ___ period. He may be bridged ___ the future
with lovenox, but he should be on the 100 mg sc bid dose. He
should be continued on Coumadin 8 mg dose and INR followed
closely. Recommend minimum of 3 months of anticoagulation for
provoked PE. He was seen by the ___ hematologists who made
these recommendations.
# Leg infection - under flap and over hardware: He was taken to
the ___ by plastic surgery and d "There was found to be fibrinous
debris and purulence directly over bone and plate" according to
the ___ report. They irrigated and derided the area as much as
possible. Cultures grew Coag+ staph, Enterobacter, and
Enterococcus.
Infectious diseases also saw the patient and recommended
treatment with IV vancomycin (1 gram tid) and IV ertapenem (1
gram daily) until ___. He has followup scheduled with
infectious diseases. He had a PICC line placed for this.
He fill followup with plastic surgery for removal of sutures and
the drain.
PLEASE OBTAIN THE FOLLOWING LAB TESTS WEEKLY:
CBC with differential, BUN, Cr, Vancomycin trough, ALT, AST,
TOTAL BILIRUBIN, ALK PHOS, ESR/CRP AND FAX RESULTS TO ___
INFECTIOUS DISEASES AT ___
He will followup with plastic surgery to have sutures removed
and with orthopedics to discuss timing of removal of hardware
after suppressive therapy with IV antibiotics. PLEASE SCHEDULE
THE APPOINTMENT WITH DRS ___ for f/u.
He was prescribed vicodin for leg pain, but took it sparingly.
# Pre-syncope at rehab on ___ and syncope the week prior: The
first episode occurred after a long warm shower, his first after
getting to rehab. I suspect that he had significant
vasodilation as a result of his shower and that this resulted ___
his syncope. The second episode by history is highly suggestive
of vasovagal symptomatology. Nonetheless, he was monitored on
telemetry during his hospitalization and there were no
concerning events. EKG notable only for sinus tachycardia.
# Anemia: Stable, improved from prior admit when he had
significant acute blood loss anemia. Continued iron
supplementation
# pain ___ leg: Well controlled on vicodin.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild
2. Ferrous Sulfate 325 mg PO BID
3. Zolpidem Tartrate 5 mg PO QHS
4. lansoprazole 30 mg oral Q24H
5. Docusate Sodium 100 mg PO BID
6. Polyethylene Glycol 17 g PO DAILY:PRN constipatoin
7. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain -
Moderate
8. Warfarin 8 mg PO DAILY16
Discharge Medications:
1. Ertapenem Sodium 1 g IV 1X Duration: 1 Dose
PLEASE DOSE EVERY 24 HOURS. PROJECTED END DATE IS ___.
2. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
3. Vancomycin 1000 mg IV Q 8H skin infection
PROJECTED END DATE ___
4. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild
5. Docusate Sodium 100 mg PO BID
6. Ferrous Sulfate 325 mg PO BID
7. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain
- Moderate
RX *hydrocodone-acetaminophen 5 mg-325 mg 1 tablet(s) by mouth
EVERY SIX HOURS Disp #*30 Tablet Refills:*0
8. lansoprazole 30 mg oral Q24H
9. Polyethylene Glycol 17 g PO DAILY:PRN constipatoin
10. Warfarin 8 mg PO DAILY16
11. Zolpidem Tartrate 5 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Pulmonary Embolism
Skin and soft tissue infection under flap of right lower leg
Hardware infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair ___
wheelchair (not weight bearing right leg)
Discharge Instructions:
You were admitted after developing chest pain ___ the ___
Emergency Room where you were found to have a blood clot
(pulmonary embolus) that travelled to your lungs. You were
seen by the hematologists who feel that this likely happened on
account of your coumadin and lovenox doses being lower than they
should be and we have made the necessary arrangements. You were
also taken to the operating room by plastic surgery where they
cleaned out the area under your flap, which was infected. The
orthopedic hardware you have is also felt to be infected. You
were started on antibiotics for this infection as well.
Followup Instructions:
___
|
10100035-DS-19 | 10,100,035 | 20,559,195 | DS | 19 | 2110-05-09 00:00:00 | 2110-05-09 18:14:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
___: ___ procedure
___: CT-guided drainage of a left perisplenic fluid
___: Ultrasound-guided drainage of left lower quadrant
collection
___: CT-guided aspiration of 3 abdominal collections
History of Present Illness:
___ with no known PMH presents to ED with 2-week history of
lower abdominal pain that acutely worsened 3 nights ago, worse
in RLQ than LLQ associated with nausea and chills but no fever,
emesis, or diarrhea. His last BM was this morning but is unsure
if he has been passing gas. He denies recent weight loss,
hematochezia, BRBPR. Appetite has been fair. Concurrent with
this pain, patient also endorses difficulty voiding over the
past week without dysuria or hematuria. Patient also mentions
that he has been battling a cold over the past 3 weeks with
primary symptoms of a dry cough and congestion.
Patient was referred to ED by PCP for urinary complaints, and CT
showed findings concerning for perforated viscus for which
surgery is consulted. Patient recounts history as above. Patient
states he has never had a colonoscopy.
Past Medical History:
PMH: none
PSH: open appendectomy (in his ___, right shoulder surgery
Social History:
___
Family History:
noncontributory
Physical Exam:
PHYSICAL EXAM:
VS - T 97.6 HR 97 BP 115/75 RR 18 92% RA
Gen: NAD, non-toxic
CV: RRR, no murmurs
Pulm: CTAB
Abd: soft, non-distended, non-tender, faint appendectomy scar at
RLQ, drains x2 in place at LUQ and LLQ/flank, wound vac in place
in midline laparotomy
Ext: no edema, 2+ peripheral pulses
Pertinent Results:
Lab Values:
___ 06:05AM BLOOD WBC-9.2 RBC-3.09* Hgb-7.7* Hct-24.2*
MCV-78* MCH-24.9* MCHC-31.8* RDW-17.7* RDWSD-48.9* Plt ___
___ 06:05AM BLOOD ___
___ 06:05AM BLOOD Glucose-120* UreaN-7 Creat-0.5 Na-135
K-4.0 Cl-99 HCO3-25 AnGap-15
___ 06:05AM BLOOD Calcium-7.5* Phos-4.0 Mg-2.0
Imaging:
___ CT abd/pelv -
1. Pneumoperitoneum with moderate ascites throughout the abdomen
compatible with a perforated viscus. While the exact site of
perforation is difficult to localize, a focal segment of
irregular wall thickening and enhancement within the sigmoid
colon is concerning for an underlying colonic mass and may be
the
source of perforation.
2. Multiple abdominal and pelvic abscesses, the largest
measuring
up to 5.5 x 4.8 cm within the deep pelvis, anterior to the
rectum.
3. Wall thickening and mural edema involving multiple loops of
ileum in the right lower quadrant as well as the ascending
colon,
likely reactive.
4. Numerous enlarged retroperitoneal and mesenteric lymph
nodes.
While these may be reactive, given the concern for an underlying
sigmoid colonic mass, these could reflect neoplastic
involvement.
5. Small bilateral pleural effusions, larger on the right.
___ CTAP
1. Patient is post exploratory laparotomy and ___ pouch.
Multiple loops of mildly dilated small bowel, up to 3.7 cm, are
identified in the left mid abdomen. A gradual tapering
transition point is thought to occur in the right mid abdomen
(see series 2, image 58). Distal to this site, multiple loops
of nondistended, more collapsed small and large bowel are
identified. Findings are thought to represent postoperative
although early obstruction might have this appearance as well.
2. Interval development of multiple fluid collections of simple
internal
attenuation, although some of which are loculated and
demonstrate thin
enhancing rims. For example, there is a 13.5 x 11.9 cm
loculated-appearing perisplenic collection with adjacent fat
stranding. A 9.8 x 7.2 cm irregular fluid collection in the
midline lower pelvis, and 2 smaller mid mesenteric collections,
are also present.
3. Bilateral nonhemorrhagic pleural effusions with overlying
compressive
atelectasis, likely postsurgical in nature.
4. No significant change in the previously described mesenteric
and
retroperitoneal lymphadenopathy.
___
1. Status post placement of pigtail drainage catheter within a
peripherally rim enhancing perisplenic fluid collection, which
has decreased in size. The pigtail formation of the catheter
appears somewhat buckled. Recommend correlation with catheter
output and its ability to be flushed.
2. Interval increase in simple free mesenteric fluid.
3. Interval decrease in size of the collection of fluid in the
pelvis with
thin, incomplete peripheral enhancement.
4. No evidence of extraluminal contrast or intra-abdominal free
air to suggest the presence of a perforated viscus.
5. Moderate bilateral pleural effusions with adjacent
atelectasis appears
similar to prior.
CXR:
Moderate left effusion with moderate bibasal opacities have not
been placed changed, given the adjacent sub phrenic
intra-abdominal collection, there is concern for infected left
pleural effusion.
___ CTAP:
1. Improvement in the organized collection lying above the
bladder as detailed above. It measures 1 cm in craniocaudal
dimension, previously 4.3 cm. It is in close contact with the
rectal stump.
2. Minimal improvement in the left upper quadrant collection.
3. Moderate amount of free intra abdominal fluid with peritoneal
enhancement compatible with peritonitis. It is difficult to
exclude omental disease in a patient with moderate amount of
ascites, and correlation with dedicated CT scan is recommended
once the acute episode resolves to exclude any omental
pathology.
4. No new collections.
___ Chest CT
No definitive evidence off infectious process within the chest.
Bibasal
atelectasis and large bilateral pleural effusions.
Multiple lymph nodes, none of them specifically pathologically
enlarged.
Multiple esophageal diverticula.
___ CT
Aspiration of right lower quadrant, mesenteric, and perisplenic
fluid with
return of serous fluid. Samples was sent for microbiology
evaluation. No new drain placement.
Microbiology:
___ 12:53 pm PERITONEAL FLUID RLQ FLUID.
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Preliminary):
ANAEROBIC CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary):
___ 12:53 pm PERITONEAL FLUID Site: PERITONEAL
MESENTERIC FLUID.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Preliminary):
ANAEROBIC CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary):
___ 12:53 pm PERITONEAL FLUID PERITONEAL FLUID.
PARA SPLENIC FLUID.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary):
ANAEROBIC CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary):
___ 2:03 am URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
Pathology:
PATHOLOGIC DIAGNOSIS:
Sigmoid colon, sigmoidectomy:
- Colonic adenocarcinoma, see synoptic report.
- Diverticular disease.
- Acute organizing serositis.
Colon and Rectum: Resection Synopsis
(Includes Transanal Disk Excision of Rectal Neoplasms)
Staging according to ___ Joint Committee on Cancer Staging
Manual - ___ Edition, ___ and College of ___
Pathologists Protocol for the Examination of Specimens from
Patients with Primary Carcinoma of the Colon and Rectum
(___)
Macroscopic
Specimen Type: Sigmoidectomy
Specimen Size: Greatest dimension: 21.3 cm.
Tumor Site: Sigmoid colon
Tumor Configuration: Exophytic (polypoid), infiltrative,
ulcerating
Tumor Size: Greatest dimension: 5.5 cm.
___
Department of Pathology Patient: ___
Page 2 of 4
Macroscopic Tumor Perforation: Present
Microscopic
Histologic Type: Mucinous adenocarcinoma (greater than 50%
mucinous differentiation)
Histologic Grade: Low-grade (well or moderately differentiated)
Extent of Invasion
TNM Descriptors: Not applicable
Primary Tumor (pT): pT3: Tumor invades through the muscularis
propria into the subserosa
or the nonperitonealized pericolic or perirectal soft tissues
Regional Lymph Nodes (pN): pN1b: Metastasis in 2 to 3 regional
lymph nodes
Lymph Nodes: Number of lymph nodes examined: 19. Number
involved: 2
Distant Metastasis: PMX: Cannot be assessed
Margins
Invasive carcinoma: Negative; distance of tumor from closest
margin: 12 mm.
Treatment Effect: No prior treatment
Lymphovascular invasion: Absent
Venous (large vessel) Invasion: Present: Extramural
Perineural Invasion: Absent
Tumor Deposits
(discontinuous extramural extension): Present
Type of polyp in which Carcinoma Arose: None identified
Additional Pathologic Findings: Not applicable
DNA Mismatch Repair Immunohistochemistry Results:
MLH1, Intact nuclear expression (performed on block 1L)
GROSS DESCRIPTION:
The specimen is received fresh in a container, labeled with the
patient's name, ___, the medical record number and additionally labeled
"sigmoid colon". The specimen
consists of a segment of colon as well as an unattached portion
of the mesentery. The unattached
portion of the mesentery is grossly unremarkable and it measures
6.7 x 3.5 x 1.6 cm. The segment of
colon measures overall 21.3 x 8.5 x 7.7 cm. The colon itself
measures 18.0 cm in length and 2.7 cm
in diameter. A portion of mesentery is attached to the colon
that measures 21.3 x 8.5 x 7.7 cm. The
specimen is oriented with a stitch at the proximal end. The
proximal margin has a staple line that
measures 2.0 cm in length. The serosa of the bowel is smooth
proximally and there is purulence
present at the distal end. A palpable mass is present within the
bowel. The serosa and mesentery
overlying the mass is inked black. The specimen is opened along
the anti-mesenteric surface to
reveal fecal material within the lumen. The distal margin is
inked orange. The radial margin is inked
green. A circumferential, polypoid, fungating mass is present
that measures 5.5 cm in length, 5.3 cm
in width, and 1.2 cm in height. The tumor appears to be present
at the distal margin. A large
perforation is present in the serosa deep to the mass. Serial
slices show that the tumor does invade
into the muscularis propria and the mesentery. The surrounding
non-neoplastic mucosa is involved
with diverticular disease. Within the mesentery, twelve lymph
nodes are identified.
Representative sections are submitted as follows:
1A-1B=radial margin
1C=proximal margin
1D=section of grossly uninvolved colon between the proximal
margin and mass
___ section from the distal margin to the tumor
1G=tumor to area of perforation
1H-1I=one slice of the tumor, bisected showing the deepest point
of invasion
1J-1K=section of tumor showing deepest point of invasion as well
as 1K also shows site of
perforation
1L=tumor to normal colon
___ of tumor
1N=section of tumor
1O-1P=one section of the tumor, bisected
1Q=one lymph node, trisected
___
Department of Pathology Patient: ___
Page 4 of 4
1R=one lymph node, bisected
1S-1T=one potential lymph node, quadrisected
1U=one potential lymph node
1V=diverticular disease
1W=diverticular disease
1X=one lymph node, trisected
___ lymph node, trisected
1Z=one potential lymph node
1AA=one lymph node, bisected
1AB=one potential lymph node, bisected
1AC=one potential lymph node
1AD=one potential lymph node, bisected
1AE=one potential lymph node
1AF=one lymph node
1AG=one potential lymph node
1AH=one potential lymph node, bisected
1AI=one potential lymph node
1AJ=one potential lymph node
1AK=one potential lymph node
1AL=diverticular disease
1AM-1BP=fibroadipose tissue
Pictures have been taken.
FROZEN SECTION DIAGNOSIS:
Intraoperative consultation is performed. The gross only
diagnosis on "sigmoid colon" by Dr. ___ is as follows: "Mass grossly located within 1 cm of the
distal resection margin".
Residents: ___, MD
By his/her signature, the senior physician certifies that he/she
personally conducted a gross and/or microscopic examination of
the described specimen(s) and
rendered or confirmed the diagnosis(es) related thereto.
Immunohistochemistry test(s), if applicable, were developed and
their performance characteristics were determined by the
Department of Pathology at ___, ___. They have not been
cleared or approved by the ___ Drug Administration.
The FDA has determined
that such clearance or approval is not necessary. These tests
are used for clinical purposes. They should not be regarded as
investigational or for research.
This laboratory is certified under the Clinical Laboratory
Improvement Amendments of ___ (___-88) as qualified to perform
high complexity clinical
laboratory testing. Unless otherwise specified, all
histochemical and immunohistochemical controls are adequate.
Brief Hospital Course:
Mr. ___ was admitted through the emergency department on
___ with a perforated colon and multiple intrabdominal
abscesses and was taken emergently to the operating room for an
exploratory laparotomy, ___ procedure and colostomy.
Intraoperatively a mass was discovered in the sigmoid colon
which was later characterizeds a 5.5 cm pT3N1Mx low grade
mucinous adenocarcinoma. Negative margins were achieved. For
more details of the procedure please refer to the operative
note. Following the procedure Mr. ___ was taken to the PACU
per routine in stable condition, and from there was transferred
to the general surgical floor.
On POD 1 he experienced some tachycardia and low level
temperatures. A CXR was taken which was unremarkable. He was
initially treated with IVF but when his symptoms persisted he
underwent a CT Abdomen/Pelvis which demonstrated multiple
abdominal fluid collections concerning for early abscesses. ___
was consulted and placed a pelvic and perisplenic drain on
___. Cultures from these collections were negative. He
continued to have intermittent fevers and was started
empirically on zosyn on ___/ Blood and fluid cultures
continued to be negative. He. On ___ his laparotomy wound was
found to be poorly healing at a 2 x 2 cm segment, so a wound vac
was placed. On ___ his abx regimen was changed to
cipro/flagyl. He continued to be febrile and on ___
underwent a CT/Abdomen/Pelvis. This demonstrated several fluid
collections had decreased in size but the perisplenic
collection, as well as a RLQ and a mesenteric collection were
persistent. ___ was reconsulted and aspirated fluid from all
three collections. Only ___ cc of fluid per collection was
obtained, and all were found to be serosanguinous, with gram
stains negative. His WBC continued to trend down and he had no
more febrile episodes. At this point being clinically well with
pain well-controlled and tolerating a PO diet with positive BMs,
he was discharged to rehabilitation with plans for 5 more days
of antibiotics, and follow up in clinic in 2 weeks.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
RX *acetaminophen 650 mg 1 tablet(s) by mouth every six (6)
hours Disp #*60 Tablet Refills:*2
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*20 Tablet Refills:*0
3. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*20 Tablet Refills:*0
4. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*11 Tablet Refills:*0
5. MetRONIDAZOLE (FLagyl) 500 mg PO TID
RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day
Disp #*16 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Perforated sigmoid colon with pT3N1Mx low grade mucinous
adenocarcinoma
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 ___ with abdominal pain and were found to
have a perforated colon. You were taken urgently to the
operating room and underwent a ___ procedure to fix the
perforation and create a diverting colostomy to allow the
intestines to heal. Your postoperative course was complicated by
multiple abscesses that required drainage in Interventional
Radiology and antibiotics. You are now tolerating a regular diet
and your colostomy is functioning; you are ready to be
discharged to rehab to continue your recovery. Please note the
following discharge instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Keep yourself well hydrated, if you notice your ileostomy output
increasing, take in more electrolyte drink such as Gatorade.
Please monitor yourself for signs and symptoms of dehydration
including: dizziness (especially upon standing), weakness, dry
mouth, headache, or fatigue. If you notice these symptoms please
call the office or return to the emergency room for evaluation
if these symptoms are severe. You may eat a regular diet with
your new ileostomy. However it is a good idea to avoid fatty or
spicy foods and follow diet suggestions made to you by the
ostomy nurses.
Please monitor the appearance of the ostomy and stoma and care
for it as instructed by the wound/ostomy nurses. ___ stoma
(intestine that protrudes outside of your abdomen) should be
beefy red or pink, it may ooze small amounts of blood at times
when touched and this should subside with time. The skin around
the ostomy site should be kept clean and intact. Monitor the
skin around the stoma for bulging or signs of infection listed
above. Please care for the ostomy as you have been instructed by
the wound/ostomy nurses.
Followup Instructions:
___
|
10100342-DS-18 | 10,100,342 | 20,148,204 | DS | 18 | 2167-09-24 00:00:00 | 2167-09-24 19:35:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
egg
Attending: ___.
Chief Complaint:
Vertigo/Weakness
Major Surgical or Invasive Procedure:
Thoracentesis ___
Paracentesis ___
History of Present Illness:
___ with a history of cryptogenic cirrhosis, complicated by
ascites, esophageal varices, and portal hypertensive
gastropathy,
DVT/PE in the setting of ___ gene mutation, hypertension, mood
disorder, and recent admission for small bowel obstruction and
HAP, who initially presented to ___ with
shortness of breath and vertigo, subsequently found to have
loculated fluid collection on CT abdomen/pelvis and lactate of
5,
prompting transfer to ___.
Recent admission ___ when he presented as a
transfer from ___ with nausea and
vomiting.
Found to have small bowel obstruction, likely secondary to
extraluminal compression by loculated ascitic fluid collection.
Underwent drainage of same with ___ on ___, with resolution of
nausea/vomiting. Hospitalization was complicated by
hospital-acquired PNA for which he completed a five day course
of
ceftazidime, and pancytopenia felt likely secondary to ___
megaloblastic anemia. Etiology of cirrhosis is unclear; patient
reports a long history of alcohol consumption although not in
large volumes, hepatitis serologies were negative, autoimmune
studies were negative, and patient has no risk factors for
NAFLD.
EGD was performed on ___ and demonstrated grade I esophageal
varices and portal hypertensive gastropathy.
Patient was in his usual state of health until about four days
ago, when he developed worsening of his vertigo symptoms and
shortness of breath. Vertigo has been a persistent issue for
many
years, present 24hrs a day, but worsened in the past few days,
making it difficult to ambulate and do his usual activities of
daily living. Shortness of breath present both at rest and on
exertion, but worsens when exerting himself and when lying flat.
Has had to prop himself up more at night to help with his
breathing. Also reports intermittent left sided chest pain over
the same time period. Denies fevers, cough, sputum production,
or
other infective symptoms.
Initially presented to ___, where he was
found to have a lactate of 5, despite being hemodynamically
stable. CT abdomen/pelvis was performed and demonstrated a
loculated fluid collection within the abdomen, concerning for
accumulation of previously drained ascitic fluid collection.
Given IV vancomycin/Zosyn, before being transferred to ___ for
further evaluation.
In the ED, initial VS were notable for;
Temp 96.7 HR 94 BP 149/75 RR 14 SaO2 97% RA
Examination notable for;
No acute distress, decreased breath sounds at posterior right
base, no wheezes/crackles, RRR, no murmurs/rubs/gallops, no
lower
extremity edema, soft/non-tender distention, moving all four
extremities with purpose, normal affect/behavior.
Labs were notable for;
WBC 2.4 Hgb 10.4 Plt 56
Na 140 K 3.9 Cl 103 HCO3 17 BUN 9 Cr 0.9 Gluc 75 AnGap 20
ALT 6 AST 16 ALP 107 Tbili 1.6 Alb 3.4
Lactate 1.3
Urine studies notable for trace proteinuria, 40 ketones, and
were
otherwise unremarkable.
ECG demonstrated sinus rhythm 94 bpm, right axis deviation,
prolonged QTc at 510msecs, otherwise normal intervals, no
pathologic Q waves, non-specific ST-T abnormalities, T wave
inversion in III, similar when compared to prior.
CXR demonstrated increased size of right pleural effusion, now
moderate to large, with right basilar compressive atelectasis,
and mild left basilar atelectasis. RUQUS re-demonstrated a
14.6cm
perihepatic anechoic collection, slightly increased in size, and
may reflect loculated ascites, in addition to patient portal
vein, coarsened hepatic parenchyma without focal liver lesion,
splenomegaly, moderate leukopenia, and right sided pleural
effusion.
Hepatology were consulted; concern for hepatic hydrothorax,
admit
to ET under Dr. ___ may need thoracentesis in AM.
No medications were given.
Vital signs on transfer were notable for;
HR 88 BP 150/98 RR 16 SaO2 99% RA
Upon arrival to the floor, patient repeats the above story.
Currently remains short of breath, but a little easier as he has
not been exerting himself over the course of the day
Past Medical History:
- Cryptogenic cirrhosis complicated by ascites/EV
- DVT/PE with a history of MTHFR gene mutation
- Atrial fibrillation
- Depression/Anxiety/PTSD
- Hypertension
- Vertigo
- Gout
- GERD
Social History:
___
Family History:
No family history of liver disease.
Physical Exam:
ADMISSION EXAM
===================
VS: Temp 97.5 BP 166/84 HR 90 RR 22 SaO2 100% RA
___: sitting comfortably in bed, no acute distress
HEENT: AT/NC, no conjunctival pallor, anicteric sclera, MMM
NECK: supple, non-tender, no JVP elevation
CV: RRR, S1 and S2 normal, no murmurs/rubs/gallops
RESP: good air entry on left side, no breath sound in right
lower
lobe, otherwise good air entry in the left upper lung
___: soft, non-tender, mild distention, BS normoactive
EXTREMITIES: warm, well perfused, no lower extremity edema
NEURO: A/O x3, moving all four extremities with purpose, CNs
grossly intact
DISCHARGE EXAM
==================
VS: 24 HR Data (last updated ___ @ 044)
Temp: 98.4 (Tm 98.4), BP: 108/68 (99-120/60-76), HR: 86
(80-120), RR: 18 (___), O2 sat: 98% (98-100), O2 delivery: Ra
___: alert, interactive, NAD
HEENT: NC/AT, sclera anicteric, MMM, OP clear
NECK: JVP not elevated
CV: RRR, no m/r/g
RESPIRATORY: CTAB, unlabored respirations, no wheezes or rales
GI: abdomen soft, non-tender, mildly distended, +BS
EXTREMITIES: warm, well perfused, no lower extremity edema
NEURO: A/Ox3, moving all four extremities with purpose, no
asterixis
Pertinent Results:
NOTABLE LABS
====================
___ 06:35PM BLOOD WBC-2.4* RBC-3.03* Hgb-10.4* Hct-32.0*
MCV-106* MCH-34.3* MCHC-32.5 RDW-17.9* RDWSD-69.9* Plt Ct-56*
___ 06:35PM BLOOD Neuts-57.8 ___ Monos-7.6 Eos-0.4*
Baso-1.3* Im ___ AbsNeut-1.37* AbsLymp-0.77* AbsMono-0.18*
AbsEos-0.01* AbsBaso-0.03
___ 06:35PM BLOOD ALT-6 AST-16 AlkPhos-107 TotBili-1.6*
MICROBIOLOGY
==================
___ 2:54 pm PLEURAL FLUID PLEURAL FLUID.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count, if
applicable.
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
__________________________________________________________
___ 3:35 pm PERITONEAL FLUID PERITONEAL FLUID.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count, if
applicable.
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
__________________________________________________________
___ 6:36 am BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
__________________________________________________________
___ 6:36 am BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
__________________________________________________________
___ 6:40 am URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
__________________________________________________________
___ 6:49 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
__________________________________________________________
___ 6:35 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
RELEVANT STUDIES
==================
___ CXR PA/LATERAL:
Increased size of right pleural effusion, now moderate to large,
with right basilar compressive atelectasis. Infection in the
right lung base is difficult to exclude. Mild left basilar
atelectasis.
___ RUQ U/S:
1. Redemonstration of a 14.6 cm perihepatic anechoic collection,
slightly
increased in size compared to prior abdominal ultrasound
performed ___, and better assessed on the same-day
abdominal CT. Findings may reflect loculated ascites in the
setting of background moderate volume ascites
2. Patent main portal vein and left portal vein. The right
portal vein is not visualized, but appears pain on the same-day
abdominal CT.
3. Cirrhotic liver without evidence for a focal lesion.
4. Unchanged splenomegaly, which along with the ascites is
consistent with
portal hypertension.
5. Right pleural effusion.
___ PARACENTESIS:
1. Technically successful ultrasound guided diagnostic and
therapeutic
paracentesis.
2. 620 cc of fluid were removed and sent for requested analysis.
___ CXR PORTABLE AP:
Right-sided pleural effusion has resolved. No evidence of
pneumothorax.
Minimal right basilar atelectasis. Otherwise, no significant
change.
IMPRESSION:
Status post right thoracentesis.
Brief Hospital Course:
___ male with PMH cirrhosis decompensated by ascites,
grade I esophageal varices, portal hypertensive gastropath, DVT
PE in setting of MTHFR gene mutation, HTN, and mood disorder who
was admitted for worsening dyspnea and progressive right pleural
effusion. Patient found to have re-accumulation of loculated
ascites. He was previously admitted for SBO and HAP and found to
have loculated intra-abdominal fluid collection. Patient
underwent thoracentesis with resolution of dyspnea and
paracentesis.
ACTIVE ISSUES:
====================
# Right hydrothorax
Presented with progressive dyspnea and radiographic evidence of
right pleural effusion increase. IP did thoracentesis on ___
with drainage of 2L pleural fluid. Pleural fluid studies were
exudative by three-test rule, however the etiology was still
thought to be hepatic hydrothorax as this can be exudative in a
minority of cases. Patient had no infectious signs or symptoms
and no further dyspnea. Lasix was increased from 40 mg to 60 mg
PO daily and spironolactone was increased from 100 mg to 200 mg
PO daily. Rivaroxaban was held prior to thoracentesis and
restarted afterward with no event.
# Cirrhosis
# Loculated ascites:
Etiology of cirrhosis potentially EtOH given prior extensive
EtOH history. Decompensated by ascites, grade I esophageal
varices, and portal hypertensive gastropathy. RUQ U/S showed
patent portal vasculature but did show re-accumulation of
___ fluid collection which was previously drained ___.
Fluid collection was drained again and was negative for SBP.
Home Lasix/spironolactone were uptitrated per above. Patient
would like to ___ with ___ upon discharge
and was care connected.
# Vertigo:
Chronic issue for many years, although has worsened over the
past few days per patient. Work-up has been done at the ___. He reportedly had MRI two months ago which was unremarkable.
Patient was prescribed nortriptyline as an outpatient and this
was restarted on day of discharge.
# Pancytopenia
History of pancytopenia, believed to be secondary to a
combination of MTHFR megaloblastic anemia and cirrhosis.
CHRONIC/STABLE ISSUES:
======================
# Atrial fibrillation: No indication for anti-coagulation.
Continue metoprolol.
# History of DVT/PE: Continue rivaroxaban 20mg
# GERD: Continue omeprazole 20mg daily
# Neuropathy: Continue gabapentin 600mg TID
# Depression/Anxiety
# PTSD: Continue mirtazapine 15mg QHS, quetiapine 300mg QHS,
prazosin 1mg QHS, trazodone 100mg QHS:PRN for insomnia.
TRANSITIONAL ISSUES
======================
MEDICATION CHANGES
[] Lasix increased from 40 mg PO daily to 60 mg PO daily
[] Spironolactone increased from 100 mg PO daily to 200 mg PO
daily
NEW MEDICATIONS
[] Nortriptyline 10 mg PO daily for vertigo. Patient was
reportedly on this medication prior to admission.
[] Consider up-titration of nortriptyline for vertigo if patient
continues to have symptoms with low dose.
[] If patient develops dyspnea, recommend repeat CXR to evaluate
for recurrence of hepatic hydrothorax. If pleural effusion
recurs, would send cytology as his pleural effusion was
exudative. This was still thought to be hepatic hydrothorax but
would need to consider malignancy if it recurs.
[] If patient has new or worsening abdominal pain, would
recommend repeat abdominal U/S to evaluate for recurrence of
loculated ascites.
[] Recommend HBV vaccine. Serologies show he is non-immune.
[] Recheck Chem-7 at PCP ___.
Discharge weight: 69.17 kg
Discharge Cr: 0.9
Discharge diuretic regimen: Spironolactone 200 mg daily +
furosemide 60 mg daily
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. FoLIC Acid 1 mg PO DAILY
2. Gabapentin 600 mg PO TID
3. Multivitamins 1 TAB PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Prazosin 1 mg PO QHS
6. Rivaroxaban 20 mg PO DAILY
7. TraZODone 100 mg PO QHS:PRN insomnia
8. Metoprolol Succinate XL 25 mg PO DAILY
9. Mirtazapine 15 mg PO QHS
10. Furosemide 40 mg PO DAILY
11. QUEtiapine Fumarate 300 mg PO QHS
12. Spironolactone 100 mg PO DAILY
Discharge Medications:
1. Nortriptyline 10 mg PO DAILY Vertigo
RX *nortriptyline 10 mg 10 mg by mouth once a day Disp #*30
Capsule Refills:*0
2. Furosemide 60 mg PO DAILY
RX *furosemide 20 mg 3 tablet(s) by mouth once a day Disp #*90
Tablet Refills:*0
3. Spironolactone 200 mg PO DAILY
RX *spironolactone 100 mg 2 tablet(s) by mouth once a day Disp
#*60 Tablet Refills:*0
4. FoLIC Acid 1 mg PO DAILY
5. Gabapentin 600 mg PO TID
6. Metoprolol Succinate XL 25 mg PO DAILY
7. Mirtazapine 15 mg PO QHS
8. Multivitamins 1 TAB PO DAILY
9. Omeprazole 20 mg PO DAILY
10. Prazosin 1 mg PO QHS
11. QUEtiapine Fumarate 300 mg PO QHS
12. Rivaroxaban 20 mg PO DAILY
13. TraZODone 100 mg PO QHS:PRN insomnia
Discharge Disposition:
Home
Discharge Diagnosis:
Hepatic hydrothorax
Decompensated cirrhosis
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 ___.
Why was I admitted?
- You were having worsening shortness of breath because you had
fluid around your right lung.
What was done for me while I was here?
- The fluid was drained from your chest and your breathing
improved.
- Fluid was drained from your abdomen as well.
- Your medications were adjusted, in particular your furosemide
and spironolactone were both increased.
What should I do when I go home?
- You should take your medications as prescribed.
- You should attend all of your ___ appointments.
We wish you the best in the future.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10100810-DS-20 | 10,100,810 | 26,011,156 | DS | 20 | 2169-03-15 00:00:00 | 2169-03-15 11:26:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
vancomycin
Attending: ___.
Chief Complaint:
right clavicular pain
Major Surgical or Invasive Procedure:
___
Right sternoclavicular joint debridement
___
PICC line placement
History of Present Illness:
___ pt of Dr ___ treated for osteomyelitis
right sternoclavicular joint was admitted ___ for apparent
drug reaction to Vancomycin. He had been discharged ___ on
IV
Vanco via PICC line and developed an itchy rash on ___.
Vanco
was held, pt placed on prednisone 60 mg but rash progressed to
cover entire body and had associated swelling. He denies any
SOB,
fever, sweats. Had Dermatology consult and punch biopsy ___,
presumed to have DRESS.
In the ED, blood cultures were drawn
Past Medical History:
HTN, arthritis, sciatica, heroin abuse
Social History:
___
Family History:
Noncontributory
Physical Exam:
T = 100.8 HR = 62 BP = 190/70 RR = 18 O2 = 100% on RA
GENERAL [x] All findings normal
[ ] WN/WD [ ] NAD [ ] AAO [ ] abnormal findings:
HEENT [x] All findings normal
[ ] NC/AT [ ] EOMI [ ] PERRL/A [ ] Anicteric
[ ] OP/NP mucosa normal [ ] Tongue midline
[ ] Palate symmetric [ ] Neck supple/NT/without mass
[ ] Trachea midline [ ] Thyroid nl size/contour
[X] Abnormal findings: erythematous over manubrium extending
laterally along right clavicle, and inferiorly over the
pectoralis muscles. There is tenderness to palpation over the
right medial clavicle
RESPIRATORY [x] All findings normal
[ ] CTA/P [ ] Excursion normal [ ] No fremitus
[ ] No egophony [ ] No spine/CVAT
[ ] Abnormal findings:
CARDIOVASCULAR [x] All findings normal
[ ] RRR [ ] No m/r/g [ ] No JVD [ ] PMI nl [ ] No edema
[ ] Peripheral pulses nl [ ] No abd/carotid bruit
[ ] Abnormal findings:
GI [x] All findings normal
[ ] Soft [ ] NT [ ] ND [ ] No mass/HSM [ ] No hernia
[ ] Abnormal findings:
GU [x] Deferred [ ] All findings normal
[ ] Nl genitalia [ ] Nl pelvic/testicular exam [ ] Nl DRE
[ ] Abnormal findings:
NEURO [x] All findings normal
[ ] Strength intact/symmetric [ ] Sensation intact/ symmetric
[ ] Reflexes nl [ ] No facial asymmetry [ ] Cognition intact
[ ] Cranial nerves intact [ ] Abnormal findings:
MS [x] All findings normal
[ ] No clubbing [ ] No cyanosis [ ] No edema [ ] Gait nl
[ ] No tenderness [ ] Tone/align/ROM nl [ ] Palpation nl
[ ] Nails nl [ ] Abnormal findings:
- patient adducts, abducts, flexes, extends, internally rotates,
and externally rotates right shoulder joint without difficulty.
LYMPH NODES [x] All findings normal
[ ] Cervical nl [ ] Supraclavicular nl [ ] Axillary nl
[ ] Inguinal nl [ ] Abnormal findings:
SKIN [x] All findings normal
[ ] No rashes/lesions/ulcers
[ ] No induration/nodules/tightening [ ] Abnormal findings:
PSYCHIATRIC [x] All findings normal
[ ] Nl judgment/insight [ ] Nl memory [ ] Nl mood/affect
[ ] Abnormal findings:
Pertinent Results:
___ 01:30PM WBC-8.3 RBC-4.29* HGB-11.4* HCT-36.6* MCV-85
MCH-26.6* MCHC-31.2 RDW-16.2*
___ 01:30PM NEUTS-78.5* ___ MONOS-1.5* EOS-0.6
BASOS-0.5
___ 01:30PM PLT COUNT-243
___ 01:30PM GLUCOSE-187* UREA N-18 CREAT-0.8 SODIUM-138
POTASSIUM-4.4 CHLORIDE-99 TOTAL CO2-32 ANION GAP-11
Cultures :
___ 2:55 pm TISSUE RIGHT PECTORALIS.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final ___:
STAPH AUREUS COAG +.
Isolated from broth media only, INDICATING VERY LOW
NUMBERS OF
ORGANISMS. SENSITIVITIES PERFORMED ON CULTURE #
350-1561K ___.
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
___ 3:25 pm TISSUE RIGHT FIRST RIB SEGMENT.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
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.
___ 2:55 pm FLUID,OTHER RIGHT STERNO-CLAVICULAR PUS.
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___:
STAPH AUREUS COAG +. SPARSE GROWTH OF TWO COLONIAL
MORPHOLOGIES.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN-------------<=0.25 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
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.
___ 3:25 pm TISSUE STERNOCLAVICULAR JOINT (RIGHT).
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final ___:
Reported to and read back by ___. ___ ___ 12:20PM.
STAPH AUREUS COAG +. RARE GROWTH.
SENSITIVITIES PERFORMED ON CULTURE # 350-1561K ___.
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
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.
___ CXR :
No acute cardiopulmonary process
___ Left ___:
No evidence of deep vein thrombosis in the left leg
Brief Hospital Course:
Mr. ___ was evaluated in the Emergency Room by the Thoracic
Surgery service and admitted to the hospital with recurrent pain
and erythema over the right sternoclavicular joint. He had
recently stopped a 6 week course of IV Vancomycin just shy of a
few days of completion due to a severe body rash (DRESS) and his
symptoms recurred about a week later. He was admitted to the
hospital for further management.
He was seen by the Infectious Disease service and started on
Daptomycin. On ___ he was taken to the Operating Room and
underwent debridement of his right sternoclavicular joint and
multiple cultures were taken. He tolerated the procedure well
and returned to the PACU in stable condition. The pain service
was also actively involved as he had been using heroin prior to
coming in to the hospital. He maintained stable hemodynamics and
his pain was well controlled with a Dilaudid PCA and Ketamine.
Following transfer to the Surgical floor he underwent dressing
changes daily and his pain regimen was changed to Methadone,
Gabapentin and a Dilaudid PCA. His Methadone was gradually
increased based on his use of the PCA and he was able to use his
incentive spirometer effectively as well as ambulate frequently.
His PCA was stopped on ___ and he was given Dilaudid ___ mg
every 4 hours as needed along with Methadone 25 mg TID and
Naprosyn.
VAC dressing were started on ___ with use of a white sponge
at the base as the jugular vein was visible. He tolerated
dressing changes every 3 days and the base of the wound was
cleaning up nicely with beefy red tissue at the base. The VAC
was removed prior to transfer and a saline wet to dry dressing
was placed.
The ID service recommended 6 weeks of treatment with Nafcillin
for MSSA osteomyelitis. He had a PICC line placed on ___
for long term therapy which will continue through ___. Due
to his VAC dressing and IV antibiotics he will need rehab for
completion of this therapy. His wound will be followed buy the
Thoracic Surgery service on a regular basis and if needed the
Plastic Surgery service will be consulted after completion of
treatment. He will also be followed by the Infectious Disease
service for antibiotic management and weekly lab follow up.
Due to his heroin addiction he will need to have social service
help him arrange follow up in a ___ as well as NA
or other group therapy. After a long hospital stay he was
discharged to rehab on ___ for continued management.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Hydrochlorothiazide 12.5 mg PO DAILY
2. Naproxen 500 mg PO Q8H:PRN pain
3. Aspirin 650 mg PO Q6H:PRN H/A
4. Buprenorphine-Naloxone (8mg-2mg) Dose is Unknown SL DAILY
none in last month as he started heroin use again
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
2. Gabapentin 900 mg PO TID pain
3. Heparin 5000 UNIT SC TID
4. Methadone 25 mg PO TID
RX *methadone 10 mg 2.5 tabs by mouth three times a day Disp
#*200 Tablet Refills:*0
5. Mirtazapine 15 mg PO HS
6. nafcillin *NF* 2 gram INTRAVENOUS EVERY 4 HOURS MSSA
osteomyelitis Reason for Ordering: +MSSA fluid culture, patient
has osteomyelitis - switching off of daptomycin
thru ___
7. Sarna Lotion 1 Appl TP QID:PRN itchyness
8. Labetalol 100 mg PO BID
Please hold for SBP <130 HR<70
9. Clonidine Patch 0.1 mg/24 hr 1 PTCH TD QTHUR
10. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
11. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
RX *Dilaudid 4 mg ___ tablet(s) by mouth every four (4) hours
Disp #*200 Tablet Refills:*0
12. Naproxen 500 mg PO Q8H:PRN pain
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
MSSA Right sternoclavicular joint infection.
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 surgical debridement of
your right collarbone infection and antibiotic therapy. You are
doing well and will need long term antibiotics as well as VAC
dressing therapy to help clean up the wound.
* A PICC line has been placed for long term antibiotics and the
Infectious Disease service will continue to follow you as an out
patient.
* Your VAC dressing will be changed ___ 3 days and if needed
you will be referred to the plastic surgeons later on if plastc
surgery is necessary.
* Continue to walk frequently to prevent clots and use your
incentive spirometer hourly along with deep breathing to prevent
any pulmonary problems.
* Eat well and stay well hydrated to promote healing.
* You will continue to need pain medication and will also need
to follow up with your pain doctor who prescribed Suboxone in
the past.
* If you develop any fevers > 101, chills, increased redness or
pain or any other symptoms that concern you please call Dr.
___ at ___.
Followup Instructions:
___
|
10100918-DS-5 | 10,100,918 | 27,236,715 | DS | 5 | 2179-08-29 00:00:00 | 2179-08-29 18:58:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
___ Cardiac catheterization with deployment of 2 ___ to
proximal LAD
History of Present Illness:
Mr. ___ is a ___ year-old gentleman with a PMH of HTN, tobacco
abuse and COPD, now presenting with chest pain, found to have an
unstable/ruptured LAD plaque and underwent 2 DES on cardiac
catheterization.
Pt reports having intermittent and worsening chest pain for the
past three weeks. At first, it was ___ in intensity, lasted
for only a few minutes at a time, a few times per day, and was
located under his sternum. A few days prior to presentation
___, 3d PTA), he developed ___ substernal pain while
taking a shower. Pain was worse with exertion (going up stairs)
and has also woken him from sleep. He experienced dyspnea,
diaphoresis, L arm tingling, and palpitations (no nausea) along
with the pain. After seeing his PCP, he began taking aspirin 325
mg PO daily for three days prior to this admission.
When he presented to cardiology clinic on ___, he was
diaphoretic from walking from his home in ___. He had
reported that the chest pain was occurring at increased
frequency and intensity, approximately ___ times per hour. In
clinic, he was noted to have R arm BP 145/100 and L arm BP
150/100. His EKG showed NSR @ 84 bpm, LVH with early
repolarization, but no evidence of ischemia. He was thence sent
to the ED for serial cardiac enzymes, CTA to rule out aortic
dissection, and possible stress test.
In the ED, initial vitals were: pain ___, T 97.1, HR 82, BP
132/92, RR 18, SaO2 98% RA. Labs were notable for normal CE's x2
(trp < 0.01, MB 2, CK 54; then trp < 0.01, MB 2, CK 56), with
all other labs WNL. CTA showed no acute cardiopulmonary process,
and no evidence of pulmonary embolism or aortic dissection. EKG
showed possible ___ and ___ STD in inferior leads and
STE in V2-3. In the ED, he received Sertraline 50mg, ___ 325mg
po ___, Enalapril 5mg and Zofran 2mg. In cath, pt received
Clopidogrel 600mg po ___ 325mg po x1. He underwent stress
test which was found to be positivewith STE in V1-3.
He underwent a catheterization and was found to have an
unstable/ruptured LAD plaque. He underwent placement of ___ 2
to lesion. He experienced some pain during proceudre but this
resolved after procedure. He was started on integrillin gtt with
a plan to continue gtt for 12hrs. He was also started on
Ticagrelor.
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 paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope
or presyncope.
On arrival to the floor, he reports ___ L lateral chest pain in
L MCL below nipple radiating to MAL under rib.
Past Medical History:
1. CARDIAC RISK FACTORS: (-) Diabetes, (+) Dyslipidemia, (+)
Hypertension
2. CARDIAC HISTORY: none
3. OTHER PAST MEDICAL HISTORY:
- Tobacco abuse
- COPD/Asthma
- Depression
- Kidney stones
- R Inguinal hernia repair ___ ago)
- Chronic back pain
Social History:
___
Family History:
FAMILY HISTORY: None. No family history of early MI, arrhythmia,
cardiomyopathies, or sudden cardiac death; otherwise
non-contributory. Grandfather with hx of throat cancer.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: BP= 149/94 HR= 70 RR= 16, O2 sat= 96%RA
General: Well appearing male in NAD
HEENT: PERRL, EOMI, MMM, NCAT
Neck: Supple, no JVD, LAD or thyromegaly
CV: RRR, no MRG, reproducible CP at L lateral chest wall
Lungs: LCTA-bl, no w/r/r
Abdomen: Soft, NTND, +NABS
Ext: FROM, no c/e/e
Neuro: CNII-XII inact, sensation grossly intact, strength ___
throughout.
Skin: No rashes
DISCHARGE PHYSICAL EXAMINATION:
VS: 98.8, 151/105, 65, 18, 97%RA; wt 75.1kg
General: Well appearing male in NAD
HEENT: PERRL, EOMI, MMM, NCAT
Neck: Supple, no JVD, LAD or thyromegaly
CV: RRR, no MRG, reproducible CP at L lateral chest wall
Lungs: LCTA-bl, no w/r/r
Abdomen: Soft, NTND, +NABS
Ext: FROM, no c/e/e; good pulses at R TR-band site
Neuro: CNII-XII inact, sensation grossly intact, strength ___
throughout.
Skin: No rashes
Pertinent Results:
ADMISSION LABS:
___ 12:56PM BLOOD WBC-9.8 RBC-5.58# Hgb-16.4# Hct-48.6#
MCV-87 MCH-29.3 MCHC-33.7 RDW-13.4 Plt ___
___ 12:56PM BLOOD Neuts-60.0 ___ Monos-4.4 Eos-2.9
Baso-1.9
___ 12:56PM BLOOD Glucose-99 UreaN-15 Creat-0.8 Na-139
K-4.4 Cl-101 HCO3-25 AnGap-17
___ 12:56PM BLOOD CK-MB-2
___ 12:56PM BLOOD cTropnT-<0.01
___ 08:00PM BLOOD CK-MB-2 cTropnT-<0.01
OTHER RELEVANT LABS:
___ 12:56PM BLOOD CK-MB-2
___ 12:56PM BLOOD cTropnT-<0.01
___ 08:00PM BLOOD CK-MB-2 cTropnT-<0.01
___ 01:15PM BLOOD cTropnT-<0.01
___ 06:45PM BLOOD cTropnT-0.13*
___ 07:11AM BLOOD CK-MB-5 cTropnT-0.11*
___ 07:11AM BLOOD Triglyc-292* HDL-33 CHOL/HD-6.3
LDLcalc-118
___ 07:11AM BLOOD %HbA1c-PND
DISCHARGE LABS:
___ 07:11AM BLOOD WBC-9.6 RBC-5.16 Hgb-15.0 Hct-44.3 MCV-86
MCH-29.0 MCHC-33.8 RDW-13.5 Plt ___
___ 07:11AM BLOOD Glucose-88 UreaN-13 Creat-0.7 Na-136
K-4.6 Cl-102 HCO3-24 AnGap-15
___ 07:11AM BLOOD CK-MB-5 cTropnT-0.11*
___ 07:11AM BLOOD Calcium-9.4 Phos-3.2# Mg-2.2 Cholest-209*
___ 07:11AM BLOOD %HbA1c- PENDING
IMAGING:
CTA ___:
FINDINGS:
CTA THORAX: The aorta and great vessels are well opacified with
no evidence of aneurysmal formation, intramural hematoma or
dissection. The intrathoracic aorta is of normal caliber
throughout. The pulmonary arteries are well opacified to the
subsegmental level with no evidence of filling defects within
the main, right, left, lobar, segmental or subsegmental
pulmonary arteries. There is no evidence of right heart strain.
CT THORAX: The airways are patent to the subsegmental level.
There is no axillary, hilar or mediastinal lymph node
enlargement. No pleural or pericardial effusion is present.
Lung windows demonstrate no evidence of focal opacity within the
lungs. The thyroid gland enhances homogeneously. The esophagus
is unremarkable. Although this study is not designed for
evaluation of subdiaphragmatic structures, there is a partially
imaged intermediate density complex cyst within the upper pole
of the left kidney, previously identified on renal ultrasound
from ___. Otherwise, the visualized solid organs
and stomach are unremarkable. OSSEOUS STRUCTURES: No lytic or
blastic lesions suspicious for malignancy is present.
IMPRESSION:
1. No evidence of pulmonary embolism or aortic dissection.
2. Partially visualized intermediate density complex cyst within
the upper pole of the left kidney for which follow up ultrasound
is recommended to ensure stability from the prior ultrasound of
___.
STRESS TEST ___:
INTERPRETATION: This ___ yo man with a PMH of HTN and asthma was
referred to the lab for evaluation of chest discomfort. The
patient
exercised for 6.5 minutes on ___ protocol and was stopped
for
progressive anginal symptoms and ST segment elevation. The
estimated
peak MET capacity was 7.5 which represents a fair exercise
tolerance for
his age. At exercise, the patient reported ___ central chest
pain which
rapidly progressed to a ___ at peak exercise. This discomfort
resolved
with the administration of 4L O2 of via nasal cannula by 2
minutes in
recovery. At peak exercise there was 1-3 mm ST segment elevation
in
leads V1-4. There were no significant reciprocal ST segment
changes
seen. The STE resolved by 2 minutes in recovery. The rhythm was
sinus
with rare isolated APBs and occasional isolated VPBs.
Appropriate HR
response to exercise. Hypertension at rest with an exaggerated
BP
response to exercise.
IMPRESSION: Marked ischemic changes with rapidly progressive
anginal
symptoms. Fair exercise tolerance. Echo report sent separately.
STRESS ECHO ___:
The aortic valve appears bicuspid.
The patient exercised for 6 minutes 30 seconds according to a
___ treadmill protocol ___ METS) reaching a peak heart rate
of 150 bpm and a peak blood pressure of 200/108 mmHg. The test
was stopped because of anginal pain. The test was stopped
because of ischemic ST changes (see exercise report for
details). This level of exercise represents a fair exercise
tolerance for age. In response to stress, the ECG showed
ischemic ST changes (see exercise report for details). There is
resting systolic and diastolic hypertension. There were normal
blood pressure and heart rate responses to stress.
Resting images were acquired at a heart rate of 71 bpm and a
blood pressure of 156/104 mmHg. These demonstrated regional left
ventricular systolic dysfunction with apical hypokinesis. The
remaining segments contracted wel (LVEF = 50 %). Right
ventricular free wall motion is normal. There is no pericardial
effusion. Doppler demonstrated no aortic stenosis, aortic
regurgitation or significant mitral regurgitation or resting
LVOT gradient.
Echo images were acquired within 74 seconds after peak stress at
heart rates of 150 - 93 bpm. These demonstrated new regional
dysfunction with extensive apical, anterior, and septal
hypokinesis. The remaining segments augment appropriately.
IMPRESSION: fair functional exercise capacity. ischemic ECG
changes with 2D echocardiographic evidence of inducible ishemia
at achieved workload.
___ CARDIAC CATH (perlim):
L dominant
LAD - diffuse ___ 80% stenosis, hazy
LCX - 60% after large OM
___ 2 to LAD
TTE ___:
The left atrium is normal in size. The estimated right atrial
pressure is ___ mmHg. Overall left ventricular systolic function
is borderline (LVEF 50%). No definite regional wall motion
abnormalities are seen. Tissue Doppler imaging suggests a normal
left ventricular filling pressure (PCWP<12mmHg). Right
ventricular chamber size and free wall motion are normal. The
aortic valve is bicuspid. The aortic valve leaflets are
moderately thickened. There is no aortic valve stenosis. Trace
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Physiologic mitral regurgitation is seen
(within normal limits). The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion. No
suprasternal notch images were obtained to assess for
coarctation.
IMPRESSION: Bicuspid aortic valve without evidence for
significant stenosis or regurgitation. No other clinically
significant valvular disease is detected. Borderline normal LV
function without definite evidence of regional abnormality.
Compared with the prior study (images reviewed) of ___,
the apical contractile function appears marginally improved.
PRIOR IMAGING:
RENAL US ___
FINDINGS: The right kidney measures 12 cm. The left kidney
measures 11.2 cm. Neither kidney demonstrates hydronephrosis or
large masses. Bilateral nonobstructing echogenic foci measuring
up to 5 mm on the right and 7 mm on the left likely represent
small stones. Within the left upper pole, there is an 8 x 9 x
11 mm avascular hypoechoic lesion with increased through
transmission and internal echogenic debris, which likely
represents a small hemorrhagic cyst. Both kidneys demonstrate
normal cortical thickness with preserved corticomedullary
differentiation. The urinary bladder is partially distended and
unremarkable.
IMPRESSION:
1. Bilateral non-obstructing nephrolithiasis measuring up to 5
mm on the
right and 7 mm on the left.
2. 11-mm renal cyst with echogenic debris in the left upper
pole. While this finding is likely benign (hemorrhagic cyst), a
follow-up ultrasound is recommended in six months to ensure
stability.
Brief Hospital Course:
Mr. ___ is a ___ year-old gentleman with a PMHx of HTN,
tobacco abuse and COPD, now presenting with chest pain, found to
have an unstable/ruptured LAD plaque and underwent ___
x 2 to LAD lesion.
# CORONARIES:
Pt presented with unstable angina and was found to have an
impressively positive stress test. He underwent cath with
placement of ___ 2 to LAD. He was subsequently treted with
integrillin gtt for 12h. Pt was thought to have low risk of
bleeding so was started on ticagrelor. He is motivated to quit
smoking. He also received ___ 81mg po daily, Metop XL 25mg
daily, enalopril 20mg po daily, and atorvastatin 80mg po daily.
# PUMP:
Pt was found to have borderline systolic function on TTE (EF
50%). BB, ACEi and Statin were started as above. Pt remained
asymptomatic.
# RHYTHM:
NSR. Good rate control was achieved with metoprolol as above
# HTN
Pt's BP was elevated to ~150s/100s shortly post-cath. Enalapril
was re-started at home dose and BB/ACEi was started as above.
# COPD
Pt has hx of COPD and notes chronic DOE/wheezing at baseline. He
received nebulizertherapy with duonebs but later reported not
using his albuterol inhaler at home.
# L Kidney Diensity
Pt was found to have a denisty in the L kidney as an incidental
finding on CTA. Ultrasound follow-up was recommended.
TRANSITIONAL ISSUES:
# CODE: Full Code
# CONTACT: ___ (Partner; ___
- Please contine smoking cessation conselling
- Please repeat TTE within several months and reassess cardiac
structure/function
- Please note: Ticagrolor started on ___
- Please follow up final cath report from ___
***** Please obtain follow-up for left renal cyst. Please
compare to US from ___ (please see results section)
*****
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Enalapril Maleate 20 mg PO DAILY
hold for SBP < 100
2. Sertraline 200 mg PO DAILY
3. Aspirin 325 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet,delayed release (___) by mouth
daily Disp #*30 Tablet Refills:*0
2. Enalapril Maleate 20 mg PO DAILY
3. Sertraline 200 mg PO DAILY
4. Atorvastatin 80 mg PO DAILY
RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
5. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet extended release 24
hr(s) by mouth daily Disp #*30 Tablet Refills:*0
6. TiCAGRELOR 90 mg PO BID
RX *ticagrelor [Brilinta] 90 mg 1 tablet(s) by mouth two times
per day Disp #*60 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS: Unstable angina
SECONDARY DIAGNOSES: tobacco abuse, hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure to participate in your care here at ___
___! You were admitted with chest pain, and
underwent an exercise stress test that showed findings
concerning for heart disease. You underwent cardiac
catheterization and received placement of 2 stents to your left
main coronary artery. Please follow up with your cardiologist as
advised below.
*It is incredibly important that you quit smoking. If you need
additional assistance with this task, please talk with your
primary care doctor. He may be able to provide you with nicotine
patches or other pharmacologic support.*
Also, please ask your doctor to perform an ultrasound of your
left renal cyst to ensure that it is not enlarging.
Best Regards,
Your ___ Medicine Team
Followup Instructions:
___
|
10101070-DS-9 | 10,101,070 | 29,592,610 | DS | 9 | 2153-12-31 00:00:00 | 2154-01-01 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:
RUQ abdominal pain
Major Surgical or Invasive Procedure:
PTC drain (___)
Biliary Drain Replacement (___)
PICC line (___)
History of Present Illness:
Mr. ___ is a ___ with dementia with history of HTN, CKD
(baseline Cr 1.2-1.3) h/o cholangitis in ___ with placement
of biliary drain which is still in place presented from nursing
home with two days of fever, RUQ abdominal pain and anorexia and
found to have acute cholecystitis. Patient was reportedly
febrile to 104 at his nursing institution and was given
ertapenem. A CT scan here at ___ is consistent with acute
cholecystitis with an otherwise decompressed biliary tree and
the previously placed I/E PTBD in good position.
Per report he also had an episode on SVT prior to arrival which
converted to sinus rhythm with adenosine. There isno clear
documentation regarding the events.
Of note patient was admitted in ___ with cholangitis and
sepsis due to E- colic bactermia. He was treated with zosyn and
bilairy drain was placed.
In the ED initial vitals; 102 102/64 18 95% RA. His labs were
notable for WBC of 5.3, lacate of 1, Cr 1.3. Other than alk phos
of 157, rest of his LFTs were within normal limits. CT abdomen
and pelvis was performed ___ showed findings consistent with
cholesystitis; there was also some stranding around transverse
colon with question of diverticulitis. Surgery was consulted
who felt patient had acute cholecyctitis and recommended ___
drainage. Patient was given vancomycin and zosyn in the ED.
Blood cultures were sent. Patient was transiently hypotentive to
SBP ___ left IJ was placed and patient was given 2L of IVF.
Currently on the floor patient is awake, and alert but oriented
only x1 which is his baseline. Patient denies any chest pain,
shortness of breath, nausea or vomiting. Reports some
discomfort int he RUQ area.
Past Medical History:
Dementia
MVR ___ not mechanical; not on anticoagulation
HTN
Prediabetes
BPH
CKD
? h/o HIT
Duodenal Ulcers / UGIB s/p EGD with clipping and epi injection
___
Social History:
___
Family History:
unknown
Physical Exam:
Admission Physical:
Vitals- 99.9 100/60 ___ 95%RA
General- elderly gentleman appears comfortable and in no acute
distress
HEENT- PEELR, sclera anicteric
Neck- supple
CV- RRR, nl s1, s2, no murmurs
Lungs- Clear to auscultation bilaterally
Abdomen- +BS, soft, non-distended, tender to palpation in the
RUQ area with rebound and guarding
GU- foley in place
Ext- Warm and well perfused, no edema
Neuro- alert and oriented x3.
.
Discharge Physical Exam:
Vitals- 98.3, 107/65, 75, 18, 95% RA
General- elderly gentleman appears comfortable and in no acute
distress
HEENT- PEELR, sclera anicteric
Neck- supple
CV- RRR, nl s1, s2, no murmurs
Lungs- crackles at the lung bases
Abdomen- some RUQ tenderness, +BS, soft, non-distended, dressing
c/d/i, PTC had minimal bilious drainage
GU- foley in place
Ext- Warm and well perfused, no edema
Neuro- alert and oriented x3.
Pertinent Results:
Admission Labs:
___ 12:20AM BLOOD WBC-5.0 RBC-4.24*# Hgb-11.3* Hct-34.3*
MCV-81*# MCH-26.7* MCHC-33.0 RDW-15.4 Plt ___
___ 12:20AM BLOOD Neuts-76.4* ___ Monos-1.5*
Eos-0.1 Baso-0.5
___ 12:20AM BLOOD ___ PTT-32.4 ___
___ 12:20AM BLOOD Glucose-178* UreaN-19 Creat-1.3* Na-140
K-4.1 Cl-105 HCO3-24 AnGap-15
___ 04:00AM BLOOD ALT-10 AST-17 AlkPhos-94 TotBili-0.4
___ 05:15AM BLOOD Calcium-7.7* Phos-3.7 Mg-2.1
___ 12:36AM BLOOD Lactate-1.3
.
Interval Labs:
___ 04:00AM BLOOD WBC-6.9 RBC-3.62* Hgb-9.7* Hct-29.3*
MCV-81* MCH-26.7* MCHC-33.0 RDW-15.4 Plt ___
___ 04:00AM BLOOD Glucose-135* UreaN-15 Creat-1.2 Na-140
K-3.5 Cl-105 HCO3-23 AnGap-16
___ 04:00AM BLOOD ALT-10 AST-17 AlkPhos-94 TotBili-0.4
___ 04:00AM BLOOD Lipase-11
___ 04:00AM BLOOD Calcium-7.2* Phos-2.3* Mg-1.6
___ 04:12AM BLOOD Type-CENTRAL VE Temp-37.4 pO2-37* pCO2-36
pH-7.41 calTCO2-24 Base XS-0
___ 04:12AM BLOOD Lactate-0.8
___ 03:09AM BLOOD WBC-5.5 RBC-3.67* Hgb-9.8* Hct-29.8*
MCV-81* MCH-26.7* MCHC-32.9 RDW-15.4 Plt ___
___ 03:09AM BLOOD Glucose-106* UreaN-15 Creat-1.2 Na-137
K-3.7 Cl-105 HCO3-26 AnGap-10
___ 03:09AM BLOOD Calcium-7.5* Phos-2.2* Mg-2.1
___ 05:15AM BLOOD WBC-5.3 RBC-3.77* Hgb-10.2* Hct-30.9*
MCV-82 MCH-27.0 MCHC-33.0 RDW-15.1 Plt ___
___ 05:15AM BLOOD Glucose-112* UreaN-17 Creat-1.4* Na-142
K-3.6 Cl-106 HCO3-29 AnGap-11
___ 05:15AM BLOOD Calcium-7.7* Phos-3.7 Mg-2.1
___ 05:15AM BLOOD Vanco-14.6
___ 06:00AM BLOOD WBC-5.0 RBC-3.76* Hgb-10.2* Hct-30.4*
MCV-81* MCH-27.1 MCHC-33.5 RDW-15.0 Plt ___
___ 06:00AM BLOOD Glucose-131* UreaN-17 Creat-1.3* Na-142
K-3.4 Cl-107 HCO3-30 AnGap-8
___ 06:00AM BLOOD ALT-8 AST-19 LD(LDH)-149 AlkPhos-145*
TotBili-0.4
___ 06:00AM BLOOD WBC-5.0 RBC-3.81* Hgb-10.2* Hct-30.8*
MCV-81* MCH-26.7* MCHC-33.0 RDW-15.0 Plt ___
___ 06:00AM BLOOD Glucose-114* UreaN-16 Creat-1.3* Na-143
K-3.8 Cl-106 HCO3-29 AnGap-12
___ 06:00AM BLOOD ALT-22 AST-41* AlkPhos-128 TotBili-0.4
___ 06:47AM BLOOD WBC-5.9 RBC-4.24* Hgb-11.5* Hct-34.2*
MCV-81* MCH-27.0 MCHC-33.5 RDW-15.1 Plt ___
___ 01:20PM BLOOD WBC-5.3 RBC-4.22* Hgb-11.4* Hct-34.3*
MCV-81* MCH-27.1 MCHC-33.3 RDW-15.2 Plt ___
___ 06:47AM BLOOD Glucose-115* UreaN-18 Creat-1.5* Na-142
K-4.1 Cl-105 HCO3-32 AnGap-9
___ 01:20PM BLOOD Glucose-146* UreaN-18 Creat-1.4* Na-139
K-3.9 Cl-103 HCO3-27 AnGap-13
___ 06:47AM BLOOD ALT-42* AST-69* AlkPhos-141* TotBili-0.5
___ 01:20PM BLOOD ALT-44* AST-70* AlkPhos-137* TotBili-0.4
___ 06:47AM BLOOD Calcium-8.7 Phos-3.5 Mg-2.1
___ 06:47AM BLOOD Vanco-17.1
.
Discharge Labs:
___ 06:32AM BLOOD WBC-5.4 RBC-3.55* Hgb-9.6* Hct-28.6*
MCV-81* MCH-27.0 MCHC-33.5 RDW-15.4 Plt ___
___ 06:32AM BLOOD Glucose-105* UreaN-17 Creat-1.3* Na-143
K-3.6 Cl-106 HCO3-26 AnGap-15
___ 06:32AM BLOOD ALT-34 AST-44* AlkPhos-105 TotBili-0.3
.
Microbiology:
# Blood Cultures x2 (___):
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
ID REQUESTED BY ___ ___/.
Isolated from only one set in the previous five days
SENSITIVITIES
PERFORMED ON REQUEST..
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN CLUSTERS.
# Bile Cultures (___): ANAEROBIC CULTURE (Final ___:
CLOSTRIDIUM PERFRINGENS. MODERATE GROWTH.
# Blood Cultures x2 (___): Pending.
# Blood Cultures x2 (___): Pending.
# C-Diff. Amplification: C. difficile DNA amplification assay
(Final ___:
Reported to and read back by ___ ___ ___ AT 10:31.
CLOSTRIDIUM DIFFICILE.
Positive for toxigenic C. difficile by the Illumigene
DNA
amplification.
# Blood Cultures x1 (___): Pending.
.
Pathology: None.
.
Imaging/Studies:
# CT Abdomen and Pelvis with contrast (___) : IMPRESSION:
Cholelithiasis with distention of the gallbladder, gallbladder
wall hyperemia and significant surrounding stranding is most
consistent with cholecystitis. Stranding in the transverse colon
as it courses by the gallbladder is most likely secondary
inflammation. Diverticulitis is a consideration given the
diverticulosis in the region, though this is thought to be less
likely. Satisfactory position of the internal-external
intrahepatic biliary drain. No intrahepatic biliary duct
dilation. Unchanged bilateral simple and minimally complex renal
cysts. Unchanged appearance of Paget's disease.
# CXR (___): IMPRESSION: Left-sided IJ catheter tip is in
the mid SVC.
Bibasilar atelectasis and small right pleural effusion.
# RUQ US (___): IMPRESSION:Successful 8 ___ percutaneous
cholecystostomy tube placement under ultrasound guidance.
# CXR (___): IMPRESSION: Increasing bilateral pleural
effusions and interstitial edema. No consolidation to suggest
pneumonia.
# CBD drain Exchange (___): IMPRESSION: Successful
replacement of ___ biliary catheter over a wire. The catheter
should be exchanged in 3 months.
# PTC drain instertion (___): IMPRESSION: Successful
replacement of ___ biliary catheter over a wire. The catheter
should be exchanged in 3 months.
# CXR (___): The lung volumes are low. Improved aeration at
both lung bases with residual minor atelectasis remaining as
well as small pleural effusions, right greater than left.
Brief Hospital Course:
___ with dementia with history of HTN, CKD (baseline Cr 1.2-1.3)
h/o cholangitis presented with acute cholecystitis.
.
Acute Diagnoses:
.
# Acute Cholecystitis/Sepsis: On ___ pt had cholangitis sp
biliary drain and antibiotics. Patient presented with RUQ
abdominal pain and was found to have acute cholecystitis.
Surgery was consulted who recommended ___ perc drain. Patient had
new gallbladder drain placed. Bile culture grew GPC and GNR
therefore he was started on vancomycin and Zosyn. His blood
cultures grew GPC with speciation pending at the time of
transfer to the regular floor. He was fluid resuscitated with 6L
NS. He required Levophed for one day which was weaned off
successfully. His CBD drain was electively changed by ___ as well
during this admission. He no longer required pressors and was
transferred to the floor. BC showed GPC. On the floor
vancomycin and Zosyn were continued per ID's recommendations.
His vancomycin trough was low on ___ and his dose was increased
to 1250 mg/day. On ___ he recieved a PICC line and the IV
vancomycin was discontinued since the GPC came back as coag
negative staph and was most likely a contaminant. He will
continue Zosyn until ___ since the bile culture ultimately grew
out clostridium perfringes. His PTC drain cannot be pulled
until 4 weeks after placement and has minimal drainage (<20
cc/day). He will then need to return to the ___
___ clinic to have fluroscopy of drain to see if it could
be removed at that time. He will follow up in the acute care
surgery clinic on ___. He will also follow up in the
infectious disease clinic.
.
#GPC bacteremia: Initially it was thought this may have been
MRSA or MSSA bacteremia from his perc drain because the blood
cultures grew out gram positive cocci. IV vancomycin was
strarted on ___. The vancomycin dose was increased to 1250
mg/day on ___ due to a low vancomycin trough at that time. The
second set of blood cultures on ___ showed no growth and the
vancomycin was discontinued on ___ since the first set of
cultures only came back positive for coag negative staph.
.
#AOCKI: His creatinine rose to 1.4 from 1.2 on ___. This was
likely secondary to dehydration. It continued to rise to 1.5 on
___. All medications were renally dosed and he was given IVF
fluids. His creatitine then returned to baseline.
.
# C-diff: C-diff assay positive. Started on oral vanc on ___ and
will continue until ___.
.
Chronic Diagnoses:
.
# ? History of HIT: Per prior discharge summary. Heparin was
held and pneumoboots were used for DVT prophylaxis.
# Dementia: Alert and oriented x1 which is baseline per his son.
# Depression: Continued mirtazapine.
# BPH: He has a history of urinary retention. A Foley catheter
was placed in the ED. The Foley was discontinued on ___ and he
had no difficulty voiding during this hospital course.
.
Transitional Issues:
# Will follow up with the ___ surgery clinic on ___.
# Will follow up with the ___ clinic in ___ weeks.
# Will follow up with ___ in four weeks to assess the PTC drain.
# Will continue Zosyn through the PICC line for cholecystitis
with bile culture + for c. perfringes until ___ and he will
continue po vancomycin for C diff until ___.
Medications on Admission:
1. Bisacodyl 10 mg PO DAILY:PRN constipation
2. Docusate Sodium 100 mg PO BID
3. Gabapentin 300 mg PO HS
4. Mirtazapine 15 mg PO HS
5. Multivitamins 1 TAB PO DAILY
6. Senna 1 TAB PO DAILY
7. Tobramycin-Dexamethasone Ophth Susp 1 DROP BOTH EYES BID
8. Acetaminophen 650 mg PO Q6H:PRN pain
9. Artificial Tears Preserv. Free ___ DROP BOTH EYES BID
10. Omeprazole 40 mg PO BID
11. zinc oxide 20 % Topical each shift
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Artificial Tears Preserv. Free ___ DROP BOTH EYES BID
3. Bisacodyl 10 mg PO DAILY:PRN constipation
4. Docusate Sodium 100 mg PO BID
5. Gabapentin 300 mg PO HS
6. Mirtazapine 15 mg PO HS
7. Multivitamins 1 TAB PO DAILY
8. Omeprazole 40 mg PO BID
9. Senna 1 TAB PO DAILY
10. Tobramycin-Dexamethasone Ophth Susp 1 DROP BOTH EYES BID
11. Piperacillin-Tazobactam 4.5 g IV Q8H
12. Vancomycin Oral Liquid ___ mg PO Q6H
13. zinc oxide 20 % Topical each shift
14. Lidocaine 5% Patch 1 PTCH TD DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Acute Cholecystitis
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You came to the hospital with abdominal pain. It was found
that your blood pressure was very low and had a CT scan that
showed that you had an infection in your gall bladder. You were
admitted to the intensive care unit were you given medicine to
raise your blood pressure. Interventional radiology exchanged
the drain that was already in your gall bladder and added a
second drain. You were given IV antibiotics. You had a PICC line
placed so that you can continue your IV antibiotics which you
will continue until ___.
You had diarrhea and were found to have a bacterial infection
in your large intestion. You were given an oral antibiotic to
treat this infection. You will continue this antibiotic for 10
days after the IV antibiotics finish ending on ___.
Please follow up with the surgery clinic on ___, the
infectious disease clinic within ___ weeks. The hospital will
call you about your infectious disease appointment, if you do
not here from them in 2 business days call ___ to
schedule an appointment. Call the ___ clinic
at ___ at the end of ___.
Once the drain output is less than 20 cc/day and you are
evaluated by interventional radiology in one month,
interventional radiology may decide to remove the drain.
Followup Instructions:
___
|
10101282-DS-18 | 10,101,282 | 25,540,971 | DS | 18 | 2161-11-23 00:00:00 | 2161-11-23 09:59:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
penicillin G / Keflex / IV Dye, Iodine Containing Contrast Media
/ Adult Low Dose Aspirin / peanut / latex / Tetracyclines /
coconut
Attending: ___.
Chief Complaint:
Flank pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ male with the past medical
history of HIV on ART, depression and anxiety with recent
inpatient psych admission at ___, ___ Sarcoma,
melanoma
who presents with flank pain, SI, depression. Patient reports L
flank pain started earlier on day of presentation. He describes
the onset as being sudden, nagging, dull pain but also at times
sharp. At its worst, pain was ___, currently ___. He endorses
nausea with pain but no emesis. Also felt warm today but states
he was outside and attributed it to being in the sun. Did not
check temperature. Denies dysuria but felt urine looked dark.
Denies diarrhea. Reports he had 4 glasses of wine 2 days prior
to
admission but no EtOH since then. Denies drug use. Denies trauma
to the area. Patient reports he was recently discharged from
___ psych facility; he left with an acquaintance from the
facility who was supposed to give him a ride back to ___.
However this person stole patient's medications and left him
stranded in ___. Patient reports feeling very angry about
this. He has had pervasive feelings of helplessness for some
time, also reports passive suicidal ideation, no plans. Denies
AVH.
In the ED, patient's vitals were as follows: T 99 HR97 RR 18 BP
137/88 100% on RA. CBC with mild leukocytosis, CMP wnl. UA with
2
RBC, 2 WBCs. CT A/P with mild fat stranding of L kidney. EtOH
level 29. he was given 1L NS. Patient was seen by psych for SI,
placed under section. He was admitted to medicine for further
work up and management of flank pain.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
HIV on ART
Kaposi Sarcoma
Melanoma
Depression
Anxiety
Social History:
___
Family History:
Reviewed. None pertinent to this hospitalization
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, 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, strength grossly full
and symmetric bilaterally in all limbs, TTP over L flank/lower
ribs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect, dismissive of concerns over
safety/SI
Pertinent Results:
___ 07:20AM BLOOD Glucose-80 UreaN-15 Creat-0.7 Na-140
K-4.0 Cl-105 HCO3-21* AnGap-14
___ 07:20AM BLOOD Calcium-8.5 Phos-3.0 Mg-1.8
___ 03:25PM BLOOD ASA-NEG Ethanol-29* Acetmnp-NEG
Tricycl-NEG
CT scan Abd Pelvis
1. Equivocal minimal asymmetric left perinephric stranding.
Ill-defined
incompletely assessed hypodensities in the upper pole of the
left kidney,
which could represent cysts, but pyelonephritis might have a
similar
appearance. Recommend correlation with urinalysis and physical
exam.
2. No evidence of urolithiasis or hydronephrosis. Normal
appendix.
Blood culture NGTD
Urine culture less than 10,000 CFU
Brief Hospital Course:
Mr. ___ is a ___ man with HIV on ART, depression and
anxiety with recent inpatient psych admission at ___,
___ Sarcoma, melanoma who presented with flank pain, SI,
depression.
L flank pain:
Possible pyelonephritis on CT scan: His CT scan was equivocal
for stranding near left kidney. His UA was negative with a
negative urine culture. He was initially treated with Bactrim
but when culture turned negative this was stopped. His pain at
this time appears MSK.
Suicidal ideation - severe depression: Placed on ___ with
1:1 sitter initially which was withdrawn by psychiatry on ___
due to continued stability. Psych did not feel that patient
needed inpatient psychiatric hospitalization.
Health insurance was a significant issue this admission and SW
worked hard to assist patient with reactivating his mass health.
Other issue is that by the end of hospitalization patient was
homeless. He was provided extensive information about resources
including information about intake in a partial program starting
___.
- started prazosin and PRN seroquel 50mg BID prn anxiety
- continued duloxetine
- continued Seroquel qhs
- continued buspirone TID
- trazodone prn insomnia
- hydroxyzine prn anxiety
CHRONIC/STABLE PROBLEMS:
HIV on ART - continued home ART
Allergic rhinitis/allergies - continued loratidine
Asthma - continued albuterol prn
Tobacco cessation/Nicotine dependence - continued nicotine patch
daily
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Albuterol Inhaler 2 PUFF IH Q2H:PRN wheezing
3. BusPIRone 15 mg PO TID
4. DiphenhydrAMINE 50 mg PO Q6H:PRN allergy, anxiety
5. DULoxetine 60 mg PO DAILY
6. EPINEPHrine 0.1 mg/mL injection as directed
7. Famotidine 20 mg PO BID
8. Gabapentin 800 mg PO QID
9. HydrOXYzine 100 mg PO Q6H:PRN itching, anxiety
10. Ibuprofen 600 mg PO Q8H:PRN Pain - Moderate
11. Loratadine 10 mg PO DAILY
12. Nicotine Patch 21 mg TD DAILY
13. Nicotine Polacrilex 2 mg PO Q1H:PRN nicotine craving
14. Emtricitabine-Tenofovir alafen (200mg-25mg) *DESCOVY* 1 TAB
PO DAILY
15. Tivicay (dolutegravir) 50 mg oral DAILY
16. Prazosin 1 mg PO QAM
17. Prazosin 7 mg PO QHS
18. Pseudoephedrine 30 mg PO Q6H:PRN nasal congestion
19. QUEtiapine Fumarate 100 mg PO TID:PRN anxiety
20. QUEtiapine Fumarate 200 mg PO QHS
21. TraZODone 100 mg PO QHS:PRN insomnia
Discharge Medications:
1. Lidocaine 5% Patch 1 PTCH TD QAM back pain
2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
3. Albuterol Inhaler 2 PUFF IH Q2H:PRN wheezing
RX *albuterol sulfate [ProAir HFA] 90 mcg 2 puffs inhaled every
two hours Disp #*1 Inhaler Refills:*0
4. BusPIRone 15 mg PO TID
RX *buspirone 15 mg 1 tablet(s) by mouth three times daily Disp
#*90 Tablet Refills:*0
5. DiphenhydrAMINE 50 mg PO Q6H:PRN allergy, anxiety
6. DULoxetine 60 mg PO DAILY
RX *duloxetine 60 mg 1 capsule(s) by mouth once daily Disp #*30
Capsule Refills:*0
7. Emtricitabine-Tenofovir alafen (200mg-25mg) *DESCOVY* 1 TAB
PO DAILY
RX *emtricitabine-tenofovir alafen [Descovy] 200 mg-25 mg 1
tablet(s) by mouth daily Disp #*30 Tablet Refills:*0
8. EPINEPHrine 0.1 mg/mL injection as directed
9. Famotidine 20 mg PO BID
10. Gabapentin 800 mg PO QID
RX *gabapentin 800 mg 1 tablet(s) by mouth four times daily Disp
#*120 Tablet Refills:*0
11. HydrOXYzine 100 mg PO Q6H:PRN itching, anxiety
RX *hydroxyzine HCl 50 mg 1 tablet by mouth every 6 hours Disp
#*50 Tablet Refills:*0
12. Ibuprofen 600 mg PO Q8H:PRN Pain - Moderate
13. Loratadine 10 mg PO DAILY
14. Nicotine Patch 21 mg TD DAILY
RX *nicotine [Nicoderm CQ] 21 mg/24 hour change patch once daily
daily Disp #*21 Patch Refills:*0
15. Nicotine Polacrilex 2 mg PO Q1H:PRN nicotine craving
16. Prazosin 1 mg PO QAM
RX *prazosin [Minipress] 2 mg 0.5 (One half) capsule(s) by mouth
every morning Disp #*15 Capsule Refills:*0
17. Prazosin 7 mg PO QHS
RX *prazosin [Minipress] 2 mg 4 capsule(s) by mouth every night
Disp #*120 Capsule Refills:*0
18. Pseudoephedrine 30 mg PO Q6H:PRN nasal congestion
19. QUEtiapine Fumarate 200 mg PO QHS
RX *quetiapine 50 mg 1 tablet(s) by mouth twice daily Disp #*60
Tablet Refills:*0
20. QUEtiapine Fumarate 100 mg PO TID:PRN anxiety
RX *quetiapine 200 mg 1 tablet(s) by mouth nightly Disp #*30
Tablet Refills:*0
21. Tivicay (dolutegravir) 50 mg oral DAILY
RX *dolutegravir [Tivicay] 50 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
22. TraZODone 100 mg PO QHS:PRN insomnia
RX *trazodone 100 mg 1 tablet(s) by mouth nightly Disp #*20
Tablet Refills:*0
Discharge Disposition:
Extended Care
Discharge Diagnosis:
1. Flank Pain
2. Depression
3. Suicidal ideation
4. HIV
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with flank pain and concern for a kidney
infection. You were started on antibiotics, but the urine
culture did not show an infection. It is likely that you have
muscular pain. You were given tylenol and ibuprofen and your
pain improved.
You continued to have suicidal ideations and our psychiatry team
titrated your medications.
It was a pleasure caring for you,
Your ___ Team
Followup Instructions:
___
|
10101287-DS-7 | 10,101,287 | 29,602,007 | DS | 7 | 2155-07-02 00:00:00 | 2155-07-02 13:13:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain, nausea, vomiting
Major Surgical or Invasive Procedure:
No surgical or invasive procedures performed during this
hospitalization.
History of Present Illness:
___ G3P1 at 20 weeks GA, s/p laparoscopic cholecysectomy on
___, here for less than 24 hours of epigastric pain and
one episode of vomiting. After her lap cholecycstectomy on
___, she reports to have been doing well, tolerating a regular
diet, and passing gas. Around 7 pm on ___, she started to
have increasing epigastric pain and was passing more gas. The
pain became gradually more intense. She tried drinking warm
water, Tums, and she took 2.5 mg oxycodone and Tylenol, but
nothing helped. The pain was exacerbated by respiration. At 2
am on ___ she vomited food, and she felt better but the pain
was still present.
She has never had such an episode before. Her gallstone attacks
were different, with worse pain. She denies fever, chills,
chest pain, diarrhea. She has occasional constipation due to
pregancy, though her last bowel movement was ___ and normal
consistency and color. She endorses "difficulty breathing" when
the pain was intense, but this has now improved. She has no
difficulty or burning with urination.
This morning the pain was better still and had since migrated
around her right lower ribs to include her lower back. She
presented to the ED with a sore stomach and lower back, and at
the time of admission feels that the pain has gone away.
Past Medical History:
G3P1 currently pregnant at 20 ___ GA with otherwise uneventful
pregnancy despite cholelithiasis necessitating cholecystectomy
Social History:
___
Family History:
FH: father had HTN, grandfather had DM and died of kidney
failure
Physical Exam:
Physical Exam on Admission:
Vitals: 98.3F, HR 68, BP 128/73, RR 18, 100% RA
General: alert, NAD, oriented x 3, pleasant, cooperative
HEENT: normocephalic, atraumatic, no scleral icterus, oral
mucosa
moist
CV: RRR, S1/S2 normal, no M/R/G
Resp: CTAB, no wheezes/rales/rhonchi
Abd: bowel sounds present, soft, nontender, nondistended but
gravid, no rebound or guarding; laparoscopic incisions are C/D/I
with Steri-Strips in place and no erythema/discharge/induration
Extremities: no edema, cords, tenderness bilaterally of the
lower
extremities; 2+ DP pulses bilaterally
Pertinent Results:
___ 09:50AM BLOOD WBC-7.9 RBC-4.43 Hgb-13.6 Hct-39.5 MCV-89
MCH-30.7 MCHC-34.5 RDW-12.6 Plt ___
___ 09:50AM BLOOD Neuts-81.4* Lymphs-14.1* Monos-3.9
Eos-0.5 Baso-0.1
___ 09:50AM BLOOD Glucose-84 UreaN-5* Creat-0.5 Na-137
K-4.2 Cl-104 HCO3-22 AnGap-15
___ 09:50AM BLOOD ALT-258* AST-436* AlkPhos-130*
TotBili-1.4
___ 09:50AM BLOOD Lipase-28
RUQ Ultrasound (___) Impression:
1. No intrahepatic bile duct dilation. Normal caliber CBD. No
proximal
ductal stones detected.
2. Coarsened liver echotexture, which may reflect hepatic
steatosis. More
advanced disease such as cirrhosis or fibrosis cannot be
excluded with this
technique.
___ 06:15AM BLOOD WBC-5.9 RBC-4.05* Hgb-12.2 Hct-36.3
MCV-90 MCH-30.0 MCHC-33.6 RDW-12.7 Plt ___
___ 06:15AM BLOOD ___
___ 06:15AM BLOOD Plt ___
___ 06:15AM BLOOD Glucose-84 UreaN-4* Creat-0.5 Na-138
K-4.3 Cl-107 HCO3-24 AnGap-11
___ 06:15AM BLOOD ALT-191* AST-184* AlkPhos-101 Amylase-44
TotBili-0.6
___ 06:15AM BLOOD Calcium-8.7 Phos-2.7 Mg-2.0
Brief Hospital Course:
The patient was admitted for observation from the ___
___ Emergency ___ on ___ with
less than 24 hours of abdominal pain and one episode of
nausea/vomiting. Of note, she is status post laparoscopic
cholecystectomy on ___. In the ED, her vital signs were
stable. Right upper quadrant abdominal ultrasound did not show
fluid collection.
At the time of admission her abdominal and back pain had
resolved, and she denied symptoms otherwise. She was taken to
the floor for monitoring and further diagnostic studies. She
was taken for MRCP, which showed a normal liver, a trace amount
of fluid at the inferior and lateral aspect of the liver,
without intrahepatic or extrahepatic biliary ductal dilation.
She was kept on sips of liquids overnight pending morning labs.
On ___ she continued to have no abdominal pain, nausea,
vomiting, or other symptoms. Morning labs demonstrated that her
transaminases and total bilirubin had decreased, and her
alkaline phosphatase had normalized. She was advanced to a
regular diet, which she tolerated well. She was felt to be
stable for discharge with followup with Dr. ___ in 2 weeks from
her surgery date. She will get outpatient liver function tests
before this visit. She understood and was in agreement with
this plan. She was discharged to home, ambulating
independently, tolerating a regular diet, without abdominal
pain, nausea, or vomiting.
Medications on Admission:
prenatal vitamins, oxycodone 2.5 mg PO Q4-6 hrs PRN pain,
Tylenol
Discharge Medications:
1. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO every ___ hours as
needed for pain: Do not take with other sedatives.
2. Tylenol ___ mg Tablet Sig: ___ Tablets PO every ___ hours as
needed for pain: Do not take more than 4000 mg of Tylenol per
day.
3. Outpatient Lab Work
Please draw blood and send for liver function tests, including:
ALT, AST, Alkaline Phosphatase, Total bilirubin, Amylase,
Lipase.
This should be done prior to office visit with Dr. ___, to
occur at some point between ___ and ___.
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:
You were admitted to ___ from
the Emergency Department with complaints of abdominal pain.
Your pain improved and on ___, you are ready for
discharge to home.
Continue to follow instructions regarding your cholecystectomy.
In brief:
- Take narcotic pain medications if needed (oxycodone 2.5 mg by
mouth every four hours as needed).
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:
___
|
10101321-DS-10 | 10,101,321 | 26,537,257 | DS | 10 | 2191-03-26 00:00:00 | 2191-03-26 21:24:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Percocet
Attending: ___.
Chief Complaint:
Brain Mets, Left-Sided Numbness
Major Surgical or Invasive Procedure:
None this hospitalization.
History of Present Illness:
Ms. ___ is a ___ female with history of breast
cancer diagnosed in ___ s/p neoadjuvant chemotherapy, modified
radical mastectomy, and XRT followed by palbociclib until
___ and currently on Exemestane who presents with
left-sided numbness and found to have brain mets.
Patient reports that she has had neuropathy in her left hand
since chemotherapy several years ago. A couple weeks ago she
noticed that her left hand numbness started to get worse as well
as spreading to down her fingers. She then developed left toe
numbness and left face/shoulder numbness about one week ago. Two
days ago the numbness started to spread up her left foot. She
also notes feeling left arm heaviness. She spoke to Dr. ___
___ who requested a brain MRI which was done on ___ ___. She was called with the results that evening
about the finding of new brain mets and was prescribed
dexamethasone 4mg QID by her PCP which she has been taking at
home. She reports no improvement in her symptoms since starting
dexamethasone.
On arrival to the ED, initial vitals were 97.3 58 166/75 16 100%
RA. Exam was notable for decreased sensation to left side of
face, left arm, and left foot with intact strength. Labs were
notable for WBC 13.2, H/H 13.9/40.3, Plt 255, Na 136, BUN/Cr
___, INR 1.0, and UA negative. No imaging or medications were
done. Prior to transfer vitals were 97.5 60 163/94 15 95% RA.
On arrival to the floor, patient denies pain. She reports mild
headache that she believes is related to not wearing her mouth
guard. She also notes left eye blurriness that started yesterday
and has since resolved. She had one episode of non-bloody
diarrhea this morning. She denies fevers/chills, night sweats,
dizziness/lightheadedness, shortness of breath, cough,
hemoptysis, chest pain, palpitations, abdominal pain,
nausea/vomiting, hematemesis, hematochezia/melena, dysuria,
hematuria, and new rashes.
Past Medical History:
She was initially diagnosed in ___. Core needle biopsy showed
an invasive lobular cancer and FNA of an axillary node was also
positive. She then received neoadjuvant chemotherapy at ___
with cyclophosphamide and doxorubicin as well as paclitaxel.
Her tumor is hormone receptor positive and HER-2/neu negative.
She underwent a modified radical mastectomy in ___
after her neoadjuvant therapy. She still had a large residual
tumor measuring 6.5 cm with both ductal and pleomorphic lobular
features. Five lymph nodes were negative. Postmastectomy
radiation therapy was given and she was started on exemestane.
Given her high risk, we entered her in a clinical trial
exploring the safety of palbociclib in addition to adjuvant
aromatase inhibitor therapy. This was ___ ___
___ trial ___. She was on therapy with this agent for 7
4-week cycles coming off treatment in late ___ because
of a pneumonitis that may have been infectious, but we were
unable to exclude a contribution of drug toxicity.
PAST MEDICAL HISTORY:
- Melanoma on left check s/p excision in ___
- Lyme Disease
- Depression
- Eczema
- s/p tear duct surgery in ___ and ___
- s/p ovarian cyst in ___ via suprapubic incision
Social History:
___
Family History:
Breast cancer in her sister.
Physical Exam:
========================
Admission Physical Exam:
========================
VS: Temp 98.1, BP 133/65, HR 64, RR 20, O2 sat 98% 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 II-XII
intact (except for decreased left facial sensation on forehead,
cheek, and nose). Strength full throughout. FTN and HTS intact
bilaterally. FNF intact. Reports decreased sensation to light
touch in left face (as above), left hand (fingertips to PIPs),
and left foot (toes to midfoot).
ACCESS: PIV.
========================
Discharge Physical Exam:
========================
VS: Temp 97.7, BP 116/72, HR 57, RR 18, O2 sat 97% RA.
Exam otherwise unchanged.
Pertinent Results:
===============
Admission Labs:
===============
___ 11:35AM BLOOD WBC-13.2*# RBC-4.08 Hgb-13.9 Hct-40.3
MCV-99*# MCH-34.1* MCHC-34.5 RDW-12.0 RDWSD-43.8 Plt ___
___ 11:35AM BLOOD Neuts-85.6* Lymphs-7.6* Monos-4.7*
Eos-0.0* Baso-0.1 Im ___ AbsNeut-11.33*# AbsLymp-1.00*
AbsMono-0.62 AbsEos-0.00* AbsBaso-0.01
___ 11:35AM BLOOD ___ PTT-26.6 ___
___ 11:35AM BLOOD Glucose-105* UreaN-17 Creat-0.6 Na-136
K-4.4 Cl-97 HCO3-25 AnGap-18
==============
Interval Labs:
==============
___ 07:00AM BLOOD LD(LDH)-197
___ 07:00AM BLOOD CEA-1.8
===============
Discharge Labs:
===============
___ 07:15AM BLOOD WBC-12.6* RBC-4.23 Hgb-14.4 Hct-40.8
MCV-97 MCH-34.0* MCHC-35.3 RDW-11.9 RDWSD-41.8 Plt ___
___ 07:15AM BLOOD Glucose-105* UreaN-16 Creat-0.6 Na-138
K-4.7 Cl-97 HCO3-27 AnGap-19
========
Imaging:
========
CT Abdomen/Pelvis w/ Contrast ___
1. No evidence of metastatic disease in the abdomen or pelvis.
2. A 3.6 cm right adnexal cystic lesion is increased in size
since ___. Recommend further evaluation with pelvic
ultrasound.
CT Chest w/ Contrast ___ - Preliminary
1. 0.8 cm low-density left lower lobe pulmonary nodule has
significantly increased in size since ___. Differential
includes lung cyst, hamartoma, exogenous lipoid pneumonia, mixed
adenocarcinoma, and less likely metastatic lesion. Additional
subcentimeter pulmonary nodule is stable.
2. Right upper lobe radiation fibrosis.
3. Pleural thickening of right minor fissure with adjacent
bronchiectasis. Differential includes post radiation changes for
which this is slightly atypical given medial location and
scarring from prior infection.
4. Left lower lobe bronchiectasis with bronchial wall thickening
suggests active infection such as ___.
5. Mild centrilobular emphysema.
=============
Microbiology:
=============
___ Urine Culture - Mixed Bacterial Flora
___ Blood Culture - Pending
Brief Hospital Course:
Ms. ___ is a ___ female with history of breast
cancer diagnosed in ___ s/p neoadjuvant chemotherapy, modified
radical mastectomy, and XRT followed by palbociclib until
___ and currently on Exemestane who presents with
left-sided numbness and found to have brain mets.
# Brain Metastases
# Left-Sided Numbness: She has had progressive numbness of her
left face, shoulder, hand, and foot. Lesion of right pons likely
explains her symptoms of numbness due to involvement of
spinothalamic tract. Likely from prior breast cancer. Currently
no weakness on exam. Continued on dexamethasone. Neurosurgery,
Neuro Onc, and Radiation Oncology were consulted. No surgical
intervention indicated by Neurosurgery. Radiation Oncology
recommended whole brain radiation which will be arranged at ___
___. Patient will follow-up with her Radiation
Oncologist at ___. She was continued on
dexamethasone with taper to be determined by her outpatient
providers.
# Breast Cancer: Continued exemestane. Will follow-up with
outpatient Oncologist.
# Leukocytosis: Likely from dexamethasone. No signs/symptoms of
infection.
# Depression: Continued citalopram.
====================
Transitional Issues:
====================
- Patient will follow-up with Dr. ___ at ___
for her whole brain radiation.
- Patient discharged on dexamethasone with taper to be
determined by her Radiation Oncologist.
- CT abdomen/pelvis noted a 3.6 cm right adnexal cystic lesion
is increased in size since ___. Recommend further
evaluation with pelvic ultrasound.
- Preliminary CT chest with 0.8 cm low-density left lower lobe
pulmonary nodule has significantly increased in size since ___.
Left lower lobe bronchiectasis with bronchial wall thickening
suggests active infection such as ___. Recommend 3 month
follow-up CT chest to assess for interval change of left lower
lobe pulmonary nodule. Please follow-up final report.
- Please follow-up blood culture from ___.
- Please monitor leukocytosis. Likely secondary to steroids.
# Code Status: Full Code
# Contact: ___ (sister) ___ (cell) ___
(home); ___ (sister) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 20 mg PO DAILY
2. Citalopram 20 mg PO DAILY
3. Dexamethasone 4 mg PO Q6H
4. Vitamin D 4000 UNIT PO DAILY
5. Vitamin B Complex 1 CAP PO DAILY
6. Ascorbic Acid ___ mg PO DAILY
7. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID
8. desoximetasone 0.25 % topical BID:PRN rash
9. Sodium Chloride Nasal 1 SPRY NU DAILY
10. azelastine 137 mcg (0.1 %) nasal DAILY
11. Fluticasone Propionate NASAL 1 SPRY NU BID
12. Exemestane 25 mg PO DAILY
Discharge Medications:
1. Dexamethasone 4 mg PO BID
2. Ascorbic Acid ___ mg PO DAILY
3. azelastine 137 mcg (0.1 %) nasal DAILY
4. Citalopram 20 mg PO DAILY
5. desoximetasone 0.25 % topical BID:PRN rash
6. Exemestane 25 mg PO DAILY
7. Fluticasone Propionate NASAL 1 SPRY NU BID
8. Omeprazole 20 mg PO DAILY
9. Sodium Chloride Nasal 1 SPRY NU DAILY
10. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID
11. Vitamin B Complex 1 CAP PO DAILY
12. Vitamin D 4000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
- Brain Metastases
- Breast Cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at the ___
___. You were admitted to the hospital
after you had left-sided numbness and were found to have brain
metastases on your brain MRI. You were continued on steroids
while in the hospital. You were seen by the Neurosurgeons,
Radiation Oncologist, and Neuro Oncologists. After further
discussion it was determined that the best treatment would be
whole brain radiation. Due to convenience you will follow-up
with Dr. ___ your radiation treatments.
You should continue to take the dexamethasone at home at a dose
of 4mg twice a day. Please follow-up with Dr. ___ to
determine the taper of this medication.
Please see below for your follow-up appointments.
All the best,
Your ___ Team
Followup Instructions:
___
|
10101340-DS-22 | 10,101,340 | 25,615,050 | DS | 22 | 2110-04-06 00:00:00 | 2110-04-06 21:09:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain, nausea, chest pain
Major Surgical or Invasive Procedure:
EGD
Colonoscopy
History of Present Illness:
___ y.o. male with hx/o CABG x 3, HTN and poorly controlled DM,
recent left total shoulder replacement (___), who p/w 3
days
of progressively worsening abdominal pain and left chest pain.
His chest pain has been occurring at rest, and was worse with
exertion. Described as a pressure, similar to previous heart
attacks, did not radiate. He also reports chest pain with deep
breath last night, none now. This was not associated with SOB.
He
also described mid upper abd pain for several days that radiates
down to the lower abdomen, but does not radiate to the back.
Pain
is constant and dull, made much worse about 10 minutes after
meals. + nausea and vomited in the ED, reports brown vomit. No
diarrhea. Last BM ___, none ___, passing flatus. He has also
had two episodes where he felt clammy over the past week. He
did
not check blood sugar at that time.
He also describes new weakness to bilateral lower extremities
since ___, pain. He was seen by PCP ___ few weeks ago who
attributed pain to radiculopathy and increased gabapentin
regimen. Also endorses some back pain. Denies fevers/chills,
HA,
dyspnea, cough and urinary sx.
On further history, patient reports 27lb weight loss over the
last 6 months. He reports he was trying to lose weight, but
notes
that he has had a reduced appetite. He reports intermittent
night
sweats for "a few years." No FH of cancer
In the ED...
- Initial vitals:
98.5 80 157/84 16 96% RA
PE:
General: obese, middle-aged male in distress.
VS:
HEENT: NC, AT. nares patent. IMMM.
Chest: CTAB
CV: tachycardic, no m/g/r. Bilateral femoral arteries bounding
and equal.
Abdomen: diffusely TTP. No HSM. Unable to visualize abdominal
aorta with US. Potential renal bruit appreciated on left side.
Ext: no swelling appreciated.
- EKG 1: NSR, left axis, poor R wave progressionstable from
prior, new t wave inversion V2, flattening V3, otherwise stable
- EKG 2: NSR, left axis, poor R wave progression stable from
prior, earlier TWI have now improved
- Labs/studies notable for:
Lipase 126, Hb12.3, WBC 10.0, Cr 1.2, BUN 41, K 137, INR 1.2,
Trop <0.01x2, lactate 3.4->2.3
CT A/P
1. No dissection.
2. Prominent mesenteric fat stranding demonstrates a higher
density than would be typical for mesenteric panniculitis.
Differential diagnosis also includes lymphoma.
3. Moderate gastric distention may be secondary to outlet
obstruction versus gastroparesis.
4. Bilateral indeterminate renal lesions and 2 hypoattenuating
lesions in the pancreas tail measuring up to 8 mm. These could
be
further evaluated with nonemergent MRI of the abdomen.
5. Cholelithiasis without evidence of cholecystitis.
Nuclear Stress
IMPRESSION: 1. Top-normal/enlarged left ventricular cavity. 2.
Partially reversible, moderate to severe, proximal to mid
inferior wall defect. 3. Decreased left ventricular ejection
fraction, measuring 42%, previously 49% in ___.
- Patient was given:
___ 22:28 IV Morphine Sulfate 4 mg
___ 22:28 IVF NS
___ 00:25 IV Morphine Sulfate 4 mg
___ 01:18 IVF NS 1000 mL
___ 02:59 PO Acetaminophen 650 mg
___ 07:27 PO Acetaminophen 650 mg
___ 07:42 PO/NG Aspirin 324 mg
___ 07:42 PO/NG Lisinopril 40 mg
___ 07:42 PO/NG Atenolol 50 mg
___ 07:42 PO/NG Gabapentin 300 mg
___ 07:42 PO/NG amLODIPine 5 mg
___ 08:49 PO/NG PARoxetine 30 mg
___ 08:49 PO/NG Chlorthalidone 25 mg
___ 08:49 PO/NG Gabapentin 600 mg
___ 08:49 IV Ketorolac 15 mg
___ 16:01 PO Acetaminophen 650 mg
___ 16:01 PO/NG Gabapentin 900 mg
___ 20:47 PO/NG Atorvastatin 40 mg
___ 20:47 PO/NG Gabapentin 900 mg
- Vitals on transfer:
98.1 71 122/84 18 95% RA
On the floor patient reports history as above. He recently ate
some food and is feeling nauseous with some abdominal pain. He
feels that his pain is a little better though. Denies current
chest pain, Having significant shooting pain down right leg when
he sits up straight in bed. He denies HA, fevers, or pain
radiating to back.
REVIEW OF SYSTEMS:
10 point ROS negative except per HPI
Past Medical History:
PMH: heart disease, hypertension, diabetes, depression/anxiety,
other psychiatric condition, arthritis, and gout.
Shx:___
Family History:
Relative Status Age Problem Onset Comments
Mother ___ ___ HEROIN ABUSE
ALCOHOL ABUSE
ALCOHOLIC CIRRHOSIS
Father ___ ___ SYPHILIS
STROKE
Brother ___ ___ HEROIN OVERDOSE
Brother ___ ___ COCAINE OVERDOSE
HEROIN ABUSE
ALCOHOL ABUSE
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
98.5 80 157/84 16 96% RA
PE:
General: obese, middle-aged male in distress.
VS:
HEENT: NC, AT. nares patent. IMMM.
Chest: CTAB
CV: tachycardic, no m/g/r. Bilateral femoral arteries bounding
and equal.
Abdomen: diffusely TTP. No HSM. Unable to visualize abdominal
aorta with US. Potential renal bruit appreciated on left side.
Ext: no swelling appreciated.
DISCHARGE EXAM
==========================
VS: Temp: 98.1 (Tm 98.5), BP: 147/75 (115-179/75-110), HR: 61
(59-78), RR: 18 (___), O2 sat: 96% (90-96), O2 delivery: RA,
Wt: 246.69 lb/111.9 kg
GENERAL: NAD, lying in bed
HEENT: AT/NC, anicteric sclera, MMM
NECK: supple, no LAD, no appreciable JVD
CV: RRR, S1/S2, no murmurs, gallops, or rubs
PULM: CTABL no increased WOB
GI: abdomen soft, mildly distended, no TTP, no rebound/guarding
EXTREMITIES: no cyanosis, clubbing, or edema
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric
Pertinent Results:
ADMISSION LABS:
================
___ 09:54PM BLOOD WBC-10.0 RBC-4.30* Hgb-12.3* Hct-38.0*
MCV-88 MCH-28.6 MCHC-32.4 RDW-14.8 RDWSD-47.5* Plt ___
___ 09:54PM BLOOD Neuts-58.6 ___ Monos-7.1 Eos-1.9
Baso-0.4 Im ___ AbsNeut-5.89 AbsLymp-3.17 AbsMono-0.71
AbsEos-0.19 AbsBaso-0.04
___ 09:54PM BLOOD Plt ___
___ 10:03PM BLOOD ___ PTT-28.1 ___
___ 09:54PM BLOOD Glucose-193* UreaN-41* Creat-1.2 Na-137
K-3.8 Cl-94* HCO3-26 AnGap-17
___ 09:54PM BLOOD ALT-13 AST-17 AlkPhos-77 TotBili-0.4
___ 09:54PM BLOOD Lipase-126*
___ 09:54PM BLOOD cTropnT-0.01
___ 09:54PM BLOOD Albumin-4.0
___ 10:05PM BLOOD Lactate-3.4*
PERTINENT INTERIM LABS:
=======================
___ 07:27AM BLOOD Calcium-10.5* Phos-3.8 Mg-2.5
___ 04:32AM BLOOD %HbA1c-7.1* eAG-157*
___ 11:50PM BLOOD CRP-18.3*
___ 12:06AM BLOOD Lactate-1.6
DISCHARGE LABS:
===============
___ 06:40AM BLOOD WBC-8.3 RBC-4.00* Hgb-11.4* Hct-35.4*
MCV-89 MCH-28.5 MCHC-32.2 RDW-14.4 RDWSD-46.1 Plt ___
___ 06:40AM BLOOD Glucose-156* UreaN-23* Creat-1.0 Na-147
K-3.2* Cl-101 HCO3-29 AnGap-17
IMAGING:
========
___ CTA Abd/Pelvis:
IMPRESSION:
1. No aortic dissection demonstrated.Prominent mesenteric fat
stranding
demonstrates a higher density than would be typical for
mesenteric
panniculitis. Differential diagnosis also includes lymphoma.
2. Moderate gastric distention may be secondary to gastric
outlet obstruction versus gastroparesis.
3. Bilateral indeterminate renal lesions and two cystic lesions
in the
pancreas tail measuring up to 8 mm could represent side-branch
intraductal papillary mucinous neoplasms. These could be
further evaluated with nonemergent MRI of the abdomen.
4. Cholelithiasis without findings of acute cholecystitis.
___ Cardiac perfusion pharm:
IMPRESSION: 1. Top-normal/enlarged left ventricular cavity.
2. Partially reversible, moderate to severe, proximal to mid
inferior wall defect.
3.Decreased left ventricular ejection fraction, measuring 42%,
previously 49% in ___.
___ Pharm Stress Test:
IMPRESSION: Atypical type symptoms. No significant ST segment
changes
from baseline. Nuclear report sent separately.
___ Chest X-Ray:IMPRESSION:
In comparison with the study of ___, the cardiomediastinal
silhouette is within normal limits and there is no evidence of
vascular congestion or acute focal pneumonia. The dense streaks
of atelectasis at the left base have cleared. Shoulder
prosthesis is seen on the left.
___ Abdominal X-Ray:
IMPRESSION:
Distended stomach is similar to prior CT from ___. No
small bowel obstruction
___ EGD:
Impressions:
- Normal mucosa in the whole esophageus
- Erythema in the stomach and antrum compatible with gastritis
(Biopsy)
- Erythema in the duodenal bulb and sweep (Biopsy)
- No gastric outlet obstruction
___ MRI L-Spine:
FINDINGS:
Mild retrolistheses of L1 on L 2, L2 on L3, L3 on L4 and L4 on
L5 are seen. Multilevel Schmorl's nodes are seen with osteophyte
formation. There is multilevel loss of signal of the
intervertebral discs on the T2 weighted images there are ___
type 1 signal intensity changes of the vertebral endplates at
L2-3. The spinal cord terminates at the L1 level. ___ type
degenerative changes are seen at L2-3.
T12-L1: No significant spinal canal or foraminal narrowing.
L1-L2: A disc bulge is seen with a central disc protrusion and
bilateral facet arthropathy. There is moderate spinal canal
narrowing with mild left foraminal narrowing.
L2-L3: A disc bulge is seen with a large central disc
protrusion. There is ligamentous hypertrophy and bilateral
facet arthropathy. There is severe spinal canal narrowing with
likely compression of the nerve roots. There is moderate right
and severe left foraminal narrowing.
L3-L4: A large disc bulge is seen with ligamentous hypertrophy
and bilateral facet arthropathy. A large disc protrusion
extends inferiorly below the level of the interspace to the
right of midline compressing the thecal sac and the traversing
right-sided nerve roots. There is severe spinal canal narrowing
with moderate right and moderate to severe left foraminal
narrowing.
L4-L5: A disc bulge is seen with ligamentous hypertrophy and
bilateral facet arthropathy. There is moderate spinal canal
narrowing with mild right and moderate left foraminal narrowing.
L5-S1: A mild disc bulge is seen with bilateral facet
arthropathy. There is no significant spinal canal or foraminal
narrowing. There is no evidence of infection or neoplasm.
IMPRESSION:
1. Severe degenerative changes of the lumbar spine, with a
severe spinal canal narrowing.
2. Large disc protrusions at L2-3 and L3-4 compressing nerve
roots in the thecal sac.
MICROBIOLOGY:
=============
___ 9:54 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
CANCELLED. Culture negative as of: ___ @11:30.
Test canceled/culture discontinued per: ___
___.
PATIENT CREDITED.
Brief Hospital Course:
Outpatient ___ y.o. male with hx/o CABG x 3, HTN and
poorly controlled DM, recent left total shoulder replacement
(___), who p/w 3 days of progressively worsening abdominal
pain/nausea and left chest pain,found to have new TWI,
reversible defect on nuclear stress. Now with concern for
gastroparesis vs malignancy as cause for constipation and
abdominal pain
ACTIVE ISSUES:
===============
#CAD
#Positive stress test
#Chest Pain
Patient presented with 3 day hx chest pain, new mild TWI V2/V3,
both now resolved, positive p-MIBI with reversible defect. No
troponin elevation. He was medically managed while in the
hospital as it was felt there aws no need for an urgent cardiac
cath. A TTE was ordered to further characterize his heart
function which showed no change from previous TTE.
#Abdominal pain
#N/V
#Constipation
Patient presented w/ significant pain in abdomen especially
post-prandially, with significant tenderness on exam although
not peritoneal, minimal bowel sounds although passing flatus,
lactate initially high but downtrended, acute abdominal series
without any free air or evidence of obstruction, CT without e/o
dissection but with concern for gastric outlet or small bowel
obstruction v gastroparesis in addition to panniculitis or
lymphoma, as well as intraductal papillary mucinous neoplasms.
Initially on floor pt w/ multiple episodes of dark emesis, had
not had a bowel movement in days. Patient was given pr dulcolax
as imgaing was more convincing for constipation/obstipation than
obstruction. His symptoms persisted but lessened after he passed
a bowel movement. GI was consulted for diagnostic/management.
They performed an EGD ___ which showed evidence of gastritis
but no evidence of obstruction. Biopsies were sent and H. pylori
was negative. Patient was less nauseous and had no episodes of
emesis since morning after admission so diet was resumed and
tolerated well. Given no evidence of obstruction and continued
constipation w/ PO intake and PO bowel regimen GI felt
colonoscopy was warranted to rule out a malignancy that may have
been causing his symptoms. Colonoscopy performed ___ was poor
prep and GI recommended outpatient colonoscopy.
#New reduced EF
Patient with EF 42% seen on pharma stress test from 49% on prior
evaluation. No evidence of volume overload. Likely ___ ischemia.
Afterload reduction w/ lisinopril, amlodipine, cholrthalidone.
Patient will follow-up as an outpatient with Cardiology.
#Radicular R leg pain
#Low Back Pain
Patient diagnosed with sciatica by his PCP and started on
regimen of tizanidine and gabapentin. During hospital course
patient reporting ___ low back and shooting pains down his
right leg. Endorsed numbness over medial knee however sensory
exam normal. Strength normal. No reg flag symptoms for cord
compression. Given acuity of pain an MRI lumbar spine was
obtained which showed extensive disc disease, nerve root
compression, facet arthropathy throughout the lumbar spine.
Patient's pain was better controlled when began asking for
tizanidine prn as he had not been getting it initially, back
pain less w/ lidocaine patch. Patient will follow-up with
Orthopedics as an outpatient.
CHRONIC ISSUES
==============
#Depression: Continued Paroxetine 30 mg PO DAILY
#Hypertension: Continued chlorthalidone 25mg, amlodipine 5 mg
daily, lisinopril 40mg daily
TRANSITIONAL ISSUES:
====================
[] Will need repeat CT Abd in ___ months w/ PCP to evaluate
interval changes in abdominal findings. Per Radiology and
Oncology, CT abdomen findings can be seen and should be followed
up with repeat CT scan. No need for oncology follow-up at this
time.
[] Please obtain MRI abdomen w/o contrast to follow-up CT
abdomen findings of Bilateral indeterminate renal lesions and
two cystic lesions in the pancreas tail measuring up to 8 mm
could represent side-branch intraductal papillary mucinous
neoplasms.
[] Ensure patient has cardiology follow-up. Pharmacologic stress
test showed reversible defect with reduced ejection fraction of
42% compared to baseline 49%.
[] Repeat calcium at follow-up visit. If hypercalcemia, consider
further work-up.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 5 mg PO DAILY
2. Atenolol 50 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Chlorthalidone 25 mg PO DAILY
5. Gabapentin 900 mg PO TID
6. GlipiZIDE 5 mg PO BID
7. Lisinopril 40 mg PO DAILY
8. MetFORMIN (Glucophage) 1000 mg PO BID
9. PARoxetine 30 mg PO DAILY
10. SITagliptin 100 mg oral DAILY
11. Tizanidine 4 mg PO TID:PRN spasms
12. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
13. Aspirin 325 mg PO DAILY
14. Multivitamins 1 TAB PO DAILY
15. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
Discharge Medications:
1. Lidocaine 5% Patch 1 PTCH TD QAM Back
RX *lidocaine 5 % Apply to lower back QAM Disp #*30 Patch
Refills:*0
2. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth Daily Disp #*30
Capsule Refills:*0
3. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
4. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
5. amLODIPine 5 mg PO DAILY
6. Atenolol 50 mg PO DAILY
7. Atorvastatin 80 mg PO QPM
8. Chlorthalidone 25 mg PO DAILY
9. Gabapentin 900 mg PO TID
10. GlipiZIDE 5 mg PO BID
11. Lisinopril 40 mg PO DAILY
12. MetFORMIN (Glucophage) 1000 mg PO BID
13. Multivitamins 1 TAB PO DAILY
14. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
15. PARoxetine 30 mg PO DAILY
16. SITagliptin 100 mg oral DAILY
17. Tizanidine 4 mg PO TID:PRN spasms
18.Rolling Walker
Rolling Walker
Dx: Muscle weakness (generalized)
ICD 10: M62.81
ICD 9: 728.2
Px: Good
___: 13 mos
Discharge Disposition:
Home
Discharge Diagnosis:
#Atypical Chest Pain
#Abdominal Pain
#Vomiting
#Constipation
#Low back pain
#Radicular Leg Pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You were admitted to the hospital because you were having
abdominal pain, nausea, and chest pain
WHAT HAPPENED TO ME IN THE HOSPITAL?
- Your heart was evaluated with a pharmacologic stress test.
This showed new changed that we felt could be medically managed
while you were in the hospital. Please follow up with your
cardiologist regarding these findings
- You had an ECHO test performed to further evaluate your heart.
This showed XXX
- We treated your nausea with IV medications
- We gave you medications to help you move your bowels when you
were constipated
- You had a CT scan performed of your abdomen. Please follow up
these results with your primary care physician. You will need a
repeat CT scan in ___ months.
- We had the GI specialists evaluate you for your abdominal
pain, nausea, and constipation.
- You had an EGD performed to look for causes of your symptoms
in your stomach and upper small intestine. This test showed
gastritis.
- You had a colonoscopy performed to look for causes of your
symptoms. There was still a lot of stool after the prep and the
colonoscopy was not effective. GI recommended outpatient
colonoscopy.
- You had an MRI of your lower back to assess for causes of your
low back and right leg pain. This showed arthritis of your spine
and bulging discs which are compressing some of your nerves
causing pain. You have follow-up with the orthopedic doctors.
- We treated your pain with IV medications when necessary,
continued your home gabapentin and tizanidine, and gave you
lidocane patches for your back.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines as prescribed
- Please follow up with your cardiologist to further evaluate
your chest pain and test results
- Please follow up with your primary care physician
___ wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10101340-DS-27 | 10,101,340 | 29,910,668 | DS | 27 | 2111-06-30 00:00:00 | 2111-07-01 16:00:00 |
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:
Left heart catheterization ___
attach
Pertinent Results:
ADMISSION LABS
==============
___ 12:45PM BLOOD WBC-8.2 RBC-4.47* Hgb-11.1* Hct-38.5*
MCV-86 MCH-24.8* MCHC-28.8* RDW-16.0* RDWSD-49.7* Plt ___
___ 12:45PM BLOOD Neuts-68.5 ___ Monos-8.8 Eos-1.8
Baso-0.4 Im ___ AbsNeut-5.58 AbsLymp-1.63 AbsMono-0.72
AbsEos-0.15 AbsBaso-0.03
___ 12:45PM BLOOD Glucose-128* UreaN-20 Creat-0.7 Na-142
K-4.5 Cl-103 HCO3-28 AnGap-11
___ 07:16AM BLOOD Calcium-9.4 Phos-4.0 Mg-1.9
___ 07:16AM BLOOD ___ PTT-33.9 ___
___ 12:45PM BLOOD proBNP-6564*
___ 12:45PM BLOOD cTropnT-<0.01
___ 07:16AM BLOOD cTropnT-0.01
PERTINENT STUDIES
=================
___ CTA CHEST
1. No evidence of pulmonary embolism or aortic abnormality.
2. Mild pulmonary edema.
3. Enlargement of the main pulmonary artery up to 3.6 cm is
suggestive of
pulmonary arterial hypertension.
4. Small right, trace left dependent pleural effusions and mild
bibasilar
atelectasis.
___ TTE
LVEF 43%.
IMPRESSION: Severe symmetric left ventricualr hypertrophy with
normal cavity size and mild regional systolic dysfunction c/w
CAD. Increased PCWP. Grade II diastolic dysfunction. Mild right
ventricular cavity dilation with mild systolic dysfunction. Mild
to moderate aortic
regurgitation. Mild mitral regurgitation. Mild tricuspid
regurgitation. Mild pulmonary artery systolic hypertension. Mild
thoracic aortic enlargement.
Compared with the prior TTE ___ , wall motion
abnormalities are new and biventricular systolic dysfunction is
now worse.
___ LHC
Findings
Moderate coronary coronary artery disease.
Recommendations
ASA 81mg per day.
Plavix 75mg/day
Secondary prevention of CAD
Maximize medical therapy
DISCHARGE LABS
==============
___ 07:56AM BLOOD WBC-7.3 RBC-4.59* Hgb-11.4* Hct-39.5*
MCV-86 MCH-24.8* MCHC-28.9* RDW-16.1* RDWSD-49.9* Plt ___
___ 07:56AM BLOOD Glucose-159* UreaN-49* Creat-1.1 Na-147
K-4.0 Cl-102 HCO3-34* AnGap-11
___ 07:56AM BLOOD Calcium-9.4 Phos-4.8* Mg-2.2
Brief Hospital Course:
===================
TRANSITIONAL ISSUES
===================
[] Recommend outpatient follow-up for syphilis screen with
negative RPR. Trep Ab (state lab) pending at discharge.
Consider outpatient ID follow-up if indicated.
[] Recommend close monitoring of weights and adherence to fluid
restriction Ensure patient is up-to-date with all preventative
health screenings and vaccinations.
[] Recommend repeat chemistry 10 panel and CBC within 3 days of
discharge to ensure stability of hemoglobin, potassium,
magnesium, creatinine.
[] Patient to follow-up with outpatient cardiologist Dr.
___ as scheduled. It is critical that the patient keep
this appointment.
[] Patient with evidence of steatosis on abdominal ultrasound.
Recommend outpatient monitoring and referral to liver clinic as
indicated. Would also ensure that patient is optimized from a
metabolic syndrome perspective.
Discharge Wt: 109.5 kg (241.4 lb)
Discharge Cr: 1.1
=================
BRIEF SUMMARY
=================
Mr. ___ is a ___ y/o male with a history of CAD s/p MI
(s/pPCI ___ and CABG ___ years ago, pMIBI in ___ with possible
partially reversible defect in the inferior wall, tx with
conservative management), DMII, HTN, HLD, depression, and OSA
presents with chest pain, found to be volume overloaded with
HFmrEF exacerbation. He was diuresed w/ IV Lasix to euvolemia.
He underwent LHC which demonstrated patent LIMA-LAD and SVG-OM
grafts. He underwent successful stent placement in the LAD
diagonal branch for an 80% occlusion. At discharge, he was
euvolemic on 80mg PO Torsemide for maintenance dosing.
CORONARIES: PCI ___ and CABG ___ years ago. Unclear anatomy
PUMP: EF 43%
RHYTHM: Sinus
===============
ACTIVE ISSUES:
===============
#HFmrEF
#Acute hypoxic respiratory failure (Resolved)
Volume overloaded on admission. Possible contributor to his
chest pain. LVEF 43% on ___ echo. Of note, the patient has had
chronic b/l ___ swelling iso reduced EF though denies ever being
on diuretics. He was placed on a fluid restriction and diuresed
with IV Lasix 80-100 mg BID to euvolemia, and later transitioned
to 80mg PO Torsemide for maintenance. We continued home
amlodipine, and held home lisinopril for LHC which was later
restarted. His home carvedilol was increased. Spironolactone was
started.
#Chest pain
#ACS/NSTEMI
#CAD s/p PCI and CABG
Presented with acute onset of chest pain with associated
diaphoresis, shortness of breath and nausea. EKG with T wave
inversions in anterior leads and poor R wave progression. Trop
negative. Significant coronary history and T wave inversions
concerning for NSTEMI. Receieved ASA 325 mg in the ED and
initiation of
a nitro gtt with resolution of his pain, later weaned and d/c'd.
Repeat TTE w/ LVEF 43% with new wall motion abnormalities c/w
CAD. We continued home aspirin 81 mg and atorvastatin 80mg
daily. Carvedilol adjusted per above. He underwent LHC on ___
which demonstrated patent LIMA-LAD and SVG-OM grafts, and
underwent successful stent placement in the LAD diagonal branch
for an 80% occlusion. He was Plavix loaded and started on 75 mg
Plavix. At discharge, patient remained chest pain free.
#Hypernatremia
Free water deficit likely ___ consumption of sugary beverages
iso diuresis. We encouraged PO water intake w/in his 2L fluid
restriction. At discharge his sodium had normalized and stable.
#Viral URI
Describes several days of nasal congestion and rhinorrhea,
consistent with viral URI. We gave Flonase daily for symptomatic
relief.
#Prolonged QTC
QTc 512 on admission EKG. Repeat EKG w/ continued QTc
prolongation, a little less than ___ of the RR interval. We
avoided QTc prolonging medications and held home Seroquel.
================
CHRONIC ISSUES:
================
# OSA
Per patient report, has not tolerated CPAP well in the past, but
he trialed CPAP while
in hospital given NC use at night with 3L when not using CPAP.
# DMII
Hgb A1c 6.4 in ___. Notes he has not needed his insulin over
the last ___ days with BG in the 100s. We continued home lantus
16u qHS and placed him on a sliding scale. We held home
sitagliptin, empagliflozin, metformin during admission, which
were restarted at discharge.
# Hypertension
Management per "afterload" above
# Chronic pain
Continued home gabapentin 800 mg TID
# Depression
Continued home paroxetine 30mg daily
# Insomnia
Held home quetiapine 12.5 mg qHS as above
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Pantoprazole 40 mg PO Q24H
2. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
3. amLODIPine 7.5 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. CARVedilol 6.25 mg PO BID
6. Docusate Sodium 100 mg PO BID
7. empagliflozin 10 mg oral daily
8. Gabapentin 800 mg PO TID
9. Glargine 16 Units Bedtime
10. Lisinopril 40 mg PO DAILY
11. MetFORMIN (Glucophage) 1000 mg PO BID
12. Methocarbamol 750 mg PO BID
13. PARoxetine 30 mg PO DAILY
14. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
15. QUEtiapine Fumarate 12.5 mg PO QHS
16. SITagliptin 100 mg oral daily
17. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Clopidogrel 75 mg PO DAILY to prevent stent thrombosis
2. Spironolactone 12.5 mg PO DAILY
3. Torsemide 80 mg PO DAILY
4. amLODIPine 10 mg PO DAILY
5. CARVedilol 12.5 mg PO BID
6. Glargine 16 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
7. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
8. Aspirin 81 mg PO DAILY
9. Atorvastatin 80 mg PO QPM
10. Docusate Sodium 100 mg PO BID
11. empagliflozin 10 mg oral daily
12. Gabapentin 800 mg PO TID
13. Lisinopril 40 mg PO DAILY
14. MetFORMIN (Glucophage) 1000 mg PO BID
15. Methocarbamol 750 mg PO BID
16. Pantoprazole 40 mg PO Q24H
17. PARoxetine 30 mg PO DAILY
18. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
19. SITagliptin 100 mg oral daily
20. HELD- QUEtiapine Fumarate 12.5 mg PO QHS This medication
was held. Do not restart QUEtiapine Fumarate until you speak to
your PCP
___:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
#Chest pain
#ACS/NSTEMI
#CAD s/p PCI and CABG
#HFmrEF
#Acute hypoxic respiratory failure
SECONDARY DIAGNOSIS
===================
#Chronic pain
#Hypertension
#DMII
#OSA
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at the ___
___!
WHY WAS I IN THE HOSPITAL?
==========================
- You came to the hospital because you were having chest pain.
- You were admitted to the hospital because you were found to
have fluid in your lungs. This was felt to be due to a condition
called heart failure, where your heart does not pump hard enough
and fluid backs up into your lungs and legs.
WHAT HAPPENED IN THE HOSPITAL?
==============================
- You were given a diuretic medication (water pill) through the
IV to help get the extra fluid out.
- Your heart arteries were examined (cardiac catheterization)
which showed a blockage of one of the arteries. This was opened
by placing a tube called a stent in the artery.
- You were given medications to prevent future artery blockages.
WHAT SHOULD I DO WHEN I GO HOME?
================================
- Be sure to take all your medications and attend all of your
appointments listed below.
- It is very important to take your aspirin and clopidogrel
(also known as Plavix) every day.
- These two medications keep the stents in the vessels of the
heart open and help reduce your risk of having a future heart
attack.
- If you stop these medications or miss ___ dose, you risk causing
a blood clot forming in your heart stents and having another
heart attack
- Please do not stop taking either medication without taking to
your heart doctor.
- You were kept on other medications to help your heart that you
were already taking, such as atorvastatin, carvedilol, and
lisinopril
- Your weight at discharge is 109.5kg (241.4 lb). Please weigh
yourself today at home and use this as your new baseline
- Please weigh yourself every day in the morning. Call your
doctor if your weight goes up by more than 3 lbs.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Your ___ Healthcare Team
Followup Instructions:
___
|
10101585-DS-6 | 10,101,585 | 23,354,592 | DS | 6 | 2130-03-23 00:00:00 | 2130-03-23 17:49:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
A. fib with RVR, lateral T wave inversions, and new peripheral
edema times one week
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms ___ is an ___ with h/o chronic AF on coumadin/diltiazem,
prior TTE with EF 50% in ___, CKD stage 3, who p/w AF w/ RVR,
lateral T wave inversions, and new peripheral edema for one
week. She complains of new swelling in all of her extremities
over the last one week. She endorses some orthopnea, but states
that this is chronic, and not new or worsened (2 pillows).
Worsening PND at night. Increased DOE for last 3 weeks. Denies
any chest pain, no fever or other infectious symptoms. She has
been losing a lot of weight recently, noticeable by family
memberss, and dropping pant sizes. Current smoker, though no new
cough or hemoptysis.
.
In the ED, initial vitals were: 97.7 123 96/63 18 100% 2L nc
Studies were significant for EKG: AF at 120bpm, LAD, ? prior
inferior MI, TWI in I, AVL, V5, V6. CXR showed cardiomegaly,
vascular congestion, no edema, atelectasis. BNP 13,000, elevated
from prior.
Past Medical History:
Atrial fibrillation with rapid ventricular response
Edema
Weight loss
CKD (chronic kidney disease) stage 3, GFR ___ ml/min
Atrial Fibrillation
TOBACCO DEPENDENCE
POSTERIOR CYCLITIS
RESTLESS LEGS SYNDROME
OSTEOARTHRITIS, UNSPEC - KNEE, left
SPINAL STENOSIS - LUMBAR
FOOT DROP, left
MENOPAUSE
CHF with EF 50%
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
Admission exam
VS: T=97.7 BP=118/95 HR=91 RR=22 O2 sat= 95% ra
GENERAL: elderly AA female in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis
of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 15cm.
CARDIAC: irreg, normal S1, S2. No m/r/g.
LUNGS: CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: ___ b/l lower extremity edema. Warm, well
perfused, 1+ pulses in all extremities.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
.
Discharge exam
VS: 98.7 105.79 100 18 94% RA
Gen: NAD, alert and oriented x3
HEENT: EOMI, MMM, OP clear
CV: irreg, nl S1 S2, no MRG
Resp: CTAB, no rales wheezes or rhonchi
Abd: soft, non-tender, non-distended
Ext: warm, well perfused, 1+ pulses. Left foot drop
Pertinent Results:
Admission labs
___ 12:15PM BLOOD WBC-3.4* RBC-5.79* Hgb-17.4* Hct-55.6*
MCV-96 MCH-30.0 MCHC-31.3 RDW-14.0 Plt ___
___ 12:15PM BLOOD ___ PTT-48.5* ___
___ 12:15PM BLOOD Glucose-81 UreaN-14 Creat-1.4* Na-142
K-3.7 Cl-108 HCO3-25 AnGap-13
___ 06:45AM BLOOD ALT-22 AST-27 LD(LDH)-347* CK(CPK)-94
AlkPhos-82 TotBili-0.7
Cardiac labs
___ 12:15PM BLOOD ___
___ 12:15PM BLOOD cTropnT-<0.01
___ 08:00PM BLOOD CK-MB-3 cTropnT-<0.01
___ 06:45AM BLOOD CK-MB-3 cTropnT-<0.01
___ 07:00AM BLOOD ___
Other labs
___ 06:45AM BLOOD calTIBC-294 Ferritn-73 TRF-226
___ 06:45AM BLOOD Triglyc-120 HDL-68 CHOL/HD-2.2 LDLcalc-56
LDLmeas-70
___ 06:45AM BLOOD TSH-1.2
___ 06:45AM BLOOD %HbA1c-6.1* eAG-128*
___ 06:45AM BLOOD Ret Aut-1.2
INR trend:
___ 07:00AM BLOOD ___
___ 06:45AM BLOOD ___
___ 07:00AM BLOOD ___
___ 06:45AM BLOOD ___
___ 06:23AM BLOOD ___
Digoxin trend:
___ 07:00AM BLOOD Digoxin-0.8*
___ 06:45AM BLOOD Digoxin-1.1
___ 07:00AM BLOOD Digoxin-1.0
___ 06:45AM BLOOD Digoxin-0.9
Discharge labs
___ 06:23AM BLOOD WBC-3.4* RBC-5.11 Hgb-15.7 Hct-48.9*
MCV-96 MCH-30.7 MCHC-32.1 RDW-13.7 Plt ___
___ 06:23AM BLOOD ___
___ 06:23AM BLOOD Glucose-80 UreaN-20 Creat-1.2* Na-141
K-4.0 Cl-108 HCO3-25 AnGap-12
___ 06:23AM BLOOD Calcium-8.2* Phos-2.6* Mg-1.9
Microbiology:
blood cultures x2 negative
urine culture negative
C diff negative
Imaging:
TTE ___:
The left atrium is moderately dilated. The right atrium is
markedly dilated. No atrial septal defect is seen by 2D or color
Doppler. The estimated right atrial pressure is at least 15
mmHg. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. There is severe global left
ventricular hypokinesis (LVEF = ___ %). No masses or thrombi
are seen in the left ventricle. There is no ventricular septal
defect. The right ventricular cavity is dilated with severe
global free wall hypokinesis. There is abnormal septal
motion/position. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. The pulmonary artery systolic pressure could not be
determined. There is no pericardial effusion.
.
CT Chest ___:
1. Moderate centrilobular emphysema.
2. Bilateral small pleural effusions and mild left lower lobe
ground glass opacity most likely represent pulmonary edema in
this clinical setting.
Stress MIBI ___:
INTERPRETATION: The patient is an ___ year old ___
female with a history of tobacco use found to have new atrial
fibrillation with RVR, globally depressed LVEF of 20%, and CHF
referred for persantine stress test with nuclear imaging. The
patient was given 0.142kg/min/min IV infusion of persantine.
There were no complaints of arm, back, neck, or shoulder
discomfort. There were no ischemic ST changes. She remained in
atrial fibrllation with normal ventricular response and rare
isolated VPBs. Hemodynamic response to infusion was appropriate.
125mg IV aminophylline was give at the completion of the study.
IMPRESSION: No anginal symptoms or ischemic EKG changes with IV
persantine. Nuclear report sent separately.
Left ventricular cavity size is moderately enlarged.
Rest and stress perfusion images reveal uniform tracer uptake
throughout the left ventricular myocardium.
Gated images reveal global hypokinesis.
The calculated left ventricular ejection fraction is 28%.
No prior study available for comparison.
IMPRESSION: Moderate left ventricular enlargement with decreased
function. LVEF of 28%. No perfusional abnormalities.
Brief Hospital Course:
___ with h/o chronic AF on coumadin/diltiazem, prior TTE with EF
50% in ___, CKD stage 3, who p/w AF w/ RVR, lateral T wave
inversions, and new peripheral edema for one week.
.
# CORONARIES: Have not previously been assessed. No chest pain
currently. Ruled out for MI with enzymes negative x3. TTE
showed global akinesis, no focal wall motion abnormality.
Stress MIBI also showed global hypokinesis. She was treated
with aspirin, metoprolol, lisinopril.
.
# PUMP: Systolic HF, EF ___. Hypervolemic, BNP 13,000 on
admission, now increased to 20,641. TTE shows dramatic decrease
in EF since ___ (50% --> ___. Dry weight not known as
patient has been losing weight at home. She was diuresed to
clinical euvolemia with dry weight ****. PFTs were performed
which revealed normal function, thus any dyspnea was likely due
to cardiac source.
.
# RHYTHM: Periods of atrial fibrillation with RVR, rate 120s at
times despite increase of metoprolol. Beta blockade increased
to provide rate control. Her INR was supratherapeutic on
admission so home warfarin held, this was then restarted as INR
drifted below 2. Given poor LVEF revealed by TTE ___,
diltiazem d/c and started digoxin.
.
# CKD: Creatinine remained at baseline (1.5-1.6) during
admission despite diuresis.
.
# Diarrhea, BRBPR: Patient reported loose stool starting ___,
transitioned to liquid stool with reddish/brown flakes. She
also had evidence of BRB on the paper after wiping, which she
stated does happen at times when she has frequent stooling. No
leukocytosis, remains afebrile. External hemorrhoid evident on
exam. Hct stable. She did not complain of cramping or pain on
stooling, states stool is forming and less blood noted. UA with
straight cath no blood, so this was not hematuria. C diff
negative.
.
# Polycythemia: Unclear if this was primary polycythemia
(polycythemia ___ vs secondary ___ smoking, dehydration,
chronic hypoxia, or epo-secreting tumor). The patient's sister
also noted that the patient had experienced weight loss over the
last several months. Given her recent diarrhea and BRBPR, an
outpatient malignancy screening workup would be advisable.
.
# Restless leg syndrome: continue pramipexole
============================
TRANSITIONAL ISSUES
- Should have outpatient work-up of polycythemia, weight loss
- Final PFT report pending at time of discharge, preliminary
report normal
Medications on Admission:
- Hydrochlorothiazide 12.5 mg Oral Capsule Take 1 capsule daily
- Warfarin 2 mg Oral Tablet TAKE UP TO 5 TABLETS DAILY AS
DIRECTED
- Diltiazem HCl 120 mg Oral Capsule, Ext Release 24 hr take 1
capsule daily
- Polyethylene Glycol 3350 17 gram/dose Oral Powder take either
nightly or every other night
- Pramipexole 0.125 mg Oral Tablet TAKE 1 TABLET AT BEDTIME
- Acetaminophen 500 mg Oral Tablet AS DIRECTED
- Trazodone 50 mg Oral Tablet take ___ tablet by mouth at
bedtime as needed for insomnia
- DOCUSATE SODIUM 100 MG CAP
Discharge Medications:
1. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily) as needed for
constipation.
2. acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6
hours) as needed for pain: no more than 2 grams/day (6 tablets).
3. pramipexole 0.125 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
___: dose to be adjusted by ___ clinic; get INR
drawn ___.
Disp:*30 Tablet(s)* Refills:*0*
7. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
8. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO twice a day.
Disp:*60 Tablet Extended Release 24 hr(s)* Refills:*0*
9. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
10. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
11. hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal TID (3
times a day) as needed for anal itching/soreness.
Disp:*qs qs* Refills:*0*
12. sodium chloride 0.65 % Aerosol, Spray Sig: ___ Sprays Nasal
QID (4 times a day) as needed for congestion.
Disp:*1 bottle* Refills:*2*
13. loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed for loose stool: 1 capsule after each episode
of loose stool, no more than 6 in one day.
Disp:*30 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
systolic heart failure, acute on chronic
atrial fibrillation
Discharge Condition:
Level of Consciousness: Alert and interactive.
Mental Status: Confused - sometimes.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
It was a pleasure taking care of you at ___
___. You were admitted for swelling in your legs,
which was due to worsening of your heart failure. You were
treated for this with diuretics to help you reduce the excess
fluid in your body. You had several tests to investigate your
heart function, including an echocardiogram and a stress test.
These showed worsening of your heart disease. You should
follow-up with a cardiologist to help you manage your
medications and follow your heart function. You were also found
to have an irregular heart rhythm called atrial fibrillation.
This was treated with medications to slow your heart rate and
with warfarin to thin your blood to avoid blood clots.
The following changes were made to your medications:
- STOP hydrochlorothiazide (HCTZ), a diuretic
- STOP diltiazem, a blood pressure medicine
- CHANGE warfarin dose to 2.5mg daily. Your ___
clinic at ___ will continue to adjust this dose.
- START Lasix (furosemide), a stronger diuretic
- START metoprolol to control your heart rate
- START digoxin to control your heart function
- START lisinopril for blood pressure
- START hydrocortisone topical cream for your hemorrhoid
- START saline nasal spray for nasal congestion
- START loperamide for diarrhea; do not use this for more than a
week
You should follow-up with your physicians as listed below. We
are setting up an appointment with a Cardiologist for you.
Followup Instructions:
___
|
10101585-DS-7 | 10,101,585 | 24,233,638 | DS | 7 | 2131-02-11 00:00:00 | 2131-02-11 14:49:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
difficulty ambulating
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is an ___ yo RHW who presented to the ED after 3
days of difficulty ambulating. The history was somewhat limited
as the patient had difficulty describing many of the symptoms.
On
___ she says that she started having more difficulty
walking. She is unsure whether this was sudden or gradual, but
says that she felt unsteady on her feet. She reports no falls,
no
vomiting and answers yes to being both lightheaded and
vertiginous. She called her sister and told her she was having
difficulty walking. She says that she had to use supports while
moving from one place to another. This lasted for the next 2
days
and she felt as if it was getting worse which promted her to
come
to the ED. At baseline she states that she has a foot drop on
the
left side, but cannot tell me the etiology. She also states that
she had a stroke that caused left arm weakness, that then
resolved. She is unsure what hospital she was treated but thinks
that it may have been the ___. She did not think her legs
were weak, but did feel some incoordination in using her right
arm.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies difficulties
producing or comprehending speech. Denies focal weakness,
numbness, parasthesiae. No bowel or bladder incontinence or
retention. Denies difficulty with gait.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or
abdominal pain. No recent change in bowel or bladder habits.
No
dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
Atrial fibrillation with rapid ventricular response
Edema
Weight loss
CKD (chronic kidney disease) stage 3, GFR ___ ml/min
Atrial Fibrillation
TOBACCO DEPENDENCE
POSTERIOR CYCLITIS
RESTLESS LEGS SYNDROME
OSTEOARTHRITIS, UNSPEC - KNEE, left
SPINAL STENOSIS - LUMBAR
FOOT DROP, left
MENOPAUSE
CHF with EF 50%
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
Vitals: 98.6 84 116/79 18 98%
General: Awake, cooperative, NAD.
HEENT: NC/AT
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: CTABL
Cardiac: RRR, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: no edema, pulses palpated
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Some hesitation while
tellign history. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic
errors.
Pt. was able to name both high and low frequency objects. Able
to read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. Pt. was able to
register 3 objects and recall ___ at 5 minutes. There was no
evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation. Funduscopic
exam revealed no papilledema, exudates, or hemorrhages.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. Slight R pronator drift
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 4+ ___- ___ 4+ 5 4+ 2 5 2
R 4+ 5 4+ ___ ___ 4+ 4+ 5 4+
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 1 1 1 1 0
R 1 1 1 1 0
Plantar response was flexor bilaterally.
-Coordination: Significant dysmetria of the right arm and
incoordination on rhythmic tapping with the right leg. On
sitting
up she fell to the right.
-Gait: unable to stand
DISCHARGE EXAM (___)
T: 97.8, BP 142/102 (120-140/70-100); HR 103 (44-103); RR 20; O2
97% RA
Gen: NAD, eating breakfast
HEENT: MMM
Pulm: CTAB
CV: Irregular
Abd: +BS, soft, NTND
Ext: WWP; left foot in AFO
Neuro Exam
MS: Alert & oriented to location; Difficult to understand as
speech dysarthric; follows commands;
CN: PERRL, sluggish but reactive pupils, EOMI, Counts fingers,
dysarthric, right facial droop; tongue midline
Motor: ___ strength in LUE and 4+ strength in left quad (rest of
LLE limited by pain from arthritis); 1+ strength in R IP but 0
through arm and 0 strength in RLE
Sensory: Intact to light touch bl
Pertinent Results:
___ 07:20AM BLOOD WBC-5.7 RBC-5.54* Hgb-16.7* Hct-51.6*
MCV-93 MCH-30.2 MCHC-32.4 RDW-13.4 Plt ___
___ 08:50AM BLOOD ___ PTT-63.3* ___
___:45PM BLOOD ___ PTT-36.6* ___
___ 04:15AM BLOOD Glucose-98 UreaN-30* Creat-1.7* Na-141
K-5.4* Cl-109* HCO3-23 AnGap-14
___ 03:45PM BLOOD ALT-14 AST-19 AlkPhos-99 TotBili-1.0
___ 04:15AM BLOOD Calcium-8.9 Phos-5.5*# Mg-2.1
___ 08:20AM BLOOD %HbA1c-5.6 eAG-114
___ 08:20AM BLOOD Triglyc-70 HDL-88 CHOL/HD-2.1 LDLcalc-80
___ 04:15AM BLOOD Digoxin-1.1
MRI/MRA (___): There is an acute subcortical lacunar infarct
in the periventricular white matter. There are extensive severe
changes of small vessel disease and moderate brain atrophy. No
midline shift or hydrocephalus. No micro-hemorrhages. Normal
MRA of the neck and head. The head MRA demonstrates no evidence
of vascular occlusion or stenosis. Slightly diminished
visualization of the sylvian branches is artifactual.
CT Head (___): Markedly motion limited study with continued
evolution of the left periventricular white matter lacunar
infarct without findings to suggest hemorrhagic conversion.
Brief Hospital Course:
Neurology Floor (___):
NEURO: Ms. ___ was admitted to the hospital and her exam was
monitored. She was initially admitted with dysmetria and
diminished right sided strength (but still anti-gravity), which
were attributed to her left lacunar infarct. On ___, she
developed sudden worsening weakness of the right side such that
she had 1+ proximal lower extremity strength but ___ strength in
the rest of her arm and her right leg. A CT was done to look
for hemorrhagic conversion which only showed evolution of the
infarct but no acute bleed.
Given her subtherapeutic INR of 1.2 and history of atrial
fibrillation, she was started on a heparin bridge while her
Coumadin was increased to 5mg QD and INR monitored daily. On
___, her INR was 2.2 so the heparin was discontinued. This
will have to be monitored in rehab.
Her stroke work-up consisted of a HgbA1c of 5.4 and a
cholesterol panel (Tchol 182, ___ 70, HDL 88, LDL 80) so no
modifications were made. Given that this was felt to be most
likely cardioembolic given the severity of the symptoms and the
fact that she has atrial fibrillation and was subtherapeutic on
Warfarin, and that she was being appropriately anti-coagulated
during the admission, it was not felt that an ECHO would provide
new information and this was not complete.
CARDIOVASCULAR: She was maintained on telemetry and had atrial
fibrillation but without RVR. Her metoprolol & digoxin was
continued, but lisinopril and Lasix were held to allow BP to
autoregulate (goal SBP <180). These will have to be restarted
in rehabilitation.
FEN/GI: She was continued on a bowel regimen. She passed a
speech and swallow.
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? () Yes (LDL = ) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) () Yes - (x) No [if
LDL >100, reason not given: ]
6. Smoking cessation counseling given? (x) Yes - () No [reason
() non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No
9. Discharged on statin therapy? () Yes - (x) No [if LDL >100,
reason not given: ]
10. Discharged on antithrombotic therapy? (x) Yes [Type: ()
Antiplatelet - (x) Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? (x) Yes - () No - () N/A
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 5 mg PO DAILY
2. Metoprolol Succinate XL 100 mg PO BID
3. Warfarin 2 mg PO DAILY16
take ___ as directed
4. Digoxin 0.125 mg PO DAILY
5. Furosemide 40 mg PO DAILY
6. pramipexole *NF* 0.125 mg Oral QHS
7. Acetaminophen 325-650 mg PO Q6H:PRN pain
8. Docusate Sodium 100 mg PO BID constipation
9. traZODONE 50 mg PO HS:PRN insomnia
10. Hydrocortisone (Rectal) 2.5% Cream 1 Appl PR TID itching or
soreness
11. Sodium Chloride Nasal ___ SPRY NU QID:PRN congestion
12. Loperamide 2 mg PO QID:PRN loose stools
Discharge Medications:
1. Digoxin 0.0625 mg PO ONCE Duration: 1 Doses
2. Warfarin 5 mg PO DAILY16
3. Docusate Sodium 100 mg PO BID
4. Senna 1 TAB PO BID:PRN constipation
5. pramipexole *NF* 0.125 mg Oral QHS Reason for Ordering: Wish
to maintain preadmission medication while hospitalized, as there
is no acceptable substitute drug product available on formulary.
6. Polyethylene Glycol 17 g PO DAILY:PRN constipation
7. Metoprolol Succinate XL 100 mg PO BID
8. traZODONE 50 mg PO HS:PRN insomnia
9. Sodium Chloride Nasal ___ SPRY NU QID:PRN congestion
10. Loperamide 2 mg PO QID:PRN loose stools
11. Hydrocortisone (Rectal) 2.5% Cream 1 Appl PR TID itching or
soreness
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
1) Lacunar stroke
2) Atrial fibrillation
3) Left foot drop
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
You were hospitalized due to symptoms of difficulty walking and
then developed weakness of your right arm and leg. These
symptoms were due to a stroke in your brain. A stroke is a
condition where a blood vessel providing oxygen and nutrients to
the brain is blocked and so a small part of your brain is
injured.
We believe the reason that you had this stroke is because of
your heart condition called atrial fibrillation. When a person
has atrial fibrillation, they need to be on blood thinners to
prevent clots from forming and causing strokes. The blood
thinner you take, Coumadin, was at too low a level (your INR was
low) so it was not protecting you.
While you were here, we started a medicine called heparin to
thin your blood while we get your Coumadin level more
appropriate (we would like your INR to be between 2 and 3). At
discharge, you had a good Coumadin level (INR was 2.2) so the
heparin was stopped.
When people have strokes, we let their blood pressure be a bit
higher than normal to help blood to get past the clot to the
brain. Therefore, we have temporarily held some of your blood
pressure medications and you will be restarting them at
rehabilitation. Please take your other medications as
___
In addition, you are on medication to help prevent fluid
overload or swelling. Please weigh yourself every morning and
call your primary care doctor or the physician at rehabilitation
if your weight goes up more than 3 lbs.
Please followup with Neurology and your primary care physician
___ 1 week of being discharged from rehabilitation.
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 ___
- 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 ___
- sudden drooping of one side of the ___
- sudden loss of sensation of one side of the body
- sudden difficulty pronouncing words (slurring of
___
- sudden blurring or doubling of ___
- sudden onset of vertigo (sensation of your environment
spinning around ___
- 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:
___
|
10101881-DS-5 | 10,101,881 | 27,682,479 | DS | 5 | 2141-06-07 00:00:00 | 2141-06-08 05:47:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Urinary retention
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old man with past medical history of BPH,
T2DM, lumbar stenosis who presents as a visit from ___ urgent
care clinic after having difficulty urinating over last 48 hours
and found to have urinary retention s/p foley placement.
At baseline, patient has LUTS with nocturia ___ times a night as
well a slightly weakened urinary stream. On ___, he
awoke and was having significant difficulty urinating. He denies
taking any new medications prior but did attend a ___
service the night prior and had several alcoholic beverages.
Over
the next ___ hours, he had increasing difficulty urinating to the
point where he was unable to void at all. He then presented to
___ urgent care and a foley catheter was placed but without
urine flow. Due to concern for continued obstruction, he was
referred to ED for further evaluation.
Of note, patient has a history of urinary retention due to
underlying BPH and has needed foley catheter at least two times
in the past. He states he has not needed one in at least a few
years and follows annually with Urology at ___. He is on both
Tamsulosin and finasteride and per last urology note, symptoms
have been stable.
In the ED:
- Initial vital signs were notable for:
T 97.0 HR 78 BP 154/94 RR 16 SpO2 97% RA
- Labs were notable for:
BMP: Na 143, K 4.5, Cl 103, HCO3 19, BUN 47, Cr 4.8
CBC: WBC 9.6, Hgb 13.3, plt 164
UA: RBC >182, WBC 12, Bact none
- Studies performed include:
Bladder scan: 995cc
Renal US:
-Trace perinephric fluid bilaterally, without evidence of stones
or
hydronephrosis.
-Prostatomegaly with a volume of 173 cc.
- Consults:
Renal:
- Continue Foley
- Consult urology
- Renal and bladder ultrasound
- Monitor urine output closely
- Continue tamsulosin and finasteride
Vitals on transfer:
T 98.6 HR 69 BP 157/83 RR 16 SpO2 95% RA
Upon arrival to the floor, patient states his abdominal
discomfort has improved after foley placement. He confirms the
above history and has not additional complaints. He denies any
pain at the catheter site. He is wondering how long he needs to
stay in the hospital as he has a planned vacation to ___
with
flight leaving 8AM ___ and is wondering if he can make it.
REVIEW OF SYSTEMS: Complete ROS obtained and is otherwise
negative.
Past Medical History:
- BPH with history of urinary retention in past (sees Dr. ___ in
At___ ___
- Lumbar stenosis without neurogenic claudication
- Type 2 DM
- Obesity
- Diverticulosis
- Elevated PSA
- ___ - PBx - vol 133.73 - path negative for
malignancy,
but with acute and chronic inflammation.
- f/u path of PBx ___ PSA 6.9 - vol 94.2gm - path benign
- Negative prostate MRI at ___ in ___.
Social History:
___
Family History:
No family history of bladder or prostate cancer. Otherwise
reviewed and non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: ___ 2356 Temp: 97.9 PO BP: 136/72 L Lying HR: 68
RR:
18 O2 sat: 94% O2 delivery: Ra FSBG: 92
GENERAL: Alert and interactive. In no acute distress.
EYES: NCAT. PERRL, EOMI. Sclera anicteric and without injection.
ENT: MMM. No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
RESP: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants.
RECTAL: Normal rectal tone. Enlarged prostate with smooth
borders. No nodules palpated.
MSK: No CVA tenderness. No clubbing, cyanosis, or edema.
SKIN: Warm. Cap refill <2s. No rash.
NEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal
sensation. Gait is normal. AOx3.
PSYCH: appropriate mood and affect
DISCHARGE PHYSICAL EXAM:
========================
24 HR Data (last updated ___ @ 1659)
Temp: 99.1 (Tm 99.1), BP: 132/81 (132-139/72-87), HR: 65
(65-86), RR: 18 (___), O2 sat: 95% (91-95), O2 delivery: Ra,
Wt: 192.1 lb/87.14 kg
GENERAL: Continues alert and interactive. In no acute distress.
EYES: NCAT. EOMI. Sclera anicteric and without injection.
ENT: MMM. No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
RESP: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants.
GU: Foley in place without trauma or bleeding around meatus
MSK: No CVA tenderness. No clubbing, cyanosis, or edema.
SKIN: Warm. Cap refill <2s. No rash.
NEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal
sensation. Gait is normal. AOx3.
PSYCH: appropriate mood and affect
Pertinent Results:
ADMISSION LABS
___ 07:00PM BLOOD WBC-9.6 RBC-4.32* Hgb-13.3* Hct-36.1*
MCV-84 MCH-30.8 MCHC-36.8 RDW-14.1 RDWSD-43.0 Plt ___
___ 07:00PM BLOOD Neuts-81.7* Lymphs-10.7* Monos-7.2
Eos-0.0* Baso-0.1 Im ___ AbsNeut-7.86* AbsLymp-1.03*
AbsMono-0.69 AbsEos-0.00* AbsBaso-0.01
___ 07:00PM BLOOD Glucose-122* UreaN-47* Creat-4.8*# Na-143
K-4.5 Cl-103 HCO3-19* AnGap-21*
DISCHARGE LABS
___ 07:42AM BLOOD Glucose-126* UreaN-29* Creat-1.5*# Na-145
K-4.1 Cl-107 HCO3-25 AnGap-13
___ 03:35PM BLOOD Glucose-99 UreaN-22* Creat-1.3* Na-146
K-4.1 Cl-107 HCO3-26 AnGap-13
___ 07:42AM BLOOD WBC-8.0 RBC-4.27* Hgb-13.3* Hct-36.0*
MCV-84 MCH-31.1 MCHC-36.9 RDW-14.2 RDWSD-43.1 Plt ___
___ 07:42AM BLOOD Calcium-8.9 Phos-2.4* Mg-2.2
___ 03:35PM BLOOD Calcium-8.8 Phos-2.6* Mg-2.2
IMAGING AND STUDIES
___ RENAL US
Impression:
1. Trace perinephric fluid bilaterally, more conspicuous on the
right, without
sonographic evidence of stones or hydronephrosis.
2. Prostatomegaly with a volume of 173 cc.
MICROBIOLOGY
___ 6:45 pm URINE; URINE CULTURE (Pending)
Brief Hospital Course:
SUMMARY STATEMENT
=================
Mr. ___ is a ___ year old man with past medical history of BPH,
T2DM, lumbar stenosis who presents as a visit from ___
___ after having difficulty urinating over last 48 hours
and found to have urinary retention s/p foley placement.
TRANSITIONAL ISSUES
===================
[] follow up with urologist Dr. ___ within 7 days after
discharge
[] repeat chemistry panel outpatient mainly to assess for
resolution of acute kidney injury with BUN and Cr levels
ACUTE ISSUES
============
#Urinary retention
#Post-obstructive acute kidney injury
Patient w/hx of BPH and past episodes of urinary retention
requiring foley catheterization, presented for 2 days of urinary
retention, foley introduced in ED with 1.6L of output. Renal US
without evidence of hydronephrosis. Suspect that his urinary
retention was due to post-obstructive process, particularly in
light of his BPH. He was found to have ___ which was rapidly
resolving post foley placement. He was deemed appropriate for
discharge with continuation of foley per urology and nephrology
services.
CHRONIC ISSUES
==============
# T2DM
Kept on ISS during the short time he was admitted.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM
2. Tamsulosin 0.4 mg PO QHS
3. Finasteride 5 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Atorvastatin 40 mg PO QPM
2. Finasteride 5 mg PO DAILY
3. Multivitamins 1 TAB PO DAILY
4. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
Acute urinary retention secondary to prostate enlargement
SECONDARY DIAGNOSIS
===================
Post-obstructive acute kidney injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at the ___
___!
WHY WAS I IN THE HOSPITAL?
==========================
- You had urinary retention that required a catheter insertion.
WHAT HAPPENED IN THE HOSPITAL?
==============================
- You had a Foley catheter inserted and watched for recovery of
your kidney function due to the 2-day urinary obstruction.
- You were seen by the general medicine service along nephrology
service and the urology service for your condition.
WHAT SHOULD I DO WHEN I GO HOME?
================================
- Please continue to take all of your medications as directed
- Please follow up with all the appointments scheduled with your
doctor
___ you for allowing us to be involved in your care, we wish
you all the best!
Your ___ Healthcare Team
Followup Instructions:
___
|
10102862-DS-10 | 10,102,862 | 23,353,872 | DS | 10 | 2159-12-14 00:00:00 | 2159-12-15 10:26:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ male with history of recurrent acute on chronic
kidney failure and left thigh chondrosarcoma, rectal mass, left
renal mass, admitted after fall/syncope with C3 nondisplaced
fracture and renal failure. Patient fell this morning when he
was walking to the bathroom with his walker. His daughter was
present at the time of the fall. Patient fell forward onto his
knees and was on the floor for approximately 1 min before he
regained responsiveness. He has been feeling dizzy, weak and
nauseated for the last 2 days with minimal PO intake. He had one
episode of emesis this week. He initially presented to ___ after
his fall. He underwent CT Head and Neck which demonstrated
nondisplaced fracture of the left C3 transverse process with
unremarkable CT head. He was transferred to ___ for
neurosurgical evaluation after receiving 1L NS. Of note patient
has R PICC for frequent IV hydration with his oncologist.
Per patient's family (son and daughter at bedside) he requires
IVFs several times per week with oncologist. Pt does not speak
much, and per pt's son is rarely able to convey his symptoms. Pt
is usually able to walk to bathroom with his walker, and he
spends most of the time sitting on the couch. He lives with his
daughter ___.
Of note patient has been hospitalized multiple times at ___ for
poor PO intake and acute renal failure. He was evaluated ___
with 1.4 cm right ureteral stone with hydronephrosis prompting
nephrostomy tube placement and a left renal cyst measuring 8
centimeters also noted at that time. In ___ he had another
episode ___ which improved with hydration. He underwent
percutaneous nephrolithotomy for a chronic ureteral stone on
___. He was hospitalized ___ for recurrent
renal failure with Cr to 4. He underwent right ureteral stent
placement at that time as well. Current episode ___ likely
represents repeat obstruction vs prerenal in setting of
dehydration.
With regards to his oncologic history he follows with Dr. ___
at ___. He has Extraskeletal myxoid chondrosarcoma of the left
thigh with small lung nodularities of undetermined significance
and a 5 centimeter left hemipelvic mass possibly representing
nodal disease. He is s/p radiation therapy ending ___. He
was evaluated by the orthopedic surgery team here at ___ and
was determined not to be a surgical candidate. He also has a 8
centimeter rectosigmoid mass, which was pedunculated, but biopsy
showing tubulovillous adenoma. He was seen by Dr. ___
___, deferred surgical management with given that it may
interfere with treatment for Sarcoma.
In the ED:
Initial vitals: 97.7 95 ___ 99% RA
Exam notable for: no contusions or points of tenderness, pt in
collar for C3 fx and neuro exam non-focal
Labs notable for WBC 12.8, Hb 10.3, HCT 31.6, Platelets 387, Mg
2.9, Ag 20, BUN 63, Cr 2.8, glucose 129.
Flu negative
Lactate 1.2
Imaging notable for: C spine with Non-displaced fx of L C3
lamina
CXR: Right upper extremity PICC tip projecting over the mid SVC.
Multiple lung nodules are better seen on the chest CT from ___. No focal consolidation.
Consults: Spine- Non-displaced fx of L C3 lamina. Neuro exam
non-concerning.
-Rigid c-collar at all times
-Pain control
-___
-Follow-up with Dr. ___ in ___ Orthopaedic Spine
clinic in 2 weeks--may be able to be transitioned to soft collar
at that time
Low threshold for C-spine MRA if patient develops any new-onset
sensory/motor deficits or acute change in mental status.
Vitals on transfer: 98.1, HR 71, BP 108/7, RR 18, O2 100% RA
On arrival to the floor patient reports he does not recall his
fall. Collateral obtained from daughter who was present during
the fall as described above. He reports feeling nauseated. Also
reports slight shortness of breath. Has persistent diarrhea.
Denies fevers, chills, neck pain, chest pain, abdominal pain,
dysuria, or leg swelling.
Past Medical History:
1. Extraskeletal myxoid chondrosarcoma of the left thigh with
small lung nodularities of undetermined significance and a 5
centimeter left hemipelvic mass possibly representing nodal
disease. s/p radiation therapy ending ___
2. An 8 centimeter rectosigmoid mass, which was pedunculated,
but biopsy showing tubulovillous adenoma.
3. Nephrolithiasis of a recurrent basis involving the right
kidney with obstructing stones
4. Multiple episodes of acute kidney injury and now chronic
kidney disease stage 3. Acute kidney injuries on the basis of
prerenal and post renal azotemia.
5. Protein calorie malnutrition.
6. Idiopathic cardiomyopathy with global hypokinesis.
7. Anemia of malignancy and renal disease.
8. Hypertension.
9. H/o afib on amiodarone
Social History:
___
Family History:
No family history of malignancy or renal pathology.
Physical Exam:
ADMISSION EXAM:
===============
Vitals: 97.4PO 115 / 80L Lying 74 16 97 Ra
General: alert, oriented x2-3 (thought year was ___, no acute
distress
Eyes: Sclera anicteric
HEENT: MMM, oropharynx clear
Neck: Hard cervical spine collar in place
Resp: Faint crackles in bilateral lung bases, no wheezes, rales,
ronchi
CV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
GI: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
MSK: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNs2-12 intact, strength ___ in bilateral upper and lower
extremities, sensation to light touch intact
DISCHARGE EXAM:
=================
Vitals: 97.4PO 103 / 70 65 18 100 Ra
General: alert, oriented x3, no acute distress
Eyes: Sclera anicteric
HEENT: MMM, oropharynx clear
Neck: ___ J cervical spine collar in place
Resp: clear to auscultation, no wheezes, rales, ronchi
CV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
GI: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
MSK: warm, well perfused, palpable pulses, no clubbing, cyanosis
or edema
Neuro: A&Ox3, strength grossly intact
Pertinent Results:
ADMISSION LABS:
===============
___ 05:15AM BLOOD WBC-12.8* RBC-3.64* Hgb-10.3* Hct-31.6*
MCV-87 MCH-28.3 MCHC-32.6 RDW-15.6* RDWSD-49.1* Plt ___
___ 05:15AM BLOOD Neuts-86.8* Lymphs-6.4* Monos-6.2
Eos-0.1* Baso-0.0 Im ___ AbsNeut-11.09* AbsLymp-0.82*
AbsMono-0.79 AbsEos-0.01* AbsBaso-0.00*
___ 05:15AM BLOOD ___ PTT-26.0 ___
___ 05:15AM BLOOD Glucose-129* UreaN-63* Creat-2.8* Na-135
K-3.5 Cl-94* HCO3-21* AnGap-20*
___ 05:15AM BLOOD Calcium-9.1 Phos-5.0* Mg-2.9*
___ 07:11AM BLOOD %HbA1c-5.8 eAG-120
___ 05:15AM BLOOD TSH-1.0
___ 06:31AM BLOOD Cortsol-26.6*
___ 06:22AM BLOOD 25VitD-22*
___ 05:27AM BLOOD Lactate-1.2
DISCHARGE LABS:
===============
___ 05:58AM BLOOD WBC-9.0 RBC-3.24* Hgb-9.0* Hct-29.0*
MCV-90 MCH-27.8 MCHC-31.0* RDW-16.2* RDWSD-53.1* Plt ___
___ 05:58AM BLOOD Glucose-111* UreaN-72* Creat-2.9* Na-139
K-3.4 Cl-105 HCO3-18* AnGap-16
___ 05:58AM BLOOD Calcium-8.9 Phos-3.7 Mg-2.7*
MICRO:
========
___: Urine culture no growth
___: C. Diff, blood cultures, with no growth
IMAGING:
=========
___ CT C spine with Non-displaced fx of L C3 lamina
___ CXR: Right upper extremity PICC tip projecting over the mid
SVC.
Multiple lung nodules are better seen on the chest CT from ___. No focal consolidation
___ TTE: The left atrium and right atrium are normal in cavity
size. 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
hypokinesis of the inferior septum, inferior and inferolateral
walls. The remaining segments contract normally. Quantitative
(biplane) LVEF = 41 %. Right ventricular chamber size and free
wall motion are normal. The descending thoracic aorta is mildly
dilated. The aortic valve leaflets (?#) appear structurally
normal with good leaflet excursion. There is no aortic valve
stenosis. Trace aortic regurgitation is seen. The mitral valve
leaflets are structurally normal with trivial mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
There is mild pulmonary artery systolic hypertension. There is
an anterior space which most likely represents a prominent fat
pad.
IMPRESSION: Suboptimal image quality. Normal left ventricular
cavity size with regional systolic dysfunciton suggestive of
CAD.Mild pulmonary artery systolic hypertension. Mildly dilated
descending thoracic aorta.
RENAL US ___:
1. Multiple small nonobstructing right renal calculi measuring
up to 0.4 cm. No evidence of hydronephrosis bilaterally.
2. A 7.2 cm isoechoic exophytic lesion without internal flow
arising from the upper pole of the left kidney was better
characterized on MR abdomen pelvis performed on ___
and was not associated with increased enhancement
3. 2.4 cm left lower pole cyst with internal septations.
4. Unremarkable bladder with stent in appropriate position.
Brief Hospital Course:
___ male with history of recurrent acute on chronic
kidney failure and left thigh chondrosarcoma, rectal mass, left
renal mass, admitted after syncope/fall secondary to orthostasis
with C3 nondisplaced fracture.
#Syncope
#Orthostasic hypotension
#Fall
Patient presenting after a fall at home with C3 fracture, CT
head unremarkable. Event likely secondary to orthostasis. He
has poor PO intake for several days and has had multiple recent
admissions for dehydration. Etiology of orthostasis likely due
to poor PO intake in setting of depression. AM cortisol above
normal, HbA1c normal and TSH normal. Per discussion with
outpatient onclogoist has undergone workup with GI and has seen
palliative care. ___ recommending rehab. Patient initiated on
Fludrocortisone 0.1mg and given IV fluid recusitation almost
daily in setting of poor PO intake. Can consider paraneoplastic
panel as outpatient.
#Depression
#Hypoactive delirium
#Poor PO intake
#Severe Malnutrition
Patient with poor PO intake in setting of depression and nausea.
He is requiring IV fluid resuscitation multiple times per week
with oncology. Per oncologist he is not on active treatment for
malignancy and is not the likely etiology for poor PO intake.
Depression/apathy likely primary driver of poor PO intake.
Evaluated by psychiatry, patient likely with adjustment disorder
with depressed mood vs depression and hypoactive delirium. His
Mirtazipine was increased from 7.5 to 22.5mg with goal of 30mg
daily (can be increased on ___ per psych). Consider initiation
of tube feeds given poor PO intake, he was refusing during this
hospitalization. Providing patient with nutritional supplements
and electrolyte repletion.
#Goals of Care
Patient with depression and poor PO as above. Recommended
initiation of tube feeds which patient refused. Discussed
possibility of transition to hospice with patient and his
family. They will continue to discuss when it would be
appropriate to make that transition.
#Long QT interval
Patient with prolonged QTc, initially >500 in setting of
amiodarone, which we discontinued during this hospitalization.
On multiple QT prolonging agents. His QTx was 469 on ___.
#C3 Fx, non-displaced:
Patient found to have non-displaced C3 fracture on CT neck.
Spine consulted in ED. Patient needs rigid collar at all times.
Follow-up with Dr. ___ in ___ Orthopaedic Spine
clinic in 2 weeks--may be able to be transitioned to soft collar
at that time.
#Anemia
Patient with Hb 9.1 from 10.3 in setting of IVF. Has a known
rectal mass, but not reporting melena/hematochezia. Has had
dilutional anemia on previous admissions.
___ on CKD III
#Recurrent R ureteral stone with hydronephrosis
Patient presenting with Cr elevation to 2.8 with baseline
2.3-2.5. Likely prerenal, has been improving with IV fluids.
Also has history of renal stones with stent placement at ___.
Renal US on admission with no obstructive stones.
#Extraskeletal myxoid chondrosarcoma
Patient with chondrosarcoma of the left thigh with small lung
nodularities of undetermined significance and a 5 centimeter
left hemipelvic mass possibly representing nodal disease. s/p
radiation therapy ending ___. Patient
evaluated by orthopedics here at ___ who did not recommend
surgery after reviewing his case at tumor board. Plan would be
to obtain repeat MRI in ___. Patient has follow up scheduled
with orthopedic oncology.
# 8 centimeter rectosigmoid mass
Biopsy showing tubulovillous adenoma. Evaluated by colorectal
surgery who did not recommend surgical intervention.
#Chronic HFrEF (41%)
#Cardiomyopathy
Per review of ___ records, patient with known idiopathic
cardiomyopathy with reported EF ___ (date unknown). TTE on
this admission with EF 41%, wall motion abnormality with likely
history of CAD. On Metoprolol Tartrate 6.25 Q6 (consolidate to
Metoprolol Succinate 25mg daily and ASA 81mg.
#Atrial fibrillation
History of afib. Anticoagulation has been deferred after
discussion with previous providers. Discontinuted amiodarone
given long QTc. On Metoprolol Tartrate 6.25 Q6 (consolidate to
Metoprolol Succinate 25mg daily). Held Carvedilol.
# Emergency contact: Daughter ___- ___, Son ___
___
# Code: DNR/DNI
TRANSITIONAL ISSUES:
=====================
-Please continue to address goals of care including tube feeds
or hospice care.
-Patient requiring 1L or IV fluids daily. Was receiving IV
hydration with Oncologist multiple times per week as an
outpatient.
- Continue to assess orthostatic vital signs. Can uptitrate
Fludricortisone.
- Please increase dose of Mirtizipine to 30mg daily on ___
- Patient with long QTc, please monitor QTc with any changes in
medication doses.
- Patient with CKD III and persistently elevated Cr throughout
hospitalization. Ensure patient follows with nephrology.
- Ensure patient follows with oncology for ongoing management of
Extraskeletal myxoid chondrosarcoma.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Carvedilol 3.125 mg PO BID
2. Aspirin 81 mg PO DAILY
3. Bisacodyl 10 mg PO DAILY:PRN constipation
4. LORazepam 0.5-1 mg PO Q8H:PRN anxiety
5. Prochlorperazine 10 mg PO Q6H:PRN nausea
6. Amiodarone 100 mg PO DAILY
7. Potassium Chloride 10 mEq PO DAILY
8. Escitalopram Oxalate 5 mg PO DAILY
9. Mirtazapine 7.5 mg PO QHS
10. Fluconazole 100 mg PO Q24H
Discharge Medications:
1. Acetaminophen 1000 mg PO TID
2. Fludrocortisone Acetate 0.1 mg PO DAILY
3. Metoprolol Succinate XL 25 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Thiamine 100 mg PO DAILY
6. Vitamin D ___ UNIT PO DAILY
7. Mirtazapine 22.5 mg PO QHS
8. Aspirin 81 mg PO DAILY
9. Bisacodyl 10 mg PO DAILY:PRN constipation
10. LORazepam 0.5-1 mg PO Q8H:PRN anxiety
RX *lorazepam [Ativan] 0.5 mg ___ tablets by mouth Every 8 hours
as needed Disp #*10 Tablet Refills:*0
11. Prochlorperazine 10 mg PO Q6H:PRN nausea
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis: C3 nondisplaced fracture
Secondary diagnosis: Orthostatic hypotension, hypoactive
delirium, depression, severe malnutrition, Extraskeletal myxoid
chondrosarcoma, atrial fibrillation, chronic heart failure with
reduced ejection fraction.
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
Why you were here?
You came to the hospital because you had a fall at home.
What we did while you were here?
We gave you a brace for your neck.
We gave you IV fluids and a medication to help increase your
blood pressure when you stand up.
We had the psychiatry team see you and you were given a
medication called Mirtazapine.
What you should do when you leave?
Please continue to work with your physical therapist
Please increase your Mirtazapine dose after talking to your
doctor.
It was a pleasure taking care of you!
Your ___ Team
Followup Instructions:
___
|
10102878-DS-3 | 10,102,878 | 22,406,437 | DS | 3 | 2173-09-08 00:00:00 | 2173-09-08 18:19:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fever, cough, dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ h/o CAD s/p valve replacement and CABG, CHF (EF
45%
and apical dyskinesis) HTN, HLD who presented to the ED with
dyspnea. Patient reported that earlier in the week he started to
develop a productive cough that worsened the night prior to
presentation. Last night he further developed rhinorrhea and
myalgias, followed by congestion and worsening of his productive
cough. He noted left-sided, non-radiating sharp chest pain,
worse
with coughing. He reported a bout of coughing earlier in the day
with associated diaphoresis. Reportedly, both his daugthers were
sick with the flu and had fevers. Of note, he recently traveled
to ___ and was able to ambulate and climb hills while there
without issues.
In the ED, initial VS were: T 100.1, HR 104, BP 132/76, RR 20,
96% RA
Exam notable for: persistent oxygen desaturation, peak flow 150,
positional shortness of breath, mild pretibial edema.
Labs showed:
WBC: 15.9 ___ Hgb: 13.5 Plt: 182
137|101| 15 AGap=15
-------------<95
6.6| 21|0.9
Repeat whole blood K: 4.0
Repeat lytes:
142|103| 17 AGap=16
-----------<112
3.9| 23|0.9
proBNP: 2989
Trop-T: <0.01 x2
___
FluAPCR: Negative
FluBPCR: Negative
UA: neg looks, mod blood, nitrite neg, 600 protein, 2 RBC, 1
WBC,
few bact
Imaging showed:
CXR ___: no acute cardiopulmonary process
CXR ___: Suggestion of mildly coarsened interstitial markings
and possible peribronchial thickening could represent mild
pulmonary vascular congestion or bronchitis.
Patient received:
___ 21:33 IH Albuterol 0.083% Neb Soln 1 NEB
___ 21:33 IH Ipratropium Bromide Neb 1 NEB
___ 21:49 PO Acetaminophen 1000 mg
___ 23:15 IH Albuterol 0.083% Neb Soln 1 NEB
___ 23:15 IH Ipratropium Bromide Neb 1 NEB
___ 23:49 IV Furosemide 20 mg
___ 00:19 IV CefTRIAXone 1 g
___ 01:34 IV Azithromycin 500 mg
___ 07:49 IH Albuterol 0.083% Neb Soln 1 Neb
___ 08:29 IH Albuterol 0.083% Neb Soln 1 NEB
___ 09:13 PO Atorvastatin 80 mg
___ 09:13 PO/NG PredniSONE 60 mg
___ 09:13 PO/NG Aspirin 81 mg
___ 09:13 PO/NG Lisinopril 5 mg
___ 09:13 PO Metoprolol Succinate XL 50 mg
___ 10:05 IV Furosemide 20 mg
___ 14:09 IH Albuterol 0.083% Neb Soln 1 NEB
___ 14:09 IH Ipratropium Bromide Neb 1 NEB
___ 17:27 IH Albuterol 0.083% Neb Soln 1 NEB
No services were consulted
Transfer VS were: AF, HR93, BP 116/74, RR 16, 94% RA
On arrival to the floor, patient reports feeling much improved
from all the interventions in the ED. States that as symptoms
first developed earlier in the week, he had a lot of
congestions,
stuffy nose, cough initially dry but then productive of yellow
sputum. He states he had subjective fevers and that the EMT
noted
fever to 100.6 on their evaluation. He states that he has not
been able to sleep flat for many years and that he gets a head
rush when he lies down. He sleeps in a recliner. Denies any PND.
Notes swelling in ankles has been stable. He has been compliant
with his meds. He had some chest pain on initial evaluation but
he attributed that to coughing. No palpitations. Had a recent
sleep study in which he was diagnosed with OSA, but has not
followed through.
REVIEW OF SYSTEMS:
10 point ROS reviewed and negative except as per HPI
Past Medical History:
-Coronary artery disease: Status post four-vessel CABG in ___ (see details below)
-Severe mitral regurgitation secondary to flail leaflet status
post bioprosthetic MVR in ___
-Hyperlipidemia
-Postcardiotomy atrial fibrillation, initially on amiodarone,
subsequently discontinued with pt remaining in NSR
-OSA and central sleep apnea (not on CPAP yet)
-Numbness in feet since CABG
Social History:
___
Family History:
Uncle - history of myocardial infarction
Physical Exam:
============================
ADMISSION PHYSICAL EXAM:
============================
VS: 98.3 PO 115/69 HR 89 RR 20 95% RA
GENERAL: NAD, pleasant man speaking with nasal voice
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, oropharynx without erythema or cobblestoning, TTP over
frontal sinuses
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, ___ systolic murmur over LUSB, no gallops or
rubs
LUNGS: CTAB, diffuse end-expiratory wheezes, no rales or
rhonchi,
breathing comfortably without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly, +BS
EXTREMITIES: no cyanosis, clubbing. trace-1+ edema LLE>RLE
(stable per pt) to distal shin
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, CN II-XII grossly intact, ___ strength in BUE and
BLE, reported numbness from distal shin bilaterally
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
=============================
DISCHARGE PHYSICAL EXAM:
=============================
VITALS: 98.3 105 / 65 83 20 96 Ra
GENERAL: NAD, pleasant man, sleeping in bed with CPAP on, alert
and oriented when awoken
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, MMM
NECK: supple
HEART: RRR, S1/S2, did not appreciate murmur this morning
LUNGS: CTAB, diffuse end-expiratory wheezes, no rales or
rhonchi,
breathing comfortably without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly, +BS
EXTREMITIES: no cyanosis, clubbing. trace-1+ edema LLE>RLE
(stable per pt) to distal shin
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all extremities spontaneously
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
=====================
ADMISSION LABS:
=====================
___ 09:20PM BLOOD WBC-15.9*# RBC-4.60 Hgb-13.5* Hct-40.0
MCV-87 MCH-29.3 MCHC-33.8 RDW-13.8 RDWSD-43.4 Plt ___
___ 09:20PM BLOOD Neuts-85.0* Lymphs-4.9* Monos-6.9 Eos-2.4
Baso-0.5 Im ___ AbsNeut-13.49* AbsLymp-0.78* AbsMono-1.10*
AbsEos-0.38 AbsBaso-0.08
___ 09:20PM BLOOD Plt ___
___ 09:20PM BLOOD Glucose-95 UreaN-15 Creat-0.9 Na-137
K-6.6* Cl-101 HCO3-21* AnGap-15
___ 09:20PM BLOOD proBNP-2989*
___ 09:20PM BLOOD cTropnT-<0.01
___ 02:50AM BLOOD cTropnT-<0.01
___ 10:13PM BLOOD Lactate-1.8 K-4.0
======================
DISCHARGE LABS:
======================
___ 05:15AM BLOOD WBC-10.3* RBC-4.01* Hgb-11.7* Hct-35.2*
MCV-88 MCH-29.2 MCHC-33.2 RDW-13.6 RDWSD-44.0 Plt ___
___ 05:15AM BLOOD Glucose-110* UreaN-37* Creat-1.1 Na-142
K-4.2 Cl-104 HCO3-23 AnGap-15
___ 05:15AM BLOOD Calcium-8.2* Phos-3.9 Mg-2.0
======================
MICROBIOLOGY:
======================
___ Blood culture: pending
___ Urine culture: NEGATIVE
___ Flu A PCR, Flu B PCR: NEGATIVE
======================
IMAGING:
======================
___ ___
No evidence of deep venous thrombosis in the left lower
extremity veins.
___ CXR
Suggestion of mildly coarsened interstitial markings and
possible
peribronchial thickening could represent mild pulmonary vascular
congestion or bronchitis.
Brief Hospital Course:
====================
BRIEF SUMMARY
====================
___ year old male with history of CAD s/p CABGx4 (___), MVR
(___), systolic CHF (EF 45%), HTN, pAfib post-CABG not on
anticoagulation, presenting with dyspnea in the setting of
cough, congestion, and sick contacts. He was initially febrile
per EMS at 100.6, and has been afebrile since. Peak flow was 150
in the ED, suggestive of obstructive process. This was thought
to be most likely bronchitis, but given that he improved
significantly after receiving broad treatment in the ED with
nebs, prednisone, and CTX/azithromycin, he was discharged with a
short course of prednisone and azithromycin. He was satting well
at rest and with ambulation on room air at discharge.
=======================
PROBLEM-BASED SUMMARY
=======================
ACUTE ISSUES:
# Dyspnea
# Cough, fever, leukocytosis
He presented with dyspnea for two days, in the setting of URI
symptoms, fever and WBC 15.9 on presentation. Peak flow in the
ED was 150, suggestive of an obstructive process. He is a never
smoker and does not have known COPD. He has systolic CHF (EF
45%) with elevated BNP on admission (no prior BNP for baseline),
but he appeared euvolemic on exam and there was low suspicion
for CHF exacerbation. CXR did not show pneumonia, but did
suggest bronchitis. He did improve markedly after receiving
broad treatment with nebs, prednisone, and CTX/azithromycin and
IV Lasix in the ED. Given his symptomatic improvement, with
persistent diffuse wheezing on exam, he was continued for a
short 5-day course of prednisone 40 and azithromycin 250 for
anti-inflammatory effect, as well as albuterol and fluticasone.
He was satting well on room air and did not desaturate with
ambulation on day of discharge. He was instructed to check peak
flow twice daily at home and call PCP for peak flow <200. He
will likely need outpatient PFTs once he is back to baseline.
# Systolic congestive heart failure
He has a known history of sCHF (EF 45%). There was initial
concern for a mild CHF exacerbation contributing to his dyspnea,
with an elevated BNP 2989 (no priors for comparison), and he
received 20 IV Lasix x1 in the ED. However, he appeared
euvolemic on exam, so home Lasix 20 PO daily was restarted. He
was continued on metoprolol succinate and lisinopril.
CHRONIC ISSUES:
# Obstructive sleep apnea: He has had a positive sleep study,
but has not started CPAP at home. He was trialed on CPAP
overnight in-house and tolerated it well. He will need
outpatient follow up for CPAP and sleep apnea.
# Chronic left lower extremity edema: Unchanged per patient. No
DVT on ___.
# History of pAfib: He has a history of paroxysmal a fib
post-CABG for which he was previously on admiodarone. He was
monitored on telemetry overnight and did not have any events.
# CAD: s/p 4v CABG-MVR. Troponin neg x2 this admission, no
changes on ECG. He was continued on home ASA, statin,
metoprolol.
# HTN: Continued on home metoprolol succinate 50 mg daily and
lisinopril 15 mg daily.
# Depression: continued escitalopram 10 mg daily
========================
TRANSITIONAL ISSUES
========================
- Patient has been instructed to check peak flow BID at home,
and to call PCP for peak flow <200.
- Consider outpatient PFTs once he is asymptomatic.
- Needs outpatient sleep follow up for initiation of CPAP.
New medications: albuterol, prednisone 40 for 5-day course,
azithromycin 250 for 5-day course, fluticasone
Changed medications: none
Stopped medications: none
#CODE: Full (presumed)
#CONTACT: ___ (wife) Phone ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 80 mg PO QPM
2. Furosemide 20 mg PO DAILY
3. Lisinopril 15 mg PO DAILY
4. Metoprolol Succinate XL 50 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Escitalopram Oxalate 10 mg PO DAILY
7. Vitamin D ___ UNIT PO 1X/WEEK (___)
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH QID:PRN shortness of breath
RX *albuterol sulfate [ProAir HFA] 90 mcg 2 puffs four times
daily Disp #*1 Inhaler Refills:*0
2. Azithromycin 250 mg PO Q24H Duration: 4 Days
Last day will be on ___.
RX *azithromycin 250 mg 1 tablet(s) by mouth daily Disp #*3
Tablet Refills:*0
3. Fluticasone Propionate NASAL 1 SPRY NU BID
RX *fluticasone 50 mcg/actuation 1 spray twice daily Disp #*1
Spray Refills:*0
4. PredniSONE 40 mg PO DAILY Duration: 4 Days
Last day will be on ___.
RX *prednisone [Deltasone] 20 mg 2 tablet(s) by mouth daily Disp
#*6 Tablet Refills:*0
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 80 mg PO QPM
7. Escitalopram Oxalate 10 mg PO DAILY
8. Furosemide 20 mg PO DAILY
9. Lisinopril 15 mg PO DAILY
10. Metoprolol Succinate XL 50 mg PO DAILY
11. Vitamin D ___ UNIT PO 1X/WEEK (___)
Discharge Disposition:
Home
Discharge Diagnosis:
======================
PRIMARY DIAGNOSIS:
======================
Shortness of breath
Fever
Leukocytosis
======================
SECONDARY DIAGNOSIS:
======================
Systolic congestive heart failure
Obstructive sleep apnea
History of paroxysmal a fib
Coronary artery disease
Hypertension
Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure to care for you at ___
___. Please find detailed discharge instructions
below:
WHY WERE YOU ADMITTED TO THE HOSPITAL?
- You were admitted because you had shortness of breath.
WHAT HAPPENED TO YOU IN THE HOSPITAL?
- In the emergency department, you received antibiotics,
steroids, and breathing treatments (nebs).
- Your symptoms improved and you felt at your baseline.
- You received an ultrasound of the veins in your left leg, to
make sure there wasn't a blood clot. No clot was found.
- You were started on an antibiotic with anti-inflammatory
effects (azithromycin) and a short course of steroids.
WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL?
- Please call your primary care provider (Dr. ___:
___ to make a follow up appointment by ___.
- Please finish your course of antibiotics and steroids, and use
your albuterol inhaler as needed for shortness of breath.
- Please check your "peak flow" twice a day. Please call your
primary care provider if it is less than 200.
We wish you the best!
- Your ___ treatment team
Followup Instructions:
___
|
10103318-DS-17 | 10,103,318 | 26,916,277 | DS | 17 | 2158-11-18 00:00:00 | 2158-11-18 19:10:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
Codeine
Attending: ___.
Chief Complaint:
right sided chest pain
Major Surgical or Invasive Procedure:
___
Right pleural pigtail placement
History of Present Illness:
___ is a ___ year old male
with a history spontaneous pneumothorax, 1 left sided, 2 right
sided treated with chest tubes, last incident treated with Right
VATS right upper lobe blebectomy and mechanical and chemical
pleurodesis on ___. Beginning this morning patient reports
onset of right chest discomfort consistent with previous
episodes
of pneumothorax. Discomfort worsened throughout the day and he
eventually decided to present to ED for further workup after
speaking with Dr. ___. He denied any dyspnea and pain
had resolved by the time he presented to ED but he reports he
continues to have an odd feeling that he can best describe as
the
feeling of air outside of his lung.
He currently denies any fevers, chills, chest pain, shortness of
breath, nausea, vomiting, subcutaneous emphysema, of difficulty
swallowing. He does endorse a slight headache from this
morning.
Past Medical History:
1. spontaneous Right pneumothorax ___ s/p anterior chest tube
2. spontaneous Left pneumothorax ___ ago, no hospital
admission, resolved without treatment
Social History:
___
Family History:
non-contributory
Physical Exam:
T 97.7 HR 88 BP 118/78 RR 18 02Sat 100% on RA
GENERAL [x] All findings normal
[ ] WN/WD [ ] NAD [ ] AAO [ ] abnormal findings:
HEENT [x] All findings normal
[ ] NC/AT [ ] EOMI [ ] PERRL/A [ ] Anicteric
[ ] OP/NP mucosa normal [ ] Tongue midline
[ ] Palate symmetric [ ] Neck supple/NT/without mass
[ ] Trachea midline [ ] Thyroid nl size/contour
[ ] Abnormal findings:
RESPIRATORY [ ] All findings normal
[X] CTA/P [ ] Excursion normal [ ] No fremitus
[ ] No egophony [ ] No spine/CVAT
[X] Abnormal findings: Decreased breath sounds over right lung
fields
CARDIOVASCULAR [x] All findings normal
[ ] RRR [ ] No m/r/g [ ] No JVD [ ] PMI nl [ ] No edema
[ ] Peripheral pulses nl [ ] No abd/carotid bruit
[ ] Abnormal findings:
GI [x] All findings normal
[ ] Soft [ ] NT [ ] ND [ ] No mass/HSM [ ] No hernia
[ ] Abnormal findings:
GU [x] Deferred [ ] All findings normal
[ ] Nl genitalia [ ] Nl pelvic/testicular exam [ ] Nl DRE
[ ] Abnormal findings:
NEURO [x] All findings normal
[ ] Strength intact/symmetric [ ] Sensation intact/ symmetric
[ ] Reflexes nl [ ] No facial asymmetry [ ] Cognition intact
[ ] Cranial nerves intact [ ] Abnormal findings:
MS [x] All findings normal
[ ] No clubbing [ ] No cyanosis [ ] No edema [ ] Gait nl
[ ] No tenderness [ ] Tone/align/ROM nl [ ] Palpation nl
[ ] Nails nl [ ] Abnormal findings:
LYMPH NODES [x] All findings normal
[ ] Cervical nl [ ] Supraclavicular nl [ ] Axillary nl
[ ] Inguinal nl [ ] Abnormal findings:
SKIN [x] All findings normal
[ ] No rashes/lesions/ulcers
[ ] No induration/nodules/tightening [ ] Abnormal findings:
PSYCHIATRIC [x] All findings normal
[ ] Nl judgment/insight [ ] Nl memory [ ] Nl mood/affect
[ ] Abnormal findings:
Pertinent Results:
___ 12:40PM WBC-5.7# RBC-5.63 HGB-16.4 HCT-49.5 MCV-88
MCH-29.2 MCHC-33.2 RDW-12.9
___ 12:40PM NEUTS-67.3 ___ MONOS-5.0 EOS-1.2
BASOS-0.6
___ 12:40PM PLT COUNT-300
___ 12:40PM ___ PTT-33.0 ___
___ 12:40PM GLUCOSE-76 UREA N-15 CREAT-0.9 SODIUM-141
POTASSIUM-5.4* CHLORIDE-104 TOTAL CO2-28 ANION GAP-14
___ CXR
New moderate right pneumothorax. No significant shift of the
mediastinal structures, although there is some mild splaying of
the
ipsilateral ribs, suggesting some degree of tension.
Brief Hospital Course:
mr. ___ was evaluated by the Thoracic Surgery service in the
Emergency Room and admitted to the hospital for management of
his right pneumothorax. His chest pain resolved and his oxygen
saturations were 95% on room air. On ___ he had a pigtail
catheter placed with subsequent talc pleurodesis. He had some
problems with pain from the talc and was placed on a Dilaudid
PCA. His chest tube remained on suction and serial films showed
improvement.
He daveloped nausea and vomiting from the Dilaudid but was
better after discontinuing it and his pain was relieved with
Ultram. He was then able to tolerate a regular diet and stay
hydrated.
His pigtail catheter was removed on ___ and the post pull
film showed persistent, small pockets of air in the R lung apex.
Pt remained hemodynamically stable, and was saturating well on
room air. He felt well enought to be discharged home. Prior to
discharge he was educated regarding his follow up plans post
discharge and he verbally expressed understanding and agreement
with these plans.
Medications on Admission:
none
Discharge Medications:
1. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*1*
2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
Discharge Disposition:
Home
Discharge Diagnosis:
Spontaneous right pneumothorax
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
* You were admitted to the hospital with right sided chest pain
and your xray showed a small pneumothorax laterally. A small
pigtail catheter was placed to evacuate the air and you then
underwent chemical pleurodesis with talc. Your chest tube is
now out and your right lung is.....
Call Dr. ___ ___ if you experience:
-Fevers > 101 or chills
-Increased shortness of breath, chest pain or any other symptoms
that concern you.
Followup Instructions:
___
|
10103318-DS-18 | 10,103,318 | 20,701,942 | DS | 18 | 2158-12-28 00:00:00 | 2158-12-28 19:14:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
Codeine
Attending: ___.
Chief Complaint:
Left sided chest pain
Major Surgical or Invasive Procedure:
___ Left video-assisted thoracoscopic blebectomy with
mechanical and chemical pleurodesis
History of Present Illness:
Mr. ___ is a ___ year old male with history significant for
multiple spontaneous pneumothoracies, (1 left sided, 3 right
sided treated with chest tubes) and previous VATS right upper
lobe blebectomy with mechanical and chemical pleurodesis
performed on ___ by Dr. ___. He was most recently
discharged from ___ on ___ after being re-admitted for
recurrent right pneumothorax which was successfully treated with
a pigtail catheter and talc pleurodesis.
Mr. ___ returned to the ED on ___ with report of sharp
left-sided chest pain that occurred when he first woke up and
stretched this morning. He states that it was identical in
quality to episodes of pain associated with his previous
pneumothoracies. Initially he did not seek medical attention as
the discomfort was relatively minor and he had no other
associated complaints. However the pain progressively increased
over the next several hours and he eventually presented to the
ED
for further evaluation.
In the Emergency Department the patient was hemodynamically
stable and saturating 100% on room air. Chest X-ray was obtained
and demonstrated a small apical left pneumothorax.
Given his extensive history of pneumothoracies, it was
determined
most appropriate to admit the patient to the Thoracic Surgery
service for further management
Past Medical History:
PAST MEDICAL HISTORY:
1. spontaneous Right pneumothorax ___ s/p anterior chest tube
2. spontaneous Left pneumothorax ___ ago, no hospital
admission, resolved without treatment
PAST SURGICAL HISTORY:
VATS right upper lobe blebectomy with mechanical and chemical
pleurodesis performed ___
Social History:
___
Family History:
Non-contributory
Physical Exam:
VITAL SIGNS:
Temp: 97.2 HR: 87 BP: 110/74 RR: 18 SaO2: 98% on
room air
GENERAL: NAD; alert and fully oriented
HEENT: Mucous membranes moist and pink; no scleral icterus; no
ocular or nasal discharge
CARDIAC: RRR; normal S1 S2; no murmur
CHEST: Incisions c/d/i; dermabond over incisions; no surrounding
erythema or induration
PULMONARY: Clear to auscultation bilaterally
ABDOMEN: Soft, nontender, nondistended; no palpable masses
EXTREMITIES: Warm and well-perfused; no swelling or edema
bilaterally
Pertinent Results:
RADIOLOGY:
Chest X-ray ___: Admission CXR
There is a small left-sided apical
pneumothorax. The right side shows no evidence of pneumothorax.
The left lung is clear. The right lung has persistent opacity at
the right lung base along the pleura consistent with the
patient's history of pleurodesis. No rib fractures are seen. The
cardiomediastinal silhouette is unremarkable. The hilar contours
are unremarkable. No signs of tension are seen.
IMPRESSION: Small left apical pneumothorax with no signs of
tension
Chest X-ray ___
Moderate left pneumothorax is unchanged. Cardiomediastinal
contours are
unchanged and midline. Surgical chain sutures are present in the
right apex.
Blunting of the cardiophrenic angles on the right could be due
to small
pleural effusion, pleural thickening, or findings post
pleurodesis. Right
lower opacity secondary to pleurodesis, is also unchanged. There
are no new lung abnormalities
Chest X-ray ___: Post-op CXR
As compared to the previous radiograph, the patient has
undergone a
left blebectomy. Two left-sided chest tubes after VATS are
visible. The
presence of a minimal millimetric pneumothorax cannot be
excluded, but the
pneumothorax is smaller than before the intervention, as
documented on the
previous image from ___.
No evidence of tension. Mild retrocardiac atelectasis. Normal
right lung
Chest X-ray ___:
Two left-sided chest tubes remain in place, one of which
terminates in the
apex and the other of which extends over the apex and down the
medial border into the left costophrenic angle. There is some
soft tissue containing loculated air at the left apex, but this
appearance is unchanged from ___ and may reflect a
combination of postoperative changes and/or a loculated
pneumothorax. Continued followup imaging would be advised. A
small amount of residual subcutaneous emphysema is seen in the
lower lateral left chest wall. No focal airspace consolidation
or pleural effusions are seen. Overall, cardiac and mediastinal
contours are stable. Interval decrease in the amount of gas
within the stomach. Surgical chain sutures are again seen at
both apices. Right lateral pleural thickening is stable and may
be result of talc pleurodesis, pleural thickening, less likely
effusion.
Brief Hospital Course:
The patient was admitted for further monitoring of his
spontaneous left pneumothorax. Follow-up chest X-rays performed
on the next day demonstrated stability in the size of his
pneumothorax, and he was pre-op'ed and consented for a VATS left
sided blebectomy with mechanical and chemical pleurodesis which
was performed on ___.
The procedure was uncomplicated and 2 chest tubes were placed.
Post-operatively the patient did well and was transferred to the
floors in good condition. His chest tubes were placed on suction
x48 hours and he was saturating well on room air.
By post-operative day 2 the patient was ambulating with chest
tubes on temporary water seal.
On post-operative day 3 the patient's chest tubes were placed on
water seal for 4 hours with repeat chest X-ray demonstrating no
significant change as compared to prior.
The chest tubes were removed and a post-pull film demonstrated a
tiny residual left pneumothorax which remained stable on
follow-up X-ray repeated 4 hours later. At that time it was
determined surgically appropriate to discharge the patient home
without need of services. At the time of discharge the patient's
pain was well controlled on oral pain medications, he was
tolerating a regular diet, was ambulating well independently,
saturating well on room air with no respiratory complaints, and
had remained afebrile through-out the entirety of his hospital
course. He will follow up with Dr. ___ in 2 weeks with a
follow-up chest X-ray in clinic.
Medications on Admission:
None
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours).
2. senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*2*
3. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*2*
4. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for PAIN for 7 days.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Left spontaneous pneumothorax
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
* You were admitted to the hospital for lung surgery and you've
recovered well. You are now ready for discharge.
* Continue to use your incentive spirometer 10 times an hour
while awake.
* Check your incisions daily and report any increased redness or
drainage. Cover the area with a gauze pad if it is draining.
* Your chest tube dressing may be removed in 48 hours. If it
starts to drain, cover it with a clean dry dressing and change
it as needed to keep site clean and dry.
* You will continue to need pain medication once you are home
but you can wean it over a few weeks as the discomfort resolves.
Make sure that you have regular bowel movements while on
narcotic pain medications as they are constipating which can
cause more problems. Use a stool softener or gentle laxative to
stay regular.
* No driving while taking narcotic pain medication.
* Take Tylenol ___ mg every 6 hours in between your narcotic.
If your doctor allows you may also take Ibuprofen to help
relieve the pain.
* Continue to stay well hydrated and eat well to heal your
incisions
* Shower daily. Wash incision with mild soap & water, rinse, pat
dry
* No tub bathing, swimming or hot tubs until incision healed
* No lotions or creams to incision site
* Walk ___ times a day and gradually increase your activity as
you can tolerate.
Call Dr. ___ ___ if you experience:
-Fevers > 101 or chills
-Increased shortness of breath, chest pain or any other symptoms
that concern you.
Followup Instructions:
___
|
10103763-DS-22 | 10,103,763 | 21,104,905 | DS | 22 | 2131-06-18 00:00:00 | 2131-06-18 15:52:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
dyspnea on exertion
Major Surgical or Invasive Procedure:
Pericardiocentesis (___)
Right heart catheterization (___)
Thoracic Harware removal (___)
History of Present Illness:
HISTORY OF PRESENTING ILLNESS:
___ with h/o rheumatic heart disease (mild MS, Moderate AS),
MSSA
bacteremia ___ T4-5 epidural abscess and discitis in ___ s/p
multiple courses of antibiotic therapy, recent NSTEMI w/ normal
stress, HCV, CKD stage 3, remote IVDU, mild cognitive
impairment,
presents with fevers, worsened shortness of breath and found to
have new large pericardial effusion.
Approxiamtely 1 month ago, patient was admitted to OSH after
acute onset AMS and shortness of breath. Found there to have a
troponin elevation that was worked up with stress test, which
was
negative for ischemia. She was then admitted to ___ ___
with AMS, fevers, soft tissue mass on her thoracic spine
concerning for phlegmon. She was treated with broad spectrum
antibiotics, phlegmon was aspiration and culture did not reveal
any micro-organism. She was discharged on her chronic
suppressive
doxycycline after feeling somewhat better. She was somewhat
better but over the past 3 days prior to this presentation she
was having shortness of breath, fevers, and increased back pain.
Also developed new sternal pleuritic chest pain, which she has
not had before.
She initially presented to an ___ where she was
found to febrile and have a large pericardial effusion with
concern for possible tamponade so she was transferred to ___
ED
for further management.
In the ED,
- Initial vitals were: 99.1 ___ 18 93% 4L NC
- Exam notable for: Negative pulsus paradoxus
- Labs notable for: WBC 10.8, hgb 8.5, lactate 0.8, BNP 1752,
albumin 2.9
- Studies notable for:
- Unilateral ___ w/ no DVT
- TTE with large pericardial effusion, no e/o tamponade.
- EKG with Sinus tachycardia to 102, low volatage, no e/o
ischemia although or pericarditis although limited by
significant
aritifact.
- Patient was given: 1 L NS and 2 g cefepime (received
vancomycin at OSH)
- Cardiology was consulted: Recommended admission to CCU for
anticipation of pericardiocentesis
On arrival to the CCU, she described history c/w the above. She
noted years of intermittent joint pains and swelling, new
intermittent rashes breaking out on arms. She noted that her
mother was diagnosed with lupus.
ROS: Positive per HPI. Remaining 10 point ROS reviewed and
negative.
Past Medical History:
-MSSA Bacteremia ___ complicated by persistent T5 epidural
abscess and discitis s/p T5-T6 corpectomy, T3-T8 posterior
fusion (___) for persistent infection/vertebral body
destruction
-Remote IVDU - ___ years ago on methadone
-HCV (unclear if treated in past)
-Mild cognitive Impairment
-Opiate dependence on methadone
-CKD III (baseline Cr 0.7-1)
-History of recurrent UTI's on macrobid suppressive therapy
-Depression/Anxiety
-Decubitus ulcers
-Mitral stenosis (per echo at ___ ___
Social History:
___
Family History:
No FH of cardiac disease per patient.
Mother with h/o hemochromatosis and SLE.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: Reviewed in Metavision
GENERAL: Chronically ill appearing.
HEENT: Normocephalic, atraumatic. Sclera anicteric. PERRL. EOMI.
NECK: Supple. JVP up at 90 degrees.
CARDIAC: regular rate tachy, ___ SEM at base. No rub.
LUNGS: Crackles at bases. No respiratory distress
ABDOMEN: Soft, non-tender, non-distended. No palpable
hepatomegaly or splenomegaly.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
Back: Warm paraspinal soft tissue mass in thoracic region
SKIN: excoriations, but no clear rashes
PULSES: Distal pulses palpable and symmetric.
NEURO: AOx3. No focal lesions
DISCHARGE PHYSICAL EXAM:
GENERAL: NAD
HEENT: AT/NC, anicteric sclera, MMM
NECK: supple, no LAD
CV: ___ midsystolic murmur auscultated in RUSB
PULM: CTAB
GI: abdomen soft, nondistended, nontender in all quadrants
EXTREMITIES: no cyanosis, clubbing, or edema
BACK: dressing clean and dry, drain removed
NEURO: Strength ___ in bilateral upper and lower extremities.
Sensation intact to light touch bilaterally.
Pertinent Results:
ADMISSION LABS
==============
___ 06:17PM BLOOD WBC-10.7* RBC-2.89* Hgb-8.5* Hct-26.9*
MCV-93 MCH-29.4 MCHC-31.6* RDW-14.3 RDWSD-48.2* Plt ___
___ 06:17PM BLOOD Neuts-71.9* Lymphs-14.1* Monos-10.5
Eos-2.1 Baso-0.5 Im ___ AbsNeut-7.66* AbsLymp-1.50
AbsMono-1.12* AbsEos-0.22 AbsBaso-0.05
___ 05:20AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-2+*
Macrocy-NORMAL Microcy-NORMAL Polychr-1+* Ovalocy-1+* Tear
Dr-OCCASIONAL
___ 06:17PM BLOOD ___ PTT-28.2 ___
___ 05:20AM BLOOD Ret Aut-2.5* Abs Ret-0.08
___ 06:17PM BLOOD Glucose-105* UreaN-15 Creat-1.2* Na-137
K-3.9 Cl-103 HCO3-23 AnGap-11
___ 06:17PM BLOOD ALT-11 AST-15 AlkPhos-78 TotBili-0.4
___ 05:20AM BLOOD ALT-13 AST-20 LD(LDH)-303* CK(CPK)-51
AlkPhos-88 TotBili-0.5 DirBili-<0.2 IndBili-0.5
___ 06:17PM BLOOD proBNP-1752*
___ 06:17PM BLOOD Albumin-2.9*
___ 05:20AM BLOOD Albumin-3.1* Calcium-8.0* Phos-3.1 Mg-1.8
Iron-16*
___ 05:20AM BLOOD calTIBC-198* Hapto-348* Ferritn-203*
TRF-152*
___ 05:20AM BLOOD RheuFac-16* ___ Titer-1:80*
CRP-161.1*
___ 05:20AM BLOOD TSH-1.3
___ 05:20AM BLOOD C3-135 C4-16
___ 06:20PM BLOOD Lactate-0.8
DISCHARGE LABS
==============
___ 08:40AM BLOOD WBC-8.8 RBC-3.00* Hgb-8.8* Hct-27.4*
MCV-91 MCH-29.3 MCHC-32.1 RDW-15.4 RDWSD-49.4* Plt ___
___ 08:40AM BLOOD ___ PTT-31.2 ___
___ 08:40AM BLOOD Plt ___
___ 08:40AM BLOOD Glucose-111* UreaN-10 Creat-1.0 Na-148*
K-3.3* Cl-109* HCO3-24 AnGap-15
___ 08:40AM BLOOD Calcium-8.4 Phos-3.6 Mg-1.8
MICRO
=====
___ BCx - final no growth
___ UCx - final no growth
___ BCx - final no growth
___ pericardial fluid - gram stain negative, acid fast smear
negative. preliminary fluid culture, anaerobic culture, acid
fast culture, viral culture with no growth ***
___ pericardial fluid in blood culture bottles - no growth
___ pericardial fluid cytology - negative for malignant
cells. Rare mesothelial cells, numerous neutrophils,
lymphocytes, histiocytes, and many red blood cells.
IMAGING AND STUDIES
===================
TTE ___:
Conclusions:
Overall left ventricular systolic function is normal. The right
ventricle has normal free wall motion. There is a small (up to
0.6 cm inferolateral to the left ventricle) to moderate (up to
1.4 cm anterior to the
right ventricle) circumferential pericardial effusion. The
effusion is echo dense, c/w blood, inflammation or other
cellular elements. There are no 2D or Doppler echocardiographic
evidence of tamponade.
IMPRESSION: Small to moderate circumferential, echodense
pericardial effusion without echocardiographic evidence for
increased pericardial pressure/tamponade physiology.
Compared with the prior TTE ___ , respiratory variation
of the mitral inflow pattern is no longer appreciated.
PET ___:
1. Increased radiotracer uptake within the subcutaneous tissues
and
paraspinal musculature extending along the pedicle screws and
interconnecting rod on the right at T7 and T8, suspicious for
infection. No increased radiotracer uptake to suggest discitis
or an epidural abscess. 2. Small pericardial effusion with mild
peripheral FDG uptake; the FDG may be due pharmacokinetics of
the effusion, but could possibly reflect infection. 3. Focus of
FDG avidity along the right pericardium without a definite CT
correlate, likely a reactive epicardial lymph node. There also
nonenlarged axillary lymph nodes with low level FDG uptake, also
likely reactive in nature. 4. Multiple foci of radiotracer
uptake throughout the large bowel, which appear to correlate
with stool and are likely physiologic. 5. Smooth septal
thickening at the lung bases bilaterally, compatible with mild
fluid overload. Small bilateral pleural
effusions with loculated components in the major fissures.
CXR ___:
In comparison with the study of ___, the pericardial drain
has been
removed. There may be a small residual component of air in the
pericardium. There is decreasing opacification at the right base
consistent with mild decrease in pleural effusion, though
residual atelectasis is again seen. Left hemidiaphragm is
obscured consistent with substantial volume loss in the left
lower lobe and possible small effusion.
TTE ___:
CONCLUSION:
The left atrium is not well seen. The estimated right atrial
pressure is ___ mmHg. There is normal regional and global left
ventricular systolic function. The visually estimated left
ventricular ejection
fraction is >=55%. Normal right ventricular cavity size with
mild global free wall hypokinesis. The aortic valve leaflets (3)
are mildly thickened. The mitral valve leaflets are mildly
thickened with no
mitral valve prolapse. There is trivial mitral regurgitation.
The tricuspid valve leaflets appear structurally normal. There
is mild [1+] tricuspid regurgitation. The pulmonary artery
systolic pressure could not be estimated. There is a moderate
circumferential pericardial effusion. There is increased
respiratory variation in transmitral/transtricuspid inflow but
no right atrial/right ventricular diastolic collapse.
IMPRESSION: Focused study. Moderate circumferential pericardial
effusion with evidence of increased pericardial pressures but
without frank echocardiographic evidence of pericardial
tamponade. Grossly biventricular systolic function. Mild
tricuspid regurgitation.
Compared with the prior TTE ___, the findings are
similar.
TTE ___:
CONCLUSION:
The estimated right atrial pressure is ___ mmHg. There is normal
regional left ventricular systolic function. Overall left
ventricular systolic function is normal. The visually estimated
left ventricular
ejection fraction is 60-65%. Normal right ventricular cavity
size with normal free wall motion. The mitral valve leaflets
appear structurally normal. The estimated pulmonary artery
systolic pressure is
borderline elevated. There is a small to moderate
circumferential pericardial effusion. There is increased
respiratory variation in transmitral/transtricuspid inflow c/w
increased pericardial pressure/tamponade physiology.
IMPRESSION: 1) Moderately sized serous fibrinous largely
circumferential pericardial effusion. The largest extent of the
pericardial effusion is anterior to the RV/RA. There is mild
respirophasic variation
in mitral inflow velocities suggestion low pressure tamponade
physiology. RA pressure appears normal. Compared with the prior
TTE (images reviewed) of ___, the size of the pericardial
effusion
has decreased. There now is very mild respirophasic variation in
mitral inflow velcities. The cut of is 25% variation and the
measurements ranged from ___. The IVC is normal in size
suggestion low pressure tamponade physiology.
CXR ___:
1. Pericardial drain in place with decreased amount of air in
the pericardium. There is no pneumothorax.
2. Decreased bilateral pleural effusions
3. Bibasilar atelectasis
TTE ___:
CONCLUSION:
The left atrial volume index is mildly increased. The estimated
right atrial pressure is >15mmHg. There is mild symmetric left
ventricular hypertrophy with a normal cavity size. There is
normal regional and
global left ventricular systolic function. Quantitative 3D
volumetric left ventricular ejection fraction is 61 %. Left
ventricular cardiac index is high (>4.0 L/min/m2). There is no
resting left ventricular outflow
tract gradient. Normal right ventricular cavity size with normal
free wall motion. The aortic sinus diameter is normal for gender
with normal ascending aorta diameter for gender. The aortic arch
diameter
is normal. The aortic valve leaflets (?#) are mildly thickened.
There is mild aortic valve stenosis (valve area 1.5-1.9 cm2).
There is no aortic regurgitation. The mitral valve leaflets
appear structurally normal
with no mitral valve prolapse. There is mild [1+] mitral
regurgitation. The tricuspid valve leaflets appear structurally
normal. There is mild [1+] tricuspid regurgitation. There is
mild pulmonary artery systolic
hypertension. There is a large circumferential pericardial
effusion. There is increased respiratory variation in
transmitral/transtricuspid inflow c/w increased pericardial
pressure/tamponade physiology.
In the presence of pulmonary artery hypertension, typical
echocardiographic findings of tamponade physiology may be
absent.
IMPRESSION: Large circumferential pericardial effusion with
signs of tamponade. Normal biventricular systolic function. Mild
aortic stenosis. Mild mitral and tricuspid regurgitation. Mild
pulmonary hypertension. Compared with the prior TTE ___,
the pericardial effusion is now larger.
CXR ___:
Pericardial drain in place with small quantity of anticipated
air in the
pericardium. Decreasing pleural effusions and opacities
suggesting
atelectasis the lung bases.
Echo ___: Overall left ventricular systolic function is
normal. The right ventricle has low normal free wall motion.
The pulmonary artery systolic pressure could not be estimated.
There is a large circumferential
pericardial effusion predominantly located adjacent to the right
ventricle. There is right atrial systolic
collapse c/w early tamponade physiology. There is mild TV/MV
inflow respiratory variation. The pericardial thickness is
normal.
IMPRESSION: Large circumferential/anterior pericardial effusion
with early signs of echocardiographic tamponade.
Compared with the prior TTE (images reviewed) of ___ ,
the pericardial effusion is larger(was present but small on
prior echo) and there are now early signs of tamponade
physiology.
Unilateral lower extremity veins right ___: No evidence of
deep venous thrombosis in the right lower extremity veins.
EKG ___: EKG with Sinus tachycardia to 102, low volatage, no
e/o
ischemia although or pericarditis although limited by
significant
aritifact.
TTE ___: EF 65%, Moderate AS, mild MS from rheumatic heart
disease.
STRESS TEST: ___: Reportedly negative at CHA.
Brief Hospital Course:
___ with h/o rheumatic heart disease (mild MS, Moderate AS),
MSSA bacteremia ___ T4-5 epidural abscess and discitis in ___
s/p multiple courses of antibiotic therapy, recent NSTEMI w/
normal stress, HCV, CKD stage 3, remote IVDU, mild cognitive
impairment, presents with fevers, worsened shortness of breath
and found to have new large pericardial effusion, now s/p
pericardiocentesis. She was then transferred to the medicine
service for ongoing management spinal soft tissue infection. Per
ID and Ortho recommendations, her spinal hardware was removed
for source control and she was started on a 6 week course of
Nafcillin.
#CORONARIES: Negative stress at CHA
#PUMP: EF 65%, Moderate AS, mild MS from rheumatic heart
disease.
#RHYTHM: Sinus tachycardia
ACUTE ISSUES:
=============
# Pericardial effusion with tamponade
New effusion with symptoms of pleuritic CP. S/p
pericardiocentesis ___. Unclear etiology. Concern for ___
syndrome. Differential includes infectious in the setting of
chornic spinal infetion, autoimmune in the setting of joint
pain/rashes, malignancy all of which are less likely. Cytology
was negative for malignancy. Autoimmune studies were remarkable
for ___ pos, RF 16 Titer 1:80, CRP 161, normal C3, C4.
Rheumatology was consulted and did not suspect a rheumatologic
etiology for her pericardial effusion given the data above.
Patient also has signs suggestive of pericarditis (ecg changes,
pleuritic chest pain on admission). Fluid studies including gram
stain and cultures have been negative to date. Patient was begun
on Colcichine 0.6 mg BID and naproxen to treat pericarditis.
Both drugs were then stopped after patient was clinically stable
due to concerns of kidney injury.
# Spinal Infection
Fevers/leukocytosis on admission likely due to spinal infection
given history of chronic spine infection on suppressive
doxycycline and recent thoracic soft tissue phlegmon. A PET scan
done on ___ showed increased radiotracer uptake within the
subcutaneous tissues and paraspinal musculature extending along
the pedicle screws and interconnecting rod on the right at T7
and T8, suspicious for infection. A CT scan on ___ showed no
evidence of hardware complication within the limitations of
streak artifact. ID and orthopedic surgery were consulted and
recommended removal of spinal hardware. S/p surgery ___.
Discharged on 6 weeks of IV naficillin 2g Q4H. Pt will require
weekly LFT and CBC check. After completion of nafcillin, pt will
not be restarted on suppressive doxycycline.
# ___ on CKD, resolved: Cr to max of 1.5 during admission
(baseline 1.0). Likely due to pre-renal hypovolemic etiology
with possible contribution from NSAIDs, resolved with IVF. No
evidence of ATN/AIN. Colchicine/naproxen stopped prior to
discharge as above. Cr 1.0 upon discharge.
# Anemia: Acute on chronic normocytic anemia. Anemia of chronic
inflammation given increased ferritin, low TIBC, low
transferrin. Also iron deficiency present given tsat 8%. Treated
with IV iron.
# Recent NSTEMI: Occurred in setting of evluation for acute
onset dyspnea at ___ ealier in ___ stress per patient
at ___. Not on statin due to low ASCVD risk per HCA notes.
Continued ASA.
# H/o Rheumatic heart disease, moderate AS, Mild MS: Murmur
notable on exam. Possible etiology of pulmonary edema. Did not
require diuresis following pericardiocentesis.
CHRONIC ISSUES:
===============
# CKD III: ___ resolved as above.
#h/o IVDU: continued methadone 89 mg QD
# Overactive bladder: oxybutynin ER not on formulary, oxybutynin
5 mg QID while in hospital.
# Pruritus: Pt with a history of pruritus. Continued home
doxepin.
# Anxiety/Depression: Continued outpt duloxetine 40 mg QD.
Continue clonazepam 1 mg qAM and 1.5 mg QPM.
# Hypothyroidism: Continue home levothyroxine 112 mcg QD
TRANSITIONAL ISSUES:
==============
[] New diarrhea on ___. Please follow up to r/o C. Diff.
Stool sample was taken on day of discharge.
[] Consider iron supplementation as outpatient
[] Weekly LFT and CBC due to Naficillin use
[] Consider repeat CRP at follow-up to ensure down-trending.
[] Continue naficllin 2g Q24 for 6 week course (last day ___
[] Check BMP at next PCP appointment to monitor Na (Na 148 on
discharge) and potassium (3.3 on discharge)
#CODE: Full
#CONTACT/HCP: Proxy name: ___ (husband)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
2. Aspirin 81 mg PO DAILY
3. ClonazePAM 1 mg PO QAM Anxiety
4. Doxepin HCl 10 mg PO HS
5. Levothyroxine Sodium 112 mcg PO DAILY
6. DULoxetine 40 mg PO DAILY
7. Methadone 89 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. Senna 17.2 mg PO QHS
10. ClonazePAM 1.5 mg PO LUNCH anxiety
11. Ditropan XL (oxybutynin chloride) 10 mg oral BID
12. Docusate Sodium 100 mg PO BID
13. Doxycycline Hyclate 100 mg PO Q12H
Discharge Medications:
1. Nafcillin 2 g IV Q4H
RX *nafcillin in dextrose iso-osm 2 gram/100 mL 2 grams IV every
4 hours Disp #*180 Intravenous Bag Refills:*0
2. Pantoprazole 40 mg PO Q24H
RX *pantoprazole [Protonix] 40 mg 1 tablet(s) by mouth once
daily Disp #*30 Tablet Refills:*0
3. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
4. Aspirin 81 mg PO DAILY
5. ClonazePAM 1 mg PO QAM Anxiety
6. ClonazePAM 1.5 mg PO LUNCH anxiety
7. Ditropan XL (oxybutynin chloride) 10 mg oral BID
8. Doxepin HCl 10 mg PO HS
9. DULoxetine 40 mg PO DAILY
10. Levothyroxine Sodium 112 mcg PO DAILY
11. Methadone 89 mg PO DAILY
Consider prescribing naloxone at discharge
12. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Pericardial effusion with tamponade
Acute Kidney Injury
Secondary diagnoses:
Normocytic anemia
CKD III
Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
Please see below for more information on your hospitalization.
It was a pleasure taking part in your care here at ___!
We wish you all the best!
- Your ___ Care Team
WHY WERE YOU ADMITTED TO THE HOSPITAL?
- You were feeling short of breath because there was fluid
built up around your heart
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL?
- We drained the fluid from around your heart and evaluated your
heart function
- We were worried that the hardware around your spine was the
source of infections so we had the surgeons remove it and
started you on new antibiotics.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Take all of your medications as prescribed (listed below)
- Follow up with your doctors as listed below
- 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.
Followup Instructions:
___
|
10103763-DS-23 | 10,103,763 | 22,549,868 | DS | 23 | 2131-07-05 00:00:00 | 2131-07-05 21:51:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Nausea, vomiting, fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a ___ with history of rheumatic heart disease, T4-5
epidural abscess/discitis c/b MSSA bacteremia ___ s/p multiple
course of antibiotics (currently on cefazolin), HCV, CKD stage
III, opiate use disorder with prior intravenous drug use
currently on methadone, and mild cognitive impairment who
presents with fevers and nausea/vomiting after recent
hospitalization notable for pericardial effusion and surgical
hardware infection.
Patient was admitted ___ after presenting with
fevers and shortness of breath, found to have new large
pericardial effusion requiring pericodiocentesis iso tamponade.
Etiology of effusion was unknown, cytology was NEGATIVE.
Rheumatologic work-up was notable for ___ POS (1:80), RF 16, CRP
161, normal C3/4. Rheumatology was consulted and did not
suspect
an underlying rheumatologic process. Of note, Dressler syndrome
was considered given recent history of NSTEMI three weeks prior
to admission (negative stress ___, patient with signs
suggestive of pericarditis. Infectious studies of her pleural
fluid were ultimately NEGATIVE as well. Patient was started on
colchicine and naproxen to treat pericarditis, subsequently
stopped iso renal injury. Patient's admission was also notable
for fevers thought to be secondary to spinal hardware infection
(on suppressive doxycycline for thoracic soft tissue phlegmon).
A PET scan performed on ___ showed increased uptake extending
along the pedicle screws and interconnecting rod on the right at
T7 and T8. ID and orthopedics were closely involved, patient
underwent removal of spinal hardware ___. She was discharged
with six weeks of nafcillin (to continue through ___, plan
not to restart doxycycline). Patient had begun to have some
diarrhea at time of discharge, Cdiff returned NEGATIVE.
Patient was evaluated in ___ clinic ___. It appears that her
nafcillin was transitioned to cefazolin given patient's concern
that it was interacting with her methadone. She has not missed
any doses of her antibiotics.
Patient initially presented to ___ ___ with
complaints of fever, increased confusion, and vomiting over the
past two days. Temperature was by report 101.4 at home. Cr
1.6,
Hb 8.1, lactate .7. Decision was made to transfer patient to
___ given her recent prolonged hospitalization.
Upon presentation to ___, patient and her husband describe the
history as above. Patient's husband says that he awoke in the
middle of the night several days ago with acute onset abdominal
pain. He rushed to the bathroom and experienced voluminous
diarrhea. He ultimately 'spent the night on the bog.' No
ongoing symptoms. Patient says that after she had dinner ___,
she exerienced acute onset nausea and subsequently threw up
several times (non-bloody, mostly food). No abdominal pain.
Patient's husband said that she complained of feeling 'off' and
'generally unwell.' He took her temperature recurrently, normal
until having a reading of 101.4F AM ___. Otherwise, patient
notes that she was feeling confused this morning, which her
husband echos. He says that she wrapped up all of her
medications in toilet paper and threw them in the toilet,
standing over the bowl and staring. He says that she seems to
have become clearer in her thinking over the course of the day.
No headaches or visual changes, no neck stiffness. As for
respiratory symtoms, patient denies any chest pain or
palipations. Her husband notes that she did seem quite short of
breath last week with some mild cough, though this has not been
persistent or worsening. No sputum production.
Past Medical History:
-MSSA Bacteremia ___ complicated by persistent T5 epidural
abscess and discitis s/p T5-T6 corpectomy, T3-T8 posterior
fusion (___) for persistent infection/vertebral body
destruction
-Remote IVDU - ___ years ago on methadone
-HCV (unclear if treated in past)
-Mild cognitive Impairment
-Opiate dependence on methadone
-CKD III (baseline Cr 0.7-1)
-History of recurrent UTI's on macrobid suppressive therapy
-Depression/Anxiety
-Decubitus ulcers
-Mitral stenosis (per echo at ___ ___
Social History:
___
Family History:
No FH of cardiac disease per patient.
Mother with h/o hemochromatosis and SLE.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: 99.4 98/59 104 18 93 Ra
GENERAL: NAD, pleasant in conversation.
HEENT: PERRL, anicteric sclera, dry mucous membranes.
NECK: No JVP elevation.
CV: Tachycardic, regular rhythm, S1/soft S2, holosystolic murmur
best heard at the RUSB/LLSB, no gallops or rubs.
PULM: Inspiratory crackles at the bases R>L, decreased
breath sounds at the R lung base, no wheezes.
GI: NABS throughout, abdomen soft, nondistended, mild diffuse
tenderness, no rebound/guarding, no hepatosplenomegaly.
EXTREMITIES: No cyanosis, clubbing, or edema.
PULSES: 1+ radial pulses bilaterally.
NEURO: Alert, oriented x3. Able to say days of week in reverse
order. CN2-1 intact. Strength ___ throughout. Sensation to
light touch intact throughout.
DERM: Warm and well perfused. L PICC site without erythema or
tenderness. Surgical scar midline over thoracic spine with 36
staples, cdi, mild erythema at edges, no purulent discharge, no
tenderness to palpation.
DISCHARGE PHYSICAL EXAM:
========================
___ 0723 Temp: 99.4 PO BP: 99/67 L Lying HR: 103 RR: 18 O2
sat: 97% O2 delivery: Ra
GENERAL: NAD, pleasant in conversation.
HEENT: PERRL, anicteric sclera, dry mucous membranes.
NECK: No JVP elevation.
CV: Tachycardic, regular rhythm, S1/soft S2, holosystolic murmur
best heard at the RUSB/LLSB, no gallops or rubs.
PULM: Inspiratory crackles at the bases R>L, decreased
breath sounds at the R lung base, no wheezes.
GI: NABS throughout, abdomen soft, nondistended, mild diffuse
tenderness, no rebound/guarding, no hepatosplenomegaly.
EXTREMITIES: No cyanosis, clubbing, or edema.
PULSES: 1+ radial pulses bilaterally.
NEURO: Alert, oriented x3. Able to say days of week in reverse
order. CN2-1 intact. Strength ___ throughout. Sensation to
light touch intact throughout.
DERM: Warm and well perfused. L PICC site without erythema or
tenderness. Surgical scar midline over thoracic spine with 36
staples, cdi, mild erythema at edges, no purulent discharge, no
tenderness to palpation.
Pertinent Results:
ADMISSION LABS:
==============
___ 03:24PM BLOOD WBC-6.7 RBC-2.38* Hgb-7.5* Hct-22.7*
MCV-95 MCH-31.5 MCHC-33.0 RDW-20.9* RDWSD-70.4* Plt ___
___ 03:24PM BLOOD Neuts-61.3 Lymphs-18.2* Monos-13.8*
Eos-5.4 Baso-0.8 Im ___ AbsNeut-4.09 AbsLymp-1.21
AbsMono-0.92* AbsEos-0.36 AbsBaso-0.05
___ 03:24PM BLOOD ___ PTT-27.6 ___
___ 03:24PM BLOOD Glucose-97 UreaN-18 Creat-1.4* Na-135
K-6.0* Cl-101 HCO3-19* AnGap-15
___ 03:24PM BLOOD ALT-<5 AST-77* AlkPhos-72 TotBili-0.4
___ 03:24PM BLOOD Lipase-21
___ 03:24PM BLOOD proBNP-1027*
___ 03:24PM BLOOD cTropnT-<0.01
___ 03:24PM BLOOD CRP-82.2*
___ 03:24PM BLOOD ASA-NEG Acetmnp-NEG Tricycl-NEG
___ 03:33PM BLOOD Lactate-0.9 K-5.1
IMAGING STUDIES:
================
CXR (___):
1. Small right pleural effusion with loculated fluid along the
lateral pleural
surface.
2. Stable moderate cardiomegaly may be partially attributed to
persistent
pericardial effusion.
CXR (___):
Left PICC terminates at the low SVC without evidence of
pneumothorax.
Opacity over the mid to lower lateral right chest may relate to
a right
pleural effusion, but underlying consolidation due to infection
or aspiration
is not excluded.
MICROBIOLOGY:
=============
**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.
___ 6:42 am BLOOD CULTURE
Blood Culture, Routine (Pending):
___ 3:41 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
___ 5:06 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
DISCHARGE LABS:
===============
___ 06:42AM BLOOD WBC-5.1 RBC-2.37* Hgb-7.4* Hct-23.4*
MCV-99* MCH-31.2 MCHC-31.6* RDW-20.6* RDWSD-72.5* Plt ___
___ 06:42AM BLOOD ___ PTT-28.0 ___
___ 06:42AM BLOOD Glucose-107* UreaN-17 Creat-1.3* Na-139
K-4.5 Cl-105 HCO3-21* AnGap-13
___ 06:42AM BLOOD ALT-<5 AST-17 LD(LDH)-339* AlkPhos-85
TotBili-0.3
___ 05:06PM URINE Color-Straw Appear-Clear Sp ___
___ 05:06PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
Brief Hospital Course:
SUMMARY:
========
___ with history of rheumatic heart disease, T4-5 epidural
abscess/discitis c/b MSSA bacteremia s/p multiple courses of
antibiotics (currently on cefazolin), HCV, CKD stage III, opiate
use disorder with prior intravenous drug use currently on
methadone, and mild cognitive impairment who presents with acute
onset fevers and nausea/vomiting likely ___ gastroenteritis.
ACUTE ISSUES:
=============
# Viral gastroenteritis
Patient presented with acute onset GI symptoms over the past
48hrs including fevers, nausea, and vomiting. Her husband also
experienced self-resolved abdominal pain/diarrhea just
beforehand. Most likely viral gastroenteritis, however, given
her complicated history of MSSA bacteremia/thoracic spinal
phelgmon (now s/p spinal hardware removal early ___ iso
infection), she was admitted overnight for monitoring. Spine was
consulted in ED and evaluated patient, without concern for
surgical site infection. Blood and urine cultures negative thus
far. No leukocytosis, LFTs wnl (AST elevation likely ___
hemolysis), liapse wnl. CXR showed small right pleural effusion
with loculated fluid along the lateral pleural surface. However,
this was also noted on prior CXR and patient has no respiratory
symptoms. Treated supportively with IVF on admission. Held off
on antibiotics given unclear source.
Since admission, her nausea and vomiting have since resolved,
and she has been afebrile. Patient is tolerating POs and feels
comfortable for discharge today. She is agreeable to return to
the ED or call her PCP if symptoms recur or worsen at home. Will
recommend follow up with PCP ___ 1 week of discharge.
Otherwise, continue home cefazolin and follow up with ID as
scheduled.
# Right chest opacity on CXR
CXR showed possible small R pleural effusion with loculated
fluid along the lateral pleural surface. Cannot rule out
underlying consolidation. Aspiration iso recent emesis is also
possible, as patient is at increased risk of aspiration given
history of esophageal dysmotility. However, no luekocytosis, no
respiratory symptoms, no pleuritic chest pain. Strep pneumo
antigen pending, legionella negative. Will hold off on
antibiotics, as patient's symptoms have resolved as above.
Recommend follow up chest x-ray vs. CT chest as an outpatient to
ensure resolution.
# Acute kidney injury
Baseline Cr 1.0, report of CKD III. Cr 1.8 at CHA prior to
transfer to ___ ED, now 1.4. UA is unremarkable. Suspect
prerenal iso acute infection and GI losses. Treated with IVF, Cr
down-trending (1.3) at discharge. Would recommend repeat
chemistry panel at 1 week follow up with PCP to ensure
___.
# Altered mental status
Patient has reported mild cognitive impairment at baseline, but
her husband noted increased confusion AM ___. Upon my
examination, patient is AOx3, attentive and interactive (she is
somewhat delayed on performance of days of the week backwards,
though is correct), no focal neurologic deficits. Mild
toxic-metabolic encephalopathy is most likely iso acute
infection and fevers. Serum/urine tox negative. Patient's mental
status improved throughout admission. Per husband, patient at
baseline at discharge.
# Normocytic anemia
Chronic anemia thought to be multifactorial, AoCD/CKD as well as
Fe deficiency, all exacerbated iso acute illness. Patient was
administered IV iron during her recent hospitalization. Hb is
down to 7.5, had been ___ during her recent admission. EGD
___ was notable for abnormal esophageal motility/dilation,
erythematous mucosa in the gastric antrum (chronic inactive
gastritis, H pylori NEGATIVE). Colonoscopy ___ was notable
for non-bleeding internal hemorrhoids. Patient denies any
black/bloody stool. She does think that she may have had some
bloody urine, though UA in the ED was negative. Would recommend
PCP follow up as an outpatient, with repeat CBC in 1 week
post-discharge.
# Elevated INR
Possibly related to nutrition and ongoing antibiotics. Treated
with PO VitK challenge during admission.
CHRONIC ISSUES:
===============
# Spinal hardware infection s/p hardware removal ___ -
Surgical site appears to be healing well, no signs of localized
infection. Patient was evaluated by spine in the ED without
concern for infection. Will continue spine follow up as
scheduled.
# Pericardial effusion s/p pericardiocentesis ___
Patient was evaluated by cardiology in the ED, noted to have
only small pericardial effusion on bedside TTE, unlikely to be
contributing to current symptoms. Previous echo ___ showing
interval decrease in effusion after pericardiocentesis.
# GERD, hx of esophageal dysmotility and gastritis
Continue home pantoprazole 40mg qd.
# Opiate use disorder
Continue home methadone. Will provide last dose letter at
discharge.
# Overactive bladder
Continue home oxybutynin 10mg ER BID.
# Pruritus
Continue home doxepin 10mg qHS.
# Anxiety/depression
Continue home sertraline.
# Hypotyroidism
Continue home synthroid ___ qd.
TRANSITIONAL ISSUES:
====================
[] F/U final blood and urine cultures
[] F/U streptococcus pneumoniae antigen
[] CXR with small R pleural effusion with loculated fluid along
the lateral pleural surface. Cannot rule out underlying
consolidation. Consider repeat CXR as an outpatient to ensure
resolution.
[] ___ on admission, treated with IVF. Cr down-trending (1.3) at
discharge. Would recommend repeat chemistry panel at 1 week
follow up with PCP to ensure continued ___.
[] Continue home cefazolin and follow up with ID as scheduled.
[] HgB 7.5 on admission, stable, but lower than prior admission.
Likely multifactorial, AoCD/CKD as well as Fe deficiency, all
exacerbated iso acute illness. Would recommend PCP follow up as
an outpatient, with repeat CBC in 1 week post-discharge.
[] Consider MRI thoracic spine to evaluate surgical site should
patient develop new back pain or other findings concerning for
abscess/osteomyelitis at surgical site
[] Received home methadone dose during admission, confirmed to
be 89mg daily. Provided last dose letter and discharge paperwork
at discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
2. ClonazePAM 1 mg PO QAM Anxiety
3. ClonazePAM 1.5 mg PO LUNCH anxiety
4. Doxepin HCl 10 mg PO HS
5. Levothyroxine Sodium 112 mcg PO DAILY
6. Methadone 89 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Pantoprazole 40 mg PO Q24H
9. Aspirin 81 mg PO DAILY
10. Ditropan XL (oxybutynin chloride) 10 mg oral BID
11. Sertraline 150 mg PO DAILY
12. CeFAZolin 2 g IV Q8H
13. Oysco-500 (calcium carbonate) 500 mg calcium (1,250 mg) oral
QAM
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
2. Aspirin 81 mg PO DAILY
3. CeFAZolin 2 g IV Q8H
4. ClonazePAM 1 mg PO QAM Anxiety
5. ClonazePAM 1.5 mg PO LUNCH anxiety
6. Ditropan XL (oxybutynin chloride) 10 mg oral BID
7. Doxepin HCl 10 mg PO HS
8. Levothyroxine Sodium 112 mcg PO DAILY
9. Methadone 89 mg PO DAILY
10. Multivitamins 1 TAB PO DAILY
11. Oysco-500 (calcium carbonate) 500 mg calcium (1,250 mg)
oral QAM
12. Pantoprazole 40 mg PO Q24H
13. Sertraline 150 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
#Gastroenteritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at the ___
___!
Why was I admitted to the hospital?
-You were admitted because you had nausea, vomiting, fevers, and
confusion.
What happened while I was in the hospital?
- You had tests to look for infection. Testing so far has been
negative.
- You were given fluids through your IV and monitored in the
hospital, and your symptoms have improved.
- Of note, you had a chest x-ray which showed some fluid in your
lung. We don't think this is infection, because you do not have
any cough, shortness of breath, etc. to suggest pneumonia.
However, it should be followed by your primary care provider
with repeat imaging. - If any of your symptoms worsen, or new
symptoms that concern you develop, please call your primary care
doctor or come into the ED.
What should I do after leaving the hospital?
- Please take your medications as listed in discharge summary
and follow up at the listed appointments.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Sincerely,
Your ___ Healthcare Team
Followup Instructions:
___
|
10103763-DS-24 | 10,103,763 | 27,193,103 | DS | 24 | 2131-09-23 00:00:00 | 2131-09-23 20:21:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Fever, cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ with history of rheumatic heart disease,
T4-5 epidural abscess/discitis c/b MSSA bacteremia ___ s/p
multiple course of antibiotics most recently on cefazolin, HCV,
CKD stage III, opiate use disorder with prior intravenous drug
use currently on methadone, and mild cognitive impairment
presenting with fever and productive cough, found to have RML
opacification requiring vasopressor support admitted due to
concern for septic shock from presumed pulmonary source.
Of note, patient with 2 recent hospitalizations. Initially
admitted ___ after presenting with fevers and SOB, found
to have new large pericardial effusion with tamponade underwent
drainage. Cytology and infectious workup was negative,
ultimately thought to have had Dressler syndrome given recent
history of NSTEMI 3 weeks prior. Fevers thought to be ___ spinal
hardware infection for which patient was on suppressive
doxycycline. Given PET ___ showed increased uptake at level of
hardware along T7 and T8, underwent removal of spinal hardware
on ___. Subsequently discharged on 6 weeks of nafcillin
however later
switched to cefazolin given c/f interaction with her methadone.
Was since admitted ___ thought to have had viral
gastroenteritis, CXR at that time showing small R PLEFF with
loculated effusion.
Since then has followed up in ___ clinic, noted to be improving
with normalization of inflammatory markers, IV cefazolin was
discontinued on ___ and was switched to suppressive
doxycycline 100 BID.
Over the last 4 days patient has noticed progressive fatigue.
Yesterday had measured fever at home to 105. Endorsing
non-productive cough. Also had one episode of nausea with emesis
several days prior however since resolved. States she has been
picking at severe lesions on her posterior mid-back however has
not noticed any spinal tenderness or pain overlying the site of
her prior disciits/hardware removal.
In the ED,
Initial Vitals: T 102.4, HR 140, BP 122/74 RR 18 O2 92%RA
Exam: Surgical site near spine, with mild erythema, and skin
abrasions lateral to the incision sites. According to the
husband these are improved from prior.
Labs:
- WBC 13.0 neturophils 86.6%, Hb 12.1 PLT 192
- Na 141, K 4.4, BUN 28, CR 1.3
- Lactate 1.2
- UA: Bland
- CRP 9.5
Imaging:
CXR: Right midlung ground-glass opacity, nonspecific, but
underlying infection not excluded and could be present. It could
potentially relate to some residual loculated pleural effusion.
Bedside Echo: NO large pericardial effusion
MRI C/T/L Spine:
1. No evidence of cord compression or cord signal abnormality.
No evidence of epidural collection.
2. Postoperative changes following laminectomy and anterior and
posterior fusion of the upper thoracic spine, with interval
removal of thoracic spinal hardware.
3. Multilevel degenerative changes of the cervical, thoracic,
and
lumbar spine, most prominent at L2-L3, where there is moderate
central canal narrowing.
4. Stable appearance of thickened and clumped cauda equina nerve
roots, adherent to the peripheral thecal sac, suggestive of
arachnoiditis.
5. Dilated, fluid-filled esophagus.
6. Bilateral, right greater than left, lung parenchymal
opacities.
7. Mild to moderate right hydroureteronephrosis, incompletely
evaluated.
8. Please note that although imaging can make the anatomic
diagnosis of cauda equina COMPRESSION, cauda equina SYNDROME is
a
clinical diagnosis based on physical examination and clinical
history. Imaging alone cannot make a diagnosis of cauda equina
SYNDROME.
Consults: None
Administered:
___ 11:40 IV CefePIME
___ 11:40 IVF LR
___ 11:44 IV CefePIME 2 g
___ 11:44 IVF LR
___ 11:44 IV Acetaminophen IV 1000 mg
___ 12:22 IV Vancomycin
___ 12:58 IVF LR 1000 mL
___ 13:00 IVF LR 1000 mL
___ 14:00 IV Vancomycin 1500 mg
___ 14:43 IV LORazepam 1 mg
___ 14:55 IV DRIP NORepinephrine (0.03-0.25 mcg/kg/min
ordered)
Patient developing worsening hypotension, SBP ___. Was enrolled
in Clover trial. Was started on Levophed.
Past Medical History:
-MSSA Bacteremia ___ complicated by persistent T5 epidural
abscess and discitis s/p T5-T6 corpectomy, T3-T8 posterior
fusion (___) for persistent infection/vertebral body
destruction
-Remote IVDU - ___ years ago on methadone
-HCV (unclear if treated in past)
-Mild cognitive Impairment
-Opiate dependence on methadone
-CKD III (baseline Cr 0.7-1)
-History of recurrent UTI's on macrobid suppressive therapy
-Depression/Anxiety
-Decubitus ulcers
-Mitral stenosis (per echo at ___ ___
Social History:
___
Family History:
No FH of cardiac disease per patient.
Mother with h/o hemochromatosis and SLE.
Physical Exam:
ADMISSION PHYSICAL EXAM
========================
GEN: Comfortable, in NAD
HEENTL: NC/AT, PERRL, EOMI
CV: Regular rate and rhythm, has II/VI systolic murmur heard
best
and RUSB
RESP: Bibasilar rales R>L. No wheezes or rhonchi
GI: Soft, NT/ND. Normoactive bowel sounds. No rebound or
guarding
MSK: On back lateral to upper thoracic spine has 5x5inc area of
erythema with several coin-sized superficial abrasions.
Non-purulent. No purulent drainage.
SKIN: Per above
NEURO: CN II-XII intact. No focal neurological deficits.
Ext: Assymetric R>L lower extremity edema
DISCHARGE Physical Exam:
========================
VITALS: ___ 1555 Temp: 98.1 PO BP: 99/57 HR: 94 RR: 18 O2
sat: 95% O2 delivery: Ra
GEN: Comfortable, in NAD
HEENTL: NC/AT, PERRL, EOMI
CV: Regular rate and rhythm, has II/VI systolic murmur heard
best
and RUSB
RESP: CTAB. No wheezes or rhonchi
GI: Soft, NT/ND. Normoactive bowel sounds. No rebound or
guarding
MSK: On back lateral to upper thoracic spine has 5x5inc area of
erythema with several coin-sized superficial abrasions.
Non-purulent. No purulent drainage. Erythema outlined with
marker
on ___
SKIN: Per above
NEURO: CN II-XII intact. No focal neurological deficits.
Ext: asymmetric lower extremities
Pertinent Results:
ADMISSION LABS
==============
___ 11:28AM BLOOD WBC-13.0* RBC-4.53 Hgb-12.1 Hct-38.4
MCV-85 MCH-26.7 MCHC-31.5* RDW-15.6* RDWSD-48.2* Plt ___
___ 11:28AM BLOOD Neuts-86.6* Lymphs-5.1* Monos-6.1 Eos-1.1
Baso-0.5 Im ___ AbsNeut-11.26* AbsLymp-0.67* AbsMono-0.80
AbsEos-0.14 AbsBaso-0.07
___ 11:28AM BLOOD Glucose-131* UreaN-28* Creat-1.3* Na-141
K-4.4 Cl-102 HCO3-23 AnGap-16
___ 04:10AM BLOOD Calcium-8.1* Phos-2.3* Mg-1.8
___ 06:12PM BLOOD O2 Sat-70
___ 11:37AM BLOOD Lactate-1.2
DISCHARGE LABS
==============
MICROBIOLOGY
============
__________________________________________________________
___ 1:05 am MRSA SCREEN Source: Nasal swab.
MRSA SCREEN (Pending):
__________________________________________________________
___ 1:03 am URINE Source: ___.
**FINAL REPORT ___
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
A negative result does not rule out infection due to other
L.
pneumophila serogroups or other Legionella species.
Furthermore, in
infected patients the excretion of antigen in urine may
vary.
__________________________________________________________
___ 12:17 pm URINE ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
__________________________________________________________
___ 11:35 am BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
__________________________________________________________
___ 11:28 am BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
IMAGING
=======
CXR: Right midlung ground-glass opacity, nonspecific, but
underlying infection not excluded and could be present. It could
potentially relate to some residual loculated pleural effusion.
Bedside Echo: NO large pericardial effusion
MRI C/T/L Spine:
1. No evidence of cord compression or cord signal abnormality.
No evidence of epidural collection.
2. Postoperative changes following laminectomy and anterior and
posterior fusion of the upper thoracic spine, with interval
removal of thoracic spinal hardware.
3. Multilevel degenerative changes of the cervical, thoracic,
and
lumbar spine, most prominent at L2-L3, where there is moderate
central canal narrowing.
4. Stable appearance of thickened and clumped cauda equina nerve
roots, adherent to the peripheral thecal sac, suggestive of
arachnoiditis.
5. Dilated, fluid-filled esophagus.
6. Bilateral, right greater than left, lung parenchymal
opacities.
7. Mild to moderate right hydroureteronephrosis, incompletely
evaluated.
8. Please note that although imaging can make the anatomic
diagnosis of cauda equina COMPRESSION, cauda equina SYNDROME is
a
clinical diagnosis based on physical examination and clinical
history. Imaging alone cannot make a diagnosis of cauda equina
SYNDROME.
___ Imaging UNILAT LOWER EXT VEINS
IMPRESSION:
No evidence of deep venous thrombosis in the right lower
extremity veins.
___ Imaging CHEST (PORTABLE AP)
IMPRESSION:
1. Interval placement of a right IJ central venous catheter
terminating in the region of the right atrium. Recommend
retraction by 4-5 cm for more optimal positioning.
2. Increased ill-defined opacity in the right mid to lower lung
concerning for pneumonia or sequelae of aspiration.
Brief Hospital Course:
Brief Hospital Course:
=======================
Ms. ___ is a ___ with history of rheumatic heart disease,
T4-5 epidural abscess/discitis c/b MSSA bacteremia ___ s/p
multiple course of antibiotics most recently on cefazolin now
transitioned back to suppressive doxycycline, HCV, CKD stage
III, opiate use disorder with prior intravenous drug use
currently on methadone, and mild cognitive impairment presenting
with fever and productive cough, found to have RML opacification
on admission, who developed very transient hypotension requiring
vasopressor support admitted for septic shock from presumed
pulmonary source. Patient improved rapidly and antibiotics were
de-escalated, given suspicion that the patient has aspiration
pneumonitis rather than pneumonia. She was however treated
empirically for CAP given fevers to 103-105 on admission with
plan for a 5-day total course to end on ___ (Cefpodoxime 200mg
PO BID, patient already on Doxycycline 100mg PO BID for discitis
suppression). Her aspiration event was likely related to
esophageal dysmotility previously worked up with barium swallow,
EGD, and manometry at ___.
TRANSITIONAL ISSUES:
====================
[ ] Patient should continue cefpodoxime 200mg PO BID until ___
to complete a course for CAP.
[ ] Patient should follow up with PCP ___ 1 week of discharge
[ ] Please reinforce teaching about eating smaller meals, while
sitting up, and avoiding lying down immediately after a meal
given her esophageal dysmotility. Lifestyle modification may
help to avoid further aspiration episodes.
# CODE STATUS: Full Code
# HCP: ___) - ___
This patient was prescribed, or continued on, an opioid pain
medication at the time of discharge (please see the attached
medication list for details). As part of our safe opioid
prescribing process, all patients are provided with an opioid
risks and treatment resource education sheet and encouraged to
discuss this therapy with their outpatient providers to
determine if opioid pain medication is still indicated.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
2. Aspirin 81 mg PO DAILY
3. Doxepin HCl 10 mg PO HS
4. Levothyroxine Sodium 112 mcg PO DAILY
5. Methadone 87 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Pantoprazole 40 mg PO Q24H
8. ClonazePAM 1 mg PO QPM anxiety
9. Ditropan XL (oxybutynin chloride) 10 mg oral BID
10. Oysco-500 (calcium carbonate) 500 mg calcium (1,250 mg) oral
QAM
11. Sertraline 150 mg PO DAILY
12. ClonazePAM 1.5 mg PO QAM Anxiety
13. Doxycycline Hyclate 100 mg PO Q12H
Discharge Medications:
1. Cefpodoxime Proxetil 200 mg PO Q12H Duration: 3 Days
RX *cefpodoxime 200 mg 1 tablet(s) by mouth twice a day Disp #*6
Tablet Refills:*0
2. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
3. Aspirin 81 mg PO DAILY
4. ClonazePAM 1 mg PO QPM anxiety
5. ClonazePAM 1.5 mg PO QAM Anxiety
6. Ditropan XL (oxybutynin chloride) 10 mg oral BID
7. Doxepin HCl 10 mg PO HS
8. Doxycycline Hyclate 100 mg PO Q12H
9. Levothyroxine Sodium 112 mcg PO DAILY
10. Methadone 87 mg PO DAILY
Consider prescribing naloxone at discharge
11. Multivitamins 1 TAB PO DAILY
12. Oysco-500 (calcium carbonate) 500 mg calcium (1,250 mg)
oral QAM
13. Pantoprazole 40 mg PO Q24H
14. Sertraline 150 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
=========
Aspiration Pneumonitis
Community Acquired Pneumonia
SECONDARY:
===========
Esophageal dysmotility
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a privilege caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You were admitted to the hospital because you had fever and a
cough.
- You blood pressure was also low because of a lung infection
and required to be admitted to the intensive care unit.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were given fluids and medications to keep you blood
pressure up.
- You were started on antibiotics for a pneumonia.
- Your blood pressure and infection improved rapidly with
treatment.
- We think your lung infection may be related to you aspirating
food.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- Make sure to always eat sitting straight up and do not lie
down immediately after eating.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10103763-DS-25 | 10,103,763 | 29,541,803 | DS | 25 | 2132-11-05 00:00:00 | 2132-11-08 21:13:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
===============
Admission labs
===============
___ 04:15PM BLOOD WBC-17.0* RBC-3.77* Hgb-11.1* Hct-34.4
MCV-91 MCH-29.4 MCHC-32.3 RDW-14.3 RDWSD-47.5* Plt ___
___ 04:15PM BLOOD Neuts-87.1* Lymphs-5.9* Monos-5.4
Eos-0.4* Baso-0.4 Im ___ AbsNeut-14.80* AbsLymp-1.00*
AbsMono-0.91* AbsEos-0.06 AbsBaso-0.07
___ 04:15PM BLOOD Glucose-109* UreaN-27* Creat-1.1 Na-138
K-5.0 Cl-107 HCO3-19* AnGap-12
___ 04:15PM BLOOD ALT-15 AST-34 AlkPhos-124* TotBili-0.8
___ 04:15PM BLOOD Albumin-3.1* Calcium-8.2* Phos-3.0 Mg-1.6
___ 04:25PM BLOOD Lactate-1.5
___ 04:41PM URINE Color-Straw Appear-CLEAR Sp ___
___ 04:41PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NORMAL pH-6.0
Leuks-NEG
===============
Pertinent labs
===============
___ 06:50AM BLOOD Neuts-80.2* Lymphs-9.7* Monos-7.1 Eos-2.0
Baso-0.5 Im ___ AbsNeut-9.25* AbsLymp-1.12* AbsMono-0.82*
AbsEos-0.23 AbsBaso-0.06
===============
Discharge labs
===============
___ 09:09AM BLOOD WBC-7.8 RBC-4.01 Hgb-11.6 Hct-36.9 MCV-92
MCH-28.9 MCHC-31.4* RDW-14.6 RDWSD-49.3* Plt ___
___ 09:09AM BLOOD Glucose-105* UreaN-17 Creat-1.1 Na-137
K-4.4 Cl-101 HCO3-25 AnGap-11
___ 09:09AM BLOOD ALT-15 AST-21 AlkPhos-125* TotBili-0.6
___ 09:09AM BLOOD Calcium-9.0 Phos-2.9 Mg-1.8
===============
Studies
===============
CXR (___):
Left lower lobe consolidation compatible with pneumonia in the
proper clinical setting.
EKG (___):
NSR
Echo (___):
LVEF 70%. Mild mitral leaflet thickening with rheumatic
deformity and mild mitral stenosis but no vevgetations. Mild
aortic valve stenosis with mildly thickened leaflets but no
stenosis. Normal left ventricular wall thickness and
biventricular cavity sizes and regional/global biventricular
systolic function. Mild pulmonary artery systolic hypertension.
Moderate tricuspid regurgitation.
===============
Microbiology
===============
___ 5:00 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 4:41 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
__________________________________________________________
___ 4:15 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
Brief Hospital Course:
SUMMARY STATEMENT:
=================
___ with history of rheumatic heart disease, T4-5 epidural
abscess/discitis c/b MSSA bacteremia ___ s/p multiple courses
of
antibiotics most recently on cefazolin, now on suppressive
doxycycline and followed by ID at ___, treated HCV with
undetectable VL, CKD stage III, opiate use disorder currently on
methadone who presented with a 2 day history of fever and
malaise, found to be septic likely secondary to a community
acquired PNA. Patient clinically improved with antibiotic
treatment and was hemodynamically stable and asymptomatic at
time of discharge.
TRANSITIONAL ISSUES:
===================
[ ] Ensure patient completes antibiotic course for CAP
ACUTE ISSUES:
=============
#Sepsis
Patient admitted with a one day history of fevers and malaise
and
found septic with fever, tachycardia, new O2 requirement and
leukocytosis on initial presentation to ___ ED. At ___ patient
received vancomycin, nafcillin and cefepime. CXR at OSH with LLL
infiltrate; however, the chronicity of this finding relative to
previous chest x-rays was uncertain. Given patient has history
of MSSA bacteremia with T5 epidural abscess, she was initially
transferred to ___ for consideration of evaluation for spinal
abscess, however, this was deferred given absence of correlating
symptoms and clinical improvement on CAP treatment. Patient was
started on vanc/cefepime however this was narrowed to
CTX/azithro within 24 hours. Blood cultures with no growth for
over 48 hours at time of discharge. Patient was discharged with
plan to complete 5 day abx course with cefpodoxime/azithromycin.
She completed an ambulatory O2 saturation test on the day of
discharge without hypoxemia.
#Chronic Anemia
Patient admitted with Hb 11.1, apparently at baseline. Her home
iron supplementation was held given concern for infection.
CHRONIC ISSUES:
===============
#CKD Stage III
Patient Cr at baseline during hospitalization
#Opioid use disorder:
- Continued home methadone
#GERD
- Continued home PPI
#OA
- Will hold home diclofenac gel
#Hypothyroidism
- Continue home levothyroxine
#PAML
- Continued home clonazepam
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ferrous Sulfate 325 mg PO DAILY
2. Multivitamins 1 TAB PO DAILY
3. Vitamin D ___ UNIT PO DAILY
4. Levothyroxine Sodium 112 mcg PO DAILY
5. Methadone 82 mg PO DAILY
6. Senna 8.6 mg PO BID
7. Diclofono (diclofenac sodium) 1.6 % topical BID:PRN
8. Oxybutynin 10 mg PO BID
9. Pantoprazole 20 mg PO Q24H
10. ClonazePAM 1 mg PO QAM
11. ClonazePAM 1.5 mg PO QPM
12. Doxycycline Hyclate 100 mg PO Q12H
13. Aspirin 81 mg PO DAILY
14. Oysco-500 (calcium carbonate) 1000 mg oral DAILY
15. Sertraline 100 mg PO DAILY
16. Docusate Sodium 100 mg PO BID
Discharge Medications:
1. Azithromycin 250 mg PO DAILY Duration: 5 Doses
RX *azithromycin 250 mg 1 tablet(s) by mouth once a day Disp #*5
Tablet Refills:*0
2. Cefpodoxime Proxetil 200 mg PO BID Duration: 11 Doses
RX *cefpodoxime 200 mg 1 tablet(s) by mouth twice a day Disp
#*11 Tablet Refills:*0
3. Aspirin 81 mg PO DAILY
4. ClonazePAM 1 mg PO QAM
5. ClonazePAM 1.5 mg PO QPM
6. Diclofono (diclofenac sodium) 1.6 % topical BID:PRN
7. Docusate Sodium 100 mg PO BID
8. Doxycycline Hyclate 100 mg PO Q12H
9. Ferrous Sulfate 325 mg PO DAILY
10. Levothyroxine Sodium 112 mcg PO DAILY
11. Methadone 82 mg PO DAILY
12. Multivitamins 1 TAB PO DAILY
13. Oxybutynin 10 mg PO BID
14. Oysco-500 (calcium carbonate) 1000 mg oral DAILY
15. Pantoprazole 20 mg PO Q24H
16. Senna 8.6 mg PO BID
17. Sertraline 100 mg PO DAILY
18. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES
=====================
Community Acquired Pneumonia
Sepsis
SECONDARY DIAGNOSIS:
===================
Rheumatic Heart Disease
T4-5 Epidural Abscess complicated by MSSA Bacteremia
Chronic Kidney Disease Stage III
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at the ___
___!
Why was I admitted to the hospital?
===================================
- You were admitted because you had fevers and felt tired and we
were concerned that you had an infection.
What happened while I was in the hospital?
==========================================
- We obtained labs and images to investigate the cause
What should I do after leaving the hospital?
============================================
- Please take your medications as listed in discharge summary
and follow up at the listed appointments.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Sincerely,
Your ___ Healthcare Team
Followup Instructions:
___
|
10103795-DS-10 | 10,103,795 | 22,741,814 | DS | 10 | 2176-07-12 00:00:00 | 2176-07-12 11:23:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Transfer for left-sided weakness, CT showing right-hemisphere
stroke
Major Surgical or Invasive Procedure:
R hemicraniectomy on ___
trach/PEG ___
History of Present Illness:
The pt is a ___ year old right handed man without significant
past
medical history who presents for evaluation of right hemispheric
stroke. History is obtained from patient and his wife.
The pt was last known well at 4:45pm yesterday ___.
His
wife had been out of town visiting relatives and ___ with him
at that time, in which he had not endorsed any acute complaints.
At 10pm, she sent him a text without response, but she thought
he
was sleeping given a recent viral respiratory illness, and did
not call. This morning, she was in the airport on her way back
and called him at 9am. He did not answer and, concerned, she
called the police to check on him. Per the patient, he states
that he had a fall at 8pm last evening after his legs "felt like
jelly". He is unable to specify which leg or both. He did not
lose consciousness, but was unable to move from his place on the
ground. This morning, police arrived to check on him and he
recalls hearing them yell through the door, then breaking open
the door. He was subsequently found and brought by ambulance to
___ in ___, where he was found to
have left facial droop, hemiplegia, and sensory loss.
Noncontrast
head CT was performed and showed hypodensity and loss of
gray-white matter differentiation in the right cerebral
hemisphere. He was given aspirin 325mg PO and transferred to
___.
At ___ ED, pt was given dose of flagyl and levofloxacin for a
?report from EMS of an aspiration pneumonia, however it is not
clear on what basis as there was no CXR image or report arriving
with him. Wife arrived from her flight and met him here in the
ED.
ROS is limited as pt has somewhat poor recall of recent events,
but he does endorse frontal headache and severe low back pain.
He
also acknowledges that he cannot move or feel his left hand
unless he touches it right his right. He did have recent cough
and congestion. He denies similar symptoms in past, and denies
chest pain or palpitations.
Past Medical History:
Borderline high cholesterol, never treated
Social History:
___
Family History:
Brother with TIA in his ___. Father had CABG in his ___.
Mother
with leukemia.
Physical Exam:
==============
ADMISSION EXAM
==============
Vitals: temp 98.0 HR 80 BP 141/79 RR 18 spO2 94% RA
General: eyes closed, appears restless and in mild distress,
cooperative.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: supple, no nuchal rigidity
Pulmonary: breathing comfortably on room air
Cardiac: RRR, nl
Abdomen: soft, NT/ND
Extremities: warm, well perfused; palpation of spine elicits no
point tenderness
Skin: no rashes or lesions noted
Neurologic:
-Mental Status: appears uncomfortable and restless, maintains
eyes closed but alert and attentive to examiner. Oriented x3.
Able to relate some history though significant difficulty with
details. 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, albeit only on right side
of
page. Able to read without difficulty. Speech was not
dysarthric.
Able to follow both midline and appendicular commands.
Significant left visuospatial/motor neglect, although he
displays
some awareness of motor deficits.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. Left gaze paresis,
cannot cross midline volitionally but can be overcome with
oculocephalic maneuver. No blink to threat on left, ?complete
hemianopsia vs visual neglect.
V: Facial sensation absent on left.
VII: Decreased left facial activation and strength on both upper
and lower divisions.
VIII: Hearing intact grossly.
IX, X: Palate elevates symmetrically.
XII: Tongue protrudes in midline.
-Motor: Severely increased tone on left upper extremity. No
adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA Gastroc
L 0 0 * 0 1 0 0 5 5 4+ 5 5
R 5 ___ ___ 5 5 5 5 5
*unclear whether was activating against resistance or merely
increased tone
-Sensory: Reports absent sensation to light touch on left
hemiside, although reacts to painful stimuli throughout.
-DTRs:
Bi Tri ___ Pat Ach
L 3 2 2 3 4
R 2 2 2 2 3
Plantar response was extensor left and flexor right.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS on right.
-Gait: Deferred
==============
DISCHARGE EXAM
==============
vitals within normal limits
General: awake, alert, on trach collar, eyes open spontaneously
HEENT: staples intact
Neck: supple, trachea midline
CV: NSR
Lungs: breathing non labored with trach collar
Abdomen: NT/ND
GU: foley
Ext: warm, well perfused
Neuro:
MS- Awake, Alert. Attends to examiner. Tracks/regards. Dense L
hemineglect. Follows midline commands and appendicular commands
on the right side. Inattentive. Oriented to self, year and
hospital.
CN- Pupils are R>L, both briskly reactive. Right gaze preference
and cannot cross midline or bring completely to midline. L
facial droop. Tongue midline.
Sensory/Motor- Left upper and lower extremity flaccid. Moves
RUE/RLE antigravity, against resistance and spontaneously. LUE
extensor postures to noxious, LLE triple flexes to noxious.
Coordination- no ataxia on R finger nose finger
Gait-deferred
Pertinent Results:
============
LABS ___
============
___ 02:15PM BLOOD WBC-10.5* RBC-4.78 Hgb-14.3 Hct-40.2
MCV-84 MCH-29.9 MCHC-35.6 RDW-13.1 RDWSD-40.3 Plt ___
___ 06:35AM BLOOD WBC-8.5 RBC-4.71 Hgb-13.5* Hct-40.6
MCV-86 MCH-28.7 MCHC-33.3 RDW-13.1 RDWSD-41.3 Plt ___
___ 09:00AM BLOOD WBC-7.2 RBC-4.36* Hgb-12.6* Hct-37.5*
MCV-86 MCH-28.9 MCHC-33.6 RDW-12.9 RDWSD-40.7 Plt ___
___ 02:15PM BLOOD ___ PTT-29.1 ___
___ 09:00AM BLOOD ___ PTT-26.2 ___
___ 02:15PM BLOOD Glucose-118* UreaN-23* Creat-0.6 Na-141
K-3.3 Cl-104 HCO3-23 AnGap-17
___ 06:35AM BLOOD Glucose-91 UreaN-16 Creat-0.6 Na-142
K-3.5 Cl-105 HCO3-23 AnGap-18
___ 09:00AM BLOOD Glucose-95 UreaN-15 Creat-0.5 Na-133
K-3.4 Cl-100 HCO3-22 AnGap-14
___ 02:15PM BLOOD ALT-24 AST-34 AlkPhos-59 TotBili-0.5
___ 06:35AM BLOOD CK(CPK)-116
___ 02:15PM BLOOD Albumin-4.4 Calcium-9.3 Phos-2.2* Mg-2.1
___ 06:35AM BLOOD Calcium-8.0* Phos-1.9* Mg-2.2 Cholest-PND
___ 06:35AM BLOOD D-Dimer-508*
___ 06:35AM BLOOD Triglyc-PND HDL-PND **********
___ 06:35AM BLOOD %HbA1c-PND *********
___ 06:35AM BLOOD TSH-PND *********
___ 12:50AM URINE Blood-TR Nitrite-NEG Protein-100
Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 12:50AM URINE Color-Yellow Appear-Clear Sp ___
___ 12:50AM URINE RBC-11* WBC-<1 Bacteri-FEW Yeast-NONE
Epi-<1
___ 12:50AM URINE bnzodzp-NEG barbitr-NEG opiates-POS*
cocaine-NEG amphetm-NEG oxycodn-SENT TO RE mthdone-NEG
___ 2:20 pm BLOOD CULTURE 2 OF 2.
Blood Culture, Routine (Preliminary):
GRAM POSITIVE COCCUS(COCCI). IN PAIRS AND CLUSTERS.
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
Reported to and read back by ___, ___, ON
___ AT
19:55..
=======
IMAGING
=======
-___ LENIs:
No evidence of deep venous thrombosis in the right or left lower
extremity veins.
- CT ___
Interval increase in diffuse right cerebral edema and
hemorrhagic
transformation of a large right infarct, with increased
effacement of the right lateral ventricle and leftward midline
shift, currently measuring up to 9 mm, compared with 6 mm
previously, increased effacement of the perimesencephalic
cisterns, and increased herniation through the craniectomy
defect. Interval increase in size of the occipital and temporal
horns of the left lateral ventricle, concerning for entrapment.
- ___ CT Head (OSH)
Multiple right-sided hypodensities
- ___ TTE
The left atrial volume index is normal. No atrial septal defect
or patent foramen ovale is seen by 2D, color Doppler or saline
contrast with maneuvers. Normal left ventricular wall thickness,
cavity size, and regional/global systolic function (biplane LVEF
= 64 %). The estimated cardiac index is normal (>=2.5L/min/m2).
Global longitudinal strain is normal (-22%). Right ventricular
chamber size and free wall motion are normal. Tricuspid annular
plane systolic excursion is normal (2.4 cm; nl>1.6cm) consistent
with normal right ventricular systolic function. The diameters
of aorta at the sinus, ascending and arch levels are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis. Trace aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Normal biventricular cavity sizes with preserved
regional and global biventricular systolic function. Mild
pulmonary artery systolic hypertension. No ASD/PFO identified.
No definite structural cardiac source of embolism identified.
- ___ MRI Brain
-Large acute to subacute infarct in the right cerebral
hemisphere involving the right frontal, parietal, occipital and
temporal lobes as well as the right basal ganglia, raising
concern for central embolic source in the setting of a right
fetal PCA.
-Slight interval increase in mass effect on the lateral
ventricles, right greater than left, with 5 mm of leftward
midline shift. Basal cisterns are patent.
-Normal MRA neck, with no source of embolism identified.
-___ CXR
Left perihilar, basilar opacities may represent asymmetric edema
or infection, with component of left basilar atelectasis.
-___ CT Head WO Contrast
1. Study is mildly degraded by motion.
2. Large right MCA territory infarction with increasing
mass-effect,
effacement of sulci, and 1 cm leftward midline shift, previously
5 mm, and no evidence of hemorrhagic conversion.
Brief Hospital Course:
SUMMARY:
Mr. ___ is a ___ year-old man who presented on with fall on ___
and was found to have extensive right hemispheric strokes. He
has significant left sided visospatial and motor neglect, left
arm plegia and sensory loss, as well as headache. MRI shows
multifocal right MCA infarcts and posterior infarcts in the
setting of a fetal PCA. Etiology is likely cardioembolic,
however TTE was negative. He was observed in the
neuro-intermediate unit for malignant edema and possible need
for hemi-craniectomy. Neurosurgery was consulted. He was
transferred to the Neuro-ICU for hyperosmolar therapy.
Unfortunately, he subsequently developed worsening swelling and
uncal herniation on repeat imaging. He was found to have
worsening of his malignant R MCA and PCA infarcts. Decision was
made to undergo right hemicraniectomy on ___. Post-operative
course was complicated by hemorrhagic conversion and increased
brain swelling after surgery. He initially received hyperosmolar
therapy with resulting stabilization in edema. He improved
slightly neurologically, but remained with dense left sided
neglect, left hemiparesis with some movement to noxious stimuli,
and inattention. He is also status post a tracheostomy and PEG
given respiratory failure and significant dysphagia.
Etiology for the patient's stroke remains UNKNOWN at this time.
Of highest concern was a cardioembolic source, but patient did
not have any atrial fibrillation noted on telemetry during
hospitalization. TTE was negative for thrombus, but imaging
quality was suboptimal. Differential also included underlying
hypercoagulability, for which the workup is still pending. His
neck and head vessel imaging (with CTA head and carotid
ultrasound of neck) did not reveal any significant vascular
disease. He also had lower extremity vascular ultrasounds which
were negative for DVT.
*************
HOSPITAL COURSE BY PROBLEM:
#Malignant Right MCA ischemic stroke:
On ___, repeat CT showed increased midline shift of 10mm, and
worsening edema. He became progressively more somnolent, raising
concerns for potential malignant MCA syndrome and herniation. An
arterial line and central line were placed for hypertonic
saline. He was taken to the OR with neurosurgery for emergent
decompressive hemicraniectomy. He was subsequently transferred
to the NICU. He was intubated prior to the procedure. A repeat
CT later in the evening showed large hemorrhagic conversion of
the infarct, likely as a result of relieved pressure on the
ischemic penumbra. Midline shift improved. Hypertonic saline was
discontinued. Blood pressure goal was liberalized to less than
180 24 hours after craniectomy. He was started on subcutaneous
heparin 24 hours post op. 48 hour scan showed extensive
hemorrhagic conversion, worsened midline shift, penumbral edema.
He became more somnolent and less able to follow commands. He
was started on hyperosmolar therapy with improvement of his
exam. Aspirin was started on POD 3. Based on his clinical
status, early tracheostomy and PEG placement was considered. He
underwent a trach/PEG on ___.
As stated above, the etiology for the patient's strokes is
UNKNOWN at this time. Of highest concern was a cardioembolic
source, but patient did not have any atrial fibrillation noted
on telemetry during hospitalization. TTE was negative for
thrombus BUT IMAGING QUALITY WAS SUBOPTIMAL, THEREFORE AN
UNDERLYING PAROXIDICAL EMBOLUS CANNOT BE EXCLUDED AT THIS TIME.
Differential also included underlying hypercoagulability, for
which the workup is still pending. His neck and head vessel
imaging (with CTA head and carotid ultrasound of neck) did not
reveal any significant vascular disease. He also had lower
extremity vascular ultrasounds which were negative for DVT.
Stroke risk factors revealed A1c 5.4, LDL 112 and TSH 1.7. The
initial hypercoagulability workup was notable for lupus
anticoagulant negative, D Dimer 508.
He was started on fluoxetine 20mg daily to help with motor
recovery and for depressed mood.
**IMPORTANT***
-IT IS CRITICAL THAT PATIENT COMPLETES TEE as an outpatient.
-Must complete genetic testing for underlying hypercoagulability
with Factor V Leiden and Prothrombin Gene Mutation
-Ordered for ___ of Hearts, 30 day event monitor, to look for
atrial fibrillation
- The remainder of the hypercoagulability workup was still
pending at time of discharge (cardiolipin and beta 2
glycoprotein) and needs to be followed up.
# Headache: Patient had extensive headache after the
hemicraniectomy managed with Tylenol and Oxycodone 5 mg PO/NG
Q4H:PRN.
# GPC bacteremia: While in the ICU, patient was started on
vancomycin and unasyn for GPC in blood, though this was felt to
be a contaminant. Post-operatively, the patient spiked a fever
to 101.2 on POD 1 and was continued on vancomycin and cefepime.
Overall, this was felt to be a contaminant, but in the setting
of possible aspiration post stroke and recent operation, he
completed 7 day course of cefepime 2gm q8 (___).
TRANSITIONAL ISSUES:
**IMPORTANT***
-IT IS CRITICAL THAT PATIENT COMPLETES TEE as an outpatient.
-Must complete genetic testing for underlying hypercoagulability
with Factor V Leiden and Prothrombin Gene Mutation
-Ordered for ___ of Hearts, 30 day event monitor, to look for
atrial fibrillation
- The remainder of the hypercoagulability workup was still
pending at time of discharge (cardiolipin and beta 2
glycoprotein) and needs to be followed up.
-Please follow up with Neurology and Neurosurgery as scheduled
-Continue aspirin 81mg daily and atorvastatin 40mg daily for
stroke secondary prevention. PENDING RESULTS OF
HYPERCOAGULABILITY WORKUP, MAY CONSIDER ANTICOAGULATION AT A
LATER TIME. CURRENTLY IT IS TOO EARLY TO DO SO GIVEN HEMORRHAGIC
CONVERSION OF INFARCTION.
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 - Mild
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Bisacodyl 10 mg PO DAILY:PRN constipation
5. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
6. Docusate Sodium 100 mg PO BID
7. FLUoxetine 20 mg PO DAILY
8. Heparin 5000 UNIT SC BID
9. OxycoDONE Liquid 5 mg PO Q4H:PRN Pain - Moderate
RX *oxycodone 5 mg/5 mL 5 mg by mouth every 4 hours as needed
Refills:*0
10. Polyethylene Glycol 17 g PO Q12H:PRN constipation
11. Senna 17.2 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right MCA ischemic stroke
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
You were hospitalized due to symptoms of left sided weakness and
facial droop, resulting from an ACUTE ISCHEMIC STROKE, a
condition where a blood vessel providing oxygen and nutrients to
the brain is blocked by a clot. The brain is the part of your
body that controls and directs all the other parts of your body,
so damage to the brain from being deprived of its blood supply
can result in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
high cholesterol
male gender
We are changing your medications as follows:
-Added aspirin 81mg daily
-Added Atorvastatin 40mg daily
Please take your other medications as prescribed.
Please follow up with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
10103795-DS-12 | 10,103,795 | 25,579,029 | DS | 12 | 2177-02-19 00:00:00 | 2177-02-19 19:30:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
seizure
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ male with history of right MCA and PCA
ischemic infarcts in ___ complicated by swelling s/p
right
hemicraniectomy with subsequent reconstruction in ___, as
well as a residual large chronic right subdural collection, and
had a secondarily generalized seizure in ___, presenting
with generally feeling fatigued, globally weak, and with 3
events
concerning for focal tonic-clonic seizure of the left lower
extremity in the past week.
He is followed by Dr. ___ in the ___ Stroke Clinic,
last
on ___.
He has been working with physical therapy consistently and
making
progress over the past several months. Typically he is able to
participate with ___ without extreme fatigue, but this past week
was harder than usual. He feels he may be "coming down with
something". He notes he has been more off balance, feeling warm
and sweating at night. While at ___ on ___ he felt
lightheaded and weak and had to sit down (BP reportedly
120/70s).
He also notes that he has had increasing "leg spasms" in his
left
arm and leg over the last week that seem to be getting worse,
and
are associated with some numbness. His wife notes his tone
seems
increased.
Notably, he has been on a titration schedule with his AEDs,
weaning off Keppra and going up on Oxcarbazepine because he was
not tolerating the Keppra due to mood side effects (despite
trial
of B6). The last change was 3 days ago when he reached the goal
dose of OXC (450mg BID) and took his last dose of Keppra (had
been 500mg BID, went to 500mg daily for 1 week then off).
Additionally, he was previously on a higher dose of gabapentin,
but that dose is now ___ TID.
His wife notes he has only had one prior known seizure in which
he became unresponsive, otherwise she has not noticed any events
concerning for seizure. He has had significant clonus in the
past, but he retains awareness and is able to stand throughout
that, it occurs most when he is exerting himself with ___.
However, over the last 3 days he has had 3 events concerning for
seizure. The first was in bed on ___ night she recalls his
left leg jerking forcefully in bed for about 30 seconds. Then
yesterday he went to lunch with friends, and he went to the
restroom where the door was very heavy and difficult to open, he
lost his balance and nearly fell but someone caught him, at that
time he had rhythmic leg jerking (I mimicked tonic-clonic
jerking
to his wife and she said it looked like that) that lasted ___
seconds then stopped on its own. He was then able to walk to
the
car and take a few steps. Then this morning, he was washing his
hands in the bathroom and he had sudden onset rhythmic left
cheek
twitching with drooling followed by left arm stiffening (still
flexed at elbow as it usually is) and left leg jerking, lasting
about 30 seconds. His wife noticed his left facial droop seemed
more significant. He was not sleepy afterwards and did not lose
consciousness. However, it made him very nervous so his wife
called ___ and he was taken to OSH.
He was taken to ___ where he had labs, notably his
sodium is normal at 141. He had a NCHCT that was stable. He
was
transferred to ___ for further management given his care is
generally here.
Of note, the etiology of his stroke is unknown; he underwent a
coagulation screening that was normal. He had mild
hyperlipidemia
before the stroke and he's now taking atorvastatin. He
underwent
___ monitor which did not show presence of atrial
fibrillation.
He was evaluated for a LinQ monitor last week and that was going
to be placed in the near future.
On neuro ROS, he denies headache, loss of vision, he does have
diplopia at times and recently got prism glasses for this. No
dysarthria, dysphagia, vertigo, tinnitus or hearing difficulty.
He has been lightheaded with ___ this week. Denies difficulties
comprehending speech, at baseline he is a bit slower to get
words
out than previously.
On general review of systems, he denies recent fever, but has
had
chills. Denies cough, shortness of breath. He has had some
stomach upset, not significant vomiting, no diarrhea, some
constipation. He thinks he is urinating more at night. No
dysuria. He is scheduled to get Botox to left side in a few
weeks.
Past Medical History:
- Right MCA/PCA strokes in ___, s/p right hemicraniectomy
- Trach placement, now reversed
- PEG placement
- Cranioplasty on ___
- Secondarily generalized seizure on ___
- neuropathic pain on the left side of his body
- left shoulder pain
- C. difficile colitis
- Hyperlipidemia
Social History:
___
Family History:
Brother with TIA in his ___. Father had CABG in his ___.
Mother
with leukemia.
Physical Exam:
General: sitting up in bed, comfortable appearing
HEENT: normocephalic, short hair growing in, no scleral icterus
noted, MMM, no lesions noted in oropharynx
Neck: supple, no nuchal rigidity
Pulmonary: breathing comfortably on room air
Cardiac: RRR, nl
Abdomen: soft, NT/ND
Extremities: warm, well perfused
Skin: no rashes or lesions noted
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history,
language is fluent but slow at times. Attentive to
conversation,
although closes eyes at times. Intact repetition and
comprehension. There were no paraphasic errors. Able to follow
both midline and appendicular commands. There was no evidence of
neglect.
-Cranial Nerves:
II, III, IV, VI: Anisocoria with R pupil 5to3mm and L pupil
4to2mm, both briskly reactive (per wife this has been noted
before). Left esotropia with possible subtle hypotropia. EOMI
without nystagmus. Left homonymous hemianopia.
V: Facial sensation decreased on left face.
VII: Left facial droop, able to activate.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: R trapezius ___, L trapezius ___.
XII: Tongue protrudes in midline.
- Motor: Left hemiparesis, UE > ___, with increased tone in left
arm and leg, contractures at fingers not at wrist or ankle; no
tremor or movement concerning for seizures
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA Gastroc
L 2 ___ 0 0 0 4 4 4 2 4
R 5 ___ ___ 5 5 5 5 5
- Sensory: Decreased sensation to light touch and pinprick
sensation of the left arm and leg. Intact on the right. He
extinguishes to DSS on the left.
- DTRs:
Bi ___ Pat Ach
L 3 2 2 2 ___ beats of clonus, toes upgoing
R 2 2 2 2 ___ beats of clonus, toes downgoing
-Coordination: No dysmetria on FNF on right, unable to test on
left.
Pertinent Results:
___ 02:45PM WBC-6.8 RBC-5.05 HGB-14.1 HCT-42.8 MCV-85
MCH-27.9 MCHC-32.9 RDW-14.0 RDWSD-43.2
___ 02:45PM NEUTS-72.8* ___ MONOS-5.3 EOS-0.3*
BASOS-0.6 IM ___ AbsNeut-4.95# AbsLymp-1.40 AbsMono-0.36
AbsEos-0.02* AbsBaso-0.04
___ 02:45PM PLT COUNT-255
___ 02:45PM ___ PTT-28.5 ___
___ 02:45PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 02:45PM ALBUMIN-4.3 CALCIUM-9.5 PHOSPHATE-3.1
MAGNESIUM-2.1
___ 02:45PM ALT(SGPT)-30 AST(SGOT)-20 ALK PHOS-116 TOT
BILI-0.3
___ 02:45PM estGFR-Using this
___:45PM GLUCOSE-96 UREA N-10 CREAT-0.6 SODIUM-146
POTASSIUM-3.9 CHLORIDE-107 TOTAL CO2-25 ANION GAP-14
Brief Hospital Course:
Mr. ___ is a ___ male with history of right MCA and PCA
ischemic infarcts in ___ complicated by swelling s/p
right hemicraniectomy with subsequent reconstruction in ___
___s a residual large chronic right subdural collection
with h/o secondarily generalized seizure in ___ who
presented for further evaluation of generally feeling fatigued,
globally weak, and with 3 events concerning for focal
tonic-clonic seizure of the left lower extremity. His exam was
at baseline with left hemiplegia (UE > ___ with decreased
sensation, left facial droop, and left homonymous hemianopsia.
Work up included:
OSH NCHCT: appears stable with large R MCA/PCA territory
encephalomalacia with ex-vacuo dilatation of R lat ventricle
cvEEG (preliminary): asymmetric attenuation and some slowing
over right hemisphere. No epileptiform discharges or seizures.
#Seizures: His clinical presentation is most consistent with
focal seizures as the location of his R MCA/PCA infarct fits
with a left-sided seizure onset. These events could have been
provoked in the setting of illness or med titration.
Toxic/metabolic work up was unrevealing. Upon admission,
oxcarbazepine was increased from 450mg BID to ___ BID.
Oxcarbazepine level was pending at time of discharge.
#R MCA/PCA infarct: Mr. ___ was continued on aspirin and
atorvastatin. Given history of chronic right subdural
collection, neurosurgery was also consulted in ED and
recommended no further intervention.
#Spasticity: Mr. ___ was continued on baclofen. He has an
upcoming appointment for botox injections.
Otherwise, Mr. ___ endorses feeling quite anxious about about
falling after these events. ___ evaluated him and walked with him
and felt that he was safe for discharge home with 24-hour
supervision, which he does have. He will also return to
___ Program.
Mr. ___ was continued on his other home medications including
fluoxetine, ranitidine and a multivitamin.
Mr. ___ will follow up with his Stroke Neurologist, Dr. ___,
on ___ at 9am.
====================================================
Transitional Issues:
1. Patient notes that he has the sensation of wanting/needing to
move his left arm. He may benefit from ___ in the future to help
with rehabilitation.
2. Patient was noted to be snoring and have transient
desaturations while sleeping. He would likely benefit from sleep
study to evaluate for sleep apnea in the future
3. If he has recurrent focal seizures, Vimpat or Briviact may be
good options for him.
4. Monitor spacticity. Currently on baclofen and scheduled to
get botox.
5. Monitor efficacy of fluoxetine to determine if adequate.
6. Please call Dr. ___ office at ___ to
reschedule appointment
7. ___ evaluated Mr. ___ and ___ he was safe for discharge
home. Recommended 24-hour supervision and return to ___ Day
program as soon as possible
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Atorvastatin 40 mg PO QPM
2. Baclofen 20 mg PO QID
3. FLUoxetine 40 mg PO DAILY
4. Gabapentin 300 mg PO TID
5. OXcarbazepine 450 mg PO BID
6. Ranitidine 150 mg PO DAILY
7. Aspirin 81 mg PO DAILY
8. Loratadine 10 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Pyridoxine 100 mg PO DAILY
Discharge Medications:
1. Simethicone 40-80 mg PO QID:PRN gas
RX *simethicone 80 mg 1 tab by mouth four times daily as needed
for gas Disp #*30 Tablet Refills:*0
2. OXcarbazepine 600 mg PO BID
RX *oxcarbazepine 600 mg 1 tablet(s) by mouth twice daily Disp
#*60 Tablet Refills:*1
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. Baclofen 20 mg PO QID
6. FLUoxetine 40 mg PO DAILY
7. Gabapentin 300 mg PO TID
8. Loratadine 10 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Ranitidine 150 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Seizure
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:
Dr. ___,
You were admitted to the Neurology service for further
evaluation of episodes concerning for seizure. You had a head CT
done at an outside hospital which showed expected changes from
your prior stroke. You also had an EEG (brain wave test) done
which did not show any seizures.
Ultimately, we feel that these episodes most likely represent
seizures. As a result, we increased oxcarbazepine to 600mg
twice daily. Please continue to take this medication as
instructed and call us if you are not tolerating your
medication.
You will follow up with Dr. ___ in neurology clinic on
___. Please call him if you have another seizure or
anything new or concerning.
Have a nice day,
___ Neurology
Followup Instructions:
___
|
10104012-DS-20 | 10,104,012 | 23,867,813 | DS | 20 | 2189-12-06 00:00:00 | 2189-12-06 15:44:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right proximal tibia fracture s/p MVC trauma
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ Critical is a ___ who was involved in a high speed MVC on
___. He was initially brought to ___
where he was intubated and sedated and subsequently transferred
to the ICU at ___. The ICU team noticed the patient was not
moving his RLE when he was thrashing during suctioning or when
the propofol was weaned. There was also concern for a right knee
effusion on exam. Radiographs of the right tib/fib were obtained
and were concerning for a nondisplaced proximal tibial fracture
prompting an orthopaedic surgery consult. An MRI of the R knee
and a CT of the right leg are pending.
Past Medical History:
None
Social History:
___
Family History:
Noncontributory
Physical Exam:
Gen: no acute distress
Neuro: alert and interactive
CV: regular rate and rhythm
Pulm: no respiratory distress on room air
RLE: in knee immobilizer and post-op shoe. SILT: MP/LP/DP/SP,
Fires: ___, Palpable DP pulse.
Pertinent Results:
___ 02:16AM BLOOD WBC-7.1 RBC-3.73* Hgb-11.1* Hct-31.8*
MCV-85 MCH-29.8 MCHC-34.9 RDW-13.1 RDWSD-40.2 Plt ___
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was
initially admitted to the Trauma Surgery Intensive Care Unit for
altered mental status requiring intubation. The patient was
subsequently extubated on hospital day one. Sedation was lifted
and his mental status normalized. On hospital day 2 he was
determined to no longer require ICUlevel care and was
transferred to the orthopaedic surgery service. His fracture was
subsequently determined to be non-operative. He was evaluated by
physical therapy who felt that discharge to home was
appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications and the patient was voiding/moving bowels
spontaneously. The patient is non-weight bearing in the right
lower extremity, and will be discharged on aspirin for DVT
prophylaxis. The patient will follow up with Dr. ___
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course
including reasons to call the office or return to the hospital,
and all questions were answered. The patient was also given
written instructions concerning precautionary instructions and
the appropriate follow-up care. The patient expressed readiness
for discharge.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Aspirin 325 mg PO DAILY Duration: 2 Weeks
3. Docusate Sodium 100 mg PO BID:PRN constipation Duration: 7
Days
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth every
12 hours as needed Disp #*14 Capsule Refills:*0
4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth every ___ hours as
needed Disp #*20 Tablet Refills:*0
5.Crutches
Diagnosis: trauma
Length of Need: 13 months
Discharge Disposition:
Home
Discharge Diagnosis:
Right proximal tibia fracture
Discharge Condition:
Gen: no acute distress
Neuro: alert and interactive
Ambulatory status: with crutches per ___
Discharge Instructions:
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- non-weight bearing right lower extremity
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take aspirin daily for 2 weeks
WOUND CARE:
- Please wear your ___ brace/knee immobilizer locked in
extension at all times
Followup Instructions:
___
|
10104289-DS-13 | 10,104,289 | 28,149,025 | DS | 13 | 2140-11-15 00:00:00 | 2140-11-15 17:04:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Subarachnoid hemorrhage
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ year old male with history of coronary
artery disease on Aspirin who is S/P motor vehicle accident
where he was struck in the left front end of his car at
approximately 40 miles per hour. Airbag deployed and he struck
his head on the windshield. He was taken to an outside hospital
where ___ showed scattered right temporal subarachnoid
hemorrhage.
Past Medical History:
CAD, Diabetes, Hypertension, Hyperlipidemia, HTN, s/p right
arm amputation ___ from injury in ___.
Social History:
___
Family History:
Non-contributory
Physical Exam:
Upon Admission:
===============
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: ___ EOMs full
Neck: Supple.
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to 4 to 3mm bilaterally.
Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
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
Note patient has amputation of left forearm
Sensation: Intact to light touch,
Toes downgoing bilaterally
Upon Discharge:
==============
He is awake, alert, and cooperative with the exam. He is
oriented to self, location, and date. PERRL, EOMI. ___, no
pronator drift. He has right arm amputation below the elbow and
moves all his extremities with ___ strength. Sensation is intact
to light touch throughout.
Pertinent Results:
Please see OMR for relevant findings.
Brief Hospital Course:
___ is a ___ year old male on ASA 81mg who is S/P
motor vehicle accident and was found to have right temporal
traumatic subarachnoid hemorrhage.
#Traumatic subarachnoid hemorrhage
He was admitted to the ___ for close neurological monitoring.
Aspirin was held on admission. Repeat ___ showed stable
hemorrhage. He remained neurologically intact on exam. His pain
was well controlled. He was tolerating a diet and ambulating
independently. His vital signs were stable and he was afebrile.
He was discharged to home in a stable condition.
Medications on Admission:
Tylenol, ASA 81mg, HCTZ 12.5mg, Lisinopril 10mg tablet,
Metformin 1000mg, Lopressor 25mg
Discharge Medications:
1. Aspirin 81 mg PO DAILY
You may resume this medication ___.
2. Acetaminophen 650 mg PO TID
3. Atorvastatin 80 mg PO QPM
4. Hydrochlorothiazide 12.5 mg PO DAILY
5. Lisinopril 10 mg PO DAILY
6. MetFORMIN (Glucophage) 1000 mg PO DAILY
7. Metoprolol Tartrate 25 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Traumatic subarachnoid hemorrhage
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Discharge Instructions:
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise for one month.
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.
You should avoid contact sports for 6 months.
Medications
You may resume your Aspirin on ___.
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 after traumatic
brain injury. Headaches can be long-lasting.
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.
More Information about Brain Injuries:
You were given information about headaches after TBI and the
impact that TBI can have on your family.
If you would like to read more about other topics such as:
sleeping, driving, cognitive problems, emotional problems,
fatigue, seizures, return to school, depression, balance, or/and
sexuality after TBI, please ask our staff for this information
or visit ___
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:
___
|
10104308-DS-18 | 10,104,308 | 24,307,783 | DS | 18 | 2161-05-20 00:00:00 | 2161-05-23 11:25:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Tunneled subclavian HD line placement
PRBC transfusion x2
Cardiac Catheterization X2 with DES to Ramus and DES to LCx/OM2
History of Present Illness:
___ with a complex medical hx including HTN, CHF, DM on insulin,
ESRD (s/p AVF placement and now revision 2 weeks ago), s/p
severe Fournier's gangrene requiring an extended MICU stay and a
diverting end-sigmoid colostomy on ___. He presented to
___ on ___ with CP, SOB, found to have
trop of 6.8, BNP 627 and EKG c/w NSTEMI, started on heparin gtt,
given nitro which relieved his pain, transferred to ___.
Past Medical History:
MEDICAL & SURGICAL HISTORY:
1. Fournier's gangrene (requiring diverting sigmoid colostomy
and multiple washouts/testicular debridements)
2. hypoxic respiratory failure
3. CHF (LVEF 50%, on ___
4. MRSA tracheobronchitis
5. type 2 diabetes mellitus
6. gastroparesis
7. kidney stones
8. hypertension
9. hyperlipidemia
Social History:
___
Family History:
Family history of diabetes. Mother died of cancer 'in her lung
and liver'
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: 98.3 153/82 97# 84
GENERAL: Well appearing in NAD
HEENT: PERRL, EOMI
NECK: no carotid bruits, mildly elevated JVD
LUNGS: Crackles in bibasilar distribution, otherwise good air
entry
HEART: RRR, normal S1 S2, no MRG
ABDOMEN: Soft, NT, NABS, no organomegaly. Ostomy without
surrounding erythema or tenderness
EXTREMITIES: 1+ edema b/l
NEUROLOGIC: A+OX3
DISCHARGE PHYSICAL EXAM
V: Afebrile 98.6, 129/73, P-65 18 95RAL
out made 250cc urine all day yesterday
GENERAL: Middle aged male in NAD, lying in bed. Oriented x3.
Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 7 cm.
CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3,
S4.
LUNGS: Resp were unlabored, no accessory muscle use. Mild
bibasilar crackles, no wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Colostomy bag in
place and draining brown stool
EXTREMITIES: 2+ pitting edema to knees bilaterally.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ DP 2+ ___ 2+
Left: Carotid 2+ DP 2+ ___ 2+
Pertinent Results:
ADMISSION LABS
___ 06:00PM BLOOD WBC-9.4 RBC-2.74* Hgb-8.7* Hct-27.0*
MCV-99* MCH-31.7 MCHC-32.1 RDW-14.8 Plt ___
___ 06:00PM BLOOD ___ PTT-96.4* ___
___ 06:00PM BLOOD Glucose-94 UreaN-67* Creat-5.5* Na-146*
K-4.5 Cl-113* HCO3-18* AnGap-20
___ 06:00PM BLOOD CK-MB-25* MB Indx-3.4
___ 08:20AM BLOOD Calcium-8.3* Phos-5.6* Mg-2.0
ON DISCHARGE
___ 05:45AM BLOOD WBC-11.5* RBC-2.79* Hgb-8.7* Hct-26.2*
MCV-94 MCH-31.1 MCHC-33.2 RDW-15.5 Plt ___
___ 05:45AM BLOOD UreaN-30* Creat-3.8*# Na-141 K-3.9 Cl-102
HCO3-31 AnGap-12
___ 05:45AM BLOOD CK-MB-5
___ 05:45AM BLOOD Calcium-8.0* Phos-3.6 Mg-2.1
EKG ___:
Sinus rhythm. Minor non-specific lateral ST-T wave
abnormalities. Compared to
the previous tracing of ___ no significant change.
CXR ___:
FINDINGS:
Cardiomegaly is noted with pulmonary edema and trace pleural
effusions, right
greater than left. No pneumothorax. Bony structures intact.
Degenerative AC
joint arthropathy.
IMPRESSION:
Findings compatible with congestive heart failure.
CXR ___
FINDINGS: As compared to the previous radiograph, there is no
relevant
change. Moderate fluid overload, combined to cardiomegaly and a
small right
pleural effusion. Hemodialysis catheter in situ. The
retrocardiac
atelectasis that pre-existed is less severe than on the previous
exam. No
newly appeared focal parenchymal opacities suggesting pneumonia.
ECHO ___:
The left atrium is moderately dilated. There is moderate
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. Due to suboptimal technical quality, a
focal wall motion abnormality cannot be fully excluded. Overall
left ventricular systolic function is low normal (LVEF 55%).
Tissue Doppler imaging suggests an increased left ventricular
filling pressure (PCWP>18mmHg). Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic stenosis or aortic regurgitation. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild to moderate (___) mitral regurgitation is seen.
The tricuspid valve leaflets are mildly thickened. There is a
small pericardial effusion. There are no echocardiographic signs
of tamponade.
Compared with the findings of the prior study (images reviewed)
of ___, the findings are similar, but the
technically suboptimal nature of both studies precludes
definitve comparison.
CARDIAC CATHETERIZATION ___
FINAL DIAGNOSIS:
1. Severe 3 vessel CAD. CAGG not a good option given no LAD or
RCA
targets.
2. Moderate elevated right sided and moderate to severely
elevated left
sided filling pressures.
3. Preserved cardiac output.
CARDIAC CATHETERIZATION ___
COMMENTS:
1. Successful PCI of Ramus with Resolute 2.75 X 22mm stent
2. Successful PCI of LCX/OM1 with Resolute 2.75 X 26mm stent
FINAL DIAGNOSIS:
1. Severe 3 vessel CAD
2. Success PCI with DESs of Ramus (Resolute 2.75 X 22mm) and
LCX/OM2
(Resolute 2.75 X 26mm).
3. ASA 81mg indefinitely. Prefer Prasugrel 60mg load and 10mg
daily for
___ year. ___ change to Plavix 75mg daily after 6 month
uninterrupted use
of Prasugrel.
4. Risk factor reduction
5. A terumo pressure band was applied to right radial artery at
the
conclusion of procedure.
Brief Hospital Course:
___ M with complex medical hx incl ESRD, DM2, CHF, p/w NSTEMI.
Hospital course complicated by acute renal failure requiring
initiation of dialysis and staged cardiac catheterization.
# NSTEMI.
Pt admitted from OSH for unstable angina, found to have trop of
1.26 and elevated MB. ECG showed lateral ST-changes. Continued
on heparin and plavix loaded. On the floor pt denied CP, SOB. Pt
initially refused catheterization fearing it might lead to
accelerated need for hemodialysis. After several conversations
w/ attending physician, pt weighed risks and benefits of
procedure and agreed to proceed. Pt appeared overloaded prior to
procedure, and received 60 IV lasix X 2 with good urine output.
He was still mildly volume positive before catheterization,
judged to be acceptable in the setting of ESRD. He received left
heart catheterization ___, revealing signficant disease with
complicated lesions in his LAD and LCx. However, he received a
large amount of dye and his case was aborted given the desire to
avoid the need for hemodialysis given his ESRD.
The patient remained chest pain free between his diagnostic cath
___ and therapeutic cath ___ on maximal medical regimen
including heparin gtt (48 hrs) ASA 325mg, plavix, metoprolol and
statin.
On ___, the patient had a DES to Ramus and DES to LCx/OM2. He
tolerated the procedure well. He has follow-up with his
outpatient cardiologist Dr. ___ in the coming weeks.
ESRD.
Pt had AVF placed six months prior to this admission, and
revision two weeks prior. Pt desires transplant and expressed
strong wish to postpone dialysis as long as possible. Renal
consulted for management of catheterization in setting of ESRD;
recommended simultaneous hydration and diuresis. Unfortunately
after cath ___, patient creatinine began to rise from 3.5 to
8.8, necessitating urgent dialysis. Unfortunately, the patient's
AV fistula was still too immature for use and a tunnel catheter
was placed ___. Mr ___ tolerated dialysis well and went for
subsequent treatments after his second cardiac cath ___. He has
been discharged with outpatient dialysis MWF, which he will
likely require long term. He also has outpatient follow up with
the transplant service.
Dirty UA with positive Urine culture
The patient had a dirty UA and a positive urine culture that
grew Klebsiella. The patient was asymptomatic. He completed a 7
day course of ciprofloxacin while in house.
Depression
While in house, the patient had passive suicidal ideations and a
depressed mood. He was seen by psychiatry, who recommended long
term therapy and medication. The patient refused both. The
psychiatry team spoke with the patient's health care proxy and
sister in law, who felt the patient was not safe at home with a
firearm. Psych had the local police department (for whom the
patient used to work) confiscate Mr ___ firearm from his
home. The patient denies any homicidal or suicidal ideations at
discharge.
Anemia
The patient appeared to have anemia from iron deficiency and
chronic kidney disease. Guaiac of stools was negative. He was
kept on PO iron and also received EPO treatments at dialysis.
Past Hx of Fournier's Gangrene c/b bowel resection.
The patient had no active issues with his ostomy site.
Diabetes
The patient had 2 episodes of AM hypoglycemia. His basal insulin
dose was decreased and his bolus doses were increased to limit
post-prandial hyperglycemia.
Transitional Issues
The patient is confirmed DNR/DNI
He will continue to follow up with Nephrology at dialysis. He
also has an appointment with the transplant team. The patient's
fistula should continue to be monitored to determine when it
will be mature enough for use. Hopefully, he will not need the
tunnel catheter for a prolonged period of time.
Cardiologist Dr ___ will monitor for symptoms of angina
post-cath. Echo in house revealed normal ejection fraction with
restrictive physiology.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
2. Calcium Carbonate 500 mg PO TID:PRN Meals
3. Rosuvastatin Calcium 10 mg PO DAILY
4. Aspirin 325 mg PO DAILY
5. Bisacodyl 10 mg PO HS
6. Calcitriol 0.25 mcg PO 5 DAYS A WEEK
7. Vitamin D 1000 UNIT PO DAILY
8. Ferrous Sulfate 325 mg PO BID
9. Furosemide 80 mg PO BID
10. Gabapentin 300 mg PO DAILY
11. Metoprolol Tartrate 50 mg PO BID
12. Omeprazole 40 mg PO DAILY
13. Prochlorperazine 5 mg PO Q8H:PRN N/V
14. Acetaminophen 1000 mg PO Q6H:PRN Pain
Not to exceed 4 grams daily
15. Albuterol Inhaler 1 PUFF IH Q4H:PRN Wheezing
16. Glargine 60 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
17. Nephrocaps 1 CAP PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain
Not to exceed 4 grams daily
2. Bisacodyl 10 mg PO HS
3. Calcitriol 0.25 mcg PO 5 DAYS A WEEK
4. Calcium Carbonate 500 mg PO TID:PRN Meals
5. Ferrous Sulfate 325 mg PO BID
6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
7. Glargine 50 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
8. Rosuvastatin Calcium 20 mg PO DAILY
RX *Crestor 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
9. Vitamin D 1000 UNIT PO DAILY
10. Prasugrel 10 mg PO DAILY
RX *Effient 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
11. sevelamer CARBONATE 800 mg PO TID W/MEALS
RX *Renvela 0.8 gram 1 Powder(s) by mouth three times daily with
meals Disp #*90 Pack Refills:*0
12. Albuterol Inhaler 1 PUFF IH Q4H:PRN Wheezing
13. Omeprazole 40 mg PO DAILY
14. Prochlorperazine 5 mg PO Q8H:PRN N/V
15. Nephrocaps 1 CAP PO DAILY
RX *Nephrocaps 1 mg 1 capsule(s) by mouth daily Disp #*30 Tablet
Refills:*0
16. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
17. Metoprolol Succinate XL 150 mg PO DAILY
RX *metoprolol succinate 50 mg 3 tablet(s) by mouth daily Disp
#*90 Tablet Refills:*0
18. Gabapentin 300 mg PO QHD
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: NSTEMI, ESRD on HD, DMII
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 came to the hospital with chest pain and shortness of
breath. An electrocardiogram and blood tests showed you were
having a heart attack. A cardiac catheterization revealed
extensive coronary artery disease. Due to your renal disease, no
stents were placed initially to limit the amount of contrast
injected into your body. Unfortunately, this contrast still
caused severe kidney damage that caused you to need dialysis.
Your AV fistula was not mature enough to be used and a tunneled
catheter was placed in your R chest.
You tolerated dialysis very well and you will continue to need
Dialysis as an outpatient. This will be done every ___,
___, and ___ @3PM at ___ Renal ___. It
will start @230PM on ___.
When your renal function stabilized, a second cardiac
catheterization was performed and 2 stents were placed in 2
different diseased arteries. With these stents, you must
continue to take Aspirin. You have been switched from Plavix to
Prasugrel, which is a very similar medication. Please see all of
your medication changes below
Please follow up with your PCP, ___, and
Kidney Transplant physicians at the appointment times listed
below.
It was a true pleasure taking care of you, Mr ___
Followup Instructions:
___
|
10104308-DS-20 | 10,104,308 | 26,552,670 | DS | 20 | 2162-07-11 00:00:00 | 2162-07-12 10:09:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Avelox / albuterol
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo M with h/o CAD, ESRD on dialysis, and fournier's gangrene
in ___ resulting in diverting sigmoid colostomy now s/p
takedown on ___ who presents from rehab with lower abdominal
pain. He was recently admitted from ___ for the colostomy
takedown and did very well and was discharged to rehab. He was
doing well at rehab and reports he was actually discharged to
home today, but this AM he had suddent dull, crampy discomfort
in his lower abdomen after eating breakfast. Mild nausea. Rated
pain as ___, non-radiating. No alleviating or exacerbating
factors. No fevers. Chills yesterday. No vomiting/diarrhea. Has
been having BMs daily but says they're small (not like his
usual).
In the ED intial vitals were: 98.9 90 154/71 16 96% ra. Exam
notable for tenderness in LUQ and RLQ. Labs notable for
macrocytic anemia, mild thrombocytopenia to 146, K 5.4 and Cr
elevated consistent with known ESRD. CT abd/pelvis obtained and
showed moderate fecal loading, intact colonic anastamosis, and
no other focal abnormalities. Colorectal surgery was consulted
and recommended bowel regimen and discharge. Renal was also
consulted due to concern that he would need to be dialyzed given
the contrast load from the CT, however they also recommended
discharge and no need for HD over the weekend unless he
developed symptoms of pulmonary edema. Given that he came from
rehab, however, it was felt he could not be discahrged home, so
he was admitted for case management assistance. VS on transfer
98.1 66 153/70 16 95% RA.
On arrival to the floor the patient appears quite well. Still
complaining of mild abdominal pain, unchanged from this AM. No
other new complaints
Review of Systems:
(+) see HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
MEDICAL & SURGICAL HISTORY:
1. Fournier's gangrene (requiring diverting sigmoid colostomy
and multiple washouts/testicular debridements)
2. hypoxic respiratory failure
3. CHF (LVEF 50%, on ___
4. MRSA tracheobronchitis
5. type 2 diabetes mellitus
6. gastroparesis
7. kidney stones
8. hypertension
9. hyperlipidemia
Social History:
___
Family History:
Family history of diabetes. Mother died of cancer 'in her lung
and liver'
Physical Exam:
ADMISSION EXAM:
Physical Exam:
Vitals- T98.3, BP 184/94, HR 72, RR 20, O2 sat 95% RA
General- middle aged man sitting up in bed, talkative, in no
acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- obese, soft, non-distended, mildly tender to palpation
in suprapubic area and moderately tender in LUQ/epigastrium.
Midline scar is healing well with steri-strips in place, ostomy
site is pink with some serosanguinous drainage
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
DISCHARGE EXAM:
Abd: still slightly tender in RLQ, wound sites CDI, no
rebound/guarding
Pertinent Results:
DISCHARGE LABS:
___ 06:35AM BLOOD WBC-6.3 RBC-2.92* Hgb-10.2* Hct-29.1*
MCV-100* MCH-35.0* MCHC-35.2* RDW-15.6* Plt ___
___ 04:00PM BLOOD Neuts-67.6 ___ Monos-7.6 Eos-5.0*
Baso-0.8
___ 06:35AM BLOOD Glucose-79 UreaN-59* Creat-8.0*# Na-141
K-5.4* Cl-102 HCO3-23 AnGap-21*
___ 04:00PM BLOOD ALT-12 AST-22 AlkPhos-105 TotBili-0.3
___ 06:35AM BLOOD Calcium-8.8 Phos-4.9* Mg-2.1
CT ab/pelvis:
IMPRESSION:
1. Interval reversal of colostomy with no evidence of hernia,
abscess or
bowel obstruction. Moderate-to-large fecal load in the right
hemicolon.
2. Perinephric stranding without evidence of renal contrast
excretion.
Please correlate for underlying renal dysfunction.
Brief Hospital Course:
___ yo M with h/o CAD, ESRD on dialysis, and fournier's gangrene
in ___ resulting in diverting sigmoid colostomy now s/p
takedown on ___ who is admitted with lower abdominal pain
from constipation.
# Constipation: Only abnormality on CT abdomen is moderate to
large fecal load in the right side of the colon proximal to the
sigmoid anastamosis site with no signs of bowel obstruction or
breakdown of the anastamosis. Colorectal surgery was consulted
in the ED and feels his presentation is consistent with mild
constipation and recommended a good bowel regimen. Its possible
that there is still some dysmotility or mild dysfunction in the
area of the anastamosis that is playing a role. In any case, no
areas of inflammation, infection, obstruction, or other
worrisome pathology seen. The patient passed some stool with his
bowel regimen. His abdominal pain was improved. He was
discharged with standing colace/miralax, and PRN senna and
dulcolax. He has follow-up with the ___ clinic on ___.
# ESRD: on MWF on HD. Will resume HD at ___ as an outpatient
# CAD: Continued aspirin, metoprolol and plavix
# Hypertension: Continued home doses of amlodipine and
metoprolol
# DM type II: Continued outpatient regimen
# Chronic pain: Continued gabapentin and oxycodone
# Emergency Contact: Sister in law ___ ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Gabapentin 300 mg PO QHD
6. Glargine 30 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
7. Metoprolol Succinate XL 100 mg PO DAILY
8. Nephrocaps 1 CAP PO DAILY
9. Omeprazole 40 mg PO DAILY
10. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
11. sevelamer CARBONATE 1600 mg PO TID W/MEALS
12. Bisacodyl 10 mg PO DAILY
13. Amlodipine 10 mg PO DAILY
14. Senna 1 TAB PO BID:PRN constipation
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Amlodipine 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Bisacodyl 10 mg PO DAILY
RX *bisacodyl [Dulcolax (bisacodyl)] 5 mg 2 tablet,delayed
release (___) by mouth Daily Disp #*60 Tablet Refills:*0
5. Clopidogrel 75 mg PO DAILY
6. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 2 capsule(s) by mouth Twice
A Day Disp #*120 Capsule Refills:*0
7. Gabapentin 300 mg PO QHD
8. Glargine 30 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
9. Metoprolol Succinate XL 100 mg PO DAILY
10. Nephrocaps 1 CAP PO DAILY
11. Omeprazole 40 mg PO DAILY
12. Senna 1 TAB PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 tablet by mouth Twice A Day Disp
#*60 Tablet Refills:*0
13. sevelamer CARBONATE 1600 mg PO TID W/MEALS
14. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 [Miralax] 17 gram 1 packet by mouth
Daily Disp #*30 Packet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Constipation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital due to abdominal pain and
concern about a problem after teh bowel surgery. We performed
some tests, including a CT scan, that showed that you did not
have an infection or fluid collection. The CT scan did show that
you were constipated. It is important to stay hydrated, take
stool softeners, and be active to get your bowels to wake up and
become more regular. Please take all medications as prescribed.
Please follow-up with all appointments.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
10104335-DS-5 | 10,104,335 | 20,429,397 | DS | 5 | 2182-11-17 00:00:00 | 2182-11-17 19:18:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Penicillins / Aspirin
Attending: ___.
Chief Complaint:
Right sided weakness x 60 minutes
Major Surgical or Invasive Procedure:
MRI, TTE,
History of Present Illness:
___ is a ___ year old female with a history of chronic
a-fib, hypothyroidism, hyperparathyroidism, prior
cerebrovascular
accident in ___ (basal ganglia without residual deficits),
recently treated for UTI (___) now presenting with a transient
episode of right sided face, arm, leg weakness. Ms. ___
was
in her usual state of health yesterday evening, walking and
talking normally. This morning awoke around 8am and complained
of right leg pains. She was unable to get out of bed herself
and
kept falling to the right side. Her right face appeared to be
drooping and she was not nearly as talkative as usual. Per her
daughter and granddaughter, she seemed confused. After
relatives
assisted her to the breakfast table, she had difficult holding
her spoon with her hand and repeatedly dropped it into her
cereal. Family did not appreciate any slurred speech and said
that at breakfast she seemed to understand their commands. When
she tried to get up and walk she swerved to the right. Because
of the persistence of symptoms, family brought her to ___. By
the time of arrival in the ED (just before 10am), symptoms had
entirely resolved.
Past Medical History:
- Atrial fibrillation on amiodarone and dig
- HTN: on amlodipine/benazepril ___
- chronic cough with symmetric biapical scarring with multilobar
bronchiectasis
- h/o enlarged thyroid
Social History:
___
Family History:
No family history of stroke or seizures.
Daughter with thyroid disease. Parents died of natural causes
at
age ___ and ___.
Physical Exam:
VS: T 97.2 // Tm 97.9 // BP 136/55 // HR 75 // RR 18 // O2sat
96% RA
Gen: Patient is awake, alert and oriented to self (name: ___
___, location: ___). Appropriately interactive
with interviewer and daughter.
___: NC/AT, no scleral icterus noted
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: afib, nl. S1S2, no M/R/G noted
NEURO:
- Mental status exam: Patient able to follow midline commands,
but unable to perform appendicular commands. Language is fluent
with intact comprehension and repetition.
- Cranial nerves: R-sided homonymous hemianopsia noted on visual
field testing. No facial droop noted.
- Motor: Normal bulk and tone noted. Strength testing difficult
to perform secondary to patient's hearing loss and language
difficulty; patient displayed symmetry with apparent movement.
No pronator drift noted. No tremor identified.
- Could not assess sensory function, coordination, gait ___
patient's hearing loss and difficulty with verbal instructions.
Pertinent Results:
___ 05:30AM BLOOD WBC-4.1 RBC-3.74* Hgb-11.5* Hct-33.7*
MCV-90 MCH-30.7 MCHC-34.1 RDW-13.1 Plt ___
___ 05:00AM BLOOD WBC-5.0 RBC-4.12* Hgb-12.6 Hct-37.7
MCV-92 MCH-30.7 MCHC-33.5 RDW-13.6 Plt ___
___ 05:15AM BLOOD WBC-5.8 RBC-3.79* Hgb-11.8* Hct-35.0*
MCV-92 MCH-31.1 MCHC-33.7 RDW-13.5 Plt ___
___ 10:00AM BLOOD ___ PTT-30.3 ___
___ 05:30AM BLOOD ___ PTT-53.4* ___
___ 05:30AM BLOOD Plt ___
___ 05:30AM BLOOD Glucose-91 UreaN-29* Creat-0.9 Na-133
K-3.8 Cl-98 HCO3-29 AnGap-10
___ 10:00AM BLOOD cTropnT-<0.01
___ 05:15AM BLOOD cTropnT-<0.01
___ 11:00AM BLOOD cTropnT-<0.01
___ 05:30AM BLOOD Calcium-10.6* Phos-3.4 Mg-1.6
___ 11:00AM BLOOD %HbA1c-5.8 eAG-120
___ 05:15AM BLOOD Triglyc-58 HDL-53 CHOL/HD-2.7 LDLcalc-80
___ 11:00AM BLOOD TSH-3.0
___ 11:00AM BLOOD Free T4-0.87*
___ 11:00AM BLOOD ___-89*
MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST; MRA NECK W/O
CONTRAST
MRI HEAD: There is an area of slow diffusion seen in the left
medial temporal
lobe, occipital lobe and in the left thalamus consistent with a
left posterior
cerebral artery territory stroke. There are no foci of abnormal
susceptibility to suggest hemorrhagic conversion. Ventricles and
sulci appear
age appropriate. There is no mass effect seen. Old infarcts are
seen in
bilateral cerebellar hemispheres. Multiple scattered T2/FLAIR
high-signal
foci are seen in bilateral periventricular white matter
consistent with small
vessel ischemic disease. The left vertebral artery flow void is
not well
appreciated. Rest of the major arterial flow voids appear
preserved.
MRA HEAD: The distal left vertebral artery flow signal is not
visualized
which may represent vertebral arterial occlusion. Bilateral
intracranial
internal carotid arteries, the right vertebral artery, basilar
artery and
their major branches are patent with no evidence of stenosis,
occlusion or
aneurysm formation.
MRA NECK: Limited MRI study of the neck was obtained as contrast
could not be
administered. Bilateral common carotid arteries and vertebral
artery flow
voids in the neck appear normal with no evidence of stenosis or
occlusion.
There appears to be moderate stenosis of the left internal
carotid artery just
beyond the bifurcation.
IMPRESSION:
1. Acute infarct left PCA territory.
2. Chronic infarcts in bilateral cerebellar hemispheres.
3. Non-visualized flow signal in distal left vertebral artery
may represent a
congenital variation/occlusion. This may be confirmed on a CTA.
4. Moderate stenosis of the left internal carotid artery just
beyond the
bifurcation with restoration of flow signal in the distal ICA.
TTE: The left atrium is mildly dilated. The left atrium is
elongated. No atrial septal defect or patent foramen ovale is
seen by 2D, color Doppler or saline contrast. There is mild
symmetric left ventricular hypertrophy with normal cavity size
and global systolic function (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Moderate (2+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
IMPRESSION: No cardiac source of embolism identified. Preserved
global and regional biventricular systolic function. Moderate
aortic regurgitation.
Compared with the prior study dated ___ (images reviewed),
the degree of aortic regurgitation has worsened.
CT Head:
1. No evidence of acute hemorrhage or vascular territorial
infarct.
2. Prominent extraaxial spaces, including within the posterior
fossa on the
right. While this could be age related atrophy changes, the
location is
unusual and could possibly represent an arachnoid cyst.
Importantly, it is
unchanged from the ___ and ___ CT of the
head.
Brief Hospital Course:
Ms. ___ presented to ___ ED after 60 minutes right sided
weakness. When she had arrived in the ED, her symptoms had
resolved. She had a noncon head ct which was non-revealing in
the ED. She was admitted to ___ for stroke/tia workup.
Examination the following day was difficult ___ to her baseline
dementia, deafness, and language barrier. Examination was
grossly normal and the family noted that she was "at baseline."
___ worked with the patient and she ambulated well with a walker.
An echo was performed looking for sources of cardiac embolus. It
was negative. Next, an MRI was performed which showed an acute
left PCA infarct. The patient was recently placed on Pradaxa for
chronic afib. Since she had a stroke on pradaxa and she had been
stroke free on coumadin that a switch to coumadin would be more
prudent. The patient was restarted on her former dose of
coumadin with a pradaxa bridge. She was discharged after 2 days
of pradaxa/coumadin therapy with follow up in two days with her
PCP for INR monitoring.
Medications on Admission:
Levothyroxine 25 mcg daily
Atenolol 100mg daily
Alendronate 70mg weekly
Vitamin D 800units daily
Calcium Carbonate 500mg TID
Pradaxa (dose unclear), on coumadin in the past
Discharge Medications:
1. senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO TID (3 times a day).
6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
7. atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. alendronate 70 mg Tablet Sig: One (1) Tablet PO QMON (every
___.
10. warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at
4 ___: Goal INR ___.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Cerebral embolism with infarction
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Neuro: baseline dementia. No deficits in strength per our
testing. Per the family the patient is 'back to normal.' Patient
is very hard of hearing.
Discharge Instructions:
You were admitted with an epidsode of right sided weakness. You
were later found to have a stroke. You were on a blood thinner
called pradaxa. This medication was designed to prevent strokes
in people who have atrial fibrillation. Since you had a stroke
on pradaxa we will be switching to you to coumadin. Dr. ___ is
aware of this change. It is important that you see him on ___
for inr monitoring. Physical therapy has cleared you to go home.
It is important you take your coumadin at 4pm everyday.
We have made the following changes to your medications:
-Stopped pradaxa
-Started coumadin 3mg
-You may resume all other home medications.
If you experience any of the danger symptoms listed below please
come back to ___ ED.
Followup Instructions:
___
|
10104346-DS-2 | 10,104,346 | 20,521,668 | DS | 2 | 2130-02-25 00:00:00 | 2130-02-25 21:54:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Altered mental status and leg weakness
Major Surgical or Invasive Procedure:
Lumbar puncture
History of Present Illness:
Ms. ___ is a ___ year-old right-handed woman with PMH
significant for HTN, HLD and T3N1M0 papillary carcinoma of the
right breast (dx ___, s/p right total mastectomy and axillary
dissection, currently on anastrazole) who presents with dry
mouth, back pain, and speech changes/ lethargy worseing over the
past 3 days. She was at the ___ on vacation and began to feel
unwell with leg weakness without back pain and no clear
precipitant. No fever, chills, wt. loss, early satiety, night
sweats, SOB, CP or HA. Pt denies vomiting/lasix. Last mammogram
in Feburary, never had a colonoscopy, but no changes in bowel
habits.
In the ED, initial vs were 98.0 83 139/77 18 93%RA. Labs
significant for K 2.3, Ca ___, Mg 1.4, Phos 1.7, Bicarb 46, Cr
1.8 (baseline 1.0). Serum tox negative for ASA, EtOH, Acetmnphn,
Benzo, Barb, Tricyc. Hct 32.6. ABG with pH 7.50, pCO2 61, PO2
97. UA with large Leuks, 25 WBC, no bacteria, <1 epi. Lipase 82,
AST 49, LFTs otherwise unremarkable. Trop-T: <0.01. ECG showed
sinus rhythm, rate 78 with diffuse TWF. Head CT showed no acute
intracranial pathology, no edema or mass with old left basal
ganglia/int capsule infarct, no hydrocephalus. Spinal xrays
showed degenerative changes and anterior wedging of T12 of
undetermined age, no obvious metastatis idenified but MRI
recommended for further eval. CXR done but unread. Received 2L
NS, Magnesium 2g IV and potassium 40meq PO and 40mg K in 1L NS
at 250/hr, which was decreased to 150/hr due to buring at IV
site.
Admitted to medicine given altered MS, electrolyte
abnormalities, metabolic alkalosis. Transfer VS 98.1 86 163/81
18 98%RA.
On arrival to the floor, patient reports feeling much better,
although still with dry mouth. She is AAOx3, and pleasant, but
somewhat tangential with exam.
REVIEW OF SYSTEMS:
As above.
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
All other 10-system review negative in detail.
Past Medical History:
- T3N1M0 papillary carcinoma of the right breast (dx ___ s/p
right Total Mastectomy and Axillary Dissection, on anastrazole;
oncologist is Dr. ___
- HTN
- HLD
- Anxiety
- Previous ankle fracture
Social History:
___
Family History:
Mother deceased age ___ with history of dementia.
Father deceased age ___ from Staph infection post-op. She has a
brother and sister who are healthy. No family history of
strokes.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS 98.2, 140/82, 78, 94% RA
GEN Alert, oriented, no acute distress
HEENT NCAT EOMI sclera anicteric, OP clear but extermely dry.
NECK supple, no JVD, no LAD, no palpable masses.
Breast exam: Left breast s/p mastectomy, ? enlarged lymphnode in
right axilla. No arm swelling. Right breast without mass,
lesion, no axillary lymphadenopathy.
Back: Point tenderness to tapping at T12 vertebrea, no
radiation.
PULM Good aeration, CTAB no wheezes, rales, ronchi
CV RRR normal S1/S2, no mrg
ABD soft NT ND normoactive bowel sounds, no hsm
EXT WWP 2+ pulses palpable bilaterally, no c/c/e
NEURO CNs2-12 intact, motor function ___ UE/ ___, 2+ reflexes UE/
___, neg babinski, normal f/n/f.
SKIN no ulcers or lesions
DISCHARGE PHYSICAL EXAM
VS 97.6, 140/70, 74, 18, 96% RA
GEN Alert, oriented, no acute distress
HEENT NCAT MMM EOMI sclera anicteric, OP clear
NECK supple, no JVD, no LAD, no palpable masses.
Breast exam: Left breast s/p mastectomy, No arm swelling. Right
breast without mass, lesion, no axillary lymphadenopathy.
Back: Bilateral paravertebral low back pain, no point tenderness
PULM Good aeration, CTAB no wheezes, rales, ronchi
CV RRR normal S1/S2, no mrg
ABD soft NT ND normoactive bowel sounds, no hsm
EXT WWP 2+ pulses palpable bilaterally, no c/c/e
NEURO CNs2-12 intact, motor function ___ UE/ ___, 2+ reflexes UE/
___, neg babinski, normal f/n/f.
SKIN no ulcers or lesions
Pertinent Results:
ADMISSION LABS:
___ 06:05PM BLOOD WBC-8.6 RBC-3.59* Hgb-12.2 Hct-32.6*
MCV-91 MCH-34.1* MCHC-37.6* RDW-12.6 Plt ___
___ 06:05PM BLOOD Neuts-71.6* Lymphs-17.2* Monos-7.3
Eos-3.0 Baso-0.8
___ 06:05PM BLOOD Glucose-116* UreaN-34* Creat-1.8* Na-139
K-2.3* Cl-83* HCO3-46* AnGap-12
___ 06:05PM BLOOD ALT-28 AST-49* AlkPhos-57 TotBili-0.7
___ 06:05PM BLOOD Lipase-82*
___ 06:05PM BLOOD cTropnT-<0.01
___ 06:05PM BLOOD Albumin-4.6 Calcium-12.9* Phos-1.7*
Mg-1.4*
___ 06:05PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 08:18PM BLOOD pO2-97 pCO2-61* pH-7.50* calTCO2-49* Base
XS-20
PERTINENT LABS:
___ 06:10AM BLOOD WBC-8.2 RBC-3.43* Hgb-11.4* Hct-31.2*
MCV-91 MCH-33.3* MCHC-36.6* RDW-12.7 Plt ___
___ 06:10AM BLOOD Glucose-125* UreaN-26* Creat-1.5* Na-143
K-2.5* Cl-100 HCO3-36* AnGap-10
___ 06:10AM BLOOD TotProt-5.6* Calcium-11.8* Phos-1.3*
Mg-1.7
___ 04:46PM BLOOD Glucose-110* UreaN-22* Creat-1.4* Na-143
K-2.7* Cl-105 HCO3-29 AnGap-12
___ 04:46PM BLOOD Calcium-10.9* Phos-0.9* Mg-1.5*
___ 06:10AM BLOOD PEP-NO SPECIFI
___ 12:26AM BLOOD PTH-12*
___ 06:10AM BLOOD TSH-2.5
___ 01:13AM BLOOD Glucose-98 UreaN-18 Creat-1.3* Na-143
K-3.0* Cl-108 HCO3-26 AnGap-12
___ 01:13AM BLOOD Calcium-10.7* Phos-1.6* Mg-2.5
___ 07:40AM BLOOD WBC-9.6 RBC-3.48* Hgb-11.7* Hct-32.0*
MCV-92 MCH-33.7* MCHC-36.7* RDW-13.1 Plt ___
___ 07:40AM BLOOD Glucose-104* UreaN-14 Creat-1.2* Na-140
K-3.4 Cl-106 HCO3-20* AnGap-17
___ 07:40AM BLOOD Calcium-9.7 Phos-1.9* Mg-1.5*
___ 06:30AM BLOOD WBC-7.5 RBC-3.16* Hgb-10.9* Hct-29.4*
MCV-93 MCH-34.4* MCHC-37.0* RDW-13.1 Plt ___
___ 06:30AM BLOOD Glucose-108* UreaN-11 Creat-1.0 Na-140
K-3.5 Cl-109* HCO3-19* AnGap-16
DISCHARGE LABS:
___ 06:45AM BLOOD WBC-5.6 RBC-3.26* Hgb-10.9* Hct-30.1*
MCV-93 MCH-33.6* MCHC-36.3* RDW-13.1 Plt ___
___ 06:45AM BLOOD Glucose-94 UreaN-10 Creat-0.9 Na-138
K-3.1* Cl-108 HCO3-19* AnGap-14
___ 06:45AM BLOOD Calcium-7.5* Phos-2.4* Mg-1.7
MICROBIOLOGY:
___ CSF - pending
___ Stool C. difficile DNA amplification - negative
PATHOLOGY
___ CSF - pending
STUDIES:
___ MRI w/ and w/o contrast: 1. No metastatic disease to the
brain. 2. Mild pachymeningeal enhancement. Correlate for
recent lumbar puncture.
___ CXR: No acute cardiopulmonary pathology.
___ Head CT w/o contrast: No acute intracranial pathology. An
MRI with contrast is more sensitive for evaluating metastatic
disease.
___ T and L-spine X-ray: Degenerative changes particularly in
the thoracolumbar junction. Mild anterior wedging of T12 which
may be old however clinical correlation is suggested. MR is
more sensitive for the detection of metastases or acuity of
fracture.
___ EKG: Artifact is present. Sinus rhythm. Non-specific ST-T
wave changes
Brief Hospital Course:
# Hypercalcemic Crisis: That patient presented with a corrected
calcium level (Alb 4.6) of 12.78 with mental status changes and
dehydration. On the first day of admission, her calcium level
corrected nicely with aggresive rehydration with normal saline,
and her mental status subsequently returned to baseline.
Regarding the etiology of her hypercalcemia, there was concern
of malignancy/metastasis given her history of breast cancer.
Her condition could also be consistent with Milk-Alkali syndrome
given the patient's history of taking Tums, low phosphate and
metabolic alkalosis with a urine anion gap. Work-up was
significant for low PTH, normal TSH, normal VitD level, negative
basic serium toxicology screen, normal SPEP and UPEP. A brain
MRI revealed no evidence of metastasis however it did show
enhancement concerning for possible carcinomatous meningitis. An
LP was recommended which was performed and fluid was sent for
cytology and flow cytometry (both pending at time of discharge).
# Lower extremity weakness: The patient presented with lower
extremity weakness, and her Thoracic/Lumbar-spine X-ray showed
wedging of T12 of unclear chronicity. However, she remained
without weakness on motor exam with likely etiology due to
hypokalemia. Physical therapy was consulted and recommended
that she be discharged home with services. She should have a
bone mineral density study as an outpatient.
# Altered mental status: The patient presented with altered
mental status and agitation which was significantly different
from her baseline. It was likely secondary to toxic metabolic
encephalopathy secondary to hypercalcemia given that her mental
status returned to baseline with correction of her hypercalcium.
Neurology was consulted, and work-up was significant for a
negative basic serum toxicology screen and lack of brain
metastases on MRI. LP was performed with cytology and flow
cytometry pending at time of discharge.
# Acute Kidney Injury: The patient had a creatinine level of 1.8
on admission up from her baseline of 1.0. Etiology was likely
prerenal given her decreased PO intake in the week prior to
admission. Her creatine improved quickly with the administration
of intravenous fluids. Initially her ACE inhibitor was held but
this was restarted prior to discharge given improvement of her
renal function.
# Metabolic alkalosis: The patient was found to be alkalotic on
admission, which could have been due to a contraction alkalosis
or due to possible GI/Kidney losses. This corrected nicely with
the administration of intravenous fluids and electrolyte
repletion.
# Hypokalemia: The patient has a history of chronic low-normal
potassium levels. On admission, her potassium level was 2.3.
Her hydrochlorothiazide was held, and she was repleted
throughout this admission both orally and intravenously. On
discharge, her potassium was stable 3.1-3.6.
# Anemia: On admission, the patient was found to have anemia
with Hct of 32 down from her baseline of high-30s. Guiac of her
stool was negative, and she was monitored for any signs of
bleeding but remained stable. On discharge, her Hct was stable
at 30.
# Breast Cancer: The patient is followed by oncologist Dr. ___
___ at ___. Per report, she had a normal mammogram 6
months ago. During this admission, she was maintained on her
home dose of anastrozole 1 mg Oral daily
# Sterile Pyuria: The patient was found to have sterile pyuria
on urinalysis on admission. The patient did not have any
urinary symptoms throughout the hospitalization.
# Hypertension: The patient has a history of resistant
hypertension. Given her acute kidney injury and electrolyte
imbalances on admission, we held her home lisinopril and HCTZ
with systolic BPs 150-160s. Her home dose of lisinopril was
restarted on ___ when her kidney function returned to
baseline with sBPs 130-140s. HCTZ was not restarted given that
it can contribute to hypercalcemia.
# Hyperlipidemia: The patient was maintained on her home dose of
Simvastatin 10 mg PO DAILY throughout this hospitalization.
TRANSITIONAL ISSUES:
- patient should have a bone mineral density study as an
outpatient
PENDING LABS:
- CSF Cytology and Flow Cytometry
- PTH-RP and 1,25-OH vit D
MEDICATION CHANGES:
- DISCONTINUED hydrochlorothiazide
- STARTED ranitidine
CODE STATUS: Full (confirmed with patient and husband)
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient Per their list, labatelol
qd.
1. anastrozole *NF* 1 mg Oral daily
2. Labetalol 400 mg PO DAILY
3. Lisinopril 40 mg PO DAILY
4. Hydrochlorothiazide 25 mg PO DAILY
5. Potassium Chloride 10 mEq PO DAILY Duration: 24 Hours
Hold for K >
6. Simvastatin 10 mg PO DAILY
Discharge Medications:
1. anastrozole *NF* 1 mg Oral daily
2. Labetalol 400 mg PO DAILY
3. Lisinopril 40 mg PO DAILY
4. Simvastatin 10 mg PO DAILY
5. Ranitidine 75 mg PO BID
6. Potassium Chloride 10 mEq PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
___:
Primary diagnoses: Hypercalcemia, altered mental status
Secondary diagnoses: Hypertension, hyperlipidemia, history of
breast cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure to take care of you during this
hospitalization. You were admitted to ___
___ for confusion and leg weakness, and were found to
have a high level of calcium in your blood and electrolyte
abnormalities. With the guidance of the Endocrine team, we
treated your high calcium level with intravenous fluids and the
drug calcitonin with return of your calcium level to normal and
improvement in your confusion. Given your history of breast
cancer, we evaluated you with imaging of your head and analysis
of your spinal fluid (results still pending at time of
discharge). We repleted your electrolytes and discontinued your
hydrochlorothiazide given your electrolyte abnormalities. You
are now safe to go home.
The following changes were made to your medications:
- Please STOP hydrocholorthiazide
- Please START ranitidine
Please take the rest of your medications as prescribed and
follow up with your doctors as ___.
You should have your electrolytes checked at your follow up
appointment with your primary care doctor.
Followup Instructions:
___
|
10104473-DS-3 | 10,104,473 | 23,712,120 | DS | 3 | 2178-04-12 00:00:00 | 2178-04-23 14:49:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Allergies/ADRs on File
Attending: ___.
Chief Complaint:
C4 fracture and L acetabular fracture
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old male fell off 17 hand horse, with helmet, fell
backwards off horse, landing off side, no LOC. Neck and back
pain. CT showed C3 fractures anterior corner chip fracture, L
acetabulum fracture.
Past Medical History:
None
Social History:
___
Family History:
N/C
Physical Exam:
GENERAL APPEARANCE: Well developed, well nourished, alert and
cooperative, and appears to be in no acute distress.
HEAD: normocephalic.
EYES: PERRL, EOMI. Fundi normal, vision is grossly intact.
EARS: External auditory canals and tympanic membranes clear,
hearing grossly intact.
NOSE: No nasal discharge.
THROAT: Oral cavity and pharynx normal. No inflammation,
swelling, exudate, or lesions. Teeth and gingiva in good general
condition.
NECK: Neck supple, non-tender without lymphadenopathy, masses or
thyromegaly. C-collar in place.
CARDIAC: Normal S1 and S2. No S3, S4 or murmurs. Rhythm is
regular. There is no peripheral edema, cyanosis or pallor.
Extremities are warm and well perfused. Capillary refill is less
than 2 seconds. No carotid bruits.
LUNGS: Clear to auscultation and percussion without rales,
rhonchi, wheezing or diminished breath sounds.
ABDOMEN: Positive bowel sounds. Soft, nondistended, nontender.
No guarding or rebound. No masses.
MUSKULOSKELETAL: Adequately aligned spine. ROM intact spine and
extremities. No joint erythema or tenderness. Normal muscular
development. Normal gait.
BACK: Examination of the spine reveals normal gait and posture,
no spinal deformity, symmetry of spinal muscles, without
tenderness, decreased range of motion or muscular spasm.
EXTREMITIES: No significant deformity or joint abnormality. No
edema. Peripheral pulses intact. No varicosities.
LOWER EXTREMITY: Examination of both feet reveals all toes to be
normal in size and symmetry, normal range of motion, normal
sensation with distal capillary filling of less than 2 seconds
without tenderness, swelling, discoloration, nodules, weakness
or deformity; examination of both ankles, knees, legs, and hips
reveals normal range of motion, normal sensation without
tenderness, swelling, discoloration, crepitus, weakness or
deformity.
NEUROLOGICAL: CN II-XII intact. Strength and sensation symmetric
and intact throughout. Reflexes 2+ throughout. Cerebellar
testing normal.
SKIN: Skin normal color, texture and turgor with no lesions or
eruptions.
PSYCHIATRIC: The mental examination revealed the patient was
oriented to person, place, and time. The patient was able to
demonstrate good judgement and reason, without hallucinations,
abnormal affect or abnormal behaviors during the examination.
Patient is not suicidal.RECTAL: Good sphincter tone with no
anal, perineal or rectal lesions. Prostate is not tender,
enlarged, boggy, or nodular.
GENITALIA: Genital exam revealed normally developed male
genitalia. No scrotal mass or tenderness, no hernias or inquinal
lymphadenopathy. No perineal or perianal abnormalities are seen.
No genital lesions or urethral discharge.
Pertinent Results:
___ 04:09PM UREA N-14 CREAT-0.9
___ 04:09PM estGFR-Using this
___ 04:09PM LIPASE-32
___ 04:09PM GLUCOSE-91 LACTATE-1.3 NA+-139 K+-4.0 CL--105
TCO2-23
___ 04:09PM WBC-15.5* RBC-4.83 HGB-14.0 HCT-42.3 MCV-88
MCH-29.0 MCHC-33.1 RDW-12.5 RDWSD-40.0
___ 04:09PM PLT COUNT-273
___ 04:09PM ___ PTT-22.6* ___
___ 04:09PM ___ 04:05PM URINE HOURS-RANDOM
___ 04:05PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG
___ 04:05PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 04:05PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-10* BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
Brief Hospital Course:
Mr. ___ was admitted to the ___ service from the ED after
fell off his horse with a helmet. CT showed C3 fractures of
anterior corner chip fracture and a L acetabulum fracture. We
managed the patients pain, followed up ___ recommendations for
discharge, and had an extensive discussion with him regarding
follow up with the spine team. The patient was in good condition
on discharge, voiding well, eating a regular diet and ambulating
without assistance.
Medications on Admission:
None
Discharge Medications:
1. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Severe
RX *oxycodone 5 mg 1 (One) tablet(s) by mouth every four (4)
hours Disp #*6 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
C4 fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
You were admitted to ___ after
you fell off a horse, and were found to have a fracture of your
spine. You were evaluated by both Neurosurgery and Orthopedic
Surgery, who noted that you do not require any emergent surgery
and you do not have an unstable hip fracture. You are recovering
well and are now ready for discharge. Please follow the
instructions below to continue your recovery:
CERVICAL SPINE FRACTURE:
* Please wear the cervical collar around your neck for one month
at all times. You may remove this collar briefly for skin care.
The collar should remain on for showering.
* If you suddenly become dizzy, lightheaded, feeling as if you
are going to pass out, or weakness, go to the nearest Emergency
Room as this could be a sign that you are having impingement of
your spinal cord from the cervical spine fracture.
ACTIVITY:
* Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
* Avoid contact sports and/or any activity that may cause injury
to your bones and/or muscles for the next ___ weeks.
* 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 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.
* You may start some light exercise when you feel comfortable.
You may climb stairs.
HOW YOU MAY FEEL:
* You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
* You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
* All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
MEDICATIONS:
* Take all the medicines you were on before the operation just
as you did before, unless you have been told differently.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Non-steroidal anti-inflammatory drugs are very effective in
controlling pain (i.e., Ibuprofen, Motrin, Advil, Aleve,
Naprosyn) but they have their own set of side effects so make
sure your doctor approves.
* 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:
___
|
10104549-DS-28 | 10,104,549 | 25,502,861 | DS | 28 | 2202-03-04 00:00:00 | 2202-03-04 16:20:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Demerol / Toradol / Actos / Dextromethorphan / Nsaids
Attending: ___.
Chief Complaint:
SOB, BLE edema
Major Surgical or Invasive Procedure:
Endotracheal intubation
History of Present Illness:
Of note, the patient is a poor and inconsistent historian.
The patient is a ___ woman with a past medical history
significant for COPD, back pain s/p intrathecal Dilaudid pump,
and opiate abuse who presents with a myriad of complaints, in
particular 2 to 3 days of worsening SOB and BLE edema. At
baseline, she is able to walk 1 to ___ yards using a walker before
she needs to stop to catch her breath. She has a productive
cough with white to yellow sputum. The past couple of days, she
has been able to walk only a couple of steps before stopping and
coughing more frequently with yellow sputum. Over the past year,
she has developed BLE edema that has progressively worsened. The
past couple of days, her edema has progressed to the point she
has difficulty walking. She also complains of central,
non-radiating chest pain, epigastric abdominal pain, and
dysuria. She denies fever, chills, diarrhea, change in her bowel
habits, or hematuria.
In the ED, her vitals were T 98.3 HR 81 BP 172/85 RR 20 SaO2 96%
on RA. On exam, she had diffuse inspiratory and expiratory
wheezing. Her Hct was low at 34.9 (basline ~40); K 3.2, which
was repleted with 40 mEq; BNP 626 (417, ___. Her EKG was
normal, and her CXR revealed increased intersitial markings and
blunting of costophrenic angles with no consolidation. She
received IV Lasix 40 MG and 40 mEq K. She also received 1 TAB
Percocet, 1.5 MG Ativan, and Ipratropium and Albuterol nebs.
On transfer to the floor, she was somnolent but arousable. She
was given 0.24 MG Narcan and became more alert.
REVIEW OF SYSTEMS: Per HPI, otherwise negative in detail
Past Medical History:
- Hypertension
- Type II Diabetes
- Depression/Anxiety
- Peripheral Neuropathy
- Gastric banding (laparoscopic adjustable band, ___,
complicated by high-grade small bowel obstruction (___)
- Chronic lower back pain, multiple back surgeries:
- Total laminectomy L4/L5, laminotomy of L3 and S1, fusion
L4-S1, placement of EBI bone stimulator (___), removal of EBI
bone stimulator (___)
- Image intensification guided facet blocks at L4-5 and L5-S1
(___)
- Partial vertebrectomy of L4 and L5, fusion L4-S1, anterior
body spacers x 2 (___)
- Revision laminectomies of L4 and L5, fusion L4-S1 (___)
- Fusion exploration L4-S1, instrumentation removal L4-S1
(___)
- Intrathecal pump implanted at ___ (Dr. ___
- ___ surgery (___)
- Cholecystectomy (___)
- Adenocarcinoma of lung s/p wedge excision (___) and complete
right lower lobectomy for local recurrence (___)
- Polysubstance abuse (Per the record, the patient has abused
Equanil, Darvon, Codeine, Percodan, Vicodin, and Valium; treated
with Suboxone in the past since ___ under the direction of
Dr. ___ had difficulties while inpatient for several
surgeries, requiring psychiatric consultation for difficult pain
management and agitation)
Social History:
___
Family History:
Mother with alcoholism and father with depression
Physical Exam:
On Admission:
Vitals: T 98.3 BP 142/90 HR 83 RR 22 SaO2 93% on RA
General: Somnolent but arousable, falls asleep mid-sentence,
obese, lying comfortably in bed
HEENT: Dilated pupils, PERRLA, sclera anicteric, MMM, oropharynx
clear
Neck: Supple, no LAD, JVP difficult to assess given body habitus
CV: RRR, normal S1/2, no m/r/g
Lungs: Diffuse end-expiratory wheezing throughout
Abdomen: Normoactive BS, soft, obese, NT/ND
Ext: 2+ edema extending to knees bilaterally, WWP, 2+ distal
pulses
Neuro: A&Ox3, CN II-XII intact, moves all extremities
On Discharge:
VS: Tm 98.3 Tc 98.2 BP 109/85 (109-143/55-85) HR 88 (69-92) RR
16 SaO2 93% on RA
I/O (24hrs) 2760(PO 660)/BRP, BM x1
FSBG 179-298
General: Alert, able to converse, obese, lying comfortably in
bed
HEENT: PERRLA, sclera anicteric, MMM, oropharynx clear
Neck: Supple, no LAD, JVP difficult to assess given body habitus
CV: RRR, normal S1/2, no m/r/g
Lungs: Diffuse end-expiratory wheezing throughout
Abdomen: Normoactive BS, soft, obese, NT/ND
Ext: Trace edema, WWP, 2+ distal pulses
Neuro: A&Ox3, CN II-XII intact, moves all extremities
Pertinent Results:
On Admission:
___ 10:20PM BLOOD WBC-9.0# RBC-4.08* Hgb-11.0* Hct-34.9*
MCV-86 MCH-26.9* MCHC-31.4 RDW-18.4* Plt ___
___ 10:20PM BLOOD Neuts-79.6* Lymphs-10.8* Monos-4.4
Eos-4.9* Baso-0.3
___ 10:20PM BLOOD Plt ___
___ 08:25AM BLOOD ___ PTT-30.1 ___
___ 10:20PM BLOOD Glucose-203* UreaN-14 Creat-1.1 Na-144
K-3.2* Cl-101 HCO3-32 AnGap-14
___ 10:20PM BLOOD ALT-5 AST-11 LD(LDH)-224 AlkPhos-131*
TotBili-0.2
___ 10:20PM BLOOD cTropnT-<0.01 proBNP-626*
___ 08:25AM BLOOD CK-MB-2 cTropnT-<0.01
___ 08:25AM BLOOD Calcium-9.3 Phos-2.7 Mg-1.8
___ 06:05AM BLOOD VitB12-227* Folate-9.3
___ 06:05AM BLOOD %HbA1c-8.6* eAG-200*
___ 06:05AM BLOOD TSH-2.0
___ 08:25AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 11:36AM BLOOD Type-ART Temp-37.0 FiO2-96 O2 Flow-3
pO2-87 pCO2-57* pH-7.45 calTCO2-41* Base XS-12 AADO2-549 REQ
O2-90 Intubat-NOT INTUBA Comment-NASAL ___
URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3
COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL
CONTAMINATION.
RAPID PLASMA REAGIN TEST (Final ___: NONREACTIVE.
Blood Culture, Routine (Final ___: NO GROWTH.
Blood Culture, Routine (Final ___: NO GROWTH.
___ EKG: NSR, WNL, unchanged from prior
___ EKG: NSR, probable prior inferior wall myocardial
infarction given new inferior Q waves
___ CXR: Possible mild pulmonary vascular congestion.
___ CXR: There is little overall change in the appearance of
the heart and lungs. Cardiac silhouette is at the upper limits
of normal in size or slightly enlarged and there is some
evidence of elevated pulmonary venous pressure and possible
atelectatic changes at the left base. There has been placement
of an endotracheal tube with its tip approximately 2.3 cm above
the carina.
___ NCHCT: No acute intracranial hemorrhage. Subacute or
chronic right parietal infarct, which is new from the most
recent prior CT of ___. Global atrophy more prominent
in the bifrontal regions.
___ MR-Head:
IMPRESSION: Biparietal, right greater than left signal
abnormality in the white and gray matter. Findings are most
suggestive of PRES. Differential includes vasculitis or
inflammatory etiology. There are additional white matter changes
in the subcortical right frontal lobe as well as in bilateral
basal ganglion , corona radiata and pons, none of which
demonstrate significant enhancement or mass effect. These
findings could represent small vessel ischemic changes or less
likely, manifestations of osmotic demyelination in the
appropriate clinical scenario.
On Discharge:
___ 07:10AM BLOOD WBC-6.8 RBC-4.08* Hgb-11.2* Hct-34.9*
MCV-86 MCH-27.6 MCHC-32.3 RDW-18.2* Plt ___
___ 07:10AM BLOOD Plt ___
___ 07:10AM BLOOD Glucose-187* UreaN-17 Creat-0.9 Na-142
K-3.3 Cl-103 HCO3-31 AnGap-11
___ 07:10AM BLOOD Calcium-10.1 Phos-2.8 Mg-1.8
___ 07:59AM BLOOD Lactate-1.6
Brief Hospital Course:
The patient is a ___ woman with a past medical history
significant for COPD, back pain s/p intrathecal Dilaudid pump,
and polypharmacy abuse who presents with worsening SOB and BLE
edema, and on arrival to the floor, with AMS. Because of
respiratory code, she required intubation and was transferred to
the MICU. Her EEG revealed status epilepticus, and she was
started on Keppra. She was transferred back onto the floor
following extubation. Her imaging and most recent EEG suggest
PRES, possibly secondary to hypertension. On return to the
floor, her AMS resolved likely ___ better BP control for PRES,
waning post-ictal state, and decreased Dilaudid dose.
#AMS: On the floor, she was somnolent but arousable. She was
given 0.24 MG Narcan x2 and was somewhat more arousable. Of
note, she has a Dilaudid intrathecal pump for back pain, and per
her son, she has a significant drug abuse history and has
experienced 50+ episodes such as these over the past ___ years
thought to be drug-induced. Her initial medical work-up was
negative, except for her UCx from ___. Per CT, she has a new
subacute stroke and findings suggestive of PRES. Her EEG also
showed bilateral parietal discharge suggestive of PRES. MRI
confirmed PRES. Chronic Pain Servce decreased her intrathecal
dose by 10%. For PRES, her goal SBP was <140, which she met on
her home Lisinopril. Her AMS resolved likely ___ better BP
control for PRES, waning post-ictal state, UTI treatment, and
decreased Dilaudid dose.
#Seizure disorder: The patient's EEG showed status epilepticus.
She was given IV Ativan 2 MG and started on Keppra, currently
1500 MG BID. Given her significant drug abuse history, her
seizures may be drug-induced, e.g., benzodiazepine withdrawal,
or could be related to PRES. On D/C, she will continue Keppra
and follow-up with Neuro.
#UTI: On admission, she reported dysuria. Her UA was
unremarkable, but UCx from ___ grew out Enterococcus. Her UTI
may have contributed to her AMS. She was started on IV
Ampicillin and transitioned to PO Amoxicillin for complicated
UTI. Her last day of antibiotics will be ___.
#HTN: Her home Lisinopril was continued.
#IDDM: Her FSBGs were relatively well-controlled on ISS and
diabetic diet.
#COPD exacerbation: Based on the Pulmonary indices on her
ventilator in the MICU, COPD exacerbation was considered
unlikely. Her Prednisone and Azithromycin (which she refused)
were D/C'ed.
#Volume overload: On admission, she was given IV Lasix x2 and
did not require any additional doses.
#Hypernatremia: At one point, she was hypernatremic to 147. Her
Na normalized following 3L D5W administration for 3L free water
deficit.
TRANSITIONAL ISSUES:
1. Given her PRES, her goal SBP is <140, which she met on her
home Lisinopril.
2. For her seizure disorder, she will be D/C'ed on Keppra 1500
MG BID and follow-up with Neuro.
3. For her UTI, she will continue Amoxicillin for 3 more days
(LAST DAY ___.
4. Her AMS was likely related to her significant polypharmacy
and narcotic use. Given her intrathecal Dilaudid pump, please
limit narcotics.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Duloxetine 30 mg PO DAILY
2. Flovent HFA *NF* (fluticasone) 220 mcg/actuation Inhalation
BID
2 puffs BID
3. Fluticasone Propionate NASAL 1 SPRY NU BID
4. Nicotine Patch 14 mg TD DAILY:PRN nicotine withdrawal
5. NPH 8 Units Breakfast
NPH 8 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
6. Lisinopril 10 mg PO DAILY
hold for SBP<100
7. Simvastatin 20 mg PO DAILY
Discharge Medications:
1. Duloxetine 30 mg PO DAILY
2. Flovent HFA *NF* (fluticasone) 220 mcg/actuation Inhalation
BID
3. NPH 8 Units Breakfast
NPH 8 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
4. Lisinopril 10 mg PO DAILY
5. Nicotine Patch 14 mg TD DAILY:PRN nicotine withdrawal
6. Amoxicillin 500 mg PO Q8H Duration: 3 Days
LAST DAY ___. LeVETiracetam 1500 mg PO BID
8. Fluticasone Propionate NASAL 1 SPRY NU BID
9. Simvastatin 20 mg PO DAILY
10. Heparin 5000 UNIT SC TID
11. Intrathecal Dilaudid Pump
Dosing managed by chronic pain service. Device requires
interrogation for dosing changes
12. Docusate Sodium 100 mg PO BID:PRN constipation
13. Senna 1 TAB PO BID:PRN constipation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Altered mental status
Seizure disorder
Urinary tract infection
PRES
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you while you were hospitalized
at ___. You were admitted to the hospital with shortness of
breath and lower extremity swelling. You developed altered
mental status, and you seized requiring transfer to the
intensive care unit. When you were transferred back to the
floor, your altered mental status resolved with better blood
pressure control, anti-seizure medication, and decreased
narcotics.
Please take care to follow-up with your various outpatient
providers and your Primary Care physician once you are
discharged from rehab.
Followup Instructions:
___
|
10104549-DS-30 | 10,104,549 | 28,611,747 | DS | 30 | 2204-10-13 00:00:00 | 2204-10-13 20:29:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Demerol / Toradol / Actos / Dextromethorphan / Nsaids
Attending: ___.
Chief Complaint:
Anemia
Left ___ pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o female with complex medical history notable for lung
cancer (adenocarcinoma s/p wedge resection in ___, right lower
lobectomy in ___ she is currently receiving daily
chemotherapy), left total ___ replacement (___), COPD, HTN,
T2DM, and chronic pain.
She presented to ___ ED after she was found to be anemic at
her residence (___). She also has left ___ pain.
She reports feeling "crummy" for about a month, with fatigue and
increased sleeping. Physicians at her living facility checked
labs, notable for Hgb 6.4, hct 23.5, PLT 353, WBC 6.7. The
patient notes that she has chronic anemia, though she is not
sure what her baseline Hbg levels have been in the recent past.
She had a fall in bathroom several weeks ago, with resultant
___ pain and swelling. She did not have syncope. She notes she
"missed the handrail" in the bathroom and fell on her left side.
She saw her orthopedist on ___ in the office who did x-rays
which were negative.
She denies fever/chills, chest pain, dyspnea, abdominal pain,
nausea, vomiting, bloody/dark/tarry stools, hematuria,
hemoptysis, dysuria.
She does report cough over the last month. Her last colonoscopy
was at ___ in ___ and had no polyps or major abnormality.
In the ED, initial vitals: 97.0 86 143/64 16 96% RA.
Labs with:
WBC 6.4 Hbg 6.5 Hct 24.9 Plt ___ 12
--------------<236
3.7 28 1.2
ALT 15 AST 13 AP 165 TBili 0.3 Alb 3.4
She was given oxycodone PO 5mg, hydromorphone 0.5mg IV and an
ipratropium nebulizer treatment.
On arrival to the floor, pt reports continued left ___ pain.
ROS:
No fevers, chills, night sweats, or weight changes. No changes
in vision or hearing, no changes in balance. No cough, no
shortness of breath, no dyspnea on exertion. No chest pain or
palpitations. No nausea or vomiting. No diarrhea or
constipation. No dysuria or hematuria. No hematochezia, no
melena. No numbness or weakness, no focal deficits.
Past Medical History:
- Hypertension
- Type II Diabetes
- Depression/Anxiety
- Peripheral Neuropathy
- Gastric banding (laparoscopic adjustable band, ___,
complicated by high-grade small bowel obstruction (___)
- Chronic lower back pain, multiple back surgeries:
- Total laminectomy L4/L5, laminotomy of L3 and S1, fusion
L4-S1, placement of EBI bone stimulator (___), removal of EBI
bone stimulator (___)
- Image intensification guided facet blocks at L4-5 and L5-S1
(___)
- Partial vertebrectomy of L4 and L5, fusion L4-S1, anterior
body spacers x 2 (___)
- Revision laminectomies of L4 and L5, fusion L4-S1 (___)
- Fusion exploration L4-S1, instrumentation removal L4-S1
(___)
- Intrathecal pump implanted at ___ (Dr. ___
- ___ surgery (___)
- Cholecystectomy (___)
- Adenocarcinoma of lung s/p wedge excision (___) and complete
right lower lobectomy for local recurrence (___)
- Polysubstance abuse (Per the record, the patient has abused
Equanil, Darvon, Codeine, Percodan, Vicodin, and Valium; treated
with Suboxone in the past since ___ under the direction of
Dr. ___ had difficulties while inpatient for several
surgeries, requiring psychiatric consultation for difficult pain
management and agitation)
Social History:
___
Family History:
- Mother with alcoholism and father with depression.
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
============================================
Vitals: 97.7 157/70 83 18 98% room air
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear
Neck: supple, no LAD
Lungs: A few scattered wheezes throughout.
CV: Regular rhythm. Soft systolic murmur.
Abdomen: soft, NT/ND bowel sounds present, no rebound tenderness
or guarding, no organomegaly
GU: no foley
RECTAL: Very small amount of light brown stool, guaiac negative.
Ext: warm, well perfused, no edema. The left ___ has some
swelling and tenderness at the midline, no warmth or erythema.
Neuro: CN2-12 intact, no focal deficits
PHYSICAL EXAM ON DISCHARGE:
============================================
Vitals: 98.4 142/73 82 18 100% room air
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear
Neck: supple, no LAD
Lungs: A few scattered wheezes throughout, most of which clear
with cough, good air movement.
CV: Regular rhythm. Soft systolic murmur.
Abdomen: soft, NT/ND bowel sounds present, no rebound tenderness
or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, no edema. The left ___ has some
swelling and tenderness at the midline, no warmth or erythema.
She is able to range the ___ on her own.
Neuro: CN2-12 intact, no focal deficits
Pertinent Results:
LABS:
========================================
___ 12:11PM BLOOD WBC-6.4 RBC-3.10* Hgb-6.5*# Hct-24.9*#
MCV-80*# MCH-21.0*# MCHC-26.1*# RDW-20.1* RDWSD-57.7* Plt ___
___ 12:11PM BLOOD Neuts-65.7 Lymphs-11.0* Monos-8.5
Eos-14.0* Baso-0.5 Im ___ AbsNeut-4.17 AbsLymp-0.70*
AbsMono-0.54 AbsEos-0.89* AbsBaso-0.03
___ 06:45AM BLOOD ___ PTT-28.6 ___
___ 12:11PM BLOOD Ret Aut-2.7* Abs Ret-0.08
___ 12:11PM BLOOD Glucose-236* UreaN-12 Creat-1.2* Na-139
K-3.7 Cl-104 HCO3-28 AnGap-11
___ 12:11PM BLOOD ALT-15 AST-13 LD(LDH)-151 AlkPhos-165*
TotBili-0.3
___ 12:11PM BLOOD Albumin-3.4* Iron-23*
___ 12:11PM BLOOD calTIBC-339 ___ Ferritn-10* TRF-261
___ 06:45AM BLOOD WBC-5.7 RBC-3.50* Hgb-7.6* Hct-27.9*
MCV-80* MCH-21.7* MCHC-27.2* RDW-19.4* RDWSD-55.8* Plt ___
___ 04:15PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-TR
STUDIES:
========================================
CHEST (PORTABLE AP) Study Date of ___:
FINDINGS:
The patient is rotated somewhat to the right. Given this, the
cardiac and
mediastinal silhouettes are stable. There appears to be some
volume loss in the right lung. The cardiac and mediastinal
silhouettes left stable. No large pleural effusion is seen on
the be difficult to exclude a trace right pleural effusion. No
pneumothorax is seen.
Brief Hospital Course:
PRIAMRY REASON FOR HOSPITALIZATION:
=========================================================
___ y/o female with complex medical history notable for lung
cancer (adenocarcinoma s/p wedge resection in ___, right lower
lobectomy in ___, L total ___ replacement (___), COPD, HTN,
T2DM.
She presented to ___ ED after she was found to be anemic at
her residence. She also has left ___ pain.
ACTIVE ISSUES:
=========================================================
#) Anemia: Patient presented after outside labs showed anemia,
Hbg is 6.5 on presentation here (MCV 80). In discussion with her
rehab facility, recent values were as follows: 8.2 on
___, 7.1 on ___. Here she was hemodynamically
stable. She had no signs of bleeding and rectal exam was with
guaiac negative brown stool. She received 1 unit of pRBCs, with
improvement in Hbg to 7.6. Hemolysis labs were negative. Retic
count was low, and ferritin was 10, indicating severe iron
deficiency. Given her stability she was discharged back to her
rehab. It was thought that her anemia was subacute, with
etiology being iron-deficiency, with likely contribution from
her lung cancer and possibly her erlotinib (which can cause
anemia). She was discharged on ferrous sulfate supplementation,
with recommendation to recheck iron studies in ___ weeks.
#) Left ___ pain: Patient reports falling at home in early
___, with resultant and persistent left ___ pain and
swelling. Of note, she is s/p left ___ replacement in ___. She
was seen in the Orthopedics Office on ___, at which time
xrays were obtained which were significant for no related
complications and a moderate effusion. She was diagnosed with a
left ___ contusion, which was felt to be likely to
self-resolve. On exam no sign of infection, though ___ has
likely effusion and is tender. She was advised to have follow-up
with her Orthopedic Team should her symptoms persist for more
than ___ more weeks.
#) Lung cancer: History of adenocarcinoma of lung s/p wedge
excision (___) and complete right lower lobectomy for local
recurrence (___). She is followed at ___ (Dr. ___
___ and is currently being treated with daily erlotinib. On
admission, the medication was discussed with the on-call
Oncologist at ___, who recommended initially holding the
medication given her anemia. Upon discharge this was restarted
given that her anemia was most likely due to iron deficiency.
This was discussed with her ___ at ___.
#) COPD: history of, with wheezing here. Chest xray here did not
show any focal process. She was placed on duoneb treatments. She
was also continued on home fluticasone inhaler and nasal spray.
#) Diabetes: last HbA1c was 8.6% in ___. Her home metformin
(1000mg TID) was held inhouse, restarted upon discharge. She was
maintained on her home NPH 20 units BID and HISS. She was
continued home simvastatin 20mg daily.
#) Depression/anxiety: continued on home buproprione SR 200mg
BID, duloxetine 60mg daily, trazodone 75mg PO qHS, and
mirtazapine 15mg PO QHS.
#) Chronic pain: continued on home oxycontin 20mg TID, dilaudid
4mg q4hrs, and duloxetine 60mg daily.
#) Hypertension: SBP in the 140-160s here. Not on any current
medications, though in the past has been on verapamil SR 240mg
daily and lisinopril 20mg daily. No antihypertensives were
started this admission.
#) Chronic kidney disease: creatinine on admission 1.2. Only
prior values in our system are from ___, at which time it
appears baseline was 0.9-1.1.
TRANSITIONAL ISSUES:
=========================================================
- Received 1 unit of pRBCs on ___. Discharge Hbg was 7.6.
- Serum ferritin was 10. She was discharged to start ferrous
sulfate 325mg daily. After 1 week this can be increased to 325mg
BID, and then to 325mg TID after another week.
- She should repeat iron studies (iron, TIBC, ferritin) in ___
weeks.
- If she has persistent left ___ pain, should make appointment
to see Orthopedics (number for appointment is ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Fluticasone Propionate NASAL 1 SPRY NU DAILY
3. Omeprazole 20 mg PO DAILY
4. Erlotinib 150 mg PO DAILY
5. Bisacodyl 5 mg PO QHS
6. Duloxetine 60 mg PO DAILY
7. Mirtazapine 15 mg PO QHS
8. Simvastatin 20 mg PO QPM
9. BuPROPion (Sustained Release) 200 mg PO BID
10. cranberry 450 mg oral BID
11. Docusate Sodium 100 mg PO BID
12. Senna 8.6 mg PO BID
13. OxyCODONE SR (OxyconTIN) 20 mg PO Q8H
14. Prochlorperazine 10 mg PO BID:PRN nausea
15. TraZODone 75 mg PO QHS:PRN insomnia
16. Lorazepam 1 mg PO Q6H:PRN anxiety
17. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing, dyspea
18. Acetaminophen 650 mg PO Q6H:PRN pain
19. LOPERamide 2 mg PO QID:PRN diarrhea
20. HYDROmorphone (Dilaudid) 4 mg PO Q3H:PRN pain
21. NPH 20 Units Breakfast
NPH 20 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Bisacodyl 5 mg PO QHS
4. BuPROPion (Sustained Release) 200 mg PO BID
5. Docusate Sodium 100 mg PO BID
6. Duloxetine 60 mg PO DAILY
7. Fluticasone Propionate NASAL 1 SPRY NU DAILY
8. HYDROmorphone (Dilaudid) 4 mg PO Q3H:PRN pain
RX *hydromorphone 4 mg 1 tablet(s) by mouth q3hr Disp #*14
Tablet Refills:*0
9. NPH 20 Units Breakfast
NPH 20 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
10. Mirtazapine 15 mg PO QHS
11. Omeprazole 20 mg PO DAILY
12. OxyCODONE SR (OxyconTIN) 20 mg PO Q8H
RX *oxycodone [OxyContin] 20 mg 1 tablet(s) by mouth three times
a day Disp #*10 Tablet Refills:*0
13. Senna 8.6 mg PO BID
14. Simvastatin 20 mg PO QPM
15. TraZODone 75 mg PO QHS:PRN insomnia
16. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheezing,
dyspnea
17. cranberry 450 mg oral BID
18. LOPERamide 2 mg PO QID:PRN diarrhea
19. Lorazepam 1 mg PO Q6H:PRN anxiety
RX *lorazepam 1 mg 1 mg by mouth q6hr Disp #*8 Tablet Refills:*0
20. Prochlorperazine 10 mg PO BID:PRN nausea
21. Ferrous Sulfate 325 mg PO DAILY
22. Erlotinib 150 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Anemia
Iron deficiency
Left ___ pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure to care for you here at ___. You were
admitted with low blood counts (anemia). You were evaluated you
showed no evidence of bleeding. Your blood counts have been low
for some time, and testing we did here show that you are iron
deficient. We will start you on an iron supplement.
Please make sure to follow-up with you cancer doctor.
You also were evaluated for left ___ pain. This is likely
related to your fall. You had xrays performed by your
Orthopedist, and these did not show any worrisome fractures or
problems with your replacement. If you continue to have pain,
you should return to see your Orthopedic Doctors.
Followup Instructions:
___
|
10104732-DS-11 | 10,104,732 | 29,256,816 | DS | 11 | 2183-11-10 00:00:00 | 2183-11-10 12:10:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
sulfa drugs
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with history of HIV (CD4 940 on ___, viral load
undetectable ___, CNS lymphoma with residual left-sided,
seizure disorder deficits presenting with abdominal pain,
nausea, and vomiting.
.
He was seen by neurology at ___ in late ___ after having a
breakthrough seizure while on depakote. He was started on
Keppra on ___ with plan to down-titrate and eventually come off
the Depakote (on ___ dose reduced to 750mg BID for 1 week with
plan to go to 750mg daily for 1 week then stop). He was
evaluated on ___ in the Emergency Department after presenting
with behavioral changes since starting the Keppra. He had a CT
head. He was seen by neurology. It was thought that the changes
were likely due to the Keppra. The plan was to continue with the
planned taper of depakote and continue the keppra. He was
transferred to Radius on ___.
.
At Radius on ___ he reported nausea, vomiting and abdominal
pain. Labs drawn and noted to have AST 980 and ALT 1122 with ALK
phos 334 and total bilirubin 5.7 (direct 2.8) with lipase of
303.
.
In the ED, initial vitals: 97.3 80 ___ 98% 3L NC. Labs
notable for ALT 1251 and AST 919 (normal ___, T-bili 5.1
(3.3 on ___, lipase 431, creatinine 1.7 (baseline 1.2-1.5).
UA with moderate blood, few bacteria. Serum acetaminophen
negative. RUQ U/S was obtained that showed nonspecific
gallbladder distention with stones, no bile duct dilation,
echogenic liver compatible with fatty deposition. He was seen by
surgery but felt unlikely that he had cholecystitis. The patient
was given unasyn prior to transfer.
.
Currently, the patient reports abdominal pain, mostly
___ to epigastric, unable to quantify or provide
description, associated wtih nausea.
.
ROS: per HPI, denies fever, chills, headache, diarrhea, dysuria.
Past Medical History:
- HIV
- CNS lymphoma, DX ___, treated at ___ w/ residual left facial
droop
- corneal ulceration s/p enucleation
- seizure disorder (keppra being up-tirtrated, depakote
down-titrated)
Social History:
___
Family History:
-parents are alive and healthy
Physical Exam:
VS: 97.9 BP:140/98 HR:90 RR:16 100%RA
GENERAL: thin male, intermittent cough
HEENT: OP dry, sclera mildy icteric
NECK: supple, no JVD
HEART: S1-S2, regular rhythm, normal rate, no murmur appreciated
LUNGS: CTAB, good air movement, resp unlabored
ABDOMEN: normal bowel sounds, soft, TTP diffusely but mostly
supra-pubic, no rebound tenderness appreciated
GU: condom catheter in place
EXTREMITIES: no edema
SKIN: no rashes or lesions
NEURO: slow to answer questions, oriented to self only,
President is "___", glass eye on left, left facial weakness,
decreased strength in lower extremities
Pertinent Results:
___ 02:00PM BLOOD WBC-10.2 RBC-4.83 Hgb-15.1 Hct-47.3#
MCV-98 MCH-31.3 MCHC-31.9 RDW-13.7 Plt ___
___ 02:00PM BLOOD Glucose-107* UreaN-19 Creat-1.7* Na-138
K-5.0 Cl-104 HCO3-20* AnGap-19
___ 02:00PM BLOOD ALT-1251* AST-919* AlkPhos-383*
TotBili-5.1* DirBili-2.2* IndBili-2.9
___ 02:00PM BLOOD Lipase-423*
___ 02:00PM BLOOD Albumin-4.1 Calcium-9.5 Phos-3.2 Mg-2.6
___ 02:11PM BLOOD Lactate-1.9
___ 06:30AM BLOOD WBC-9.3 RBC-3.80* Hgb-12.2* Hct-37.1*
MCV-98 MCH-32.2* MCHC-32.9 RDW-13.5 Plt ___
___ 06:30AM BLOOD Glucose-92 UreaN-13 Creat-1.0 Na-138
K-3.9 Cl-105 HCO3-23 AnGap-14
___ 06:30AM BLOOD ALT-361* AST-114* AlkPhos-276*
TotBili-3.4*
___ 06:30AM BLOOD Albumin-3.8 Calcium-9.2 Phos-1.6* Mg-2.4
___ 06:40AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE IgM HAV-NEGATIVE
___ 06:40AM BLOOD Smooth-NEGATIVE
___ 06:40AM BLOOD ___
CT ABDOMEN:
HISTORY: ___ male with HIV and suprapubic pain as well
as abnormal
LFTs and elevated lipase; question cause for pain.
TECHNIQUE: Helical CT images were acquired of the abdomen and
pelvis without
oral or IV contrast and reformatted into coronal and sagittal
planes.
FINDINGS:
LUNG BASES: There is minimal bibasilar atelectasis. The lungs
are otherwise
clear. The heart is normal in size. There is no pleural or
pericardial
effusion.
ABDOMEN: The liver, spleen, and adrenals are normal in
appearance. The
gallbladder is normal in morphology, with several dense
gallstones seen in the
region of the gallbladder neck. There is no evidence of acute
cholecystitis.
There is no intra- or extra-hepatic biliary ductal dilatation.
The pancreas
demonstrates mild inflammatory fat stranding around it,
extending along the
anterior pararenal space bilaterally, right greater than left,
and down the
right paracolic gutter. There is a moderate amount of free
fluid within the
pelvis. The stomach is collapsed. Loops of small bowel are
normal in caliber.
PELVIS: The bladder is normal appearing. The prostate is
unremarkable. The
colon is normal in appearance, with adjacent fat stranding,
likely reflecting
pancreatic pathology. There is no intraperitoneal free air.
There is no bony or soft tissue abnormality.
IMPRESSION:
1. Stranding around the pancreas, extending into the right
greater than left
anterior pararenal space, likely reflecting resolving
pancreatitis in the
appropriate clinical setting.
2. No evidence of acute cholecystitis, despite the presence of
gallstones.
The study and the report were reviewed by the staff radiologist.
___. ___
___. ___
___: MON ___ 11:12 ___
Brief Hospital Course:
ASSESSMENT:
___ with history of HIV (CD4 940 on ___, viral load
undetectable ___, CNS lymphoma with residual left-sided,
seizure disorder deficits presenting with abdominal pain and
nausea found to have abnormal LFT
.
#Acute pancreatitis
#Gallstones
#Transaminitis and hyperbilirubenimia
Patient with abdominal pain found to have predominantly
hepatocellular pattern of injury on LFTs (acute elevation of
ALT/AST with more mild increase in bilirubin), which is new
compared to labs from late ___. The RUQ U/S did not show CBD
dilation concerning for choledocholithiasis/cholangitis, portal
vein thrombosis, or changes in the visible portions of the
pancreas. Abdominal CT showed gallstones and inflammation
around his pancreas. Given that his lipase was elevated to 450
and he had CT changes it was felt that he had acute pancreatitis
attributed to gallstone disease. Given his other chronic
medical issues and lack of acute cholecystitis, the general
surgery consultants felt that he did not have an operation at
this time but that he can be seen in surgical clinic to discuss
cholecysectomy to avoid future episodes of gallstone
pancreatitis. He was NPO, received IVF and then resumed a
regular diet which he tolerated with the absence of abdominal
pain before discharge. He does have mild transaminitis and BIlI
of 2.5 on discharge. Serologies show immune to HBV status,
negative anti-mitochondrial and ___. Depakote was stopped
because of transaminitis with consultation by neurology.
[]HCV VL PENDING
.
#ENCEPHALOPATHY NOS: Patient with reduced attention and
orientation on exam today - not clear if worse today compared to
when evaluted in ED although at that time noted to be AOx2.
Medication side effect considered as changes started soon after
initiation of keppra. Alternative etiologies include subclinical
seizure, recurrence of CNS lymphoma, infectious, hepatic
encephalopathy, or CVA. Recent head CT without obvious evidence
of CNS lymphoma or large territory CVA. I discussed EEG
findings ___ neurology who advised continuing him only on
Keppra 1000mg BID and stopping depakote because of his
transaminitis.
EEG showed expected changes including encephalopathy and
background slowing
"This is an abnormal continuous ICU monitoring study because of
both a diffuse encephalopathy manifest by background slowing
into the mid to
upper theta bandwidth and focal slowing over the left posterior
quadrant
strongly that is suggestive of a structural abnormality. There
were also
isolated interictal epileptic transients from the left posterior
quadrant.
There also was asymmetric spindle formation with relative
suppression in the
left parietal region suggesting disruption of thalamo-cortical
projections in
that area." RPR NEGATIVE
#SEIZURE DISORDER: History of seizure disorder, recent
breakthrough seizure on depakote thought to be due to long-term
effect of HIV and radiotherapy rather than recurrence of
lymphoma or infection. Continued only on keppra at discharge.
Neuro consulted as above.
.
#HIV: Appears to be well controlled on HAART. I spoke with
pharmacy and his HIV provider, Dr. ___ at ___ and
kept him on atazanavir, ritonavir, truvada
#CHRONIC RENAL DISEASE: Creatinine ranging from 1.4-1.7 and
improved ___ hydration with creat of 1.0 on ___
.
#? HYPERTENSION: Appears to have been started on labetalol and
amlodipine while at Radius. Will hold for now as appears
controlled of anti-hypertensives thus he is not continued on
these agents at discharge but these can be resumed if needed.
TRANSITIONAL ISSUES
[]F/U ___ GENERAL SURGERY FOR POSSIBLE CHOLECYSTECTOMY
[]FOLLOW LFTS TO ENSURE NOT WORSENING WHILE ON HAART
[]IF ISSUES ARISE WITH HIS EPILEPSY THEN SPEAK WITH HIS
NEUROLOGIST, ___. ___
___, SLP RECOMMENDED
[]HCV VL PENDING
Discharge Medications:
1. Atazanavir 300 mg PO DAILY
2. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
3. LeVETiracetam 1000 mg PO BID
4. RiTONAvir 100 mg PO DAILY
5. Lorazepam 1 mg PO HS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
acute pancreatitis
gallstones
seizure disorder
HIV, asymptomatic
malnutrtion, mild
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:
you are admitted with abdominal pain and found to have
pancreatitis (inflammation of the pancreas) and also gallstones.
we stopped your depakote because your LFTs were abnormal. we
are referring you to surgery as an outpatient to discuss
gallbladder operation
your lfts remain abnormal and you should have repeat LFTs next
week
Followup Instructions:
___
|
10104732-DS-12 | 10,104,732 | 25,583,405 | DS | 12 | 2184-01-06 00:00:00 | 2184-01-10 21:12:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
sulfa drugs
Attending: ___.
Chief Complaint:
Left arm tingling
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with history of HIV (CD4 940 on ___, viral load
undetectable ___, CNS lymphoma with residual left-sided
weakeness and left facial droop, presented with transient L arm
tingling at 2:30 this afternoon. The patient said that he was
lying on his right side when he noticed tingling of the left
hand and fingers and weakness on that side as well. He turned
over and lifted his arm up, but his symptoms did not improve for
some time. He Cannot recall how long his symptoms persisted. He
was seen by a health care provider at the time and Vitals were:
97.8, 136/95, 92, 18, 95% RA. Given these new onset of symptoms,
he was sent to the ED for further evaluation. Symptoms resolved
before hospital arrival.
The patient denies fevers, chills, URI symptoms, sore throat,
dyshpagia, odynophagia, SOB, DOE, Chest Pain, Abd Pain N/V/D,
new joints or muscle pains although has chronic pain of the
lower extremities.
In the ED, initial vs were: 98.0 83 122/81 14 100% 4L Nasal
Cannula. Labs were remarkable for WBC 19.7 (N:15 Band:0 ___ M:3
E:1 Bas:3), ALT: 19 AP: 238 Tbili: 3.0 Alb: 4.9 AST: 28, H/H
12.5/33.8, U/A negative for infection, but with Glucose 300.
Code stroke was called in the ED, but neuro felt that he was
close to his baseline and possible breakthrough seizure although
need more information. Patient not given any medications. Vitals
on Transfer: 97.8 89 129/84 16 100%.
On the floor, patient feeling well with no symptoms.
Past Medical History:
- HIV
- CNS lymphoma, DX ___, treated at ___ w/ residual left facial
droop
- corneal ulceration s/p enucleation
- seizure disorder (keppra being up-tirtrated, depakote
down-titrated)
Social History:
___
Family History:
-parents are alive and healthy
Physical Exam:
ADMISSION:
Vitals: T: 97.4 BP: 117/87 P: 82 R: 16 O2: 100% RA
General: Alert, no acute distress
HEENT: Left eye prosthesis, Right pupil reactive to light,
sclera anicteric, EOMI of the right intact MMM, oropharynx
clear, poor dentition
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
Lymph Nodes: No anterior/posterior cervical chain adenopathy, no
supra/infraclavicular adenopathy, no axillary LAD, small 1cm
right inguinal lymph node mobile and non-tender to palpation
Neurologic:
(If applicable)
___ Stroke Scale score was 7:
1a. Level of Consciousness: 0
1b. LOC Question: 2
1c. LOC Commands: 0
2. Best gaze: 0
3. Visual fields: 0
4. Facial palsy: 3
5a. Motor arm, left: 0
5b. Motor arm, right: 0
6a. Motor leg, left: 0
6b. Motor leg, right: 0
7. Limb Ataxia: 1
8. Sensory: 0
9. Language: 0
10. Dysarthria: 1
11. Extinction and Neglect: 0
-Mental Status: Alert, oriented x 1 (able to state his name and
that he was in a hospital, but not sure which one, stated
___, did not guess current year). Able to relate history
with great difficulty and with multiple intrusions and
circumlocutions. Speech is dysarthric but language is fluent
with
intact repetition and comprehension for simple requests and
simple questions. Normal prosody. There were no paraphasic
errors. Pt. was able to name both high and low frequency
objects. 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 2mm and brisk on the right. VFF to confrontation
on the right.
III, IV, VI: EOMI without nystagmus on the right. Normal
saccades.
V: Facial sensation intact to light touch.
VII: Left facial droop, facial musculature asymmetric.
VIII: Hearing intact to finger-rub on the right but not left.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 0
R 2 2 2 2 0
Plantar response was upgoing bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
Dysmetria on FNF on the right but not on the left.
-Gait: deferred
DISCHARGE:
Vital Signs: 98.2 111/71 79 18 100%RA
Lying comfortably in bed, pleasant, interactive, no acute
distress.
Exam otherwise unchanged.
Pertinent Results:
ADMISSION:
___ 04:15PM BLOOD WBC-19.7*# RBC-3.75* Hgb-12.5* Hct-33.8*
MCV-90# MCH-33.2* MCHC-36.9*# RDW-15.4 Plt ___
___ 04:15PM BLOOD Neuts-15* Bands-0 Lymphs-78* Monos-3
Eos-1 Baso-3* ___ Myelos-0
___ 04:15PM BLOOD Glucose-95 UreaN-15 Creat-1.1 Na-137
K-3.8 Cl-104 HCO3-22 AnGap-15
___ 04:15PM BLOOD ALT-19 AST-28 AlkPhos-238* TotBili-3.0*
___ 04:15PM BLOOD Albumin-4.9
URINE:
___ 08:15PM URINE Color-Straw Appear-Clear Sp ___
___ 08:15PM URINE Blood-TR Nitrite-NEG Protein-30
Glucose-300 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
___ 08:15PM URINE RBC-1 WBC-<1 Bacteri-NONE Yeast-RARE
Epi-0
___ 08:15PM URINE
DISCHARGE:
___ 06:50AM BLOOD WBC-8.8# RBC-4.11* Hgb-13.3* Hct-37.7*
MCV-92 MCH-32.4* MCHC-35.4* RDW-14.3 Plt ___
___ 06:50AM BLOOD Neuts-46.4* Lymphs-46.0* Monos-5.0
Eos-1.7 Baso-1.1
___ 07:25AM BLOOD Glucose-103* UreaN-19 Creat-1.3* Na-139
K-3.5 Cl-107 HCO3-24 AnGap-12
___ 06:50AM BLOOD ALT-23 AST-23 AlkPhos-269* TotBili-2.9*
DirBili-0.4* IndBili-2.5
___ 07:25AM BLOOD Calcium-9.4 Phos-2.4* Mg-2.3
STUDIES:
___ CTA HEAD/NECK:
IMPRESSION:
1. No acute hemorrhage or evidence of acute major vascular
territorial infarction on non-contrast head CT. Motion-limited
CT perfusion study demonstrates no clear evidence for a large
area of acute ischemia or acute infarction. MRI would be more
sensitive for excluding an acute infarction, if clinically
warranted.
2. No evidence of arterial occlusion in the head and neck.
Moderate calcified plaque at the origin of the right internal
carotid artery with mild, less than 40% stenosis.
3. Unchanged moderate area of encephalomalacia in the left
parietal lobe. Unchanged extensive supratentorial white matter
hypodensities. These findings could be related to prior
infarction and chronic small vessel ischemic disease,
respectively, but they could also be related to the patient's
known central nervous system lymphoma and post-treatment
changes. Comparison with prior MRIs is needed for better
interpretation. MRI could be obtained for assessing the status
of the patient's lymphoma, if clinically indicated.
4. Moderate cerebral atrophy, unexpected for age.
5. Diffusely mottled bones, particularly in the calvarium, in
part related to demineralization, but lymphomatous involvement
cannot be excluded.
6. Left greater than right mastoid air cell opacification
___ CXR:
FINDINGS:
Cardiac, mediastinal and hilar contours are normal. The
pulmonary vascularity is normal. Lungs are clear without focal
consolidation. No pleural effusion or pneumothorax is present.
No acute osseous abnormality seen.
IMPRESSION:
No acute cardiopulmonary process
Brief Hospital Course:
___ with HIV with undetectable VL and normal CD4, h/o CNS
lymphoma s/p chemo-radiation who presents with brief episode of
left arm tingling and numbness most likely secondary to
self-limited extrinsic peripheral nerve compression from arm
positioning.
ACUTE ISSUES:
# Left Arm Tingling: Resolved, likely due to brief extrinsic
compression from arm hanging over armrest of wheelchair. Given
this neurologic chief complaint and his complicated history,
code stroke was called in the ED though subsequent neurological
evaluation revealed that his neuro deficits were stable and at
his baseline. CTA head/neck imaging without acute changes in
brain but did note a mottled appearance of calvarium bone which
raised question of lymphomatous involvement. No evidence of
seizure activity around the time of this episode. He remained
without any changes in his neurological status during his stay.
MRI will be ordered as outpatient to further evaluate the
mottled bone appearance. Scheduled for Neurology follow-up as
well.
# Leukocytosis: Self-resolved, lymphocyte-predominant on
admission. Unclear cause. No PNA on CXR and UA was clean. This
was monitored without recurrence or clinical correlation.
CHRONIC ISSUES:
# Hyperbilirubinemia: Has baseline elevation, likely secondary
to his HAART meds. His acute rise in bilirubin and transaminases
from last admission had resolved with resolution of his
gallstone pancreatitis. AP elevation could also be related to
bone abnormalities on CT head as above, unlikely biliary source.
MRI head as above, follow LFTs as outpatient.
# HIV on HAART - diagnosed in ___. CD4 940 on ___, viral
load undetectable ___.
- RiTONAvir 100 mg PO DAILY
- Atazanavir 300 mg PO DAILY
- Emtricitabine 200 mg PO Q24H
- Tenofovir Disoproxil (Viread) 300 mg PO DAILY
# Seizure disorder
- LeVETiracetam 1000 mg PO BID
# Corneal ulcer s/p L eye enucleation
- Artificial Tears
# CODE: Full Code
# CONTACT: Patient, Father (___)
TRANSITIONAL ISSUES:
- MRI to eval mottled calvarium appearance to rule out
lymphomatous involvement
- follow LFTs as outpatient, likely related to HAART, if
clinically indicated
- follow-up with outpatient Neurology recs
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Potassium Chloride 20 mEq PO DAILY
Hold for K >
2. RiTONAvir 100 mg PO DAILY
3. Atazanavir 300 mg PO DAILY
4. Emtricitabine 200 mg PO Q24H
5. LeVETiracetam 1000 mg PO BID
6. Neutra-Phos 1 PKT PO TID
7. Artificial Tears ___ DROP BOTH EYES TID
8. Lorazepam 1 mg PO HS:PRN insomnia/anxiety
9. Mirtazapine 15 mg PO HS
10. Amlodipine 5 mg PO DAILY
Hold for SBP<100
11. Milk of Magnesia 30 mL PO Q12H:PRN constipation
12. Ondansetron 4 mg PO Q6-8H:PRN nausea
13. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
14. Tenofovir Disoproxil (Viread) 300 mg PO DAILY
15. Acetaminophen 325 mg PO Q6H:PRN pain
Discharge Medications:
1. Acetaminophen 325 mg PO Q6H:PRN pain
2. Amlodipine 5 mg PO DAILY
3. Artificial Tears ___ DROP BOTH EYES TID
4. Atazanavir 300 mg PO DAILY
5. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
6. Emtricitabine 200 mg PO Q24H
7. LeVETiracetam 1000 mg PO BID
8. Lorazepam 1 mg PO HS:PRN insomnia/anxiety
9. Milk of Magnesia 30 mL PO Q12H:PRN constipation
10. Mirtazapine 15 mg PO HS
11. Neutra-Phos 1 PKT PO TID
12. Ondansetron 4 mg PO Q6-8H:PRN nausea
13. Potassium Chloride 20 mEq PO DAILY
14. RiTONAvir 100 mg PO DAILY
15. Tenofovir Disoproxil (Viread) 300 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Mild, self-limited peripheral nerve compression
Secondary Diagnosis:
Mottled calvarium on CT scan, cannot rule out lymphomatous
involvement
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 during your hospitalization.
You were admitted on ___ after having an episode of numbness
and tingling in your left arm. You underwent an evaluation in
the hospital including physical exams, labs, and imaging studies
of your head.
Based on these studies, this episode was most likely due to
pinching the nerve in your arm as it was hanging over the
wheelchair rather than to any worrisome cause in the brain.
However, it is still important for you to undergo a repeat MRI
scan of your brain to be sure that there is no evidence of
recent changes.
Please be sure to follow-up with your PCP and with ___.
*** Please call ___ to make an appointment for an MRI
of the brain within the next ___ weeks ***
We wish you the best of luck!
Followup Instructions:
___
|
10104945-DS-18 | 10,104,945 | 23,927,263 | DS | 18 | 2137-10-08 00:00:00 | 2137-10-08 14:31:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
NSAIDS (Non-Steroidal Anti-Inflammatory Drug)
Attending: ___.
Chief Complaint:
Tib-fib fracture
Major Surgical or Invasive Procedure:
Placement of ex-fix ___, ___
History of Present Illness:
___ male presents with the above fracture s/p mechanical fall.
___ hours prior to visit, pt jumped fence and "landed on left
leg funny". Denies headstrike or LOC. Immediate pain on landing.
___. Worse with movement. Alleviated with fentanyl. Denies
numbness or tingling in the extremities. Pt does note productive
cough x1 week. Pt on day 3 of azithromycin and prednisone burst.
Past Medical History:
Cardaic arrest x2 (last "few years ago), CAD s/p MI with 6
stents, pulmonary fibrosis
Social History:
Unemployed on disability. Denies alcohol or drug use. 1 ppd
smoking history.
Physical Exam:
General: Well-appearing male in no acute distress.
Left lower extremity
- Skin intact
- Mild deformity distal to knee. Mild ecchymosis. No erythema,
induration
- Soft, non-tender thigh and leg
- Pain with motion of knee and ankle
- Fires ___
- SILT S/S/SP/DP/T distributions
- 1+ ___ pulses, WWP
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left tibial plateau fracture in the setting of active
pneumonia and was admitted to the orthopedic surgery service.
The patient was taken to the operating room on ___ for
placement of an external fixator, which the patient tolerated
well. For full details of the procedure please see the
separately dictated operative report. The patient was taken from
the OR to the PACU in stable condition and after satisfactory
recovery from anesthesia was transferred to the floor. The
patient was initially given IV fluids and IV pain medications,
and progressed to a regular diet and oral medications by POD#1.
The patient was given ___ antibiotics and
anticoagulation per routine. The patient's home medications were
continued throughout this hospitalization. The patient worked
with ___ who determined that discharge to rehab was appropriate.
The ___ hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, pin sites were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
NWB in the left lower extremity, and will be discharged on
Lovenox for DVT prophylaxis but not resumed on Plavix as his
next surgery will be on ___ of the upcoming week. The
patient will come back to the OR for a scheduled removal of
external fixator and conversion to ORIF with Dr. ___
___ 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.
While in the hospital the patient was seen and followed by the
internal medicine service for his medical comorbidities as well
as his active pneumonia. At the time of discharge, the medicine
service felt that his pneumonia had resolved.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. LORazepam 0.5 mg PO TID
2. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheeze, dyspnea
3. Simvastatin 20 mg PO QPM
4. Metoprolol Succinate XL 50 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Clopidogrel 75 mg PO DAILY
7. Lisinopril 5 mg PO DAILY
8. Gabapentin 800 mg PO TID
9. Mirtazapine 15 mg PO QHS
10. Topiramate (Topamax) 25 mg PO QHS
11. PredniSONE 50 mg PO DAILY
12. Azithromycin 250 mg PO Q24H
13. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
Discharge Medications:
1. Acetaminophen 650 mg PO 5X/DAY
2. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H Wheezing
3. Nicotine Patch 14 mg/day TD DAILY
4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
5. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheeze, dyspnea
6. Aspirin 81 mg PO DAILY
7. Gabapentin 800 mg PO TID
8. Lisinopril 5 mg PO DAILY
9. LORazepam 0.5 mg PO TID
10. Metoprolol Succinate XL 50 mg PO DAILY
11. Mirtazapine 15 mg PO QHS
12. Simvastatin 20 mg PO QPM
13. Topiramate (Topamax) 25 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left tibial plateau fracture
Discharge Condition:
AVSS
NAD, A&Ox3
LLE: Pin sites are clean dry and intact. There is mild swelling
about the knee. Fires ___, FHL, gastroc, tib ant. SILT in the
saphenous, sural, deep peroneal, superficial peroneal, and
tibial nerve distributions. Foot and toes are warm and
well-perfused.
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- NWB LLE
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is
an over the counter medication.
2) Add oxycodone as needed for increased pain. Aim to wean
off this medication in 1 week or sooner. This is an example on
how to wean down:
Take 1 tablet every 3 hours as needed x 1 day,
then 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per state regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you
should drink eight 8oz glasses of water daily and continue
following the bowel regimen as stated on your medication
prescription list. These meds (senna, colace, miralax) are over
the counter and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your
physicians at discharge.
8) Continue all home medications unless specifically
instructed to stop by your surgeon.
ANTICOAGULATION:
- Please take Lovenox nightly until your next surgery this
upcoming ___. Please do not resume Plavix until after your
upcoming surgery.
Followup Instructions:
___
|
10105017-DS-20 | 10,105,017 | 24,900,930 | DS | 20 | 2147-12-02 00:00:00 | 2147-12-02 16:26:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
oxaliplatin / hydrochlorothiazide / fenofibrate / cat
Attending: ___.
Chief Complaint:
shortness of breath, abdominal distention
Major Surgical or Invasive Procedure:
___: ___ therapeutic and diagnostic paracentesis:
drained 1.85L
___: ___ guided paracentesis and pleurx catheter placement
History of Present Illness:
___ yrs. woman with metastatic colon cancer(KRAS wild type, BRAF
negative, elevated CEA, MSI stable) with rising CEA associated
with nausea which has progressed on ___, oxali, irinotecan, ___,
and cetuximab based therapies including Y90 treatments to the
liver most recently s/p WBRT for brain mets completed ___ and
started on lonsurf (trifluridine-tipiracil) at ___ on ___
followed by neulasta administration ___ presenting with
shortness of breath and abdominal distention.
She reports abd distention and shortness of breath with dry
cough
worsening over past several weeks w/ bilateral lower ext
swelling, but at this point cont to worsen over past week
prompting admission. No fevers, nausea, vomiting, confusion, abd
pain (distention sensation only), dysuria, diarrhea, or sore
throat/nasal congestion/headache. Shorntess of breath is worse
laying down than sitting upright. Endorses DOE but no chest
pain.
Her last ___ labs were done ___ and showed creat 0.6, calcium
8.7, AP 553, AST 87, ALT 31, Tbili 4.3 with 2.1 indirect,
albumin
3.0. WBC 9.1 Hct 31.4. Plts 172.
In ED initial VS 99 84 105/65 20 95%RA
labs notable for WBC 33.8, elevated LFTs w /bili 4.3, lactate
4.0
CXR showed Multiple pulmonary nodules concerning for metastatic
disease. Small pleural effusions with lower lobe consolidation
concerning for atelectasis versus pneumonia. Notably, ED did
bedside U/S more suggestive of liver displaced superiorly rather
than R pleural effusion which was only trace. Noted significant
quantity of ascites. Lactate elevation felt to be due to poor
liver clearance of ascites. She was given vanc/Zosyn 4.5g in ED
Paracentesis was not done but it appears she also got 25g
albumin.
On arrival to the floor she is calm and fairly comfortable but
reports swelling of legs and abd distention cont to bother her
though no overt pain. Denies fevers, chets pain, hemoptysis,
diarrhea, dysuria, all othe 10 point ROS neg.
Past Medical History:
PAST ONCOLOGIC HISTORY:
___: Started treatment with FOLFOX x6. CEA down
trended appropriately.
___: Switched to FOLFIRI ___ oxaliplatin allergy.
Avastin started in ___ when the rectal bleeding rsolved
___: Regimen changed per patient preference for
XELIRI
to Q3 week regimen despite stable CEA and imaging. She was off
Xeloda from the end of ___ due to gastric
discomfort.
___: MRI at ___ showed multiple lesion in both lobes of
the
liver concerning for metastatic disease and more prominent
subcentimenter upper abdominal and retroperitoneal lymph nodes.
___: PET showed large focal region of intense FDG-avidity
within segment 2 ___s a small focus of mild FDG-avidity in
segment 8 consistent with known metastatic colon cancer lesions,
and a new 1.5 mm right upper lobe nodule.
___: Left lateral liver resection and resection of
descending and sigmoid colon at ___ by Dr. ___. Path
revealed met adenocarcinoma, consistent with colonic primary.
Patient elected for break in treatment to allow healing after
surgery and was asymptomatic of remaining liver lesions.
___: MRI abdomen at ___ on ___ revealed progression of
remaining liver metastasis.
___ and ___: CEA began rising (145 from 107). Treated
with
FOLFOX with oxaliplatin desensitization x 2 cycles.
___: After ___ cycle, patient experienced lip and tongue
swelling from oxaliplatin desensitization and recommendation
from
allergy was to avoid oxaliplatin due to angioedema. CEA also up
trending to 158. Referred to Dr. ___ at ___ for ___
opinion. Decision was made to start FOLFIRI and Erbitux.
___: MRI at ___ revealed a large 10.6 x 8.0 x 10.6 cm
heterogeneous mass with multiple enhancing within the middle
pelvis. Consulted with OB/GYN at ___ on ___.
___: Pelvic mass resection/bilateral
salpingo-oophorectomy
performed by Dr. ___ at ___. Path was consistent
with colon cancer. Continued FOLFIRI + Erbitux after recovery.
___: MRI abdomen/pelvis revealed marked progression of her
intrahepatic metastatic disease with numerous new lesions in
both
lobes of the liver and lymphadenopathy in celiac axis. CEA also
up to 838 from 787.
___ opinion from Dr. ___ at ___ who
recommended Xeloda + Avastin, ___ + Avastin, or Regorafenib.
___: ___ + Avastin ___: CEA
increasing from 787-838. Oxaliplatin desensitization restarted
in
addition to mFOLFOX6 with Avastin. CEA down trending
appropriately with her lowest being 193 on ___. CT
abdomen/pelvis on same date showed decrease in hepatic
metastasis. CEA slowly began to uptrend on ___. Continued
with regimen until cycle 10 when she experienced substantial
back
pain requiring narcotics and rash requiring steroids after
oxaliplatin desensitization. Allergy felt since it occurred late
in her infusion that it was rate related and slowing infusion
could help prevent reaction.
___ - seen back at ___ for second opinion to Dr ___,
Y90 to liver recommended, received on ___ and ___ - seen by Dr ___ at ___ in onc for follow up. CT shows
worsening multiple lung nodules and masses which have increased
significantly in size and number compared to prior study. The
appearance is consistent with worsening
metastatic disease and multiple new lesions within the left and
right lobe of the liver. Previously noted lesions have increased
in size. Enlarged retroperitoneal lymph node also noted. CEA
stable. After a long discussion, she decided to wait on starting
chemo since she was feeling well
___ - seen in urgent care for nausea. CT abd/pelvis done at
___ but imaging not compared to previous. CT chest not
done. CEA increased from 1064 to 3702.
___ - Previously followed in our dept by Dr ___ today
to establish care with me since Dr ___ has moved out of state.
Reports she was took dex yesterday and nausea resolved. Feels
like she has to gag when it comes. Took PPI x 14 days with some
improvement, then stopped. Symptoms returned. No vomiting. Feels
abd is tight, small ascites noted on CT at ___. Has
compazine, zofran and ativan prn at home. Doesn't find compazine
helpful, zofran is constipating and thinks ativan is sedating.
Here alone today. Denies fevers, chills, unintentional weight
loss, or night sweats. No CP or abd pain or SOB.
___ Seen by DFCI Dr ___ clinical
trials available now as would have to be 4 weeks out from RT and
off protocol Lonsurf recommended
___ completed brain RT for
CNS disease
PAST MEDICAL HISTORY:
Colon cancer with metastases to the liver, lung, and right ovary
(Dx ___, KRAS wild type, BRAF negative)
Hypertriglyceridemia
Hypothyroidism
Hypertension
Myopic macular degeneration
Bilateral cataracts
Posterior vitreous detachment
Lattice degeneration of peripheral retina
Horseshoe retinal tear of left eye
Dermatitis, eczematous
Myopic macular degeneration
Cataracts, bilateral
PVD (posterior vitreous detachment)
Lattice degeneration of peripheral retina
Horseshoe retinal tear of left eye
Social History:
___
Family History:
Maternal grandfather had colon cancer in his ___.
Maternal grandmother possibly had lymphoma.
Father had prostate cancer at age ___. One paternal aunt had
pancreatic cancer in her ___.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
General: NAD, fairly comfortable
VITAL SIGNS: 97.5 ___ 18 93% 2L
HEENT: MMM, no OP lesions,
Neck: supple, no JVD
Lymph: no cervical, supraclavicular, axillary or inguinal
adenopathy
CV: RR, NL S1S2 no S3S4 or MRG
PULM: diffuse crackles throughout
ABD: BS+, distended but no peritoneal signs or guarding, RUQ
tenderness
EXT: warm well perfused, bilateral 2+ pitting edema symmetric
of
lower extr
SKIN: No rashes or skin breakdown
NEURO: alert and oriented x 4, ___, EOMI, no nystagmus, face
symmetric, no tongue deviation, full hand grip, shoulder shrug
and bicep flexion, full toe dorsiflexion and hip flexion
DISCHARGE PHYSICAL EXAM
========================
Physical Exam:
VS: 98.5, 110/70, 110, 18, 98%/RA (TFD 1260)
GEN: NAD, lying in bed
HEENT: PERRLA. MMM. no LAD. no JVD. neck supple. No LAD. Eyes
jaundiced
Cards: RR S1/S2 normal. no murmurs/gallops/rubs.
Pulm: Non-labored. No wheezes/rhonchi/crackles
Abd: SNT, distended, mid-line vertical scar + BS, no HSM. Large
R sided dressing C/D/I
Extremities: WWP (R leg colder), PPP, b/l 3+ pitting edema
Skin: no rashes or bruising
Neuro: AOx3
Pertinent Results:
ADMISSION LABS
==============
___ 06:49PM ___ PTT-27.9 ___
___ 05:32PM GLUCOSE-144* UREA N-18 CREAT-0.6 SODIUM-135
POTASSIUM-4.2 CHLORIDE-99 TOTAL CO2-20* ANION GAP-20
___ 05:32PM estGFR-Using this
___ 05:32PM ALT(SGPT)-54* AST(SGOT)-179* ALK PHOS-727*
TOT BILI-4.3*
___ 05:32PM proBNP-332*
___ 05:32PM ALBUMIN-3.2*
___ 05:32PM LACTATE-4.0*
___ 05:32PM WBC-33.5*# RBC-3.59* HGB-10.9* HCT-34.7
MCV-97 MCH-30.4 MCHC-31.4* RDW-26.5* RDWSD-89.9*
___ 05:32PM NEUTS-84* BANDS-12* ___ MONOS-0 EOS-1
BASOS-0 ___ METAS-2* MYELOS-1* AbsNeut-32.16* AbsLymp-0.00*
AbsMono-0.00* AbsEos-0.34 AbsBaso-0.00*
___ 05:32PM HYPOCHROM-OCCASIONAL ANISOCYT-1+ POIKILOCY-1+
MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-1+
TEARDROP-1+ ACANTHOCY-OCCASIONAL
___ 05:32PM PLT SMR-NORMAL PLT COUNT-183
MICROBIOLOGY
============
Blood culture x2 (___): No growth
Peritoneal Fluid (___): No growth
IMAGING
=======
CXR (___):
Right chest wall Port-A-Cath is seen with catheter tip in the
mid SVC. There are multiple bilateral pulmonary nodules
compatible with known metastatic disease. Bilateral pleural
effusions are present. Lower lobe consolidation, right greater
than left is concerning for atelectasis and/or pneumonia. No
pneumothorax. Cardiomediastinal silhouette is stable. Bony
structures are intact.
IMPRESSION:
Multiple pulmonary nodules concerning for metastatic disease.
Small pleural effusions with lower lobe consolidation concerning
for atelectasis versus pneumonia.
LENIS (___):
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower
extremity veins.
RUQU/S w/Doppler (___):
IMPRESSION:
1. Numerous hepatic masses, better characterized on prior MR.
2. Patent main portal vein but slow flow.
3. Small volume ascites and small left pleural effusion.
4. No intrahepatic or extrahepatic biliary ductal dilation.
CT Torso w/contrast (___): PRELIM
IMPRESSION (Chest):
Many pulmonary metastases, possible associated pulmonary
hemorrhage.
Right lower lobe consolidation more likely atelectasis common
due to diaphragm elevation, than pneumonia.
Small bilateral pleural effusions do not contribute to
respiratory compromise. No pericardial effusion. No bronchial
occlusion.
IMPRESSION (Abdomen/pelvis):
1. Innumerable hepatic metastases with associated upper
retroperitoneal and porta hepatis lymphadenopathy, grossly
similar to the recent MRI and markedly progressed compared with
___.
2. Small to moderate ascites without definite associated
peritoneal disease.
3. Please see the separately submitted report of the same day CT
Chest for findings above the diaphragm.
Brain MRI (___):
IMPRESSION:
1. Expansion and enhancing bone marrow infiltration of the left
frontoparietal calvarium with underlying pachymeningeal
thickening and enhancement most suggestive of osseous metastasis
with secondary dural involvement. This is new compared to the
most recent available comparison study from ___, though
OMR note state a newer study was performed at an outside
hospital mentioning " diffuse leptomeningeal enhancement." This
newer study is not available for comparison.
2. No parenchymal enhancing mass.
OTHER STUDIES
=============
___ paracentesis (___):
Technically successful ultrasound-guided diagnostic and
therapeutic
paracentesis (1.85L RLQ).
Diagnostics:
Peritoneal fluid: Protein 2.0, Albumin 1.3 (Serum albumin 3.0),
SAAG, 1.7, WBC 170, RBC 309, Polys 53%, Lymph 10%, Mono 0%, Eo
0%, Macrophage 35%, Other 2%
DICHARGE LABS
=============
___ 05:02AM BLOOD WBC-45.7* RBC-3.10* Hgb-9.5* Hct-29.6*
MCV-96 MCH-30.6 MCHC-32.1 RDW-27.3* RDWSD-91.0* Plt ___
___ 05:02AM BLOOD Plt ___
___ 05:02AM BLOOD ___ PTT-26.7 ___
___ 05:02AM BLOOD Glucose-74 UreaN-22* Creat-0.7 Na-130*
K-3.9 Cl-91* HCO3-19* AnGap-24*
___ 05:02AM BLOOD Calcium-8.6 Phos-3.0 Mg-1.9
Brief Hospital Course:
Ms. ___ is a ___ with metastatic colon cancer (KRAS wild type,
BRAF
negative, elevated CEA, MSI stable) with rising CEA, associated
with nausea which has progressed on ___, oxali, irinotecan, ___,
and cetuximab based therapies including Y90 treatments to the
liver, and most recently completed WBRT ___, now presenting with
worsening of shortness of breath and ascites.
#Shortness of breath/hypoxia: Pt has known multiple pulmonary
nodules, which are reconfirmed with some atelectasis on CXR ___.
These mets are likely restricting breathing, with possible
contribution from pt's significantly distended liver and
ascites. Doubt PNA, as pt is afebrile, cough is chronic and not
productive. Leukocytosis likely ___ to neulasta and advancing
cancer. Pt got vanc/zosyn in ED but will hold off for now. Low
suspicion for PE as pt is not tachycardic or hypotensive, but
given worsening b/l ___ swelling, got LENIS ___, which are
negative. CT Torso ___ shows many pulmonary mets, some
w/hemorrhage, and innumerable hepatic metastases w/ associated
upper retroperitoneal and porta hepatis LAD, grossly similar to
the recent MRI and markedly progressed versus ___. Brain MRI
___ notable for osseous mets as below. ___ discussion with
patient and her sisters, with patient deciding that she would
like to go home with ___. Continuing nebs in house. Patient will
likely need to be discharged on 2L O2.
- DC with albuterol inhaler
#Ascites: CXR ___ suggests small pleural effusions w/
atelectasis vs PNA as above, but ED felt that on U/S this was
actually ascites displacing the liver upwards, and causing
atelectasis. BNP 332. LFTs are elevated compared to prior with
AP 727 from 500s in ___, and ALT 54 from 31. Tbili largely
stable, but at 4.3. Suspect malignant ascies, as pt with known
significant metastases to the liver and ovary. Doubt SBP as no
abdominal pain, fevers, AMS, and leukocytosis likely ___ recent
neulasta. As above, pt got Abx in ED, but no para was done. U/S
on floor on arrival did not reveal clear loculated pocket safe
to tap. ___ guided paracentesis done on ___ (drained 1.85L)
significant for SAAG 1.7, c/w malignant ascites. PMN 53%,
absolute 90, not suggestive of SBP. Patient would like to stop
dexamethasone, given that it is worsening her fluid retention,
but agrees to keep it on for now at 4 mg PO qd given worsening
nausea today. ___ guided paracentesis with pleurx catheter
placement ___, drained 1000 cc on ___ prior to discharge.
#Leukocytosis: WBC elevated >45 o ___, likely ___ neulasta use
on ___ and also from advancing cancer. Less likely PNA as pt is
afebrile, w/chronic dry cough reported, not observed on exam
today. Low concern for SBP as above. Other infectious causes
less likely given absence of other sx including dysuria,
vomiting/diarrhea. Sepsis unlikely given absence of hypotension
and tachycardia, and elevated lactated likely ___ to impaired
clearance w/liver dysfunction. No antibiotic therapy was
pursued.
#Worsening transaminitis/bilirubinemia: This is likely ___ to
liver failure due to progressive metastases, and potential
contribution from recent tx with Lonsurf. RUQU/S w/Doppler ___
confirms significant hepatic mets, now also showing reduced
portal vein flow. CT torso ___ shows worsening hepatic mets and
retroperitoneal and porta hepatis LAD as above. GOC of
discussion with patient and her sister as below on ___ with
patient endorsing desire to go home with ___ for now. Will
continue to trend LFTs during admission.
#Metastatic colon cancer: as above, progressed despite multiple
therapies. Pt was last seen at end of ___ by Dr. ___ at ___. Pt
was being considered for clinical trial at ___, but at that
point she was on dexamethasone. Current Treatment Plan: Lonsurf
15mg/6.14mg tablet. Take 4 tablets twice daily within 1 hour of
a
meal D1-5 and D8-12 every 28 days. ___ was C1D8 and she
received
neulasta ___. RUQU/S ___ redemonstrated significant hepatic
mets, and now significant for reduced portal vein flow. CEA up
___ from 15000s in ___. CT torso ___ shows numerous
pulmonary mets some w/ hemorrhage and innumerable hepatic mets
and LA. Brain MRI ___ notable for new L frontoparietal osseous
metastasis. Per ___ discussion with patient and her sisters on
___, pt would like to go home with ___. After discussion with
attending ___, code status was changed to DNR/DNI
#Fluid retention: Pt was on 4mg dex daily, but was concerned
that it could be contributing to fluid retention and wanted to
stop it, however, she was also nauseous, so we decided continue
dex 4 mg daily for now as above. LENIS ___ negative for DVT as
above. RUQU/S ___ redemonstrated significant hepatic mets, and
now significant for reduced portal vein flow. Workup/management
for ascites as above.
#Hypothyroidism: Continue home levothyroxine in house.
TRANSITIONAL ISSUES:
- please drain pleurex twice weekly and as needed up to 1L at a
time
- pleurx last drained 1000ml on ___
- Ensure patient comfortable. Ativan 0.25mg PO has been helpful
for nausea
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 88 mcg PO DAILY
2. Atenolol 25 mg PO DAILY
3. Dexamethasone 4 mg PO DAILY
4. Ondansetron 8 mg PO Q8H:PRN nausea
5. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN dyspnea
RX *albuterol sulfate [ProAir HFA] 90 mcg ___ puff PO every four
(4) hours Disp #*1 Inhaler Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*30 Capsule Refills:*0
3. LORazepam 0.25-0.5 mg PO Q4H:PRN nausea, anxiety
RX *lorazepam 0.5 mg ___ tablet by mouth Q4hr prn nausea,
anxiety Disp #*30 Tablet Refills:*0
4. Morphine Sulfate (Concentrated Oral Solution) 20 mg/mL 5 mg
PO Q2H:PRN Pain - Severe
RX *morphine concentrate 100 mg/5 mL (20 mg/mL) 0.25 ml by mouth
Q2hr prn: pain, respiratory distress Refills:*0
5. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*30 Tablet Refills:*0
6. Simethicone 40-80 mg PO QID:PRN gas pain
RX *simethicone [Gas Relief] 80 mg 1 tablet by mouth QID prn:
dyspepsia Disp #*30 Tablet Refills:*0
7. Dexamethasone 4 mg PO DAILY
8. Levothyroxine Sodium 88 mcg PO DAILY
9. Omeprazole 20 mg PO DAILY
10. Ondansetron 8 mg PO Q8H:PRN nausea
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Malignant Ascites
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted for shortness of breath and stomach bloating.
During your hospital stay we conducted a number of tests to rule
out things such as a lung infection, clots in your lungs, or an
infection in your stomach that could have contributed to your
shortness of breath. Unfortunately, we found that your cancer is
getting worse. You were found to have fluid in your stomach
("ascites") which was drained. This fluid accumulated as a
result of your colon cancer. You were also continued on steroids
to help with nausea and inflammation. A catheter was placed to
drain any further fluid in order to improve your comfort.
Thank you for allowing us to be part of your care,
Your ___ Team
Followup Instructions:
___
|
10105440-DS-15 | 10,105,440 | 29,406,428 | DS | 15 | 2170-01-29 00:00:00 | 2170-01-29 09:55:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
Percocet
Attending: ___.
Chief Complaint:
Headaches
Major Surgical or Invasive Procedure:
None
History of Present Illness:
patient is a ___ year old female who presents to the ER at
___ with headaches for just over a month and being found to
have bilateral SDH at an OSH. Her history begins 2 months ago
when she recalls striking her head on the roof of a car while
getting out. She reports that a few days later she noted ringing
in her ears, and subsequently about a month ago developed
intractable headaches. She reports she has tried motrin and
tylenol without relief and that sleeping makes the headaches
better. She had initially been worked up and treated for a sinus
infection with amoxocillin and azithromycin without improvement.
Last evening she developed nausea and then 2 episodes of emesis
and was subsequently seen and head CT obtained this morning
prior
to coming to ___. She denies changes in vision, hearing, or
speech, difficulty ambulating, changes in bowel or bladder
habits, changes in her ability to work or drive. Family reports
no episodes of altered mental status since striking her head.
Past Medical History:
HTN
Social History:
___
Family History:
NC
Physical Exam:
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRL EOMs intact without nystagmus
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4mm to
2mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Coordination: normal on finger-nose-finger, rapid alternating
movements
On Discharge: Non focal
Pertinent Results:
CT Head ___
Bilateral subdural hematoma, no midline shift or hydrocephalus
CT Head ___
In comparison to study obtained one day prior, there is no
significant change in diffuse bilateral subdural hematomas.
These subdural collections display heterogeneous attenuation.
Hematocrit levels are more apparent on today's exam, perhaps due
to redistribution of blood products.
Brief Hospital Course:
Pt was admitted to the neurosurgery service for observation of
her bilateral SDH's. She was started on Dilantin 100mg TID for
seizure prophylaxis. She had a repeat CT head on ___ that
showed no change in her SDH. She was DC'd home on ___ in stable
condition. She will follow up in 4 weeks with repeat CT head.
Medications on Admission:
HCT
Discharge Medications:
1. hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
2. phenytoin sodium extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
Disp:*90 Capsule(s)* Refills:*2*
3. acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6
hours) as needed for fever/pain.
4. Dilaudid 2 mg Tablet Sig: ___ Tablets PO every four (4) hours
as needed for pain.
Disp:*75 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Bilateral Subdural hematomas
Discharge Condition:
AOx3. Activity as tolerated. No lifting greater than 10 pounds.
Discharge Instructions:
Take your pain medicine as prescribed.
Exercise should be limited to walking; no lifting, straining,
or excessive bending.
Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
If you were on a medication such as Coumadin (Warfarin), or
Plavix (clopidogrel) prior to your injury, you may safely resume
taking this only after follow up with repeat CT head.
If you have been prescribed Dilantin (Phenytoin) for
anti-seizure medicine, take it as prescribed and follow up with
laboratory blood drawing in one week. This can be drawn at your
PCPs office, but please have the results faxed to ___.
If you haven been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
New onset of tremors or seizures.
Any confusion, lethargy or change in mental status.
Any numbness, tingling, weakness in your extremities.
Pain or headache that is continually increasing, or not
relieved by pain medication.
New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
___
|
10105456-DS-7 | 10,105,456 | 20,186,962 | DS | 7 | 2181-01-19 00:00:00 | 2181-01-19 16:34:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
syncope, fatigue
Major Surgical or Invasive Procedure:
___: EGD
History of Present Illness:
___ yo M with PMH DVT one year ago on coumadin who experienced
syncope on ___ - fell, hit head. EMS was called but pt refused
transport. Since then he has felt weak so came to ED today.
Admitted to ___ of melena on questioning. No prior history of
syncope or GI bleeding. Denies regular NSAID use. Last
colonoscopy was a long time ago (pt estimated at least ___ years
ago) and showed polyps.
In the ED VS 98.8, 94, 126/57, 20, 98% RA. On exam pt had
melanotic stool that was guaiac positive. Hct was 17.7 and INR
6.1. Last INR at ___ was 3.3 on ___. He felt lightheaded. GI
was consulted and recommended reversing INR and giving blood
with plan for scope tomorrow. He was given 2 units PRBC, 2 unit
FFP, and 10mg vitamin K. Head CT neg for bleed.
On arrival to the MICU, VS 98.4, 98, 126/69, 18, 100% RA. Pt
stated he felt better and his lightheadedness had resolved.
ROS:
Denies CP, abd pain, constipation, diarrhea, dysuria. Admits to
SOB x few weeks, new. Admits to N/V today but denies
hematemesis.
Past Medical History:
Epiglottitis requiring intubation at age ___
DVT
Pulmonary embolus
Spontaneous pneumothorax x 2
hypothyroidism
gout
Social History:
___
Family History:
Mother with rheumatic heart disease and HTN. Father's history is
unknown. 2 brothers with colon cancer, diagnosed at ages ___ and
___. Sister with breast cancer.
Physical Exam:
ADMISSION EXAM:
===============
Vitals - VS 98.4, 98, 126/69, 18, 100% RA.
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, conjunctival
pallor
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:
===============
VS - 98.2 110/56 73 18 100% RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pale conjunctiva,
patent nares, MMM, good dentition, nontender supple neck, no
LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS:
================
___ 01:39PM BLOOD WBC-9.0# RBC-2.01*# Hgb-5.3*# Hct-17.7*#
MCV-88# MCH-26.5*# MCHC-30.1*# RDW-19.5* Plt ___
___ 08:00PM BLOOD Hct-21.5*
___ 01:39PM BLOOD Neuts-84.4* Lymphs-10.7* Monos-4.3
Eos-0.4 Baso-0.3
___ 12:20PM BLOOD ___ PTT-39.3* ___
___ 12:20PM BLOOD Glucose-119* UreaN-19 Creat-0.9 Na-140
K-3.5 Cl-103 HCO3-25 AnGap-16
___ 12:20PM BLOOD ALT-47* AST-40 AlkPhos-44 TotBili-0.4
___ 12:20PM BLOOD Albumin-4.4
___ 08:00PM BLOOD Calcium-8.2* Phos-2.5* Mg-2.0
IMGAGING:
=========
___ CT head no acute process
___ CXR no acute process
EGD ___
Impression: Linear erythema in the esophagus compatible with
severe erosive esophagitis
Medium hiatal hernia
Angioectasias in the third part of the duodenum. Given the
absence of other findings to explain his bleed and significant
hct drop, two angioectasias were treated with BiCAP.
Otherwise normal EGD to third part of the duodenum
Recommendations: High dose BID PPI
Monitor hgb/hct
If patient is to go back on coumadin, recommend close monitoring
of INR to avoid supratherapeutic ranges
Left ___ ___: negative for DVT
MICROBIOLOGY:
=============
Urine ___: no growth
DISCHARGE LABS:
===============
___ 08:06AM BLOOD WBC-5.6 RBC-3.25*# Hgb-9.2*# Hct-29.2*
MCV-90 MCH-28.2 MCHC-31.5 RDW-18.1* Plt ___
___ 08:06AM BLOOD ___ PTT-25.2 ___
___ 08:06AM BLOOD Glucose-103* UreaN-8 Creat-0.8 Na-137
K-3.9 Cl-105 HCO3-22 AnGap-14
___ 08:06AM BLOOD Calcium-8.5 Phos-2.9 Mg-2.1
Brief Hospital Course:
MICU Course:
___ yo M with PMH DVT one year ago on coumadin admitted with GI
Bleed.
Melena suggested upper GI bleed or slow, right sided lower
bleed. Supratherapeutic on coumadin which likely caused
bleeding. HDS but has symptomatic anemia. s/p 2 unit PRBC, 2
FFP, and 10mg Vit K, symptomatically improved. Initially on PPI
gtt. Held coumadin, reversed INR. GI performed EGD and
cauterized AVM's in duodenum; no active bleeding.
Hemodynamically stable and called out to the floor.
FLOOR COURSE:
Mr ___ is a ___ with h/o DVT one year ago on coumadin, who
p/w syncope on ___ - fell, hit head, found to be anemic w/ GI
bleed, ___ erosive esophagitis.
ACUTE ISSUES:
=============
#) Upper GI bleed: ___ severe erosive esophagitis and possibly
angioectasias. Vitals and hgb now stable. Hgb stable at 9 at
time of discharge. He drinks ___ Scotch's per night, which is
likely precipitant, as well as supratherapeutic INR 6.1.
Counseled patient to stop drinking. Placed on PPI BID. GI does
not need follow up with patient. Diet was admvanced, patient
tolerated well. Discharged with close PCP follow up.
#) DVT: h/o DVT ___ year ago in setting of gout flair. Per PCP Dr
___ to stop coumadin for now in no residual DVT. Left ___
negative for clot. Coumadin discontinued on discharge.
CHRONIC ISSUES:
===============
#) hypothyroidism: continued home levothyroxine
#) Gout: continued home allopurinol
TRANSITIONAL ISSUES:
====================
- stopped coumadin given negative ___ for DVT, DVT felt to be
provoked in setting of gout
- will need to define duration of pantoprazole BID (at least 8
weeks)
- emailed ___ nurses about prior auth for pantoprazole
# CODE: FULL
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Allopurinol ___ mg PO DAILY
2. Warfarin 5 mg PO DAILY16
3. Pantoprazole 40 mg PO Q24H
4. Levothyroxine Sodium 125 mcg PO DAILY
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Levothyroxine Sodium 125 mcg PO DAILY
3. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp
#*14 Tablet Refills:*0
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
4. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 tab by mouth twice a day Disp
#*30 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
# Primary:
- Upper GI bleed secondary to erosive esophagitis
# Secondary:
- Deep Vein Thrombosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr ___,
It was a pleasure taking care of you at the ___
___. You came in with anemaia, found to
have upper GI bleed due to errosive esophagitis, likely in part
due to alcohol use. You should avoid or limit alcohol use in
the future to prevent this from happening again. You are being
started on a new medication, pantoprazole (or Protonix) to
protect your stomach from further bleeds. We stopped your
coumadin, as there were no signs of clot in your leg.
Followup Instructions:
___
|
10105515-DS-11 | 10,105,515 | 28,439,066 | DS | 11 | 2137-10-10 00:00:00 | 2137-10-22 16:55:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ yo F with a history of IgG kappa MGUS, PD,
traumatic femur fracture, osteoporosis, hyperpara who p/w back
pain x3 months and ongoing radicular symptoms, found to have
unstable T11 fracture with cord compression.
The patient fell 8 feet down a work shaft ___ and fractured
her right femur. Since that time she has had intermittent lower
back pain (also notes ___ years of stable left-sided radicular
pain). She did have any back imaging at that time per report. In
the last 3 months the back pain has become much more severe, to
the point in the last few weeks that her mobility has been
impaired (currently using walker to ambulate). Has had ongoing
radicular symptoms that are unchanged on the left. Had some
urinary urgency last month that resolved. No bowel/bladder
incontinence or pelvic anesthesia.
2 weeks ago was sent for spinal X-ray which showed T12
fracture. MRI yesterday showed severe, 3 columb T11 fracture
with mild cord compression. She was subsequently sent to the ED
for evaluation.
She denies any falls since ___. Prior to the last few weeks
she was climbing at least two flights of stairs with DOE or
chest pain.
She follows with Atrius onc for her MGUS which has been
longstanding without MM. She also has a h/o hyperCa from
hyperparathyroidism, with osteoporosis. Was going to get Prolia
this week prior to fracture diagnosis (last dose prior to her
fracture in ___
In the ED, initial vital signs were: 96.7 75 123/63 16 100% RA
- Exam was notable for: ___ neuro exam
- Labs were normal
- Imaging: CT T/L spine with severe 3 column fracture at T11
with cord compression
- The patient was given no meds
- Consults: Orthospine. No evidence of symptomatic cord
compression, recommended log-roll precautions, NPO for possible
repair in the AM, admission to medicine
Vitals prior to transfer were: 98.5 75 166/104 18 100% RA
Upon arrival to the floor, the patient has ongoing lower back
pain.
Past Medical History:
- BREAST CHANGES - FIBROCYSTIC
- Osteoporosis
- BURSITIS - TROCHANTERIC
- Ovarian Cyst
- HYPERTENSION - ESSENTIAL, not on therapy
- ANXIETY
- IgG Kappa MGUS
- OA
- ___ disease
- h/o R femur fracture, ___ closed comminuted intra-articular
fracture of distal femur
- Cataracts, bilateral
Social History:
___
Family History:
Father CAD/PVD
Maternal Aunt ___
Mother ___ Hyperlipidemia
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: 97.7 129/73 78 18 100% RA
GENERAL: Intermittently tearful during the interview, thin, in
no apparent distress.
HEENT - normocephalic, atraumatic, no conjunctival pallor or
scleral icterus, PERRLA, EOMI, OP clear.
NECK: Supple, no LAD, no thyromegaly, JVP flat.
CARDIAC: RRR, normal S1/S2, no murmurs rubs or gallops.
PULMONARY: Clear to auscultation bilaterally, without wheezes or
rhonchi.
ABDOMEN: Normal bowel sounds, soft, non-tender, non-distended,
no organomegaly.
EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or
edema.
SKIN: Without rash.
NEUROLOGIC: A&Ox3, CN II-XII grossly normal, normal sensation,
with strength ___ throughout. Pelvic sensory exam deferred given
just performed by orthopedics resident prior to arrival on the
floor, ___ strength/sensation currently, and pt feeling
emotionally distraught over her diagnosis
DISCHARGE PHYSICAL EXAM:
Vital Signs: 97.3 131/75 86 18 98%RA
General: Elderly woman, appears comfortable, lying in bed
wearing TLSO. Choreic movements of head and extrems
HEENT: MMM
Lungs: CTAB anteriorly, exam limited by brace
CV: II/VI holosystolic murmur loudest RUSB
Abdomen: Soft, NTND, NABS
Ext: WWP, no c/c/e
Skin: Without rashes or lesions
Neuro: AOx3, moving all extrems equally
Pertinent Results:
ADMISSION LABS:
___ 08:05PM BLOOD WBC-6.5 RBC-3.77* Hgb-11.4 Hct-35.4
MCV-94 MCH-30.2 MCHC-32.2 RDW-12.8 RDWSD-43.8 Plt ___
___ 08:05PM BLOOD Neuts-67.6 ___ Monos-8.7 Eos-1.7
Baso-0.9 Im ___ AbsNeut-4.42 AbsLymp-1.36 AbsMono-0.57
AbsEos-0.11 AbsBaso-0.06
___ 08:05PM BLOOD Glucose-85 UreaN-11 Creat-0.7 Na-138
K-4.1 Cl-106 HCO3-23 AnGap-13
___ 08:19AM BLOOD TotProt-7.0 Calcium-9.7 Phos-3.8 Mg-1.9
PERTINENT LABS:
___ 08:19AM BLOOD PEP-ABNORMAL B IgG-2256* IgA-8* IgM-LESS
THAN IFE-MONOCLONAL
DISCHARGE LABS:
___ 07:55AM BLOOD WBC-6.3 RBC-4.13 Hgb-12.4 Hct-38.8 MCV-94
MCH-30.0 MCHC-32.0 RDW-12.7 RDWSD-43.7 Plt ___
___ 07:55AM BLOOD Glucose-124* UreaN-9 Creat-0.6 Na-139
K-4.0 Cl-105 HCO3-26 AnGap-12
___ 07:55AM BLOOD Calcium-10.1 Phos-3.4 Mg-1.8
===============================================================
STUDIES:
___ CT T spine
1. Severe T11 burst fracture of undetermined age likely subacute
to chronic. There is 7mm retropulsion with thecal sac and
likely cord compression at this level.
2. Non-displaced T10 spinous process fracture.
3. Remote right ___ and 11th rib fractures.
___ CT L spine
1. No lumbar spine fracture.
2. Remote right ___ and 11th rib fractures.
Brief Hospital Course:
___ yo F with a history of IgG kappa MGUS, osteoporosis,
hyperparathyroidism, recent traumatic R femur fracture,
___ disease, who presents with 3 months progressive back
pain and found to have unstable T11 fracture with evidence of
cord compression on imaging.
# T11 compression fracture: Neuro exam was nonfocal without any
bowel or bladder incontinence. Patinet was seen by orthopedic
surgery and deferred surgery. She had TLSO brace placed. She
will follow up with orthopedics and continue home ___.
# MGUS: IgG Kappa without history of MM. At last visit with
hem/onc in ___ labs were stable, IgG at 2.3 g/dl. Given this
there was no concern for multiple myeloma contributing to
compression fracture.
# Osteoporosis/hyperparathyroidism: Unclear history. Ca/Phos
normal here. Continued home calcium and vitamin D.
# ___ disease: Continued home regimen of stalevo,
carbidopa-levodopa, rasagiline
# Anxiety: Continued home sertraline.
# CONTACT: Husband ___ cell phone
# CODE STATUS: Full
TRANSITIONAL ISSUES:
=====================
[ ] Patient should wear the brace during the day during any
activity. It should be put on in the supine position. She has
follow up with orthopedics.
[ ] SPEP pending at time of discharge.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Stalevo 75 (carbidopa-levodopa-entacapone) ___ mg
oral 6X/day
2. Sertraline 100 mg PO DAILY
3. Azilect (rasagiline) 0.5 mg oral DAILY
4. melatonin 5 mg oral QHS
5. Gabapentin 300 mg PO TID
6. Carbidopa-Levodopa CR (___) 1 TAB PO QHS
7. Carbidopa-Levodopa (___) 0.5 TAB PO DAILY
8. Carbidopa-Levodopa (___) 0.25-0.5 TAB PO BID:PRN PD
symptoms
9. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. Carbidopa-Levodopa (___) 0.5 TAB PO DAILY
2. Carbidopa-Levodopa (___) 0.25-0.5 TAB PO BID:PRN PD
symptoms
3. Carbidopa-Levodopa CR (___) 1 TAB PO QHS
4. Gabapentin 300 mg PO TID
5. Sertraline 100 mg PO DAILY
6. Stalevo 75 (carbidopa-levodopa-entacapone) ___ mg
oral 6X/day
7. melatonin 5 mg oral QHS
8. Vitamin D ___ UNIT PO DAILY
9. Rasagiline (rasagiline) 0.5 mg ORAL DAILY
10. Acetaminophen 1000 mg PO Q8H:PRN pain/fever
RX *acetaminophen 500 mg 2 tablet(s) by mouth q8h prn Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary
Unstable T11 vertebral compression fracture
Secondary
Osteoporosis
Monoclonal gammopathy of uncertain significance
___ 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. ___,
You were admitted to the hospital because you had imaging of
your back that showed a compression fracture with concern for
compression of your spinal cord. You did not have any symptoms
concerning for cord compression. You were seen by orthopedic
surgery. Because you would prefer not to have surgery at this
time, they recommended the use of a brace to stabilize your
spine.
You need to wear the brace any time you are sitting up,
including driving, or walking around. You do not need to wear
the brace if you are lying in bed or reclining.
You will follow up with orthopedic surgery.
It was a pleasure taking care of you during your stay in the
hospital.
- Your ___ Team
Followup Instructions:
___
|
10105515-DS-12 | 10,105,515 | 26,900,189 | DS | 12 | 2138-11-04 00:00:00 | 2138-11-05 17:23:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
bowel incontinence
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HISTORY OF THE PRESENTING ILLNESS:
___ with a history of IgG kappa MGUS, osteoporosis,
hyperparathyroidism, ___ disease, and previous T12
compression fracture presenting to the emergency department with
new bowel incontinence.
Patient has long history of low back pain complicated with
previous compression fractures. Previously has seen spinal and
neurology doctors and ___ had multiple MRIs with positive
findings however she has not had any surgical intervention.
This weekend she was told to be on look out for worsening
symptoms by 1 of her neurologist who is concerned that she has
worsening cord compression. Over the weekend had diarrheal
illness. On morning of admission around 4:00 she was getting
ready to shower. Felt urge to go to the bathroom. Decided to try
to shower first because she was ready. In the shower she had a
bowel movement. She called her neurologist and she was referred
into the ED. Additionally patient states that when she tries to
urinate and sometimes has difficulty urinating. However she
denies any leg weakness, leg numbness, leg tingling, or any
decreased sensation while wiping. Patient also denies fevers or
chills.
In the ED, initial vitals were: 97.9 84 133/102 16 100% RA
PVR showed 240 cc.
- Exam notable for: intact neurological exam without signs of
myelopathy
- Labs notable for:
+ Chem 10: Na 132, K 4.2, Cl 99, HCO3 21, BUN 7, Creat 0.7
+ CBC: WBC 7.1, H/H: 11.4/33.5, Plt 313
+ Urine showed: Mod Leuk, few bacteria, 3 WBC, 2 RBC, 3 Epi.
- Imaging was notable for: Severe compression fracture of T12
appears chronic. Protrusion of the posterior vertebral body
results in moderate spinal canal narrowing at this level without
effacement of the spinal cord. There is severe neural foraminal
narrowing on the right at L5-S1. There is moderate to severe
neural foraminal narrowing on the left at L3-4. There is
moderate to severe neural foraminal narrowing at T12-L1 and L1-2
on the left although evaluation is limited by motion
- Neurosurgery was consulted who stated: MRI shows grossly
stable fracture with retropulsion into the canal, effacement of
the spinal cord without evidence of signal change within the
cord. It also shows stable degenerative changes and
neuroforaminal stenosis worst at L5-S1 on the right.
Patient can follow up with her outpatient providers for ongoing
management. There is no role for emergent Neurosurgical
intervention. If she chooses she can follow up with Dr. ___
in Spine clinic.
- Patient was given: No meds
Transfer vitals: 97.9 77 164/87 16 98% RA
Upon arrival to the floor, patient reports no pain and feels
very well. She has not had further episodes of bowel
incontinence.
Past Medical History:
- BREAST CHANGES - FIBROCYSTIC
- Osteoporosis
- BURSITIS - TROCHANTERIC
- Ovarian Cyst
- HYPERTENSION - ESSENTIAL, not on therapy
- ANXIETY
- IgG Kappa MGUS
- OA
- ___ disease
- h/o R femur fracture, ___ closed comminuted intra-articular
fracture of distal femur
- Cataracts, bilateral
Social History:
___
Family History:
Father CAD/PVD
Maternal Aunt ___
Mother ___ Hyperlipidemia
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vital Signs: 97.5 PO 143 / 92 105 14 98 Ra
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL.
Neck: Supple. JVP not elevated. no LAD
CV: Regular rate and rhythm. Normal S1+S2, no murmurs, rubs,
gallops.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred. Intact sensation to light touch in lower extremities.
DISCHARGE PHYSICAL EXAM:
Vital Signs: 97.4 PO 135 / 81 77 16 99
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL.
Neck: Supple. JVP not elevated. no LAD
CV: Regular rate and rhythm. Normal S1+S2, no murmurs, rubs,
gallops.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred. Intact sensation to light touch in lower extremities.
Pertinent Results:
ADMISSION LABS:
___ 12:04AM BLOOD WBC-7.1 RBC-3.73* Hgb-11.4 Hct-33.5*
MCV-90 MCH-30.6 MCHC-34.0 RDW-12.9 RDWSD-42.2 Plt ___
___ 12:04AM BLOOD Neuts-66 Bands-1 ___ Monos-9 Eos-1
Baso-0 Atyps-1* Metas-1* Myelos-1* AbsNeut-4.76 AbsLymp-1.49
AbsMono-0.64 AbsEos-0.07 AbsBaso-0.00*
___ 12:04AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
___ 12:04AM BLOOD Glucose-94 UreaN-7 Creat-0.7 Na-132*
K-4.2 Cl-99 HCO3-21* AnGap-16
DISCHARGE LABS:
IMAGING:
MRI L SPINE ___:
1. Please note that numbering is been performed based on the
first rib-bearing
vertebral body designated as T1 on the prior CT from ___.
2. Acute, minimally displaced fracture is seen involving the S1
vertebral
body, with extensive paraspinal edema, not seen on the prior CT
from ___.
3. Late subacute to chronic compression deformity is seen
involving the T11
vertebral body, unchanged compared to the prior CT from ___.
retropulsion of fragments by approximately 0.9 cm causes at
least mild to
moderate spinal canal narrowing at this level. No cord signal
abnormalities
identified.
4. Moderate to severe lumbar spondylosis as described above.
MICROBIOLOGY:
None
Brief Hospital Course:
___ with a history of IgG kappa MGUS, osteoporosis,
hyperparathyroidism, ___ disease, and previous T12
compression fracture presenting to the emergency department with
new bowel incontinence.
# Bowel incontinence: Pt with one episode of loose bowel
incontinence on ___ while in the shower, with diarrhea/fevers in
the past few days. MRI on ___ with new S1 fracture but chronic
changes and no acutely worsening spinal cord compression. Has
not had further episodes of bowel incontinence, describes being
able to sense bowel fullness. Also with full lower extremity
strength on exam throughout hospitalization. Neurosurgery saw
the patient on ___ and recommended no acute surgical
intervention warranted based on a wet read of the MRI. Ortho
then saw patient on ___ (nsgy does not evaluate sacral spine)
and felt that no immediate surgical intervention warranted.
Overall, it was felt that the etiology of her bowel incontinence
x1 appears to be secondary to loose stool or infectious etiology
of diarrheal (though WBC wnl, thus ? viral) versus concerning
cord compression (less likely). She had few ___ per day)
episodes of loose stool during her hospitalization, though no
frank diarrhea. No weakness or changes in sensation. On day of
discharge, pt was independently ambulatory.
CHRONIC ISSUES:
#T11 fracture: Stable on MRI, not in pain.
# MGUS: IgG Kappa without history of MM. At last visit with
hem/onc in ___ labs were stable, IgG at 2.3 g/dl. Given this
there was no concern for multiple myeloma contributing to
compression fracture.
# Osteoporosis/hyperparathyroidism: Unclear history. Ca/Phos
normal here. Continued home calcium and vitamin D
# ___ disease: Continued home regimen of stalevo,
rasagiline
# Anxiety: Continued home sertraline
TRANSITIONAL ISSUES:
===================
Medications we started:
None
Medications we changed:
None
Medications we stopped:
None
TRANSITIONAL ISSUES:
[]f/u loose stools: Pt reports fever to 101 several days prior
to admission. Did not have frank diarrhea while here but did
have few ___ per day) episodes of loose stool. She was afebrile
while inpatient.
[]f/u S1 fracture, minimally displaced. Evaluated by orthopedic
surgery here and determined to be non-operative. Follow up with
Dr ___ in ___ weeks
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 300 mg PO TID
2. Sertraline 100 mg PO DAILY
3. Stalevo 75 (carbidopa-levodopa-entacapone) ___ mg
oral 6X/day
4. Vitamin D ___ UNIT PO DAILY
5. Rasagiline (rasagiline) 0.5 mg ORAL DAILY
6. Gabapentin 600 mg PO QHS
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
2. Gabapentin 300 mg PO TID
3. Gabapentin 600 mg PO QHS
4. Omeprazole 20 mg PO DAILY
5. QUEtiapine Fumarate 25 mg PO QHS
6. Rasagiline (rasagiline) 0.5 mg ORAL DAILY
7. Sertraline 100 mg PO DAILY
8. Stalevo 75 (carbidopa-levodopa-entacapone) ___ mg
oral 6X/day
9. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
S1 fracture
Secondary diagnosis
Parkinsons
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___
(___) due to
While here, you had an MRI of your spine that showed a new,
small fracture in your sacral spine. You were seen by the spine
surgeons who recommended that surgery was not immediately
necessary. We monitored you to see if you had any more weakness
or bowel incontinence.
Please follow up with your outpatient providers and all your
scheduled appointments. Thank you for allowing us to be involved
in your care.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10105515-DS-13 | 10,105,515 | 29,408,813 | DS | 13 | 2140-12-05 00:00:00 | 2140-12-05 12:16:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
Right valgus impacted femoral neck fracture
Major Surgical or Invasive Procedure:
Right hip closed reduction percutaneous pinning
History of Present Illness:
___ yo female w/ PMH of ___ presents after a mechanical
fall. Patient was walking with her walker and the walker slipped
over the sidewalk and she fell along with a walker onto her
right hip. Patient denies any head strike, LOC. Patient is not
on a blood thinner. She presented to the emergency department
where x-rays and impacted mildly displaced fracture of the right
femoral neck. Orthopedics was consulted for further evaluation.
Past Medical History:
- BREAST CHANGES - FIBROCYSTIC
- Osteoporosis
- BURSITIS - TROCHANTERIC
- Ovarian Cyst
- HYPERTENSION - ESSENTIAL, not on therapy
- ANXIETY
- IgG Kappa MGUS
- OA
- ___ disease
- h/o R femur fracture, ___ closed comminuted intra-articular
fracture of distal femur
- Cataracts, bilateral
Social History:
___
Family History:
Father CAD/PVD
Maternal Aunt ___
Mother ___ Hyperlipidemia
Physical Exam:
General: Well-appearing, breathing comfortably
MSK:
- Dressing clean dry and intact
- Soft, non-tender thigh and leg
- Full, painless AROM/PROM of ankle
- ___ fire
- SILT SPN/DPN/TN/saphenous/sural distributions
- 1+ ___ pulses, foot warm and well-perfused
Pertinent Results:
___ 06:28AM BLOOD WBC-8.7 RBC-3.34* Hgb-10.2* Hct-32.0*
MCV-96 MCH-30.5 MCHC-31.9* RDW-13.8 RDWSD-48.3* Plt ___
___ 06:28AM BLOOD Glucose-97 UreaN-15 Creat-0.8 Na-138
K-4.9 Cl-104 HCO3-25 AnGap-9*
Brief Hospital Course:
Ms. ___ presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a right valgus impacted femoral neck fracture and was
admitted to the orthopedic surgery service. The patient was
taken to the operating room on ___ for a closed
reduction percutaneous pinning, which the patient tolerated
well. For full details of the procedure please see the
separately dictated operative report. The patient was taken from
the OR to the PACU in stable condition and after satisfactory
recovery from anesthesia was transferred to the floor. The
patient was initially given IV fluids and IV pain medications,
and progressed to a regular diet and oral medications by POD#1.
The patient was given ___ antibiotics and
anticoagulation per routine. The patient's home medications were
continued throughout this hospitalization. The patient worked
with ___ who determined that discharge to rehab was appropriate.
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
weightbearing as tolerated in the right lower extremity, and
will be discharged on aspirin 325 mg daily for DVT prophylaxis.
The patient will follow up with Dr. ___ routine. A
thorough discussion was had with the patient regarding the
diagnosis and expected post-discharge course including reasons
to call the office or return to the hospital, and all questions
were answered. The patient was also given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient expressed readiness for discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Stalevo 75 (carbidopa-levodopa-entacapone) ___ mg
oral 6x/day
2. Rasagiline 0.5 mg PO DAILY
3. Carbidopa-Levodopa (___) 0.25 TAB PO DAILY
4. QUEtiapine Fumarate 25 mg PO QHS
5. Sertraline 100 mg PO DAILY
6. Gabapentin 600 mg PO QHS
7. melatonin 3 mg oral QHS:PRN insomnia
8. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. Senna 8.6 mg PO BID:PRN Constipation - First Line
4. Carbidopa-Levodopa (___) 0.25 TAB PO DAILY
5. Gabapentin 600 mg PO QHS
6. melatonin 3 mg oral QHS:PRN insomnia
7. QUEtiapine Fumarate 25 mg PO QHS
8. Rasagiline 0.5 mg PO DAILY
9. Sertraline 100 mg PO DAILY
10. Stalevo 75 (carbidopa-levodopa-entacapone) ___ mg
oral 6x/day
11. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right valgus impacted femoral neck fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated.
ACTIVITY AND WEIGHT BEARING:
-Weightbearing as tolerated right lower extremity
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This
is an over the counter medication.
2) Please take all medications as prescribed by your
physicians at discharge.
3) Continue all home medications unless specifically
instructed to stop by your surgeon.
ANTICOAGULATION:
- Please take Aspirin 325mg daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever >101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
Physical Therapy:
WBAT RLE
Clinical Impression/Prognosis: Pt is a ___ with a history of
osteoporosis who presents to physical therapy s/p distal femur
fracture. Pt is functioning well below baseline limited by
impairments in body structure and function including pain and
limited balance ___ weight bearing precautions. Pt is also
presents with activity limitations in mobility and self care
contributing to difficulty in fulfilling societal role of an
independent adult and wife. The patient's Basic Mobility Short
Form AM-PAC t-score less than or equal to 42.9 is consistent
with
a requirement of rehabilitation at discharge. However, given pt
and husband preference for non operative management pt with
significant difficulty maintaining weight bearing precautions
during session today. After further education pt and family plan
to make a decision on potential surgical fixation, and ___ will
follow up post surgery to assess for final discharge
recommendations.
Goals: Time Frame: 1 Week
___ Pt will require S to transfer supine to sit with HOB
elevated and bed rail
___ Pt will require CGA to transfer sit to stand to RW
___ Pt will require ___ to perform stand pivot transfer
with RW
___ Pt will require ___ to ambulate 30 feet with RW feet
maintaining WB precautions
___ Pt will I verbalize post-operative activity guidelines
and WB precautions
- Pt will score greater than or equal to 16 on the Activity
Measure for Post-Acute Care
Recommended Discharge: ( X)rehab see clinical impression
Treatment Plan:
Progress functional mobility including bed mobility, transfers,
gait and stairs as tolerated.
Balance training
Pt/caregiver education RE: post-operative activity guidelines,
WB
precautions, HEP
D/C planning
Frequency/Duration: ___ for 1 week
Recommendations for Nursing:
Encourage flat supine positioning for 30min 3x/day. (unless
respiratory precautions)
Encourage patient's independent performance of prescribed
therapeutic exercise 3x/day.
Pt is at high risk for deconditioning please encourage frequent
mobility and maximize independence in ADLs.
Assist of 1 for out of bed to chair with RW 3x/day.
Please use pressure relieving air cushion / chair alarm when out
of bed.
Normalize sleep-wake cycle to decrease risk of delirium.
Treatment Frequency:
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
Followup Instructions:
___
|
10105529-DS-4 | 10,105,529 | 27,539,048 | DS | 4 | 2158-04-20 00:00:00 | 2158-04-20 21:15:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___
Chief Complaint:
transient vision loss, diplopia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The ___ was performed:
(within 6 hours of patient presentation or neurology consult)
___ Stroke Scale score was : 0
1a. Level of Consciousness: 0
1b. LOC Question: 0
1c. LOC Commands: 0
2. Best gaze: 0
3. Visual fields: 0
4. Facial palsy: 0
5a. Motor arm, left: 0
5b. Motor arm, right: 0
6a. Motor leg, left: 0
6b. Motor leg, right: 0
7. Limb Ataxia: 0
8. Sensory: 0
9. Language: 0
10. Dysarthria: 0
11. Extinction and Neglect: 0
t-PA given: no, symptoms resolved
Endovascular Procedure Done: no
I was present during the CT scanning and reviewed the images
instantly within 20 minutes of their completion.
HPI: Patient is a ___ male with multiple stroke risk factors
including history of right carotid stenosis s/p carotid
endarterectomy on daily ASA 81mg, stable thoracic abdominal
aneurysm, DM and HTN who presents with 2 reports of transient
visual changes that have since resolved.
First episode occurred at 9am when patient was reading the
newspaper. He reports sudden darkening of all his visual fields.
He could see through the darkness "he describes it as a dark
cloud". Patient denies any "curtain coming down" and states
symptoms were sudden, although later reports darkness came on
over few seconds. He closed both his eyes and symptoms
disappeared after 5min.
At 12pm on ___ patient was with his son having a
conversation
when he noted vertical diplopia. One object was slightly above
the other (some overlap). Diplopia was worse with looking down
(for example going down stairs). Unclear if diplopia was
worsened
by distance or convergence. Patient reports diplopia was present
with straight gaze, improved by closing either eye. There was no
compensatory head tilt. Entire episode lasted roughly 30min.
There was associated nausea, ___ squeezing headache located at
top of head. No neck pain.
Upon arrival to ___ ED symptoms had resolved. NIHSS 0 in ED with
non focal neurological exam. Of note patient had not taken his
BP
medications today and his BP was elevated at 186/84 upon arrival
to ___ ED which subsequently trended down.
A NCHCT did not reveal acute process. CTA head and neck revealed
ectasia versus fusiform dilatation of the V4 segment of the left
vertebral artery, measuring up to 4-5 mm (3:218) and right
thyroid hypodensity, otherwise unremarkable. ___ was consulted
who did not recommend any surgical intervention.
On neuro ROS, the pt denies blurred vision, dysarthria,
dysphagia, lightheadedness, vertigo, tinnitus or hearing
difficulty. Denies difficulties producing or comprehending
speech. Denies focal weakness, numbness, parasthesia. 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 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:
dyslipidemia, arthritis, DM2, GERD, pancreatitis,
diverticulitis, thoracic aortic aneurysm, HTN, peptic ulcer
disease/UGIB, nephrolithiasis, DVT
Social History:
___
Family History:
Father - CAD. Mother - CVA. Siblings (3 brothers, 5 sisters) -
rectal cancer x 2, brain tumor, HTN, CVA, cystic fibrosis.
Physical Exam:
ADMISSION EXAM:
Physical Exam:
Vitals: T:afebrile P:68 ___ RR:16 SaO2: 100 RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple. No nuchal rigidity
Pulmonary: Normal work of breathing
Cardiac: RRR, warm, well-perfused
Abdomen: soft, non-distended
Extremities: No ___ edema.
Skin: no rashes or lesions noted.
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Pt was able to name both high and low frequency objects. Able
to
read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. Pt was able to
register 3 objects and recall ___ at 5 minutes. 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. Fundoscopic
exam revealed no papilledema, exudates, or hemorrhages.
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, proprioception throughout. No extinction to
DSS.
Romberg absent
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
Plantar response was flexor bilaterally.
-Coordination: No intention tremor. Normal finger-tap
bilaterally. No dysmetria on FNF or HKS bilaterally
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem without difficulty.
====================
DISCHARGE EXAM:
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM
Neck: Supple. No nuchal rigidity
Pulmonary: Normal work of breathing
Cardiac: WWP
Abdomen: soft, non-distended
Extremities: L>R ___ edema
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Language fluent with intact
comprehension.
-Cranial Nerves:
PERRL 3 to 2mm and brisk. EOMI without
nystagmus. Normal saccades. VFF to confrontation.
Mild R NLF flattening, symmetric facial mvts with activation
Hearing intact to speech
Palate elevates symmetrically.
-Motor: mild R pronator drift. Full strength on L arm.
R delt 4+/5
R tri ___
b/l ___ ___ in IP, quad, TA
-Sensory: No deficits to light touch
-DTRs: deferred
-___: No intention tremor. Normal finger-tap
bilaterally.
-Gait: independently ambulatory
Pertinent Results:
___ 09:50AM BLOOD WBC-6.9 RBC-4.05* Hgb-12.9* Hct-39.2*
MCV-97 MCH-31.9 MCHC-32.9 RDW-13.2 RDWSD-47.8* Plt ___
___ 09:50AM BLOOD ___ PTT-28.4 ___
___ 06:25AM BLOOD Glucose-123* UreaN-18 Creat-1.1 Na-142
K-4.5 Cl-105 HCO3-26 AnGap-11
___ 09:50AM BLOOD ALT-29 AST-28 LD(LDH)-172 CK(CPK)-41*
AlkPhos-84 TotBili-0.8
___ 09:50AM BLOOD Triglyc-59 HDL-62 CHOL/HD-1.8 LDLcalc-36
MRI ___:
1. There is no evidence of acute intracranial process or
hemorrhage,
specifically no diffusion abnormalities are seen to indicate
acute/subacute
ischemic changes.
ECHO ___:
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). with normal free
wall contractility. The aortic root is mildly dilated at the
sinus level. The ascending aorta is mildly dilated. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. Trace aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: No intracardiac source of thromboembolism
identified.
The patient has a mildly dilated ascending aorta. Based on ___
ACCF/AHA Thoracic Aortic Guidelines, if not previously known or
a change, a follow-up echocardiogram is suggested in ___ year; if
previously known and stable, a follow-up echocardiogram is
suggested in ___ years.
CTA ___:
1. No acute intracranial abnormality.
2. Tortuous origin of the right common carotid artery which
demonstrates focal
kinking and mild-to-moderate narrowing.
3. Evidence of a right carotid terminus 3 mm infundibulum at the
origin of the
posterior communicating artery.
4. Mild focal ectasia of the left vertebral artery V4 segment
measuring up to
6 mm.
5. Generalized parenchymal volume loss, likely age related.
6. Enlarged right pulmonary artery measuring up to 3.5 cm can be
seen in
setting of pulmonary arterial hypertension.
Brief Hospital Course:
___ is a ___ year old man with history of
hypertension, R carotid endarterectomy, and diabetes, who
presented with transient vision loss and diplopia, diagnosed
with transient ischemic attack.
#TIA: CTA showed L ICA calcifications without occlusion of
either carotid. No acute stroke was noted on CT or MRI brain.
Cardiac echo did not show any thrombus or abnormality in wall
motion. There was a mildly dilated aorta that was previously
known to patient.
#HTN: He was initially hypertensive to SBP 220s in the ED, which
improved with single dose of IV hydralazine. Patient was managed
on home metoprolol with SBP in the 130s-140s range.
=============
Transitional Issues:
- Patient discharged with ___ monitor for atrial
fibrillation, will follow up on results at neurology visit
- patient to schedule neurology clinic follow up in ___ months,
with Dr. ___
- blood pressure initially elevated in ED setting, continue to
trend BPs and adjust medication as necessary
- dilated aortic root (known to patient, and stable), follow per
cardiologist recommendations.
================
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 - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 70) (x) Yes - () No [if LDL
>70, reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
6. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No
9. Discharged on statin therapy? (x) Yes - () No [if LDL >70,
reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
10. Discharged on antithrombotic therapy? (x) Yes [Type: (x)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - (x) N/A
35 minutes were spent on discharge summary.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. MetFORMIN (Glucophage) Dose is Unknown PO BID
2. Tamsulosin Dose is Unknown PO QHS
3. Celebrex Dose is Unknown oral BID
4. Metoprolol Succinate XL 12.5 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 40mg PO daily
Discharge Medications:
1. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*11
2. Aspirin 81 mg PO DAILY
3. Celecoxib unknown oral BID
4. MetFORMIN (Glucophage) 500 mg PO BID
5. Metoprolol Succinate XL 12.5 mg PO DAILY
6. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Transient Ischemic Attack
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 resulting from a
TRANSIENT ISCHEMIC ATTACK (TIA), a condition where a blood
vessel providing oxygen and nutrients to the brain is
temporarily blocked. 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.
TIA can have many different causes, so we assessed you for
medical conditions that might raise your risk of having a stroke
in the future. In order to prevent future strokes, we plan to
modify those risk factors. Your risk factors are:
high blood pressure
carotid artery disease
diabetes
We are changing your medications as follows:
Please increase atorvastatin to 80mg (if not already at that
dose).
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:
___
|
10105747-DS-5 | 10,105,747 | 21,346,337 | DS | 5 | 2151-06-27 00:00:00 | 2151-06-27 17:28:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Wound infection
Major Surgical or Invasive Procedure:
___ Craniectomy wound washout/debridement
Cranialization of sinus w/temporal muscle
History of Present Illness:
___ year old male with a history of TBI ___ years ago s/p
craniectomy, now presenting as a transfer from OSH for
neurosurgery evaluation for forehead swelling with purulent
drainage, found to have a complex extradural fluid collection.
Patient notes that he has had a similar swelling in ___
which self resolved after 1 week. Patient reports that the
swelling returned 3 days ago, and that he developed pus-like
drainage 1 day prior. Patient is otherwise asymptomatic and in
his usual state of health. He explicitly denies fevers, vision
changes, headaches.
In the ED initial vitals were:98.8 80 107/64 14 99%
- Labs were not performed in the ED, however they were within
normal limits at the OSH. CT head showed a 5mm extradural
complex fluid collection. He was seen by neurosurgery who felt
that they could not determine the chronicity of the collection
with only a single image, and therefore felt that it would be
reasonable to admit to medicine for superficial cellulitis.
- Patient was given vanc/zosyn at the outside hospital.
Review of Systems:
(+) per HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
-TBI ___ years ago in ___
Social History:
___
Family History:
Mother with PVD, ___
Physical Exam:
ON ADMISSION:
Vitals - 98.2 101/60 80 18 97RA
GENERAL: NAD
HEENT: 1cmx1cm area of induration, erythema over R eyebrow with
purulent drainage
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
ON DISCHARGE:
Vitals -AVSS
HEENT: cranioplasty with sutures and staples
Alert and oriented to person, place and time. Moves all
extremities with full strength.
Pertinent Results:
MRI of HEAD: ___
IMPRESSION:
Right frontal craniotomy with postoperative changes as described
above. There is dural thickening and enhancement underlying the
surgical site. This may be this dural postoperative change.
However, in the setting of a history of infection, opacification
of an adjacent right frontal sinus air cell, and a defect in the
posterior wall of the sinus, these findings are worrisome for
superimposed infection.
HEAD CT ___:
S/p right craniectomy at the site of prior craniotomy, with
blood at the
craniectomy site which does not exert mass effect on the brain
parenchyma. No parenchymal hemorrhage or edema.
CT of SINUS: ___
IMPRESSION:
Extensive disease of the left sphenoid sinus soft-tissue changes
as noted above with dehiscence of the bone covering left foramen
Rotundum as noted above.
CXR for line placment ___. Malpositioned right PICC line which likely enters right IJ.
Requires
repositioning.
2. No evidence of acute cardiopulmonary process.
Brief Hospital Course:
Mr. ___ is a ___ year old gentleman with a remote history of
TBI ___ years ago s/p craniectomy at the time who presented to
___ on ___ as a transfer from OSH for neurosurgical
evaluation of forehead swelling with purulent drainage and 5mm
extradural complex fluid collection found on CT from OSH,
initially thought to be concerning for superficial cellulitis
and possibly an underlying abscess and requiring further work-up
including neurosurgical evaluation.
Active Issues:
#Soft tissue abscess vs pre-septal cellulitis vs osteomyelitis:
Patient describes a few days of swelling of right supraorbital
tissues with subsequent drainage of yellow fluid. No draining
was noted on exam (though scant yellow drainage seen on tissue)
and he was non-toxic and without leukocytosis since admission.
He reports that, prior to ___ when he experienced similar
symptoms that spontaneously resolved within a week, he had never
had any issues s/p craniectomy. Wound cultures from outside
hospital showed mixed GPCs and sparse staph aureus growth, no
GNRs. The differential included preseptal cellulitis
(purulent), soft-tissue abscess, cyst extruding non-purulent
serous or caseous material. There was little concern for
orbital or CNS infection given that he had no focal neurological
findings. An MRI was performed which indicated some marrow
edema in the area raising concern for osteomyelitis and the
decision was made to take his to the operating room on ___ for
right bone flap removal and wash-out. Infectious disease also
became involved on ___ and recommended narrowing antibiotics to
vancomycin until intra-op wound cultures showed sensitivities.
Chronic Issues:
#Tobacco use: He has smoked a ___ ppd since being a teenager.
While admitted he was provided with a 14 mg nicotine transdermal
patch.
___ Course:
On ___, patient was taken to the OR with neurosurgery for R
craniectomy and washout and debridement of R eyebrow. There were
no complications intraoperatively. Cultures were sent from his
wound. A subgaleal drain was placed and his incision was closed
with sutures and staples. He was extubated and transferred to
the PACU for further managment. On post operative examination,
patient was neurologically intact and post op head CT showed
post op changes. ID recommendations were to start patient on
vancomycin/cefepime/ampicilin.
On ___, patient remained intact. ENT evaluated the patient and
recommended a CT fusion of the sinus and bactroban ointment for
his nares. ID also recommended changing his antibiotics to
vancomycin and zoysn after cultures from the OR revealed 2+ GPC,
GPR, GNR and polys. A vancomycin trough was ordered for later in
the day. His subgaleal drain was removed and stitch was placed.
On ___, the infectious disease recommended continuing the
vanc/zosyn IV. The patient remained neurologically and
hemodynamically intact and was transferred to floor in stable
condition.
On ___, labs were obtained, his ESR was 64, and CRP was 95.9.
The vancomycin trough was 9.7, and his vancomycin was increased
to 1250mg TID.
On ___, the patient remained stable. He remained on
vanco/zosyn. He was ordered for a vanco level for tomorrow
morning per ID recs. A PICC line was ordered for long term
antibiotic use, the patient was consented. The patient
complained of headaches despite pain meds, he was started on
fioricet with good effect. The patient remained intact and had
his PICC line placed on ___ which needed adjustment with ___.
___, Mr. ___ was medically stable. ENT wants him to follow
up in two weeks with the ENT surgeon, Dr. ___. Infectious
disease left their final recommendations which were to
discontinue the Vancomycin and to continue the Zosyn for a total
of six weeks. A PICC line was placed for antibiotic treatment
which was found to be malpositioned on a chest x-ray. The
patient was taken down to interventional radiology for another
placement which showed that the PICC line was in the proper
placement. He was discharged to rehab in stable condition with
plans for antibiotic treatment and surgery follow up with both
neurosurgery as well as Ear ___ and Throat surgery.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain, fever
2. Acetaminophen-Caff-Butalbital ___ TAB PO Q4H:PRN headache
3. Docusate Sodium 100 mg PO BID
4. Heparin 5000 UNIT SC TID
5. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line flush
6. HydrALAzine ___ mg IV Q6H:PRN SBP > 160
7. LeVETiracetam 1000 mg PO BID
8. Mupirocin Nasal Ointment 2% 1 Appl NU BID Duration: 7 Days
9. Nicotine Patch 14 mg TD DAILY
10. Ondansetron 4 mg IV Q8H:PRN Nausea
11. Piperacillin-Tazobactam 4.5 g IV Q8H
12. Senna 8.6 mg PO BID:PRN constipation
13. Sodium Chloride 0.9% Flush 10 mL IV DAILY and PRN, line
flush
14. Sodium Chloride 0.9% Flush 3 mL IV Q8H and PRN, line flush
15. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Wound infection
Cranial Defect
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Have a friend/family member check your incision daily for
signs of infection.
Take your pain medicine as prescribed.
Exercise should be limited to walking; no lifting, straining,
or excessive bending.
Your wound was closed with sutures and staples. You may wash
your hair only after sutures and staples have been removed.
You may shower before this time using a shower cap to cover
your head.
Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
You have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
Clearance to drive and return to work will be addressed at
your post-operative office visit.
Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
**There is no bone flap on the R of the skull. A helmet must be
worn at all times the patient is out of bed.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
New onset of tremors or seizures.
Any confusion or change in mental status.
Any numbness, tingling, weakness in your extremities.
Pain or headache that is continually increasing, or not
relieved by pain medication.
Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
Fever greater than or equal to 101.5° F.
Followup Instructions:
___
|
10105826-DS-5 | 10,105,826 | 29,397,818 | DS | 5 | 2128-02-07 00:00:00 | 2128-02-07 15:25:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Lactose
Attending: ___.
Chief Complaint:
Swallowing two AA bateries
Major Surgical or Invasive Procedure:
EGD with battery retrieval
History of Present Illness:
___ MEDICINE ATTENDING ADMISSION NOTE .
___
Time: ___
_
________________________________________________________________
PCP: Name: ___
Location: ___
Address: ___, RT 28, STE#202, ___
Phone: ___
Fax: ___
.
HPI: > or equal to 4 ( location, quality, severity, duration,
timing, context, modifying factors, associated signs and sx)
The patient is a poor historian due to mental illness so her
caretaker from her group home is with her and she helps me to
complete the ROS
___ history of mental illness - MR with disorder of low muscle
tone, autism, ___ and anxiety (autism versus ___ and also
history of swallowing foreign objects in the past, the patient
at around 5 to 6:00 ___ swallowed 2 AA batteries from her TV
remote control. She has not had any respiratory issues. She has
not had any problems swallowing or clearing her secretions. The
patient is appropriate for her baseline. The patient has not
vomited at all. The patient was seen at outside hospital and was
transferred here for GI evaluation
Has a care worker present, on seclusion in the ___ with a sitter
to prevent further ingestion of foreign objects.
Per the ___ RN's signout "Intermittently agitated, but
redirectable. Irritable with delays. Likes video games (Sonic
the Hedgehog) and Christmas music. Music used in the ___ for
distraction"
Upon discussion with the ___ RN her caretaker informed the
RN that its thought that the patient ingests foreign bodies so
that she can come to the hospital so that her mother will visit
her there. (Her mother is involved in her care at baseline.)
When her mother comes to visit her she insists that she wants to
go home. When she can't go home this results in escalating
behaviors. They are going to avoid having her mother visit her
here to see if this can break the cycle.
In ER: (Triage Vitals: 98.4 84 ___ 100% )
Meds Given:
ativan
Fluids given: 200 cc
Radiology Studies: abdominal X ray series
consults called: GI aware and will scope in am
Admission VS; 98.2 hr 110 bp 117/78 sa 02 100% ra rr 16
.
PAIN SCALE: ___ in her stomach
Then I went back in the room and she denies any pain at all in
the esophagus or stomach.
________________________________________________________________
REVIEW OF SYSTEMS: 10 or 2 with "all otherwise negative"
CONSTITUTIONAL: [X] All Normal
[ ] Fever [ ] Chills [ ] Sweats [ ] Fatigue [ ] Malaise
[ ]Anorexia [ ]Night sweats
[ ] _____ lbs. weight loss/gain over _____ months
Eyes
[X] All Normal
[ ] Blurred vision [ ] Loss of vision [] Diplopia [ ]
Photophobia
ENT [X]WNL
[ ] Dry mouth [ ] Oral ulcers [ ] Bleeding gums [ ] Sore throat
[] Sinus pain [ ] Epistaxis [ ] Tinnitus
[ ] Decreased hearing [ ] Other:
RESPIRATORY: [X] All Normal
[ ] Shortness of breath [ ] Dyspnea on exertion [ ] Can't
walk 2 flights [ ] Cough [ ] Wheeze [ ] Purulent sputum
[ ] Hemoptysis [ ]Pleuritic pain
[ ] Other:
CARDIAC: [X] All Normal
[ ] Palpitations [ ] Edema [ ] PND [ ] Orthopnea [ ]
Chest Pain [ ] Dyspnea on exertion [ ] Other:
GI: [] All Normal
[- ] Nausea [-] Vomiting [+] Abd pain ___- can't really
tell me where in her abdomen the pain is [] Abdominal swelling
[- ] Diarrhea [ ] Constipation [ ] Hematemesis
[ ] Blood in stool [ ] Melena [ ] Dysphagia: [ ] Solids
[ ] Liquids [ ] Odynophagia [ ] Anorexia [ ] Reflux
[ ] Other:
GU: [X] All Normal
[ ] Dysuria [ ] Incontinence or retention [ ] Frequency
[ ] Hematuria []Discharge []Menorrhagia
SKIN: [X] All Normal
[ ] Rash [ ] Pruritus
MS: [X] All Normal
[ ] Joint pain [ ] Jt swelling [ ] Back pain [ ] Bony pain
NEURO: [X] All Normal
[ ] Headache [ ] Visual changes [ ] Sensory change [
]Confusion [ ]Numbness of extremities
[ ] Seizures [ ] Weakness [ ] Dizziness/Lightheaded [ ]Vertigo
[ ] Headache
ENDOCRINE: [x] All Normal
[ ] Skin changes [ ] Hair changes [ ] Heat or cold
intolerance [ ] loss of energy
HEME/LYMPH: [X] All Normal
[ ] Easy bruising [ ] Easy bleeding [ ] Adenopathy
PSYCH: [] All Normal
[ ] Mood change [-]Denies suicidal ideation [ x] at
baseline per caretaker
ALLERGY:
[+ ]Medication allergies
Lactose Unknown
Level of Certainty: Uncertain History
Penicillins Unknown
Level of Certainty: Uncertain
[ ] Seasonal allergies
[X]all other systems negative except as noted above
Past Medical History:
Most of her records are at ___ - GI Doctor: Dr.
___ is known very well by ___ which is usually
where she goes when she swallows foreign objects.
Acute bowel Obstruction in ___ s/p bowel resection - in
___ c/b b/l PNA requiring vent support
for several days
Lactose intolerance
Mobius- like syndrome with deficits in CN IX, X and IX
B/h hand weakness,low muscle tone throughout her body,
dysarthria and swallowing difficulties
Constipation
Edentulous
Esophageal constriction requiring intermittent dilatation with
episodic obstruction by solid foods or intentionally swallowed
objects.
Fundoplication at 5 months for GERD
Teeth extracted at a young age due to tooth decay
Obsessive compulsive disorder
Pervasive developmental disorder
ADHD
Anxiety disorder
___
? Bipolar disorder
Social History:
___
Family History:
Grandmother and Grandfather with DM.
Physical Exam:
PHYSICAL EXAM: I3 - PE >8
VITAL SIGNS:
PAIN SCORE ___
1. VS Tm 98.5 T 98.5 P 90 BP 105/65 RR 22 O2Sat on 94% on RA -
per RN, pt's extremities very cold which could explain her
decreased O2 sat.
GENERAL: Young female laying in bed. She is occasionally mildly
agitated but does well with reassurance.
Mentation
2. Eyes: [X] WNL
PERRL, EOMI without nystagmus, Conjunctiva:
clear/injection/exudates/icteric Ears/Nose/Mouth/Throat: MMM, no
lesions noted in OP
3. ENT [X] WNL
[] Moist [] Endentulous [] Ulcers [] Erythema [] JVD ____ cm
[] Dry [] Poor dentition [] Thrush [] Swelling [] Exudate
4. Cardiovascular [x] WNL
[X] Regular [] Tachy [X] S1 [X] S2 [-] Systolic Murmur /6,
Location:
[] Irregular []Brady []S3 [] S4 [] Diastolic Murmur /6,
Location:
[X] Edema RLE None [] Bruit(s), Location:
[X] Edema LLE None [X] PMI
[] Vascular access [X] Peripheral [] Central site:
5. Respiratory
[X] CTA bilaterally [ ] Rales [ ] Diminshed
[] Comfortable [ ] Rhonchi [ ] Dullness
[ ] Percussion WNL [ ] Wheeze [] Egophony
6. Gastrointestinal [ ] WNL
[X] Soft [-] Rebound [-] No hepatomegaly [] Non-tender [+]
Tender [] No splenomegaly [+]Well healed midline abdominal scar
[+] Non distended [] distended [] bowel sounds Yes/No []
guiac: positive/negative
7. Musculoskeletal-Extremities [] WNL
[ ] Tone WNL [ +]Upper extremity strength ___ and symmetrical
[ ]Other:
[ ] Bulk WNL [+] Lower extremity strength ___ and symmetrica
[ ] Other:
[+] Normal gait- pt observed walking to the BR []No cyanosis [
] No clubbing [] No joint swelling
8. Neurological [] WNL
[X ] Alert and Oriented x 3 [ ] Romberg: Positive/Negative [ ]
CN II-XII intact [ ] Normal attention [ ] FNF/HTS WNL []
Sensation WNL [ ] Delirious/confused [ ] Asterixis
Present/Absent [ ] Position sense WNL
[ ] Demented [ ] No pronator drift [] Fluent speech
9. Integument [] WNL
[X] Warm [] Dry [] Cyanotic [] Rash:
none/diffuse/face/trunk/back/limbs
[ ] Cool [] Moist [] Mottled [] Ulcer:
None/decubitus/sacral/heel: Right/Left
10. Psychiatric [] WNL
[] Appropriate [] Flat affect [+] Anxious [] Manic []
Intoxicated [] Pleasant [] Depressed [+] Mildly Agitated []
Psychotic
[] Combative
11. Hematologic/Lymphatic [ x]WNL
[X] No cervical ___ [] No axillary ___ [] No supraclavicular
___ [] No inguinal ___ [] Thyroid WNL [] Other:
12. Genitourinary [] WNL
[ ] Catheter present [] Normal genitalia [ ] Other:
TRACH: []present [x]none
PEG:[]present [X]none [ ]site C/D/I
COLOSTOMY: :[]present [X]none [ ]site C/D/I
Pertinent Results:
acute abdominal series ___:
IMPRESSION: Two double A batteries are seen in the distal
esophagus
.
EGD ___:
Impression: One AA battery was seen in the mid/distal esophagus.
There was no evidence of caustic or other mucosal injury.
Another AA battery was seen in the stomach. Again there was no
evidence of caustic or other mucosal injury.
(foreign body removal)
After removal of both batteries, the scope was reintroduced and
advanced to the third part of the duodenum. Careful inspection
did not reveal any mucosal injury. Otherwise normal EGD to third
part of the duodenum
Recommendations: Routine post-anesthesia care. No follow-up
needed. Please page GI fellow with any issues or questions.
.
___ 07:15AM BLOOD WBC-6.1 RBC-3.83* Hgb-11.3* Hct-34.2*
MCV-89 MCH-29.6 MCHC-33.1 RDW-12.2 Plt ___
___ 07:15AM BLOOD Neuts-58.0 ___ Monos-5.0 Eos-1.0
Baso-0.3
___ 07:15AM BLOOD Plt ___
___ 07:15AM BLOOD ___ PTT-33.7 ___
___ 12:55PM BLOOD Na-138 K-3.9 Cl-111* HCO3-19* AnGap-12
___ 07:15AM BLOOD Glucose-82 UreaN-10 Creat-0.7 Na-139
K-3.8 Cl-111* HCO3-18* AnGap-14
___ 07:15AM BLOOD ALT-12 AST-15 AlkPhos-62 Amylase-31
TotBili-0.4
___ 07:15AM BLOOD Lipase-26
___ 07:15AM BLOOD Calcium-8.5 Phos-3.3 Mg-1.9
___ 07:07AM URINE Hours-RANDOM
___ 07:07AM URINE UCG-NEG
Brief Hospital Course:
The patient is a ___ year old female with history of mental
retardation, OCD, pervasive developmental disorder h/o bowel
obstruction, h/o swalling foreign body objects who presents
after swallowing two AA batteries.
.
#foreign body ingestion: Pt required removal of these 2
batteries as she was at risk of developing an esophageal burn,
given persistence in the esophagus. Abdominal imaging in the ___
confirmed the presence of batteries in the distal esophagus. GI
was consulted and pt was closely monitored on a 1:1 sitter to
ensure that she does not swallow other foreign objects. Pt was
made NPO and taken to the EGD suite where endoscopy did not find
any evidence of mucosal or foreign body induced injury; the 2
batteries were successfully retrieved. Upon rearrival to the
floor, pt's diet was advanced to regular without complications.
She did not have any pain or nausea. Per report, pt tends to
swallow foreign objects in order to have her mother (who is
involved in her care) come to visit her in the hospital. Urine
HCG negative.
.
#non-gap metabolic acidosis-Pt presented with a bicarb of 18,
non-gap acidosis. In terms of etiology, no evidence for
diarrhea. This could be due to IV fluid resuscitation with
normal saline. Chemistry panel was repeated and bicarb was 19
upon recheck. There was no evidence of fever, infection. AA
batteries are alkaline in nature which would not cause acidosis.
Given that pt was asymptomatic and was tolerating a diet, pain
free, she was discharged to her group home with instructions to
have a repeat chemistry panel checked at her PCP's on ___.
.
#Psych/Obsessive compulsive disorder/mental retardation-After
home medication list was obtained, pt was continued on her home
doses of paxil, buspirone, risperdol, lamictal, clonidine prn
and ativan prn. Pt was redirectable during admission.
.
DVT PROPHYLAXIS: hep SC TID
.
PRECAUTIONS: [X] Foreign body object ingestion
.
DISPOSITION: [ X] Group Home
.
Code Status: FULL CODE given young age.
HCP: Mother- HCP ___- updated on admission
___: home ___ also updated on admission
Medications on Admission:
The ___ caregiver gave ___ list of medications to ___
___. Unfortunately they only recorded the names and not the
doses.
-------
Polyethylene Glycol 3350
Clonididne HCL
Risperdal
Paxil
Guaifenesis
Seasonale
Discharge Medications:
1. Paxil 30 mg Tablet Sig: One (1) Tablet PO at bedtime.
2. Miralax 17 gram Powder in Packet Sig: One (1) PO once a day
as needed for constipation.
3. Risperdal 3 mg Tablet Sig: 0.5 Tablet PO twice a day.
4. ___ Plus 8.6-50 mg Tablet Sig: One (1) Tablet PO once a day
as needed for constipation.
5. Jolessa 0.15-30 mg-mcg Tablet, Dose Pack, 3 Months Sig: One
(1) Tablet, Dose Pack, 3 Months PO once a day.
6. lamotrigine 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for anxiety.
8. buspirone 10 mg Tablet Sig: Two (2) Tablet PO three times a
day.
9. clonidine 0.2 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime): anxiety.
10. Beano Tablet Sig: ___ Tablets PO three times a day.
11. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every
four (4) hours as needed for fever or pain.
12. Tussin 100 mg/5 mL Liquid Sig: 120ml PO every twelve (12)
hours as needed for cold symptoms.
13. ibuprofen 200 mg Tablet Sig: Two (2) Tablet PO every six (6)
hours as needed for pain: menstrual cramps.
14. Outpatient Lab Work
Please have a basic metabolic panel with bicarbonate drawn on
___. Please fax results to
Name: ___.
Location: ___
Address: ___, ___
Phone: ___
Fax: ___
Discharge Disposition:
Home
Discharge Diagnosis:
ingestion of foreign body (2 batteries)
non-gap metabolic acidosis
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for a procedure (an endoscopy) to remove the
batteries that you swallowed. This procedure was successful and
your diet was advanced without complication. Please do not
ingest any non-food or drink items as they may be harmful or
cause choking or death.
.
Medication changes:
none
.
Please take all of your medications as prescribed and follow up
with the appointments below.
Followup Instructions:
___
|
10105923-DS-20 | 10,105,923 | 27,532,611 | DS | 20 | 2122-10-14 00:00:00 | 2122-10-14 17:15:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Antihistamines / cephalexin / famiciclovir / gluten / latex
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
TEE/Cardioversion ___
Repeat Cardioversion ___
Pacemaker implantation ___
History of Present Illness:
Ms. ___ is an ___ year old female with ___ Afib with RVR (on
metoprolol, Eliquis, and amiodarone), HTN, CKD, dementia, and
hypothyroidism transferred at family request from ___
in ___ for tachycardia and dyspnea.
Patient lives in an LTAC and was noted by staff to be
tachypneic. Vitals were obtained and showed tachycardia to 108.
Patient denied any symptoms including chest pain, cough,
abdominal pain or fever. ___ family reported history of PE and
concern about patient's ability to report symptoms ___ to
dementia she was sent to ___.
At ___ labs showed a BNP of 24,000 and a CXR showed
bilateral pleural effusions. EKG was non-ischemic with a
negative troponin. ___ these findings she was started on IV
Lasix. As this point family requested transfer to rule out
pulmonary embolism ___ persistent tachycardia.
Of note patient recently had an ECHO at ___ on ___
which showed moderate to severe mitral regurgitation most
consistent with nonischemic cardiomyopathy, 47% EF; mildly
reduced global LV systolic function with relative hypokinesis of
the basal segments first apical segment. Mild tricuspid
regurgitation. Moderate bilateral pleural effusions noted.
- In the ___, initial vitals were:
- T 97.0, HR 116, BP 126/96, RR 20, 97%RA
- Exam was notable for:
- General: confused but NAD
- Resp: Decreased breath sounds. Crackles in bases
bilaterally. Mild wheezing. No respiratory distress or
accessory muscle use.
- CV: Regular rate and rhythm, No JVD. No lower extremity
edema.
- Neuro: CN2-12 grossly intact, moving all extremities
spontaneously. Dementia.
- Labs were notable for:
11.8 138|100|26
6.7>----<245 -----------<96
39.6 4.4| 24|1.1
- ___ 17.8, PTT 34.5, INR 1.6
- ___ 28987
- Dig <0.04
- Trop-T <0.01
- Ca ___, Mg 2.0, Phos 3.6
- UA with moderate leuk, few bacteria, trace blood
- Studies were notable for:
- CTA Chest
1. No evidence of pulmonary embolism or aortic abnormality.
2. Large bilateral pleural effusions, right greater than
left.
3. Diffuse bilateral ground-glass opacities suggest
pulmonary edema.
4. 4 mm left upper lobe pulmonary nodule. Please refer to
___ criteria below for follow-up recommendations.
For incidentally detected single solid pulmonary nodule
smaller than 6 mm, no CT follow-up is recommended in a
low-risk patient, and an optional CT in 12 months is
recommended in a high-risk patient.
- The patient was ___:
- Ceftriaxone 1 gm IV
- Metoprolol 25 mg
- Furosemide 40 mg IV
- Atrius cardiology were consulted
On arrival to the floor, patient was altered and ripped out her
IV. Became calm after a few minutes and fell asleep.
Past Medical History:
Atrial Fibrillation
Cardiomyopathy
CKD
Dementia
Heart Failure, reduced EF 19%
HTN
Hypothyroidism
OSA
RA
Celiac Disease
Babesiosis in ___
Social History:
___
Family History:
Unable to obtain
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS:
24 HR Data (last updated ___ @ 042)
Temp: 97.6 (Tm 97.6), BP: 101/72, HR: 127, RR: 20, O2 sat:
97%, O2 delivery: RA
GENERAL: Resting comfortably in bed, NAD
HEENT: PERRL, EOMI. MMM.
CARDIAC: Tachycardic, no m/r/g appreciated though difficult
to assess at current HR.
LUNGS: Decreased breath sounds with crackles at the bases
bilaterally.
ABDOMEN: Soft, NT, ND, +BS
EXTREMITIES: No clubbing, cyanosis, or edema.
SKIN: Warm. No rashes.
NEUROLOGIC: Deferred ___ to patient agitation overnight.
DISCHARGE PHYSICAL EXAM
========================
24 HR Data (last updated ___ @ 805)
Temp: 96.9 (Tm 98.8), BP: 97/63 (90-120/50-72), HR: 77
(74-79), RR: 16 (___), O2 sat: 98% (96-98), O2 delivery: RA
GENERAL: Elderly frail woman lying in bed, appears comfortable,
CPAP in place.
NECK: No JVP appreciated.
CV: RRR Normal S1/S2. No murmurs.
PULM: CTAB in all fields, no crackles or wheezes. Non-labored
breathing.
EXTR: No ___ edema b/l. Warm.
NEURO: Alert and oriented x1, pleasant. No focal deficits obs.
Pertinent Results:
ADMISSION LABS:
==============
___ 06:35PM BLOOD WBC-6.7 RBC-4.22 Hgb-11.8 Hct-39.6 MCV-94
MCH-28.0 MCHC-29.8* RDW-19.9* RDWSD-67.7* Plt ___
___ 06:35PM BLOOD Plt ___
___ 06:35PM BLOOD Glucose-96 UreaN-26* Creat-1.1 Na-138
K-4.4 Cl-100 HCO3-24 AnGap-14
___ 06:49AM BLOOD ALT-22 AST-23 LD(LDH)-269* AlkPhos-76
TotBili-0.7
___ 06:35PM BLOOD ___
___ 06:35PM BLOOD cTropnT-<0.01
___ 06:35PM BLOOD Calcium-10.0 Phos-3.6 Mg-2.0
___ 06:49AM BLOOD TSH-3.3
___ 06:35PM BLOOD Digoxin-<0.4*
DISCHARGE LABS:
==============
___ 07:00AM BLOOD Plt ___
___ 07:00AM BLOOD ___ PTT-32.1 ___
___ 07:00AM BLOOD Glucose-82 UreaN-28* Creat-1.5* Na-141
K-3.9 Cl-98 HCO3-32 AnGap-11
IMAGING STUDIES:
===============
CTA CHEST ___. No evidence of pulmonary embolism or acute aortic
abnormality.
2. Mild-to-moderate cardiac enlargement.
3. Moderate enlarged bilateral pleural effusions, right greater
than left.
4. Diffuse bilateral ground-glass opacities suggest
mild-to-moderate pulmonary
edema.
5. 3 to 4 mm left upper lobe pulmonary nodule. Please refer to
___
criteria below for follow-up recommendations.
TTE ___
The left atrial volume index is SEVERELY increased. The right
atrium is mildly enlarged. The estimated right atrial pressure
is ___ mmHg. There is mild symmetric left ventricular
hypertrophy with a normal cavity size. There is SEVERE global
left ventricular hypokinesis. Quantitative biplane left
ventricular ejection fraction is 19 % (normal 54-73%). Normal
right ventricular cavity size with moderate global free wall
hypokinesis. The aortic sinus diameter is normal for gender with
normal ascending aorta diameter for gender. There is a normal
descending aorta diameter. The aortic valve leaflets (3) are
mildly thickened. There is no aortic valve stenosis. There is
trace aortic regurgitation. The mitral valve leaflets are mildly
thickened with no mitral valve prolapse. There is moderate [2+]
mitral regurgitation. The pulmonic valve leaflets are not well
seen. The tricuspid valve leaflets appear structurally normal.
There is trivial tricuspid regurgitation. The pulmonary artery
systolic pressure could not be estimated. There is no
pericardial effusion.
IMPRESSION: 1) Severe global LV systolic dysfunction and
moderate RV global systolic dysfunction.
TEE ___
There is no spontaneous echo contrast in the body of the left
atrium. There is mild spontaneous echo contrast in the left
atrial appendage. The left atrial appendage ejection velocity is
mildly depressed. No spontaneous echo contrast or thrombus is
seen in the body of the right atrium/right atrial appendage. The
right atrial appendage ejection velocity is depressed. There is
no evidence for an atrial septal defect by 2D/color Doppler.
Overall left ventricular systolic function is moderately
depressed. There are simple atheroma in the aortic arch with no
atheroma in the descending aorta to 30 cm from the incisors. No
aortic dissection is seen. The aortic valve leaflets (3) are
mildly thickened. No masses or vegetations are seen on the
aortic valve. No abscess is seen. There is trace aortic
regurgitation. The mitral valve leaflets are mildly thickened
with no mitral valve prolapse. No masses or vegetations are seen
on the mitral valve. No abscess is seen. There is moderate [2+]
mitral regurgitation. The tricuspid valve leaflets appear
structurally normal. No mass/vegetation are seen on the
tricuspid valve. No abscess is seen. There is physiologic
tricuspid regurgitation. There is a small pericardial effusion.
IMPRESSION: Mild spontaneous echo contrast but no thrombus in
the left atrial appendage. No spontaneous echo contrast or
thrombus in the body of the left atrium/right atrium/right
atrial appendage. Moderate mitral regurgitation. Moderately
depressed left ventricular function.
MICROBIOLOGY:
=============
___ 7:56 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE
IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 32 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
___ 10:33 pm URINE Source: Catheter.
**FINAL REPORT ___
REFLEX URINE CULTURE (Final ___:
GRAM NEGATIVE ROD(S). ~1000 CFU/mL.
STAPHYLOCOCCUS SPECIES. ~1000 CFU/mL.
___ 07:00AM BLOOD WBC-5.6 RBC-3.71* Hgb-10.3* Hct-34.1
MCV-92 MCH-27.8 MCHC-30.2* RDW-18.8* RDWSD-64.3* Plt ___
Brief Hospital Course:
Ms. ___ is an ___ female with ___ Afib with RVR (on
metoprolol, apixaban, and amiodarone), HTN, CKD, dementia, and
hypothyroidism transferred at family request from ___
in ___ for tachycardia and dyspnea with labs and imaging
consistent with acute on chronic HFrEF (EF 47%), likely due to
progression of tachyarrhythmia-induced cardiomyopathy (EF now
19%) due to persistent Afib w/ RVR. On ___, following
TEE/cardioversion, pt converted from afib with RVR to sinus
bradycardia. Converted back to AF on ___. She was loaded with
amiodarone for 6 days prior to repeat cardioversion ___, again
to sinus bradycardia, with subsequent pacemaker implantation
___.
TRANSITIONAL ISSUES
===================
[ ] Please perform frequent dressing checks at site of pacemaker
implantation (left upper chest wall). If recurrent bleeding or
oozing, consider holding apixaban for ___ days.
[ ] LVEF now 19%. Would recommend ongoing medication
optimization.
[ ] At rehab, we would strongly recommend daily standing weights
and notifying the MD on call if weight changes by 3 pounds in
either direction.
[ ] We would also recommend daily pulse rate checks and if
elevated the MD should be notified as this may indicate
recurrent atrial fibrillation.
[ ] Please also monitor for signs of heart failure daily --this
should include daily weights, lung auscultation for rales,
jugular venous distention, and lower extremity edema.
Furthermore, daily pulse oximeter should be checked to ensure
patient is not becoming hypoxic.
[ ] Once renal function and creatinine normalized, consider
resuming diuresis and adjust dose accordingly (presumed home
euvolemic dose of PO Lasix 40-60 mg daily). If planning to
resume diuresis, would also monitor and replete electrolytes
frequently.
[ ] With regard to her amiodarone, she should remain on 200mg
BID for 2 weeks through ___, then the dose should be reduced to
200mg daily going forward.
[ ] Consider restarting lisinopril if renal function improves
and blood pressure tolerates
Long term considerations (for cardiology/PCP follow up):
[ ] Consider restarting metoprolol ___ LV dysfunction and
history of atrial fibrillation
[ ] 4 mm left upper lobe pulmonary nodule. Per ___
criteria, for incidentally detected single solid pulmonary
nodule smaller than 6 mm, no CT follow-up is recommended in a
low-risk patient, and an optional CT in 12 months is recommended
in a high-risk patient.
[ ] Ongoing evaluation for MitraClip ___ moderate MR on our
TTE. To be followed up as an outpatient with Dr. ___.
ACUTE ISSUES
=============
#Atrial Fibrillation with RVR
#Sick sinus syndrome
Patient with recent history of atrial fibrillation requiring
cardioversion at ___ in ___ and subsequently
converted back into atrial fibrillation in the following weeks.
Presented with atrial fibrillation with rates 120s-130s. Despite
diuresis, A fib with RVR persisted. ___ the relatively rapid
progression of her tachyarrhythmia-induced cardiomyopathy, as
demonstrated on TTE on ___, successful TEE/cardioversion was
performed on ___. Afterward, patient continued to have
asymptomatic sinus bradycardia in the ___. Metoprolol was held.
Her amiodarone and apixaban were continued. Unfortunately, on
___ she went back into atrial fibrillation with rates in the
110s. A repeat cardioversion was performed on ___ which was
again complicated by asymptomatic sinus bradycardia with HR
___. We withheld metoprolol and amiodarone; a pacemaker was
implanted ___. We restarted her apixaban 2.5 BID and amiodarone
200 mg BID which will be continued through ___ before
decreasing to to a dose of 200 mg daily indefinitely.
# Acute on chronic HFrEF (47% EF previously, EF now 19%)
Patient presented with tachypnea and tachycardia, BNP 24,000 and
bilateral pleural effusions consistent with CHF exacerbation.
She underwent TTE On ___ that showed marked progression of
cardiomyopathy with LVEF 19%, severe global LV, systolic
dysfunction, moderate RV, global systolic dysfunction (before
47%), and 2+ MR. ___ her atrial fibrillation with rapid
ventricular rate, we suspect that her worsening EF is likely
secondary to tachycardia induced cardiomyopathy. Patient was
diuresed with IV Lasix and transitioned to PO, remaining
euvolemic remainder of admission. She could not tolerate
neurohormonal blockade with metoprolol ___ her bradycardia
(see below). At rehab, we would strongly recommend daily
standing weights and notifying the MD on call if weight changes
by 3 pounds in either direction. We would also recommend daily
pulse rate checks and if elevated the MD should be notified as
this may indicate recurrent atrial fibrillation. Please also
monitor for signs of heart failure daily -- this should include
lung auscultation for rales, jugular venous distention, and
lower extremity edema. Furthermore, daily pulse oximeter should
be checked to ensure patient is not becoming hypoxic. She was
euvolemic at time of discharge; lisinopril and diuretics
continued to be withheld due to elevated creatinine
(downtrending).
# Moderate mitral regurgitation
At ___, family discussed the option of Mitral Clip with
the cardiologists. Patient was evaluated by our structural heart
team who recommended she follow up as an outpatient for further
consideration. If they are still interested in this
intervention, please call the structural heart clinic at
___ to schedule a follow up appointment with Dr. ___.
#Hypoactive delirium
History of hypoactive delirium in the setting of decreased
neurocognitive reserve with advanced dementia. Per family's
report, outpatient sleep physician has attributed this delirium
to sleep apnea. Patient was intermittently unresponsive
throughout her admission without symptoms of pneumonia or UTI;
this was presumed to be due to baseline dementia and hypoactive
delirium.
CHRONIC/STABLE ISSUES:
======================
#Hypothyroidism
- Continued home levothyroxine
#Rhematoid Arthritis
- Continued home methylprednisolone
- Continued home Hydroxychloroquine
- Held home leflunomide as nonforumlary. Can be restarted as
outpatient.
- Held home celecoxib as nonformulary. Can be restarted as
outpatient.
#GERD
- Continued home famotidine
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. leflunomide 20 mg oral DAILY
2. Miconazole 2% Cream 1 Appl TP BID
3. Apixaban 2.5 mg PO BID
4. Amiodarone 200 mg PO DAILY
5. Ascorbic Acid ___ mg PO DAILY
6. Celecoxib 200 mg oral DAILY
7. Famotidine 20 mg PO DAILY
8. Hydroxychloroquine Sulfate 200 mg PO DAILY
9. Levothyroxine Sodium 175 mcg PO DAILY
10. Methylprednisolone 4 mg PO DAILY
11. Multivitamins W/minerals 1 TAB PO DAILY
12. Pyridoxine 50 mg PO DAILY
13. Magnesium Oxide 400 mg PO BID
14. Docusate Sodium (Liquid) 100 mg PO BID
15. Ferrous Sulfate (Liquid) 300 mg PO DAILY
16. Metoprolol Tartrate 50 mg PO Q6H
17. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
18. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
bloating/cramps
Discharge Medications:
1. Amiodarone 200 mg PO BID
2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
3. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
bloating/cramps
4. Apixaban 2.5 mg PO BID
5. Ascorbic Acid ___ mg PO DAILY
6. Celecoxib 200 mg oral DAILY
7. Docusate Sodium (Liquid) 100 mg PO BID
8. Famotidine 20 mg PO DAILY
9. Ferrous Sulfate (Liquid) 300 mg PO DAILY
10. Hydroxychloroquine Sulfate 200 mg PO DAILY
11. leflunomide 20 mg oral DAILY
12. Levothyroxine Sodium 175 mcg PO DAILY
13. Magnesium Oxide 400 mg PO BID
14. Methylprednisolone 4 mg PO DAILY
15. Miconazole 2% Cream 1 Appl TP BID
16. Multivitamins W/minerals 1 TAB PO DAILY
17. Pyridoxine 50 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis
==================
Acute on chronic HF with reduced EF
Atrial fibrillation with RVR
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ from ___.
WHY WERE YOU ADMITTED?
======================
- You were admitted because you were having worsening shortness
of breath caused by a heart failure exacerbation due to
recurrent atrial fibrillation.
WHAT HAPPENED WHILE YOU WERE ADMITTED?
======================================
- You were ___ medication to remove the extra fluid from your
body.
- You underwent a procedure called a cardioversion to stop your
heart from beating too fast. This was initially unsuccessful as
your atrial fibrillation recurred. We performed a repeat
cardioversion and pacemaker placement to control the heart
rhythm and keep your heart beating at an optimal speed. We
restarted your amiodarone for rhythm control and Eliquis (blood
thinner) to prevent clots from forming.
WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL?
===============================================
- Take all of your medications as prescribed.
- Follow up with your doctors as listed below.
- Your discharge weight was 114 lbs, please use this as your
baseline and notify your primary physician if you notice a
weight gain of over 3 lbs from your baseline.
It was a pleasure caring for you!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10106244-DS-7 | 10,106,244 | 22,486,493 | DS | 7 | 2148-05-17 00:00:00 | 2148-05-17 16:18:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Demerol / Methadone / Keflex / Sulfa (Sulfonamide Antibiotics) /
Iodinated Contrast Media - IV Dye
Attending: ___.
Chief Complaint:
subacute confusion and unsteady gait
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ old right-handed woman with a
history
of CAD s/p LAD stents x2 (___), chronic angina, HLD, COPD,
iron deficiency anemia getting iron infusions and DMII on an
insulin pump who presents with subacute confusion and unsteady
gait.
Patient reports that approximately 1 month ago, she began having
falls. These were characterized by her legs giving out beneath
her. One time, she fell down 12 stairs secondary to weakness
the
legs and hit her back but not her head. There are a few other
falls that she does not recall the exact circumstances. She has
never used any sort of walking aid, but recently she has needed
to hold onto walls with walking. Over the past week, she has
noticed that her gait is gotten progressively more unsteady.
There has been no sudden change just a subacute decline.
She also describes that she is more confused over the past
month.
She states, "I am not connecting words or thoughts." She
endorses a feeling of depression secondary to retiring from
nursing, which she had been doing for over ___ years.
Today, she was staying over her daughter's house and there was
an
episode that concerned her daughter for worsening confusion and
so they recommended she go to the emergency room. Patient has
difficulty describing the exact details of the episode and is
different from what the daughter tells me. Patient describes
that this morning, she felt "edgy, anxious." She "did not feel
right." Her daughter told her she was hallucinating but she
does
not remember this.
Getting collateral history from the daughter, she reports that
this morning she heard a sound of glass breaking in the kitchen
and she came downstairs and found a mass in the kitchen. Her
mom
had dropped a coffee pot. She was stumbling around the kitchen
and acting confused. It was dark outside and patient was having
visual hallucinations. She looked at the window and said, "do
see that animal eating that bird?" "Look, there is a lion eating
that bird." Her daughter further describes that she was hearing
voices coming from her grandkids bedroom however her daughter
knew that they were asleep. The patient went to check in the
bedroom to make sure that the kids were sleeping because she
kept
hearing voices. The daughter then called patient's cardiologist
who recommended she present to the emergency room.
The daughter describes two other episodes of confusion over the
past two months. On was about three weeks ago, when she was
talking about her uncle to her mother, the patient thought she
was talking about a cousin. The other time was when the patient
was on the phone with her sister, she began talking about having
upcoming ___ day off but holiday had already passed.
The daughter also describes that she has been recently stumbling
around a lot in the past week. She is also been more irritable
and forgetful recently. She was previously independent and
lives
alone.
Of note, she has an extensive cardiac history and is currently
going to cardiac rehab at ___.
Past Medical History:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS
- Insulin Dependent Diabetes Mellitus, on insulin pump
- Hypertension
- Hyperlipidemia
- Smoking
2. CARDIAC HISTORY
- CABG: None
- CAD by cath at ___ in ___
- Cath ___
1. Small vessel coronary artery disease
2. Patent DES in the mid LAD
3. Patent BMS in the distal LAD.
- Cardiac Cath ___:
Impressions:
Complex intervention of the mid LAD s/p DES to the mid LAD and a
2.0 BMS to the distal LAD complicated by a very distal wire
dissection
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY
- COPD
- Asthma
- GERD
- Depression
- ___: exploratory back surgery
- Two prior left shoulder surgeries
- Right TFCC surgery
- Polycystic ovary disease at a young age
- s/p hysterectomy for endometriosis
- Sleep apnea- patient snores very heavily and wakes several
times during the night. Has not had formal sleep study
- Kidney cysts
Social History:
___
Family History:
Mother with borderline DM, two MIs. Father CABG in ___. Older
brother with quintuple CABG when ___, passed away. Younger
brother with 2 or 3 PCI placed in ___. Uncle who "dropped dead,"
thought to be secondary to cardiac disease/ACS.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
Physical Exam:
Vitals: T: 98.0 P: 83 R: 16 BP: 123/78 SaO2: 100% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
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: MOCA 13 out of 30 with impairments in executive
functioning, visuospatial skills, recall, attention and
obstruction. On clock drawing, she drew all the numbers on the
right side of the page and did not know where to put the hands.
She had difficulty following a Luria sequence. She name 9 words
that begin with F in 1 minute. She was unable to draw a cube or
complete the trails B test. She is oriented to self, place and
date. She is able to say the months of the year backwards, but
is unable to do serial sevens. Language is fluent with intact
repetition to short phrases but not complex ones. Comprehension
was intact to simple commands but not complex ones. 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. Patient had difficulty
registering 5 words and took 5 practice rounds to remember them.
She was unable to recall any of them 5 minutes later. There was
no evidence of apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI with direction
changing nystagmus. 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.
-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, proprioception throughout. Romberg positive
with
eyes open.
-DTRs:
Bi Tri ___ Pat Ach
L 3 2 3 - -
R 3 2 3 - -
Could not assess reflexes the legs that she would not relax.
Plantar response was flexor bilaterally.
-Coordination: No dysmetria on FNF or HKS bilaterally.
-Gait: Markedly unsteady, veers to both sides. Wide-based
PHYSICAL EXAMINATION:
Vitals: Tcurrent: 97.8, BP 129/74, HR 68, RR ___, 90-93% RA
-Mental Status: Alert, oriented to person, place, and time. On
clock drawing, she drew correct clock and numbering but put the
incorrect hands on the face (drew 11:50 instead of ten past 11).
She is able to say the months of the year backwards, but is
unable to do serial sevens. Language is fluent with intact
repetition to short phrases but not complex ones. 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. Patient had difficulty
registering 3 words and but was able to identify with category
cue.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI with direction
changing nystagmus. 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.
-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, proprioception throughout. Romberg positive
with
eyes open.
-DTRs:
Bi Tri ___ Pat Ach
L 3 2 3 - -
R 3 2 3 - -
Could not assess reflexes the legs that she would not relax.
Plantar response was flexor bilaterally.
-Coordination: No dysmetria on FNF or HKS bilaterally.
-Gait: Markedly unsteady, veers to both sides, cautious as if
she is afraid to fall, difficult to characterize. Wide-based.
Pertinent Results:
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW RDWSD Plt
Ct
___ 08:10AM 12.2*# 4.48 11.6 37.1 83 25.9* 31.3*
23.2* 68.2* 251 Import Result
___ 08:10AM ERROR ERROR ERROR ERROR ERROR ERROR ERROR
ERROR ERROR ERROR Import Result
___ 07:31AM 6.3 5.07 13.2 41.1 81* 26.0 32.1 22.5*
64.4* 265 Import Result
___ 01:31PM 7.6 5.07 13.2 41.2 81* 26.0# 32.0 22.4*
63.6* UNABLE TO Import Result
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas Im
___ AbsLymp AbsMono AbsEos AbsBaso
___ 01:31PM 62.9 23.5 8.3 4.2 0.7 0.4 4.79 1.79
0.63 0.32 0.05 Import Result
BASIC COAGULATION ___, PTT, PLT, INR) ___ PTT Plt Smr Plt Ct
___
___ 10:30AM 9.7 26.9 0.9 Import Result
___ 08:10AM 251 Import Result
___ 08:10AM ERROR Import Result
___ 08:10AM 9.4 26.7 0.9 Import Result
___ 07:31AM 265 Import Result
___ 07:31AM 10.5 32.3 1.0 Import Result
___ 01:31PM UNABLE TO UNABLE TO Import Result
INHIBITORS & ANTICOAGULANTS Lupus
___ 10:30AM NEG Import Result
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
___ 08:10AM 180* 18 0.8 139 4.0 ___ Import
Result
___ 07:31AM 266* 14 0.8 134 3.9 97 23 18 Import
Result
___ 01:31PM 119* 16 0.8 142 4.0 ___ Import
Result
ESTIMATED GFR (MDRD CALCULATION) estGFR
___ 01:31PM Using this Import Result
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
___ 10:30AM 34 Import Result
___ 01:31PM 15 19 0.3 Import Result
CARDIAC MARKERS cTropnT
___ 01:31PM <0.01 Import Result
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
___ 01:05PM 6.0* Import Result
___ 08:10AM 9.0 2.8 2.1 Import Result
___ 07:31AM 9.2 3.1 2.1 110 Import Result
___ 01:31PM 4.2 9.6 3.8 2.1 Import Result
HEMATOLOGIC calTIBC VitB12 Folate Ferritn TRF
___ 07:31AM ___ 270 Import Result
DIABETES MONITORING %HbA1c eAG
___ 08:30AM 7.8* 177* Import Result
PITUITARY TSH
___ 07:31AM 1.4 Import Result
IMMUNOLOGY ___ CRP Anti-Tg dsDNA Thyrogl antiTPO
___ 10:30AM <10 LESS THAN NEGATIVE 8 LESS THAN
Import Result
___ 07:31AM NEGATIVE 8.5* Import Result
PROTEIN AND IMMUNOELECTROPHORESIS PEP IgG IgA IgM IFE
___ 01:05PM AWAITING F 652* 92 109 PND Import Result
HIV SEROLOGY HIV Ab
___ 01:05PM Negative Import Result
TOXICOLOGY, SERUM AND OTHER DRUGS ASA Ethanol Acetmnp Bnzodzp
Barbitr Tricycl
___ 01:31PM NEG NEG NEG NEG NEG NEG Import Result
LAB USE ONLY
___ 01:05PM Import Result
MRI SPINE:
1. At C5-C6, minimal retrolisthesis, broad-based posterior
endplate
osteophytes, and thickening of the ligamentum flavum cause
moderate to severe
spinal canal stenosis with spinal cord deformation, but no
evidence for cord
signal abnormalities allowing for motion artifact. There is
also severe right
and moderate to severe left neural foraminal narrowing at C5-C6.
Mild
degenerative changes are present at other cervical levels
without mass effect
on the spinal cord.
2. Normal appearance of the thoracic spinal cord and conus
medullaris.
3. Previously seen T11 vertebral body fracture demonstrates
slightly
increased, less than 10% loss of height without retropulsion or
marrow edema.
4. Previously seen L2 vertebral body fracture demonstrates new,
approximately
40% loss of height, new mild retropulsion with mild spinal canal
narrowing but
no mass effect on the intrathecal nerve roots. Residual marrow
edema is
likely present, with superimposed ___ type 1 discogenic bone
marrow change.
5. Multilevel lumbar degenerative disease with mass effect on
several
traversing and exiting nerve roots, as detailed above. No
significant mass
effect on the intrathecal nerve roots.
MRI BRAIN:
1. Study is moderately degraded by motion.
2. Extensive relatively symmetric bilateral periventricular,
subcortical, and
deep white matter lesions are nonspecific, but correspond to
hypodensities
seen on prior CT scans dating back to ___. The
distribution
suggests chronic microangiopathy as a possible etiology.
3. Within limits of study, no evidence of hemorrhage, mass,
mass effect, or
acute infarction.
4. Grossly patent circle of ___.
5. Approximately 30% narrowing of bilateral internal carotid
artery origins by
NASCET criteria.
6. Left origin vertebral artery not well visualized on current
motion degraded
exam. Otherwise, grossly patent bilateral cervical vertebral
and carotid
arteries as described.
Brief Hospital Course:
___ is a ___ year old woman with a past medical
history significant for diabetes mellitus requiring insulin
pump, CAD x stenting with baseline chronic angina, obesity, and
COPD who presented to the Neurology service with an increased
frequency in falls due to gait imbalance, and hallucinations
with memory issues.
MRI brain showed significant white matter disease/ vascular
disease . EEG was done which was negative for any slowing nor
any epileptiform discharges. Her mental status examination was
tracked and improved over a few days as we discontinued sedating
medications including Percocet and flexeril which we thought was
contributing to her altered mental status given her baseline mri
brain. We noted her mental status to improve once these
medications were discontinued as her MOCA was ___ after these
changes.
In regards to her gait , we imaged the spine with an MRI which
showed significant cervical spine disease with nerve compression
and disc portrusions as well as lumbar spine pathology which
could explain her antalgic gait. We started the patient on
gabapentin to control her nerve pain which we anticipate will
help with her gait as well.
Next, we obtained an echocardiogram given that the patient was
persistently short of breath to see her baseline EF, echo showed
normal EF. ABG was done as well and did not show any co2
retention.
Patient required nebulizers and 02 at times but was stable on
the neurology floor.
Lastly, the patient endorsed significant anxiety and depression
, for which we consulted psychiatry to help with therapy. We
noted that the patient was dependent on Xanax which we want to
also taper off and replace this with different therapy that will
improve her mental status and not cause memory issues.
We also encouraged Trazodone at night for sleep.
Patient required nebulizers and 02 at times but was stable on
the neurology floor.
Lastly, the patient endorsed significant anxiety and depression
, for which we consulted psychiatry to help with therapy and a
taper off xanax. We noted that the patient was dependent on
Xanax which we want to also taper off and replace this with
different therapy that will improve her mental status and not
cause memory issues.
We also encouraged gabapentin for pain and sleep.
Please follow the Xanax taper:
Xanax is generally tapered over several weeks by ___ per week
with close monitoring for withdrawal.
Patient was also discharged so she can attend her feraheme
infusion at the ___.
Transitions of care issues:
1. Please follow up with PCP ___ , he will put you on the
Xanax taper
2. Please take gabapentin for pain and STOP taking
cyclobenzaprine (Flexeril) and Percocet
3. Please work with your PCP to find an outpatient therapist
4. A referral to the sleep study was made for you
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
2. ALPRAZolam 0.5 mg PO BID:PRN anxiety
3. Celecoxib 100 mg oral DAILY
4. Citalopram 40 mg PO DAILY
5. Cyclobenzaprine 10 mg PO BID
6. Diltiazem Extended-Release 240 mg PO DAILY
7. Breo Ellipta (fluticasone-vilanterol) 200-25 mcg/dose
inhalation DAILY
8. Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY
9. Losartan Potassium 50 mg PO DAILY
10. Ranexa (ranolazine) 500 mg oral BID
11. Aspirin 81 mg PO DAILY
12. Clopidogrel 75 mg PO DAILY
Discharge Medications:
1. Celecoxib 100 mg oral DAILY
2. Gabapentin 100 mg PO BID
RX *gabapentin 100 mg 1 capsule(s) by mouth TWICE DAILY Disp
#*60 Capsule Refills:*3
3. Insulin Pump SC (Self Administering Medication)Insulin
Lispro (Humalog)
Basal rate minimum: 1.2 units/hr
Basal rate maximum: 1.4 units/hr
Bolus minimum: 1 units
Bolus maximum: 8 units
Target glucose: ___
Fingersticks: QAC and HS
MD acknowledges patient competent
MD has completed competency
4. Ramelteon 8 mg PO QHS
RX *ramelteon [Rozerem] 8 mg 1 tablet(s) by mouth AT NIGHT Disp
#*60 Tablet Refills:*2
5. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
6. ALPRAZolam 0.5 mg PO BID:PRN anxiety
7. Aspirin 81 mg PO DAILY
8. Breo Ellipta (fluticasone-vilanterol) 200-25 mcg/dose
inhalation DAILY
9. Celecoxib 100 mg oral DAILY
10. Citalopram 40 mg PO DAILY
11. Clopidogrel 75 mg PO DAILY
12. Diltiazem Extended-Release 240 mg PO DAILY
13. Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY
14. Losartan Potassium 50 mg PO DAILY
15. Ranexa (ranolazine) 500 mg oral BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Cervical spondylosis, Lumbar radiculopathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear ___,
You were admitted after you were having difficulty with your
memory, walking/balance, and some visual hallucinations for
which you were evaluated on the Neurology service for. You had a
number of tests done to look for causes including MRI brain , MR
spine, and a number of blood tests.
Overall, your brain MRI showed evidence of white matter disease
likely from long standing coronary artery disease and diabetes.
Thankfully no large tumors, bleeds, or strokes were seen. You
also had a number of blood tests including autoimmune testing,
thyroid testing etc. which came back negative. You were also
connected to EEG to make sure you were not having seizures, and
this test came back negative. Next, we suspected based on your
exam that you had spinal disease and we obtained an MRI spine
which showed significant nerve compression and disc bulges in
your neck and lower back which can explain both your pain and
your difficulty walking.
Lastly, we discovered that a lot of your medications probably
were making you very sedated and contributing to your memory
issues given the white matter disease in your brain, as you are
more susceptible to medication side effects.
Your Percocet was switched to gabapentin which is more suitable
for the nerve pain in your neck and back. Psychiatry evaluated
you to help with anxiety and depression and suggested a Xanax
taper which will be in your discharge summary for your PCP to
follow. In addition, they suggested outpatient therapy. Your
echocardiogram did not show a low ejection fraction.
You were discharged home and were able to receive the iron
infusion at the ___ after discharge.
We wish you the best,
Sincerely Your ___ Team
Followup Instructions:
___
|
10106434-DS-20 | 10,106,434 | 27,363,634 | DS | 20 | 2182-07-08 00:00:00 | 2182-07-19 09:40:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
hematemesis, melena
Major Surgical or Invasive Procedure:
EGD ___
History of Present Illness:
___ y/o female w/ no known PMH p/w with hematemesis and melena x3
days. She reports 8 episodes of hemetemeis associated with
lightheadedness. She also reports LLQ pain. She denies fevers
and nausea. States she has never had a GIB before. She drinks "a
small cup" of alcohol daily (whiskey-soda). No h/o liver
disease. She took an aspirin daily until last week for her lower
back pain. She reports flu like symptoms during the past week
including fatigue and chills. She denies all respiratory
complaints and chest pain. Denies tylenol use, h/o hepatitis,
HIV. Denies IVDU. Down in the ER, social work was consulted for
son, who arrived with the patient and stated that his mother at
home is "wasted". Unclear when last EtOH was however the patient
denies alcohol in the past week. GI was consulted in the ER and
recommended NG lavage which ER did not do. Rectal done by ER
showed minimal stool but heme pos without gross blood. The
patient has not seen her PCP ___ ___ years.
In ED VS were 96.4 120 133/83 18 100% RA. Labs were remarkable
for Neg UTox, Neg Serum Tox, neg U/A, HCO3 34, ALT 54, AST 140,
TBili 6.8, WBC 13 and Hct 32. Imaging: CT A/P: Cirrhosis with
splenomegaly, varices, and small amount of ascites.
Diverticulosis without evidence of diverticulitis. Fatty
infiltration of the ascending colon wall suggestive of chronic
inflammation. Porcelain gallbladder containing numerous
calcified gallstones, which increases risk for gallbladder
carcinoma. Non-emergent surgical consult is recommended.
Interventions: zofran, 2 PIVs were placed, given 2 L of NS, 80mg
IV PPI followed by GTT at 8/hr.
Vitals on transfer were 98.6 100 110/60 18 100%
ROS:
(+) Per HPI
Past Medical History:
No significant past medical or surgical history.
Social History:
___
Family History:
ETOH: whiskey daily, unclear amt, patient states she drinks a
pint per week plus some beer
Tobacco: quit ___ years ago, 7.5 pack-yr history
Drugs: denies
Living situation: in motel with sons
Physical Exam:
ADMISSION PHYSICAL
VS: 98.8 113/71 88 18 100% RA
GENERAL: AOx3, NAD, jaundiced, no asterixis
HEENT: MMM. no LAD. no JVD. neck supple.
HEART: RRR S1/S2 heard. no murmurs/gallops/rubs.
LUNGS: CTAB no crackles or wheezes, non labored
ABDOMEN: soft, nontender, nondistended.
EXT: wwp, trace edema. DPs, PTs 2+.
SKIN: dry, no rash
NEURO/PSYCH: CNs II-XII intact. strength and sensation in U/L
extremities grossly intact. gait not assessed.
DISCHARGE PHYSICAL
VS: 97.8 108/70 80 16 100% RA
GENERAL: AOx3, NAD, jaundiced improved, no asterixis
HEENT: MMM. no LAD. no JVD. neck supple.
HEART: RRR S1/S2 heard. no murmurs/gallops/rubs.
LUNGS: CTAB no crackles or wheezes, non labored
ABDOMEN: soft, nontender, nondistended.
EXT: wwp, trace edema. DPs, PTs 2+.
SKIN: dry, no rash
NEURO/PSYCH: CNs II-XII intact. strength and sensation in U/L
extremities grossly intact. gait not assessed.
Pertinent Results:
Admission labs:
___ 10:50PM BLOOD WBC-12.9* RBC-2.93* Hgb-10.5* Hct-31.8*
MCV-109* MCH-35.9* MCHC-33.1 RDW-14.1 Plt ___
___ 10:50PM BLOOD Neuts-82.4* Lymphs-14.1* Monos-3.1
Eos-0.1 Baso-0.3
___ 10:50PM BLOOD ___ PTT-35.0 ___
___ 10:50PM BLOOD Glucose-254* UreaN-24* Creat-0.4 Na-142
K-3.9 Cl-101 HCO3-34* AnGap-11
___ 10:50PM BLOOD ALT-54* AST-140* AlkPhos-132*
TotBili-6.8*
___ 10:50PM BLOOD Lipase-41
___ 08:50AM BLOOD Albumin-2.6* Calcium-8.0* Phos-3.1 Mg-1.6
Discharge labs:
___ 12:55PM BLOOD WBC-9.1# RBC-2.61* Hgb-9.4* Hct-29.3*
MCV-113* MCH-35.9* MCHC-31.9 RDW-14.2 Plt ___
___ 06:15AM BLOOD ___
___ 12:55PM BLOOD UreaN-15 Creat-0.6 Na-140 K-3.7 Cl-104
HCO3-29 AnGap-11
___ 12:55PM BLOOD ALT-66* AST-257* AlkPhos-122*
TotBili-5.7*
___ 06:15AM BLOOD Calcium-7.8* Phos-2.9 Mg-1.7 Iron-51
Liver labs:
___ 10:50PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
___ 10:50PM BLOOD Smooth-POSITIVE *
___ 10:50PM BLOOD ___ * Titer-1:40
___ 10:50PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 10:50PM BLOOD HCV Ab-NEGATIVE
CT abd/pelvis
ABDOMEN:
The liver has a nodular contour with hypertrophy of the left
hepatic lobe, most suggestive of cirrhosis. No focal hepatic
lesion is visualized on this single phase exam. The gallbladder
wall is calcified and contains numerous calcified gallstones.
The intra and extrahepatic bile ducts, pancreas, and adrenal
glands are normal. The spleen is enlarged, measuring up to 18.1
cm. The kidneys enhance symmetrically. The ureters have a
normal course and caliber. The stomach is unremarkable. The
small and large bowel have a normal course
and caliber. Colonic diverticulosis is present without evidence
for
diverticulitis. No retroperitoneal or mesenteric
lymphadenopathy. Splenic and gastric varices are present. The
portal and intra-abdominal systemic vasculature are otherwise
unremarkable. A small to moderate amount of low density ascites
is primarily perihepatic but also tracking along both pericolic
gutters into the pelvis. No abdominal wall hernia,
pneumoperitoneum, or free abdominal fluid. PELVIS: The bladder
and terminal ureters are normal. The uterus and adnexa are
unremarkable. No pelvic side-wall or inguinal lymphadenopathy.
No inguinal hernia. OSSEOUS STRUCTURES: Moderate thoracolumbar
spine degenerative changes are
present. L1 superior endplate deformity is of uncertain
chronicity, probably non-acute. No focal lytic or sclerotic
lesion concerning for malignancy. IMPRESSION: 1. Cirrhosis with
splenomegaly, varices, and small amount ascites. 2.
Diverticulosis without evidence of diverticulitis. 3. Porcelain
gallbladder containing numerous calcified gallstones, which
increases risk for gallbladder carcinoma. Non-emergent surgical
consult is recommended. 4. L1 superior endplate deformity, of
uncertain chronicity.
RUQ U/S
FINDINGS:
The hepatic architecture is nodular in appearance consistent
with the
patient's known cirrhosis. No concerning liver lesion is
identified. No
biliary dilatation is seen and the common duct measures 0.4 cm.
The wall of the gallbladder is calcified consistent with the
patient's known porcelain gallbladder. The pancreas is
unremarkable, but is only partially visualized due to overlying
bowel gas. The spleen is enlarged measuring 17.3 cm. There is
no hydronephrosis on limited views of the kidneys. A trace of
ascites is seen in the right upper quadrant. There is a small
right pleural effusion. DOPPLER EXAMINATION: Color Doppler and
spectral waveform analysis was performed. The main and right
portal veins are patent with hepatopetal flow. Flow within the
left portal vein is difficult to detect likely representing
extremely slow flow. Hepatopetal flow is seen in the SMV and
the splenic vein in the midline. The hepatic veins and IVC are
patent. Appropriate arterial waveforms are seen in the main,
right and left hepatic arteries. IMPRESSION: 1. No biliary
dilatation identified. 2. Nodular hepatic architecture with
splenomegaly and a trace of ascites. 3. Porcelain gallbladder.
4. Patent hepatic vasculature. Flow within the left portal vein
is noted to
be difficult to detect likely representing slow flow.
Brief Hospital Course:
___ y/o female with no significant past medical history
presenting with hematemesis and melena x 3 days. Initial CT scan
in the ED showed evidence of cirrhosis.
# GASTROINTESTINAL BLEED: The initial concern for this patient
was upper GIB secondary to esophageal or gastric varices. The
patient was started on a PPI drip in the emergency department.
Upon arrival to the floor she was started on ceftriaxone and
octreotide and taken to the GI endoscopy suite. EGD demonstrated
3 cords of grade I-II esophageal varices without stigmata, mild
esophagitis, and antrum erythema with few erosions/small healing
ulcer. The duodenal bulb and second part of the duodenum were
normal. The ceftriaxone and octreotide were discontinued after
the EGD. The patient was started on ciprofloxacin x 4 days and
nadolol prior to discharge. H. pylori antibody screen returned
negative. She was also discharge on a BID PO PPI and instructed
to avoid aspirin and NSAIDs.
# CIRRHOSIS/HEPATITIS: Based on the patient's history this is
likely related to alcohol abuse. AST:ALT ratio >2. The patient
denied a history of hepatitis infection, IVDA, family history of
liver disease and personal history of autoimmune disease.
Hepatitis B/C titers showed no evidence of prior or active
disease. Iron:TIBC ratio was within normal limits. ___ and
anti-SM returned mildly positive; but of undetermined clinical
significance. RUQ ultrasound showed no biliary dilatation,
nodular hepatic architecture with splenomegaly and trace
ascites. The patient's obesity and associated metabolic profile
may have predisposed her to NAFLD/NASH and related cirrhosis.
Discriminant function was ~21 on admission therefore she was
unlikely to benefit from steroids. She had no evidence of
hepatic encephalopathy. The patient was extensively counselled
on the importance of sobriety. She was seen by social work and
set up with prompt outpatient follow up.
# ANEMIA: MCV 109, baseline unclear. The patient's hematocrit
remained stable. Contributing factors to her anemia include
recent GIB, splenomegaly and alcohol abuse. B12/folate testing
should be considered as an outpatient.
# Porcelain gallbladder containing numerous calcified
gallstones, which increases risk for gallbladder carcinoma.
Non-emergent surgical consult is recommended.
TRANSITIONAL ISSUES:
********************
-Porcelain gallbladder requires non-emergent surgical consult
-Consider testing for folate/B12 deficiency
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Multivitamins 1 TAB PO DAILY
2. Aspirin 325 mg PO Q6H:PRN pain
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H Duration: 4 Days
RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth twice a
day Disp #*7 Tablet Refills:*0
2. Nadolol 20 mg PO DAILY
RX *nadolol 20 mg 1 tablet(s) by mouth once daily Disp #*30
Tablet Refills:*1
3. Omeprazole 20 mg PO BID
RX *omeprazole 20 mg 1 capsule(s) by mouth twice a day Disp #*60
Capsule Refills:*1
4. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Peptic ulcer disease
Esphageal varices
Cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure to take care of you at ___
___. You were admitted for vomiting blood and dark
stools. We diagnosed you with a stomach ulcer and cirrhosis of
the liver. It is very important that you stop taking aspirin and
other NSAIDs (Motrin, ibuprofen, Aleve, naproxen) and stop
drinking all alcohol.
Please take your medications as prescribed and follow up with
the appointments listed below.
The following changes were made to your medications:
STOPPED aspirin
Followup Instructions:
___
|
10107132-DS-15 | 10,107,132 | 28,170,894 | DS | 15 | 2176-03-24 00:00:00 | 2176-03-24 11:00:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fall, headache, nausea and dizziness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ y/o male with hx of Afib, on Coumadin s/p fall ___ days
ago with head strike. He presents today with headaches, nausea,
and dizziness. A head CT was obtained and showed a left SDH with
minimal MLS. Neurosurgery was consult for surgical planning. The
patient denies any vomiting, SOB, or CP, but c/o blurred vision
since his fall.
Past Medical History:
HTN, CAD, HLD, AS, Afib, MV prolapse, PVD, OA, Gout, spinal
stenois, BPH, HOH and ___ syndrome.
Pshx: Right SDH s/p evacuation x2 many years ago at ___
Social History:
___
Family History:
NC
Physical Exam:
Gen: WD/WN, comfortable, NAD.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger
On Discharge:
Gen: WD/WN, comfortable, NAD.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
II: PERRL, 2mm 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. No pronator drift
Sensation: Intact to light touch
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger
Pertinent Results:
___ CT CERVICAL
1. Minimal anterolisthesis of C3 on C4 and C7 on T1, likely
degenerative in nature, however acuity cannot be definitively
establish without prior
examination. If there is high clinical suspicion for
ligamentous injury, MRI, if there no contraindications would be
more sensitive.
2. No evidence of acute fracture.
3. Multilevel multifactorial degenerative changes.
4. Right thyroid nodule measuring up to 1.7 cm, for which
further ___ with thyroid ultrasound is suggested by
current ACR recommendations for
incidentally noted thyroid nodules.
___ CT HEAD W/O CONTRAST
1. Acute on chronic left subdural hematoma measuring 1.5 cm in
maximal
thickness. Subdural hematoma layering along the anterior left
falx and left tentorial leaflet is also identified.
2. 4 mm of left-to-right midline shift. Patent basal cisterns.
3. Additional findings as described above.
___ CT HEAD W/O CONTRAST
1. Limited examination due to motion artifact. Within these
limitations,
acute on chronic left subdural hematoma measures 1.2 cm in
maximal thickness without evidence of new hemorrhage. Stable
small volume subdural hemorrhage layering along the left
tentorium and anterior falx.
2. Stable 4 mm of left-to-right midline shift. Patent basal
cisterns.
Brief Hospital Course:
Pt admitted on ___ for acute on chronic left SDH s/p fall.
He presented with headache, nausea and dizziness. The patient
was admitted to the neurosurgery floor for close monitoring.
#___
Pt has a history falls at home, presents with SDH. INR upon
presentation was 2.5 he received Kcentra and Vit K to reverse
his INR which he received in the ED. He was loaded with 1 gm of
Keppra in the ED as well. Repeat CT on ___ showed stable
acute/chronic SDH. It was determined that the patient would not
undergo surgery for evacuation of the SDH as he was clinically
stable. This was communicated to the patient and his family
while at the bedside. He was seen and evaluated by ___ who
recommended discharge to home with home ___ and OT.
#Cardiac
Pt has a history of HTN, HLD, CAD, AS, Afib, MV prolaspse.
Cardiology was consulted on ___ and cleared him for surgery.
As it was determined he would not go to surgery they were
consulted a second time regarding the patients Coumadin plan. A
discussion was had and it was determined that he would hold his
Coumadin x 4 weeks and he would follow up with Dr. ___ in 4
weeks.
#Polypharmacy
Geriatrics was consulted. Their recommendations were to consult
with ___ Cardiology, ___ consults, limit use of narcotics,
and delirium precautions.
At the time of discharge the patient expressed readiness for
discharge. He was tolerating a regular diet and moving his
bowels spontaneously. He will ___ with Dr. ___ in ___s with his cardiologist to discuss resuming any
blood thinning medication
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Allopurinol ___ mg PO DAILY
3. Furosemide 10 mg PO DAILY
4. omeprazole 20 mg oral DAILY
5. Simvastatin 40 mg PO QPM
6. Warfarin 5 mg PO DAILY16
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Allopurinol ___ mg PO DAILY
3. Furosemide 10 mg PO DAILY
4. omeprazole 20 mg oral DAILY
5. Simvastatin 40 mg PO QPM
6. HELD- Aspirin 81 mg PO DAILY This medication was held. Do
not restart Aspirin until cardiology ___
7. HELD- Warfarin 5 mg PO DAILY16 This medication was held. Do
not restart Warfarin until cardiology ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Left acute on chronic SDH
CAD
Afib
MVP
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Discharge Instructions
Brain Hemorrhage without Surgery
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your ___ 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 neurosurgery ___ and
PCP ___.
***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 have been prescribed Dilantin (Phenytoin) for
anti-seizure medicine, take it as prescribed and follow up with
laboratory blood drawing in one week. This can be drawn at your
PCPs office, but please have the results faxed to ___.
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 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:
___
|
10107231-DS-16 | 10,107,231 | 27,138,036 | DS | 16 | 2133-11-20 00:00:00 | 2133-11-20 16:11:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
rofecoxib / latex / lisinopril / morphine / adhesive / Augmentin
/ Benadryl
Attending: ___.
Chief Complaint:
minimally displaced DRFx and displaced R FNFx
Major Surgical or Invasive Procedure:
Right hip replacement
History of Present Illness:
___ retired RN RHD h/o ___ disease, HTN, presents
s/p mechanical fall with R displaced FNFx, R non-displaced DRFx.
Patient reports that she was ambulating with trash bins outside
when the trash bin was subsequently hit by a car, causing her to
stumble and fall. She landed on her right hip and her right
wrist, and felt immediate pain, deformity and inability to
ambulate. She was subsequently transferred to ___ for
definitive care, and diagnosed with a right distal radius
fracture and right femoral neck fracture. Orthopedics is
consulted for further management.
On interview, the patient denies numbness and tingling distally.
She denies head strike or loss of consciousness at the time of
her injury. She reports pain in her right hip but no pain on
her
contralateral lower extremity. She denies antecedent symptoms
prior to her fall. She reports she is otherwise been in good
health, although was hospitalized approximately ___ year ago for
diverticulitis. Her ___ is under good control, and she
does not ambulate with any assistive devices. Review of systems
is otherwise negative.
Past Medical History:
___ Disease (___)
Osteoporosis
Stage III CKD (reported GFR ~30)
Osteoarthritis
HTN
Social History:
___
Family History:
Colon cancer, concern for Lynch Syndrome
Physical Exam:
VS: hemodynamically stable
GEN: NAD, A&O
CV: no cardiac distress
PULM: breathing comfortably on room air
EXT:
Right upper extremity:
- Splint in place
- EPL/FPL/DIO (index) fire
- SILT axillary/radial/median/ulnar nerve distributions
- Significant swelling and ecchymosis over R ___ digit.
- WWP
Right lower Extremity:
- ___ fire
- SILT SPN/DPN/TN/saphenous/sural distributions
- Foot warm and well-perfused
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopaedic surgery team. The patient was found
to have minimally displaced distal radius fracture and right hip
fracture. She was admitted to the orthopaedic surgery service.
The patient was taken to the operating room on ___ for
right hip hemiarthroplasty, which the patient tolerated well.
For full details of the procedure please see the separately
dictated operative report. The patient was taken from the OR to
the PACU in stable condition and after satisfactory recovery
from anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient was given ___ antibiotics and anticoagulation
per routine. The patient's home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to [] was appropriate. The ___
hospital course was otherwise unremarkable.
Minimally displaced distal radius fracture and right hip
fracture
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
WBAT RLE; NWB RUE in splint, and will be discharged on Lovenox
40 mg daily x4 weeks for DVT prophylaxis. The patient will
follow up in the orthopedic surgery trauma 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:
BUSPIRONE - buspirone 10 mg tablet. 1 tablet(s) by mouth twice a
day - (Prescribed by Other Provider)
CARBIDOPA-LEVODOPA - carbidopa 25 mg-levodopa 100 mg tablet. 1.5
tablet(s) by mouth three times a day - (Prescribed by Other
Provider)
LACTOBACILLUS COMBINATION NO.4 [PROBIOTIC] - Dosage uncertain -
(Prescribed by Other Provider)
METOPROLOL SUCCINATE - metoprolol succinate ER 25 mg
tablet,extended release 24 hr. 1 tablet(s) by mouth once a day -
(Prescribed by Other Provider)
MULTIVITAMIN - multivitamin tablet. 1 tablet(s) by mouth once a
day - (Prescribed by Other Provider)
OMEPRAZOLE MAGNESIUM [PRILOSEC OTC] - Dosage uncertain -
(Prescribed by Other Provider)
POLYETHYLENE GLYCOL 3350 [MIRALAX] - Miralax 17 gram/dose oral
powder. 1 powder(s) by mouth once a day as needed - (Prescribed
by Other Provider)
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line
3. Docusate Sodium 100 mg PO BID
4. Enoxaparin (Prophylaxis) 30 mg SC QHS
RX *enoxaparin 30 mg/0.3 mL 30 mg SC once a day Disp #*28
Syringe Refills:*0
5. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate
RX *hydromorphone 2 mg 1 tablet(s) by mouth every four (4) hours
PRN Disp #*20 Tablet Refills:*0
6. Polyethylene Glycol 17 g PO DAILY
7. Senna 8.6 mg PO DAILY
8. BusPIRone 10 mg PO BID
9. Carbidopa-Levodopa (___) 1.5 TAB PO TID
10. Omeprazole 20 mg PO DAILY
11. TraZODone 25 mg PO QHS:PRN sleep aid
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
minimally displaced DRFx and displaced R FNFx
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- WBAT RLE; NWB RUE in splint
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is
an over the counter medication.
2) Add 2.5 to 5 mg of oxycodone as needed for increased pain.
Aim to wean off this medication in 1 week or sooner. This is an
example on how to wean down:
then 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per state regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you
should drink eight 8oz glasses of water daily and continue
following the bowel regimen as stated on your medication
prescription list. These meds (senna, colace, miralax) are over
the counter and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your
physicians at discharge.
8) Continue all home medications unless specifically
instructed to stop by your surgeon.
ANTICOAGULATION:
- Please take lovenox 40mg daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
- Splint must be left on until follow up appointment unless
otherwise instructed.
- Do NOT get splint wet.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever <101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
FOLLOW UP:
Please follow up with your Orthopaedic Surgeon, Dr. ___.
You will have follow up with ############### in the Orthopaedic
Trauma Clinic 14 days post-operation for evaluation. Call
___ to schedule appointment upon discharge.
Please follow up with your primary care doctor regarding this
admission within ___ weeks and for any new medications/refills.
THIS PATIENT IS EXPECTED TO REQUIRE <30 DAYS OF REHAB
Followup Instructions:
___
|
10107267-DS-16 | 10,107,267 | 29,833,625 | DS | 16 | 2174-05-29 00:00:00 | 2174-05-31 11:50:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Tenofovir Disoproxil Fumarate
Attending: ___.
Chief Complaint:
fevers, n/v, poor PO
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with HIV, last CD4 on ___ (17%) with HIV RNA < than 20
copies/mL. on Evafirenz and Abacavir/Lamivudine who presents
with one week of subjective fevers, chills, dizziness, n/v, and
generalized weakness.
Patient reports that she has been feeling subjective fevers with
chills for the past ___ weeks, in association with a poor
appetitie and nausea, with vomiting after any PO intake. She
reports she has not been able to eat anything substantial during
this time, and has been drinking minimal water and juice. She
denies diarrhea, dysuria, chest pain, and cough.
On arrival to the ED, Temp: 98 HR: 105 BP: 93/50 Resp: 18
O(2)Sat: 100. CXR could not rule out infection, but did not
show new regions of consolidation. UA, however, revealed UTI and
she was given ceftriaxone for UTI in immunocompromised patient.
Additionally, she was given IVFs, and was admitted to the
medicine service for further evaluation and management of
infection and immune status.
On arrival to the floor, patient reports that her dizziness has
resolved following the IVFs. She continues to complain of
thirst, however, in addition to nausea, and reports 1 loose BM
since being on ___ 7. On further review, she reports that her
urine has appeared darker and cloudy over the course of the past
week; this has never happened before. She denies dysuria,
increased frequency, or incontinence. Also of note, patient
reports one episode of sharp RUQ pain, which she brushed off as
possible mittelschmertz pain (has irregular periods, last ___.
She took ibuprofen ith complete resolution of symptoms.
ROS: per HPI, denies headache, vision changes, rhinorrhea,
congestion, sore throat, cough, shortness of breath, chest pain,
abdominal pain, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria.
Past Medical History:
HIV - CD4 225 (17%), HIV RNA < than 20 copies/mL
Cerebral toxoplasmosis now on atovaquone ppx
Hypercholesterolemia
Uterine fibroids s/p myomectomies
Secondary Amenorrhea (last period ___
h/o abnormal chest CT scan/positive sputum for m. ___ ___.
Thyroid nodule - bx normal
Social History:
___
Family History:
Father DM, HTN; Mother healthy
Physical ___:
ON ADMISSION:
VS - Temp 99.3F, BP133/67 , HR96 , RR19 , O2-sat 100% RA
General: well appearing woman, lying in bed, in NAD
HEENT: NCAT, MMM, no LAD appreciated; pupils equal and reactive
to light; no erythema or signs of oral candidiasis
Neck: supple, JVP flat
CV: RRR, nl s1/s2, no m/g/r
Lungs: CTAB, no crackles, rhonchi
Abdomen: soft, nontender, nondistended; well-healed mid-line
infra-umbilical scar at site of prior myomectomy; no RUQ pain;
no rebound or guarding; could not appreciate liver edge
Ext: WWP, multiple well-healed scars over lower extremities;
no rashes
Neuro: very pleasant, AOx3, EOMI
AT DISCHARGE:
VS - Tm 100.2 Tc98.2, BP100-110s/60-90s, HR80-90s , RR18-22,
O2-sat 99% RA
General: sitting up in bed, comfortable, in NAD
HEENT: NCAT, MMM, no LAD appreciated; pupils equal and reactive
to light; improved oral candidiasis
Neck: supple, JVP flat
CV: RRR, nl s1/s2, no m/g/r
Lungs: CTAB, no crackles, rhonchi
Abdomen: soft, nontender, nondistended; well-healed mid-line
infra-umbilical scar at site of prior myomectomy; no RUQ pain;
no rebound or guarding; could not appreciate liver edge
Ext: WWP, multiple well-healed scars over lower extremities;
no rashes
Neuro: very pleasant, AOx3, EOMI
Pertinent Results:
___ 09:08AM BLOOD WBC-18.5*# RBC-3.77* Hgb-10.3* Hct-31.7*
MCV-84 MCH-27.5 MCHC-32.7 RDW-13.9 Plt ___
___ 09:08AM BLOOD Neuts-86.3* Lymphs-8.6* Monos-3.9 Eos-0.8
Baso-0.4
___ 08:00AM BLOOD WBC-11.1* RBC-3.47* Hgb-9.7* Hct-28.9*
MCV-83 MCH-27.9 MCHC-33.4 RDW-14.0 Plt ___
___ 11:45AM BLOOD WBC-10.3 RBC-3.42* Hgb-9.4* Hct-28.5*
MCV-83 MCH-27.4 MCHC-32.9 RDW-14.0 Plt ___
___ 09:08AM BLOOD Glucose-216* UreaN-30* Creat-1.4* Na-137
K-3.4 Cl-102 HCO3-19* AnGap-19
___ 11:45AM BLOOD Glucose-187* UreaN-13 Creat-0.8 Na-140
K-3.0* Cl-105 HCO3-21* AnGap-17
___ 09:08AM BLOOD ALT-53* AST-58* AlkPhos-219* TotBili-0.7
___ 08:00AM BLOOD ALT-58* AST-63* AlkPhos-200* TotBili-0.5
___ 11:45AM BLOOD ALT-51* AST-39 AlkPhos-176*
CXR ___: Asymmetric left greater than right basilar
opacities. On the left it may represent a combination of
scarring and atelectasis noting that acute infection is not
completely excluded. No new region of consolidation.
ABDOMINAL U/S ___: Unremarkable abdomen ultrasound.
Brief Hospital Course:
___ with HIV (CD4 200s) on HAART who p/w ___ weeks of fever and
malaise, found to have UTI on UA with ?early urosepsis given
constitutional symptoms.
ACTIVE ISSUES:
# fevers/chills/n/v: Patient complaining of fevers, chills, and
n/v. In the ED, found to have UTI and was empirically started
on ceftriaxone, per recommendations for treatment of UTI in
immunocompromised patient. Blood cultures were taken, but
remained without growth during hospitalization. Urine culture
grew pan-sensitive E. coli on hospital day 3 and ceftriaxone was
changed to ciprofloxacin at discharge. During hospitalization,
ID curbsided, who recommended further workup of kidneys for
possible pyelonephritis in immunocompromised host. Abdominal
U/S unremarkable. Patient's last fever to 100.9 less than 24
hours prior to discharge; however, patient expressed strong
desire to go home. Discussed at length with patient the dangers
of going home without at least 24 hours of being afebrile;
patient expressed understanding and promised to continue
monitoring temperatures at home with close follow-up with her
physicians. She denied N/V, lightheadedness, and reported
feeling much better at discharge.
___: Admission creat 1.4, BUN 30; likely prerenal given h/o
decreased PO intake. Appeared dry on exam. After IVFs,
creatinine came back down to baseline of 1.0.
# HIV: Last CD4 on ___ (17%) and HIV RNA<20 copies/mL.
Other sources of infection were considered in this
immunocompromised host. CXR appeared to be unchanged from
prior. RUQ u/s unremarkable for gallbladder pathology, which
was suspected as patient had mild transaminitis on admission.
Blood cultures NGTD. Patient continued on home atovaquone and
HAART regimen. Also started on nystatin mouthwash for thrush
found on exam.
INACTIVE:
# h/o toxoplasmosis c/b seizure: continued levetiracetam
#HL: continued rosuvastatin
TRANSITIONAL:
#anemia: Patient with Hct of 28.5 at discharge. Patient
asymptomatic. No history of bleeding. Guaiac negative.
Further work-up recommended.
#CODE STATUS: Full
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. LeVETiracetam 750 mg PO BID
2. Atovaquone Suspension 750 mg PO BID
3. Rosuvastatin Calcium 10 mg PO DAILY
4. Efavirenz 600 mg PO HS
5. abacavir-lamivudine *NF* 600-300 mg Oral daily
Discharge Medications:
1. Atovaquone Suspension 750 mg PO BID
2. Efavirenz 600 mg PO HS
3. LeVETiracetam 750 mg PO BID
4. Rosuvastatin Calcium 10 mg PO DAILY
5. abacavir-lamivudine *NF* 600-300 mg Oral daily
6. Nystatin Oral Suspension 5 mL PO QID
RX *nystatin 100,000 unit/mL 5 mL by mouth four times a day Disp
___ Milliliter Refills:*0
7. Ciprofloxacin HCl 500 mg PO Q12H Duration: 7 Days
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth twice a day Disp
#*14 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
urinary tract infection
HIV
hypotension
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 ___ for fevers. On initial
evaluation, you had a low blood pressure and were feeling dizzy.
We gave you intravenous fluids which helped your blood pressure
and made your dizziness go away.
In the emergency room, you were found to have a urinary tract
infection. You were treated with intravenous antibiotics. At
discharge, we sent you home on a 7-day course of oral
antibiotics. It is very important to take this for the full
seven day course, even if you feel better before you are done.
Sometimes urinary tract infections can spread to the blood. We
took some blood samples to look for infection in your blood. So
far, we have not found bacteria in your blood. If we find any
bacteria in your blood samples, we will notify you to come back
immediately to hospital.
It is very important to take your temperature if you feel
feverish or unwell or have chills. Please call your doctor
immediately if you have a temperature above ___, or if you are
unable to eat or drink.
Please continue your medications, in addition to the new
antibiotic, as they are prescribed. We have also made follow-up
appointments with some of your doctors. ___ attend these
appointments, or reschedule as needed.
It was a pleasure caring for you!
Followup Instructions:
___
|
10107664-DS-11 | 10,107,664 | 22,578,905 | DS | 11 | 2160-05-21 00:00:00 | 2160-05-23 15:01:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Aspirin
Attending: ___
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Briefly, Mr. ___ is a ___ yoM with recent pancytopenia,
splenomegaly, monoclonal gammopathy in transformation to
smoldering multiple myeloma, severe spinal stenosis L5-S1 where
there is severe bilateral neural foraminal narrowing, and stage
I-II liver fibrosis p/w severe back pain.
Pt states he went bowling day prior to admission and awoke
morning with severe ___ lower back pain, non-radiating, worse
with movement, minimally better with rest. Unable to walk due to
pain. Has numbness and tingling in both feet no increase over
his baseline. No urinary retention or bowel control. No saddle
anesthesia. He had an MRI two weeks ago that showed severe
spinal stenosis. No f/c/cp/sob/abd pain.
Patient relays that he has had over the past ___ years, lower
bilateral back pain with radiating pain down the legs and
associated paresthesias. The pain that started today is
different however than previously.
In the ED, initial vitals were:
97.7 70 122/68 18 98% RA
- Exam notable for:
no ttp over the L/S spine, decreased sensation in bilateral
feet, no perineal anesthesia, normal rectal tone. ___ strength
in BLE, normal reflexes, neg babinski's.
- Labs notable for:
WBC 2.6, Hgb 9.8, Plt 53
___
- Imaging was notable for:
MRI notable for:
IMPRESSION:
1. Interval development of fluid within the L3-4 and L4-5
intervertebral discs since the study of ___.
Although this finding could be seen in the setting of infection,
the adjacent vertebral endplates appear normal and there is only
minimal enhancement of the discs after contrast administration.
Thus, this is most likely a manifestation of degenerative disc
disease.
2. Severe degenerative disc disease otherwise appears unchanged
since the prior study.
- Patient was given:
___ 11:09 PO Diazepam 5 mg
___ 11:09 PO OxyCODONE (Immediate Release) 5 mg
___ 11:13 PO Acetaminophen 1000 mg
___ 11:13 PO/NG Diazepam 5 mg
___ 12:29 PO OxyCODONE (Immediate Release) 5 mg
___ 13:53 IV Morphine Sulfate 2 mg
___ 14:47 PO Lorazepam .5 mg
___ 18:56 TD Lidocaine 5% Patch 1 PTCH
Upon arrival to the floor, patient reports that he has had ___
pain today. Lying down straight he feels nothing. Pain stays in
the lower back when he moves. He also feels ongoing sciatica. No
weakness. Has continuing numbness in the toes and ankles and
lower part of legs and dorsum of the feet. Reports no saddle
anesthesia. No urinary retention or fecal incontinence.
This morning, patient reports story as above. Pain is aggravated
by any back movement, but is minimal if lying flat. No BMs in
the hospital, has been urinating well.
Past Medical History:
gastric cancer (___)
Hernia repair
HLD
severe lumbar DJD:
--L5 b/l radiculopathies with sensorimotor polyneuropathy with
mixed axonal and demyelinating features.
Stage I-II liver fibrosis
IgG kappa monoclonal gammopathy. On bone marrow biopsy: 9 or 10%
involvement by plasma cells, consistent with monoclonal
gammopathy in transformation to smoldering multiple myeloma and
possible MDS as well.
Social History:
___
Family History:
His mother had gastric cancer, sister had breast cancer, and his
father died of alcoholic cirrhosis.
Physical Exam:
ADMISSION EXAM
==============
VITAL SIGNS: 97.7 PO 144 / 76 51 95 Ra
GENERAL: Patient appears younger than stated age in NAD lying
comfortably flat on back
HEENT: NCAT, PERRLA, EOMI, no LAD
CARDIAC: S1/S2, RRR
LUNGS: CTA anteriorly, could not move to examine the back
ABDOMEN: soft, non tender, non distended
EXTREMITIES: No bruising, rashes or echymosses. Straight leg
raise positive
NEUROLOGIC: Sensation to soft touch and pinprick sensation is
diminished in the dorsum of feet bilaterally and dorsum of toes,
and lower legs. down going toes. ___ strength intact in lower
extremities but exam limited by pain. Reflexes 2+ in lower
extremities. LABS: reviewed. See below.
DISCHARGE EXAM
==============
VITAL SIGNS: 97.5PO 117/66 56 18 94RA
GENERAL: NAD, lying comfortably flat on back
CARDIAC: S1/S2, RRR
LUNGS: CTAB anteriorly
ABDOMEN: soft, non tender, non distended
EXTREMITIES: No bruising, rashes or echymosses. Straight leg
raise positive bilaterally.
BACK: No pain over spinous processes, no step-offs, slight
paraspinous muscle pain.
NEUROLOGIC: Sensation to soft touch intact in lower extremities.
___ strength intact in lower extremities but exam limited by
pain.
Pertinent Results:
ADMISSION/DISCHARGE LABS
==============
___ 01:30PM BLOOD WBC-2.6* RBC-3.12* Hgb-9.8* Hct-29.4*
MCV-94 MCH-31.4 MCHC-33.3 RDW-13.5 RDWSD-46.3 Plt Ct-53*
___ 01:30PM BLOOD Neuts-61 Bands-1 ___ Monos-7 Eos-1
Baso-0 Atyps-4* ___ Myelos-0 AbsNeut-1.61 AbsLymp-0.78*
AbsMono-0.18* AbsEos-0.03* AbsBaso-0.00*
___ 01:30PM BLOOD Hypochr-NORMAL Anisocy-OCCASIONAL
Poiklo-1+ Macrocy-OCCASIONAL Microcy-NORMAL Polychr-OCCASIONAL
Ovalocy-1+ Tear Dr-OCCASIONAL
___ 01:30PM BLOOD Plt Smr-VERY LOW Plt Ct-53*
___ 01:30PM BLOOD Glucose-102* UreaN-22* Creat-0.7 Na-142
K-4.1 Cl-108 HCO3-23 AnGap-15
IMAGING
=======
___ MR ___
IMPRESSION:
1. Interval development of fluid within the L3-4 and L4-5
intervertebral discs
a since the study of ___. Although this finding
could be seen in
the setting of infection, the adjacent vertebral endplates
appear normal and
there is only minimal enhancement of the discs after contrast
administration.
Thus, this is most likely a manifestation of degenerative disc
disease.
2. Severe degenerative disc disease otherwise appears unchanged
since the
prior study.
Brief Hospital Course:
HOSPITAL COURSE
===============
Mr. ___ is a ___ man with lumbar
degenerative joint disease, spinal stenosis, pancytopenia with
likely smoldering multiple myeloma who presented with severe
back pain. The patient experienced this pain the morning after
he felt a twinge while bowling. Fluid notable on spine MRI,
likely not infectious, and may be secondary to inflammation from
DJD. Symptoms control with Tylenol, oxycodone, flexeril. No
systemic signs of cord compression or infection.
ACTIVE ISSUES
=============
# Lower back pain
# Degenerative joint disease:
# Back and lower extremity numbness pain and paresthesias:
Patient was being seen by multiple specialists including
neurology and was going to see the spine clinic on day of
admission to evaluate his multilevel lumbar degenerative changes
with spinal stenosis, when he had acute worsening of back pain
to the point he could not move without extreme discomfort. He
may have worsened pain after inadvertently hurting it during
activity (bowling). There was fluid notable on MRI, likely not
infectious, and may be secondary to inflammation from DJD.
Spinal stenosis may have contributed to patient's pain prior to
presentation as well. No symptoms of infection or cord
compression. Symptoms controlled with Tylenol, oxycodone,
flexeril; avoiding NSAIDS due to prior gastric cancer with
partial gastrectomy and concern for bleed. Patient able to
ambulate and pain tolerable by time of discharge.
# Pancytopenia: Unclear etiology, but underwent extensive work
up including bone marrow biopsy by hem/onc and underwent
extensive liver work up and liver etiology for pancytopenia was
not found. Hem/onc believes he may have some element of
myelodysplastic syndrome; however, there were no cytogenetic
abnormalities on biopsy and he had a 9% involvement of plasma
cells consistent with monoclonal gammopathy, bordering
smoldering multiple myeloma. Stable inpatient, will be seen by
Dr. ___ for follow up
CHRONIC ISSUES
==============
# HLD: Continued statin.
# BPH: Continued tamsulosin.
TRANSITIONAL ISSUES
===================
[] New medications
- Cyclobenzaprine 10 mg PO/NG TID:PRN pain
- OxyCODONE (Immediate Release) ___ mg PO/NG Q6H:PRN
[] Patient instructed to call PCP (___) in the next two
weeks
[] consider outpatient physical therapy and/or epidural steroid
injections if symptoms fail to improve.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Simvastatin 20 mg PO QPM
2. Tamsulosin 0.4 mg PO QHS
3. Topiramate (Topamax) 25 mg PO BID
4. TraMADol 50 mg PO DAILY:PRN Pain - Moderate
5. Centrum Silver
(multivit-min-FA-lycopen-lutein;<br>mv-min-folic acid-lutein)
0.4-300-250 mg-mcg-mcg oral DAILY
6. Cyanocobalamin 500 mcg PO DAILY
7. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
Discharge Medications:
1. Cyclobenzaprine 10 mg PO TID:PRN pain
RX *cyclobenzaprine 10 mg 1 tablet(s) by mouth Three times a day
as needed Disp #*21 Tablet Refills:*0
2. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth Every six hours as
needed Disp #*10 Tablet Refills:*0
3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
4. Centrum Silver
(multivit-min-FA-lycopen-lutein;<br>mv-min-folic acid-lutein)
0.4-300-250 mg-mcg-mcg oral DAILY
5. Cyanocobalamin 500 mcg PO DAILY
6. Simvastatin 20 mg PO QPM
7. Tamsulosin 0.4 mg PO QHS
8. Topiramate (Topamax) 25 mg PO BID
9. TraMADol 50 mg PO DAILY:PRN Pain - Moderate
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis
- Spinal stenosis
Secondary diagnosis
- Pancytopenia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital because you were having severe
back pain. A repeat MRI was normal; your pain is likely from
pulling a muscle while bowling.
We started several medications which helped your pain, and you
were able to walk with nursing. We feel that with supportive
care, you will continue to improve. If your symptoms persist,
you may benefit from outpatient physical therapy.
It was a privilege to care for you in the hospital, and we wish
you all the best.
Sincerely,
Your ___ Health Team
Followup Instructions:
___
|
10107664-DS-13 | 10,107,664 | 25,136,353 | DS | 13 | 2162-01-27 00:00:00 | 2162-01-28 08:58:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Aspirin
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
Temporary HD Line Placement
History of Present Illness:
___ is an ___ man with MDS/MPN, DLBCL, smoldering
myeloma, remote gastric cancer, cirrhosis, who presents with
severe LUQ pain hours after splenic arterial embolization for
large splenomegaly with splenic infarcts and subcapsular
hematoma.
Mr. ___ was diagnosed with MDS/MPN in ___, but began
to have worsening macrocytic anemia ___ with workup
culminating in a BM Bx done ___ showing MDS with acquisition
of trisomy 8 and mutations in RUNX1 and KRAS. In ___, he
began
to have worsening leukocytosis and repeat BM Bx ___ was
consistent with evolving MDS/MPN overlap. CT A/P done in late
___ also demonstrated worsening splenomegaly and subcapsular
splenic hematoma.
He was admitted ___ for the splenic findings. He remained
HDS during that admission. ACS was consulted and recommended ___
splenic artery embolization to shrink spleen size and control
bleeding if possible prior to considering splenectomy. However,
on review of images with ___, embolization was deferred as there
was no evidence of active bleed.
After discharge, he continued to have LUQ pain and repeat CT
___
showed new splenic infarcts and increased perisplenic hemorrhage
without active extravasation. He therefore underwent outpatient
___ splenic artery embolization via left radial access on ___
(day prior to admission).
Mr. ___ reports that on the way home from his procedure,
he began to note LUQ pain. This accelerated over the course of
hours until he was experiencing the worst pain of his life. He
describes it is a sharp, stabbing/hitting with a hammer,
continuous pain that is worse with movement, deep breaths, and
eating. He reports associated nausea but no emesis, diarrhea,
fevers, chills. He did notice some dampness without frank night
sweats.
He spoke with his outpatient oncologist who recommended
presentation to the ED for further evaluation.
In the ED: T 97.5 | 84 | 117/85 | 100% RA. He was noted on exam
to have tender splenomegaly a bedside FAST exam was negative.
Splenic ultrasound did not reveal increased hematoma. A CTA A/P
was then obtained, showing worsened subcapsular hematoma without
active extravasation and numerous small air locules in the
spleen.
He was given IV morphine 4, dilaudid 1 x 2, Zofran 4 prior to
admission.
=== REVIEW OF SYSTEMS ===
Constitutional: No fevers, chills. Non drenching night sweats
per
HPI. Appetite is decreased in s/o pain. No fatigue
Neurologic: No headache, blurry vision.
HEENT: No rhinorrhea, sore throat
Cardiovascular: No chest pain, palpitations
Respiratory: No shortness of breath, cough
Gastrointestinal: Per HPI
Genitourinary: No dysuria
Hematologic: No blood per rectum, epistaxis
Musculoskeletal: No myalgias, swelling
Dermatologic: No rashes
All other review of systems are negative unless stated otherwise
Past Medical History:
-Diffuse large B cell lymphoma
-Smoldering multiple myeloma
-MDS/MPN
-Gastric cancer, resected in ___, no chemotherapy or
radiotherapy, with no evidence of disease recurrence since that
time.
-Hypercholesterolemia
-Severe lumbar degenerative joint disease
-Peptic ulcer
-Sciatica and severe DJD
Oncologic hx:
- ___: Develops mild leukopenia (WBC 3.3) and
thrombocytopenia
(142,00).
- ___: Found to have monoclonal IgG kappa representing 7%
of total protein, approximately 500 mg/dL. Serum free light
chain
ratio at that time was 3.62, with quantitative IgG 1200, IgA
155,
and IgM 63. There was no ___ proteinuria. BUN,
creatinine, and calcium all normal. This was thought to
represent
MGUS.
- ___: Initial evaluation by Dr. ___ at ___, who
agrees with the diagnosis of MGUS, but believes that the mild
leukopenia and transient thrombocytopenia represent a separate
process. She recommends monitoring of SPEP and SFLC q4-6 months,
then yearly if stable, as well as yearly CBC monitoring.
- ___: Transitions Hematology care to Dr. ___ at
___, who also plans to monitor SPEP, SFLC, and CBC
periodically.
- ___: Incidentally noted to have progressive cytopenias on
evaluation for steroid injection for lower back pain, with WBC
3.0 (66% PMNs, 28% Lymphs, 5% Monos, 1% Atypical), Hgb 11.0, Plt
72. Also noted on renal ultrasound to have splenomegaly to 14.5
cm.
- ___: Bone marrow biopsy reveals hypercellularity for age
(70-80%), with maturing trilineage hematopoiesis and mildly
increased megakaryocytes, with plasma cells representing 9% of
aspirate differential. Flow cytometry consistent with
involvement
by a kappa-restricted plasma cell dyscrasia. The history of
cytopenias, hypercellular marrow and mild megakaryocytic
abnormalities raised the possibility of an evolving
myelodysplastic syndrome. Cytogenetics revealed 46,XY[20] with
FISH positive for t(11;14). Because of a firm liver edge and
mild
splenomegaly he was referred to Hepatology. It is Dr. ___ that this likely represents an early/evolving
myelodysplastic syndrome.
- ___: Evaluated by Drs. ___ of Hepatology,
who
recommend a Fibroscan, which demonstrated a score of 8.8 kPa,
consistent with liver scarring at a Metavir Stage 2, possibly
indicative of moderate fibrosis.
- ___: EGD does not demonstrate any esophageal varices.
- ___: Liver biopsy demonstrates active hepatitis and focal
lymphocytic cholangitis with rare granuloma associated with a
large central vein.
~ ___: Develops a palpable right supraclavicular lymph node
in
the context of 25 pound weight loss over the preceding year. He
denies fever and night sweats.
- ___: PET scan demonstrates FDG-avidity in a right
supraclavicular lymph node, diffusely abnormal mildly-increased
FDG uptake throughout the skeleton, and mild splenomegaly
without
FDG uptake.
- ___: Undergoes excisional biopsy of right supraclavicular
lymph node which indicates DLBCL positive for CD20, CD10, BCL6,
negative for MUM1 in the majority of cells, Ki67 70%, germinal
center phenotype by ___, cytogenetics with
46,XY,add(16), negative for translocations involving myc, Bcl2,
and Cyclin D1.
- ___: Repeat bone marrow biopsy at ___ by Dr. ___.
This reveals markedly hypercellular bone marrow for age (70-80%
cellular) with mild dyspoiesis, involvement by plasma cell
dyscrasia ___ kappa light chain restricted plasma cells). No
diagnostic morphologic findings of involvement by lymphoma were
seen. Karyotype demonstrated 46,XY[20], with FISH negative for
MDS panel; however, FISH did again demonstrate t(11;14),
consistent with prior plasma cell dyscrasia finding. Rapid Heme
panel reveals mutations in ASXL1, EZH2, TET2, CBL, and RIT1,
consistent with underlying/evolving myelodysplastic syndrome.
Serum monoclonal IgG kappa 480 mg/dL. Therefore, he was
additionally diagnosed with MDS ___ score 3 consistent with
low risk disease) and smoldering multiple myeloma.
- ___: C1 rituximab.
- ___: C1 CHOP.
- ___: Frankly neutropenic and thrombocytopenic on C1D10 of
CHOP. Filgrastim 300 mcg x 1 and platelet transfusion
administered.
- ___: Ongoing severe neutropenia without fever; filgrastim
480 mcg x 1 administered. Given these significant cytopenias
(likely related to underlying MDS), the treatment plan is
altered
to consist of definitive involved field radiotherapy with
rituximab/prednisone alone (i.e. no further cytotoxic
chemotherapy).
- ___: C2 rituximab/prednisone. Platelet transfusion
administered.
- ___: Ongoing cytopenias (platelet count 16,000 per
microliter), transfused 1 unit platelets. Initial evaluation by
Drs. ___ of Radiation Oncology, who plan
to perform definitive involved field radiotherapy.
- ___: Platelet count 9,000 per microliter, ANC 1120.
Platelet transfusion administered and given a 5 day course of
prednisone 50 mg daily.
- ___: Initiates radiotherapy for DLBCL. Platelet count
31,000 per microliter, ANC 4100.
- ___: Improvement in thrombocytopenia to 42,000 per
microliter, ANC 1520.
- ___: Completes radiotherapy.
- ___: C3 rituximab/prednisone.
- ___: PET reveals interval resolution of previously seen
FDG
avid right supraclavicular lymphadenopathy, with no evidence of
new FDG avid disease. Additionally, interval increase in size of
non-FDG-avid splenomegaly (to 17.6 cm) was noted, as well as
unchanged mild diffuse FDG uptake in the skeleton.
- ___: CBC stable. Monoclonal protein improved (120 mg/dL)
and serum free light chain ratio improved (1.2),
- ___: CBC again stable (WBC 2.2, ANC 1170, Hgb 9.8, Plt
66).
- ___: CBC again stable (WBC 3.5, ANC 2210, Hgb 9.2, Plt 70,
kappa/lambda ratio 1.5).
- ___: CBC shows worsening anemia (Hgb 8.1, MCV 102) but
improved thrombocytopenia (115). Serum free kappa/lambda ratio
1.6.
- ___: Again worsening macrocytic anemia is noted (Hgb 7.8,
MCV 105).
- ___: Bone marrow biopsy performed:
Pathology: Consistent with involvement by the patient's known
myelodysplastic syndrome and plasma cell dyscrasia.
Cytogenetics: 47,XY,+8[1]/46,XY[19]
Myeloid Sequencing: 4 mutations were detected by targeted next
generation sequencing: RUNX1 exon 8 frameshift deletion S322fs;
TET2 Q740*; KRAS D33E; and EZH2 D620E. Findings are associated
with an aggressive clinical course with increased risk of
progression to acute myeloid leukemia.
- ___: Darbepoetin 300 mcg SC q2weeks initiated.
- ___: 2 units PRBC transfusion for hemoglobin 5.8 g/dL.
- ___: Repeat hemoglobin level 7.8 g/dL.
- ___: Reports new left upper quadrant abdominal pain. CT
abdomen/pelvis revealed significant increase in splenomegaly to
22.5 cm compared to the PET scan from ___. In addition, there
appears to be several splenic infarcts, as well as a
subscapsular
splenic hematoma. He is transfusde 1 unit PRBCs.
- ___: Transfused 1 more unit PRBCs and admitted for
evaluation and management of the splenic hematoma. Both General
Surgery and Interventional Radiology are consulted regarding
management options for the subcapsular splenic hematoma.
Ultimately, it is decided to proceed with conservative
management, with the plan for splenic arterial coil embolization
in the event of worsening splenic hemorrhage.
- ___: Discharged to home after stable hemoglobin level of
8.4 g/dL without transfusion since ___. Darbepoetin in case
at all contributory to splenic infarct/hematoma.
- ___: Hemoglobin stable at 8.6 g/dL. PET scan reveals no
evidence of FDG avid uptake in the chest, abdomen, or pelvis,
stable retroperitoneal adenopathy without FDG-avidity, marked
splenomegaly without FDG avidity, interval increase in diffuse
FDG uptake in the
skeleton, multiple bilateral pulmonary nodules measuring up to
0.4 cm, and a hypodense non-FDG-avid cystic lesion in the
pancreatic uncinate process.
- ___: Hemoglobin decrease to 6.9 g/dL, transfused 1 unit
PRBCs.
- ___: Hemoglobin 7.2 g/dL.
- ___: Hemoglobin 7.4 g/dL. Repeat bone marrow biopsy
performed for persistent left-shifted leukocytosis (WBC
22,500/uL
with 83% neutrophils, 2% Metas, 2% Myelos, and 1% blasts).
Social History:
___
Family History:
Mother died from gastric cancer in her ___. Sister had breast
cancer in her mid-___, currently recovered. Has three sisters
and
one son.
Physical Exam:
ADMISSION PHYSICAL EXAM:
=========================
VITALS: T 98.6 F | 116/74 | 98 | 93% RA
General: Uncomfortable appearing man occasionally wincing in
pain
during interview, looks younger than stated age
Neuro:
PERRL, palate elevates symmetrically. Oriented, provides clear
history. Occasional dozing off when interviewed at 3 am.
HEENT: Oropharynx clear, MMM
Cardiovascular: RRR no murmurs. JVP at base of neck
Chest/Pulmonary: Decreased breath sounds at bilateral bases.
Respiratory effort limited ___ pain
Abdomen: Large splenomegaly, tender to palpation over the LUQ,
no
rebound. audible bowel sounds. Nondistended
Extr/MSK: No peripheral edema. Left radial access site dressed
with gauze and tegaderm. C/d/i and nontender to palpation
Skin: No rashes
Access: PIV
DISCHARGE PHYSICAL EXAM:
==========================
___ 0510 Temp: 98.2 PO BP: 119/76 HR: 76 RR: 20 O2 sat: 96%
O2 delivery: Ra
General: NAD
HEENT: Oropharynx clear, MMM
CV: RRR, nl s1/s2, no m/r/g
Chest: CTAB
Abdomen: Soft, NT/ND, no rebound/guarding.
Ext: WWP, no ___ edema
Skin: No rashes
Pertinent Results:
ADMISSION LABS:
================
___ 07:35AM BLOOD WBC-40.5* RBC-2.34* Hgb-7.1* Hct-21.5*
MCV-92 MCH-30.3 MCHC-33.0 RDW-16.8* RDWSD-55.4* Plt ___
___ 07:35AM BLOOD Neuts-69 Bands-6* Lymphs-6* Monos-3*
Eos-3 Baso-2* ___ Metas-5* Myelos-5* Blasts-1*
AbsNeut-30.38* AbsLymp-2.43 AbsMono-1.22* AbsEos-1.22*
AbsBaso-0.81*
___ 07:35AM BLOOD ___ PTT-30.3 ___
___ 07:35AM BLOOD Plt Smr-LOW* Plt ___
___ 12:00AM BLOOD D-Dimer-1646*
___ 11:27AM BLOOD ___ 01:35PM BLOOD G6PD-NORMAL
___ 07:35AM BLOOD UreaN-25* Creat-1.0 Na-142 K-4.1 Cl-104
HCO3-26 AnGap-12
___ 07:35AM BLOOD ALT-36 AST-38 LD(LDH)-274* AlkPhos-145*
TotBili-0.7
___ 07:35AM BLOOD TotProt-6.7 Albumin-4.2 Globuln-2.5
Calcium-9.2 UricAcd-6.5
DISCHARGE LABS:
=================
___ 05:30AM BLOOD WBC-3.0* RBC-2.55* Hgb-7.5* Hct-22.4*
MCV-88 MCH-29.4 MCHC-33.5 RDW-14.5 RDWSD-46.4* Plt Ct-7*
___ 05:30AM BLOOD Glucose-102* UreaN-32* Creat-0.7 Na-137
K-4.4 Cl-103 HCO3-23 AnGap-11
IMAGING/REPORTS:
===========
___ Splenic US:
FINDINGS:
SPLEEN: The spleen is enlarged and measures 19.6 cm. There are
at least 2
peripheral wedge-shaped echogenic areas within the spleen
demonstrating a
similar distribution to the prior CTA which consistent with
areas of known
splenic infarcts. These have not significantly changed since
prior CT. Also,
given the differences in technique, small perisplenic fluid has
also not
significantly changed since prior.
IMPRESSION:
Allowing for differences in technique, the perisplenic fluid has
not
significantly changed since the most recent prior CT. Echogenic
areas in the
spleen compatible with infarcts.
___ CTA Abd/Pelvis:
IMPRESSION:
1. Massive splenomegaly with multiple new areas of infarction
associated with
tiny locules of air secondary to aseptic necrosis. Infection is
in the
differential only in the appropriate clinical scenario, please
note air
locules may be present without infection following splenic
embolization.
2. Stable size of subcapsular hematoma, that was also noted on
the pre
embolization scan. No active extravasation of contrast to
suggest ongoing
bleed seen. Small hemoperitoneum.
3. Artifact from embolization coil at the proximal splenic
artery without
evidence of dissection. There is narrowing of the native
splenic artery
caliber distal to the embolization without presence of a
thrombus.
___ CXR:
IMPRESSION:
In comparison with the study of ___, the there are lower
lung volumes
that accentuate the prominence of the transverse diameter of the
heart.
Nevertheless, the cardiac silhouette is within normal limits and
there is
tortuosity of the descending thoracic aorta. No evidence of
vascular
congestion or pleural effusion.
In the retrocardiac region there is increased opacification that
could merely
reflect atelectatic changes. However, in the appropriate
clinical setting,
superimposed pneumonia would have to be considered.
___ CTA Chest:
IMPRESSION:
1. Limited evaluation of the segmental and subsegmental
pulmonary arteries in
the lower lobes of both lungs due to degradation from
respiratory motion.
Otherwise, no evidence of pulmonary embolism.
2. Trace left pleural effusion and bibasilar atelectasis.
3. Multiple pulmonary nodules measuring up to 3 mm in the right
upper lobe are
unchanged as compared to CT chest ___. Previously
characterized 6
mm subpleural nodule left lower lobe noted on chest CT ___ is not
identified on the study.
For incidentally detected multiple solid pulmonary nodules
smaller than 6mm,
no CT follow-up is recommended in a low-risk patient, and an
optional CT
follow-up in 12 months is recommended in a high-risk patient.
___ CXR:
IMPRESSION:
Lungs are low volume with bibasilar atelectasis. There are
small bilateral
effusions right greater than left. Right-sided central line
projects to the
cavoatrial junction. Cardiomediastinal silhouette is stable.
No pneumothorax
is seen
___ CTA Abd/Pelvis:
IMPRESSION:
1. Redemonstration of massive splenomegaly (measuring up to 21.3
cm,
previously 24 cm) with large areas of infarction, and
subcapsular splenic
hematoma with associated locules of air, likely aseptic
necrosis. Superimposed
infection cannot be excluded in the appropriate clinical
setting. The
subcapsular hematoma has slightly decreased in thickness,
however there is
interval increase in patient's hemoperitoneum in the abdomen and
pelvis.
2. Status post embolization of the proximal splenic artery, with
persistent
flow to the distal splenic branches. No evidence of active
contrast
extravasation.
3. Unchanged lymphadenopathy in the mesentery and
retroperitoneum, consistent
with patient's known history of lymphoma.
4. Interval increase in small bilateral pleural effusions with
adjacent
compressive atelectasis. Lung bases show no findings concerning
for active
infection. 2 mm nodule in the right middle lobe requires no
follow-up in low
risk population. See full set of recommendations below, if
clinically
indicated.
___ TTE:
CONCLUSION:
The left atrium is normal in size. There is no evidence for an
atrial septal defect by 2D/color Doppler. The
estimated right atrial pressure is ___ mmHg. There is normal
left ventricular wall thickness with a normal
cavity size. There is normal regional and global left
ventricular systolic function. Overall left ventricular systolic
function is hyperdynamic. The visually estimated left
ventricular ejection fraction is >=75%. There is no
resting left ventricular outflow tract gradient. No ventricular
septal defect is seen. Tissue Doppler suggests a
normal left ventricular filling pressure (PCWP less than
12mmHg). Normal right ventricular cavity size with
normal free wall motion. The aortic sinus diameter is normal for
gender. The aortic valve leaflets (3) are
mildly thickened. There is no aortic valve stenosis. There is no
aortic regurgitation. The mitral valve leaflets
are mildly thickened with no mitral valve prolapse. There is
trivial mitral regurgitation. The tricuspid valve
leaflets appear structurally normal. There is mild [1+]
tricuspid regurgitation. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Normal left ventricular
wall thickness, cavity size, and
hyperdynamic regional/global systolic function. Mild tricuspid
regurgitation. Moderate pulmonary artery
systolic hypertension.
Compared with the prior TTE ___ , the degree of tricuspid
regurgitation and the estimated
pulmonary artery systolic pressure have increased.
___ CTA Abd Pelvis:
IMPRESSION:
1. No evidence of active hemorrhage.
2. Stable marked splenomegaly with extensive infarction and
subcapsular
hematoma. Mildly increased volume of ascites, with increased
density in
keeping with hemoperitoneum.
3. Stable appearance of mild abdominal and pelvic
lymphadenopathy.
___ ___ US
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
___ US
1. Splenomegaly with multiple hypoechoic splenic infarcts,
overall unchanged
compared to the recent CT abdomen.
2. 4 mm hyperechoic focus in the gallbladder, could represent a
polyp or
stone. No sonographic signs of acute cholecystitis
___ CXR
Lungs are low volume with moderate pulmonary edema. Right-sided
central line
is unchanged. Cardiomediastinal silhouette is stable.
Bilateral effusions
left greater than right are unchanged. No pneumothorax is seen
___ US
Splenomegaly measuring 22.3 cm with a heterogeneous appearance
compatible with
previously described splenic infarcts. Anechoic fluid
surrounding the spleen
with at least one septation could reflect an evolving
subcapsular hematoma or
loculated pleural fluid.
___ CT Abd
1. Small amount of layering hyperdensity within the right
paracolic gutter and
mild peritoneal enhancement, which may be related to recent
paracentesis.
2. Moderate amount of stool within the rectum with surrounding
bowel wall
thickening and enhancement and thickening of the anus, which may
represent
fecal impaction with developing stercoral colitis.
3. Unchanged severe splenomegaly with extensive parenchymal
infarction.
4. Redemonstration of a possible cystic lesion within the
pancreatic head,
better characterized on prior multiphasic CTA studies.
___ CXR
The right IJ central venous catheter has been removed. There
are low lung
volumes. Linear opacities in the bilateral lung bases most
likely represent
subsegmental atelectasis. There is no focal consolidation,
pleural effusion
or pneumothorax. The cardiomediastinal silhouette is within
normal limits.
There is no significant pulmonary edema. There are no acute
osseous
abnormalities.
Brief Hospital Course:
Mr ___ is a ___ y/o M with MDS/MPN, DLBCL, smoldering
myeloma, gastric cancer (s/p surgical resection in 1980s),
cryptogenic cirrhosis (without history of decompensation), who
presents after splenic arterial embolization with splenic
infarcts and
subcapsular hematoma. His hospital course was complicated by
severe leukocytosis (WBC 40>140 after admission), as well as
oliguric ___ ___ contrast induced nephropathy, requiring brief
period of CRRT and supplemental oxygen in the ICU. He was later
transferred back to the floor for further management of
cytopenias, ascites, and his abdominal discomfort. He received
multiple therapeutic paracenteses. We attempted to start
treatment with azacitadine, which was stopped after 2 days due
to ___ and hypervolemia. He also developed a stool ball and
stercoral colitis requiring disimpaction. At the time of
discharge, all acute issues were resolved, but he was requiring
frequent blood and platelet transfusions. The patient will
receive careful outpatient care for transfusions and monitoring
of blood counts.
ACTIVE ISSUES:
==============
# Splenic Hematoma/Infarcts (s/p splenic arterial embolization)
Massive splenomegaly from MDS/MPN, with splenic hemorrhage, so
embolization was completed on ___ in his attempt to control
bleeding and allow for treatment initiation. The patient
unfortunately developed further hematoma, hemorrhage, resulting
in the complications below.
#Oliguric Acute Kidney Injury
#CIN/ATN
Patient noted to have Cr increase to 2.4 from 1.0 overnight
___. Most likely this represents a contrast induced
nephropathy. Nephrology consulted on ___: agreed with CIN with
development of ATN based on casts seen on microscopy. Patient
ultimately required CRRT while kidney function recovered. Was
able to be taken off CRRT with good UOP by ___. Renal function
subsequently improved back to baseline. He did also develop
hyperuricemia and was started on allopurinol.
#Acute Hypoxemic Respiratory Failure
Patient triggered overnight ___ for O2 sats in low ___ on room
air. O2 sats improved on 5L NC to low ___.
Felt to be likely related to volume overload/pulmonary edema
from heavy IVF for contrast nephropathy/TLS as well as worsening
renal failure. Hypoxemia resolved after CRRT/improved urine
output.
#Leukocytosis
Elevation of WBC 40--> 140s after admission. This is most likely
due to the patient's underlying disease, or leukemoid type
reaction given splenic arterial embolization. He was continued
on hydroxyurea 2000mg bid until ___. White count trended down
after this time.
# MDS/MPN/Chronic Neutrophilic Leukemia
# Chronic anemia
# Thrombocytopenia
# Leukocytosis
Anemia and thrombocytopenia have been worsening over the course
of admission, likely due to splenic infarction/hematoma and
underlying worsening MDS and likelihood that spleen was
supporting platelet production via extra-medullary
hematopoiesis. Azacitadine was attempted on ___ to manage
underlying disease, but had to be discontinued after 2
days because patient developed ___. Now planned to trial
ruxolitinib, but will likely require supportive platelet
transfusions while using this drug. Plan to obtain medication,
then treat as an outpatient with every other day visits. The
patient was
transfused to maintain hgb > 7, plt > 10, and required daily
platelet transfusions and frequent RBC transfusions.
#Cryptogenic Cirrhosis
#Ascites
Patient with history of cryptogenic cirrhosis, seen by Dr ___
in ___ clinic in ___, and s/p full workup including
liver
biopsy. He never has had any complications or decompensations in
the past. Patient also noted to have ascites on CT, which is
possibly from bleeding but also likely ascites from
decompensated
liver disease. S/p therapeutic paracentesis on ___.
Peritoneal fluid demonstrates SAGG ~ 1.0, concerning for
non-portal HTN etiologies of ascites. Cytology within normal
limits, and no other etiology could be found. Unclear etiology
of cirrhosis at this time, but still
appears that portal hypertension is most likely contributing.
The patient was continued on Lasix 20 po /spirono 50 daily with
improvement in his ascites.
#Fecal Impaction, resolved
#Stercoral colitis, resolved
Patient with worsening abdominal pain, with CT on ___ showing
large fecal impaction and stercoral colitis. Patient suffering
extreme lower abdominal pain. Patiently initially failed
aggressive bowel regimen, enemas, disimpaction, but was
successfully disimpacted by colorectal surgery and GI, with
multiple large BM since that time. He will be continued on daily
scheduled bowel regimen, as well as symptomatic care for
hemorrhoids.
#Severe Malnutrition
Continued on regular diet while hospitalized. Nutrition was
consulted to assist with diet, which was supplemented with high
protein drinks
CHRONIC ISSUES:
==============
#Germinal center type DLBCL-
S/p R-CHOP x 1 cycle (stopped for cytopenia), then 2 cycles of
ritux/prednisone, involved field radiotherapy, with complete
response via PET.
#Sciatica, DJD
Continued lidocaine patch.
TRANSITIONAL ISSUES
=====================
[ ] Patient will require appointments at least every other day
for blood checks, transfusions, and 1x per week with Dr
___
[ ] Continue to work to obtain Jakafi
[ ] Continue to monitor ascites, electrolytes, renal function on
new Lasix and spironolactone regimen
[ ] Consider further Hepatology workup if portal
hypertension/ascites worsen
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lidocaine 5% Patch 1 PTCH TD QAM
2. Allopurinol ___ mg PO DAILY
3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate
Discharge Medications:
1. Acyclovir 400 mg PO Q12H
RX *acyclovir 400 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
2. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
3. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram/dose 1 powder(s) by mouth
once a day Refills:*0
4. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth once a day Disp
#*60 Tablet Refills:*0
5. Spironolactone 50 mg PO DAILY
RX *spironolactone 50 mg 1 tablet(s) by mouth once a day Disp
#*30 Tablet Refills:*0
6. walker miscellaneous Daily
ROLLING WALKER
Dx: ___.1 for Chronic myeloproliferative disease
Px: good.
___: 13 months
RX *walker Disp #*1 Each Refills:*0
7. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
8. Allopurinol ___ mg PO DAILY
RX *allopurinol ___ mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
9. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*20 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
#Splenic Infarct and Necrosis
#Oliguric Acute Kidney Injury
#Contrast Induced Nephropathy
#Tumor Lysis Syndrome
#Hyperuricemia
#Hyperphosphatemia
#Hyperkalemia
#Uremia
#Stercoral colitis
#Constipation
Secondary:
#MDS/MPN
#DLBCL
#Cirrhosis
#Coagulopathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring of you at ___.
WHY WAS I IN THE HOSPITAL?
- You were admitted to the hospital because you were having
abdominal pain after your recent procedure
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You received supportive care for bleeding after you had a
splenic arterial emboliztion
- Your kidneys were injured and unable to work properly while in
the hospital. You required special filtration of your blood for
a short period of time
- You received blood products as necessary when your counts got
low
- We trialed chemotherapy medicine, which was not well
tolerated.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10108132-DS-20 | 10,108,132 | 23,202,997 | DS | 20 | 2174-05-31 00:00:00 | 2174-06-01 17:37:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ on Coumadin for saddle PE diagnosed in ___ who presents
with a 2 day history of abdominal pain. Has been on the right
side consistently. Also reports two episodes of emesis day
prior to presentation. Was constipated, then took milk of
magnesium, then had diarrhea. Also reports chills. No fevers,
night sweats, other symptoms. Denies anorexia.
Past Medical History:
Hypertension
Morbid obesity
Saddle pulmonary embolus
Social History:
___
Family History:
His mother had breast cancer in her ___ and had genetic testing
that was negative. He thinks his grandmother may have had a
blood in her ___. He is not aware of any other family history of
blood clots or family members with multiple miscarriages.
Physical Exam:
Physical exam upon admission; ___
VS: 97.5, 88, 118/95, 16, 100% RA
Gen: NAD
CV: RRR
Pulm: no distress
Abd: obese, soft, nondistended. tender focally on right side of
abdomen in between RUQ and RLQ.
Ext: no edema
Physical exam upon discharge; ___
Vitals stable
Gen: NAD
CV: RRR
Pulm: no distress
Abd: obese, soft, nondistended, no focal tenderness
Ext: no edema
Pertinent Results:
___ 09:42AM BLOOD ___ PTT-35.7 ___
___ 08:55AM BLOOD WBC-5.6 RBC-5.25 Hgb-13.6* Hct-40.7
MCV-78* MCH-25.9* MCHC-33.4 RDW-16.4* RDWSD-45.7 Plt ___
___ 08:50AM BLOOD WBC-7.2 RBC-5.30 Hgb-13.6* Hct-40.9
MCV-77* MCH-25.7* MCHC-33.3 RDW-16.5* RDWSD-45.5 Plt ___
___ 09:04AM BLOOD WBC-11.4* RBC-5.61 Hgb-14.9 Hct-43.0
MCV-77* MCH-26.6 MCHC-34.7 RDW-17.8* RDWSD-45.5 Plt ___
___ 06:50PM BLOOD WBC-6.5 RBC-4.28* Hgb-11.4* Hct-33.7*
MCV-79* MCH-26.6 MCHC-33.8 RDW-16.8* RDWSD-47.5* Plt ___
___ 06:50PM BLOOD Neuts-66.1 ___ Monos-8.2 Eos-0.3*
Baso-0.2 Im ___ AbsNeut-4.28 AbsLymp-1.60 AbsMono-0.53
AbsEos-0.02* AbsBaso-0.01
___ 08:55AM BLOOD Plt ___
___ 08:50AM BLOOD Plt ___
___ 08:50AM BLOOD ___ PTT-36.3 ___
___ 08:55AM BLOOD Glucose-150* UreaN-11 Creat-0.9 Na-139
K-3.8 Cl-95* HCO3-25 AnGap-19*
___ 06:50PM BLOOD ALT-9 AST-14 AlkPhos-37* TotBili-0.4
___ 06:50PM BLOOD Lipase-12
___ 08:55AM BLOOD Calcium-9.1 Phos-2.9 Mg-2.0
___ 03:54AM BLOOD K-3.3
___: liver US
Severely limited study due to patient body habitus. The
gallbladder is not seen.
___: CT abdomen and pelvis
1. Findings concerning for perforated tip appendicitis with
small ___ abscess. Surgical consult recommended.
2. Hepatic steatosis
___: CT abdomen and pelvis:
Interval enlargement of a ___ abscess which now
measures 6.7 x 5.6 cm, previously measuring 3.4 x 3.___bdomen and pelvis ___.
___: CT abdomen and pelvis:
Soft tissue phlegmon seen in the right lower quadrant. With the
phlegmon is a small focus of extravasated contrast and a small
focus of air, but no drainable fluid component. Given the
absence of drainable fluid, percutaneous drainage was not
attempted.
Brief Hospital Course:
Mr. ___ was admitted to ___ on ___ and
was diagnosed with perforated appendicitis with a 3x3cm abscess
formation on imaging. Upon presentation to the emergency
department the patient was admitted to the Acute Care Surgery
Unit. Coumadin was withheld given the possibility that the
patient might had to undergo a surgical procedure.
Upon further evaluation it was determined that the abscess was
too small to be drained with an interventional radiology
procedure. For this reason the decision was made to treat Mr.
___ with IV antibiotics. He was recovering well and he was
placed on a heparin drip with the intention to bridge him back
to Coumadin. His IV antibiotics were stopped. During this time,
Mr. ___ experienced again pain in the right lower quadrant.
A concern for an increase of the abscess formation was made. In
light of possible need for ___ drainage the heparin was withheld.
Upon evaluation and consultation with interventional radiology
the abscess was not amenable to drainage. Antibiotics were
continued and the heparin was appropriately bridged to Coumadin.
Upon discharge his INR was in therapeutic levels.
During this hospitalization, the patient ambulated frequently,
was adherent with respiratory toilet and incentive spirometry,
and actively participated in the plan of care.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan.
The patient agreed and verbally confirmed that he would be
following up on ___ with the clinic where he gets
his INR checked. He confirmed that he will also follow up with
his PCP within the same time frame.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Warfarin 8 mg PO DAILY16
2. Chlorthalidone 25 mg PO DAILY
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 2 Days
Please continue taking until ___. Thank you.
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth every twelve (12) hours Disp #*4 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Perforated appendicitis with abscess formation
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 a perforated appendix and
abscess. The abscess was too small to place a drain. You were
treated with a course of antibiotics. Your white blood cell
count has normalized. You are preparing for discharge home with
the following instructions. Please report back to hospital if
you experience any of the following:
* Recurrence of abdominal pain
*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.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Followup Instructions:
___
|
10108233-DS-13 | 10,108,233 | 25,975,579 | DS | 13 | 2161-12-21 00:00:00 | 2161-12-21 21:12:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
tPA-directed lysis of PE vis EKOS catheter system - ___
History of Present Illness:
Ms. ___ is a ___ yo F w/ PMH HTN, HLD, DMII, who presented to
___ w/ abd pain, SOB, and vomiting. Epigastric pain
started 4 days ago after vomiting. She reported that the pain
was worse with movement and better with rest. Associated SOB,
lightheadedness, diaphoresis. OSH d-dimer was elevated, so she
underwent a CTA which showed numerous bilateral pulmonary
embolisms w/ associated right heart strain. She was given a
heparin bolus, placed on IV heparin, and transferred. No trop
leak at OSH.
She was feeling tired yesterday with chest pain. It was pain in
the top of the stomach. Has been having these symptoms since
___. Denies fevers. Also endorses SOB and DOE after walking 2
steps.
In ___ in ___ she had the same symptoms and
the same diagnosis and they gave her Coumadin for 6 months. They
never knew why she had PEs before.
Past Medical History:
Type 2 Diabetes Mellitus
Hyperlipidemia
Hypertension
h/o pulmonary emboli
Social History:
___
Family History:
Her niece had blood clot history as well.
Physical Exam:
Admission Exam
==============
Vitals: T:98.2 BP: 136/95 P: 93 R: 18 O2: 95% on 2L
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: T:98.3 BP:118/71 P:84 R:18 O2:98% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, neck supple
Lungs: CTAB, no w/r/r
CV: RRR, normal S1 + S2, no m/g/r
Abdomen: soft, non-tender, non-distended, no rebound tenderness
or guarding, no masses
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Without rashes or lesions
Neuro: Moves all 4 extremities freely
Pertinent Results:
Admission labs
==============
___ 12:18AM BLOOD WBC-7.7 RBC-4.21 Hgb-11.9 Hct-35.7 MCV-85
MCH-28.3 MCHC-33.3 RDW-13.2 RDWSD-40.0 Plt ___
___ 12:18AM BLOOD Neuts-40.8 Lymphs-54.6* Monos-3.6*
Eos-0.4* Baso-0.3 Im ___ AbsNeut-3.16 AbsLymp-4.22*
AbsMono-0.28 AbsEos-0.03* AbsBaso-0.02
___ 12:18AM BLOOD ___ PTT-128.3* ___
___ 12:18AM BLOOD Glucose-186* UreaN-13 Creat-0.6 Na-139
K-3.6 Cl-104 HCO3-20* AnGap-19
___ 12:18AM BLOOD proBNP-1530*
___ 12:18AM BLOOD cTropnT-<0.01
___ 12:18AM BLOOD Calcium-8.4 Phos-3.0 Mg-1.6
Micro
=====
None
Discharge labs
==============
___ 07:30AM BLOOD WBC-5.8 RBC-4.48 Hgb-12.5 Hct-39.0 MCV-87
MCH-27.9 MCHC-32.1 RDW-13.8 RDWSD-41.5 Plt ___
___ 07:30AM BLOOD Plt ___
___ 07:30AM BLOOD ___ PTT-27.8 ___
___ 07:30AM BLOOD Glucose-169* UreaN-11 Creat-0.7 Na-136
K-4.7 Cl-101 HCO3-19* AnGap-21*
___ 07:30AM BLOOD Calcium-8.8 Phos-3.4 Mg-1.9
Imaging
=======
TTE ___
IMPRESSION: Mild symmetric left ventricular hypertrophy with
relatively small cavity and low normal global systolic function.
Moderately dilate right ventricle with moderate systolic
dysfunction (apex relatively preserved - ___ sign). Along
with severe pulmonary hypertension this suggests there may be
acute on chronic thromboembolic pulmonary hypertension in
context of known acute PE. Very small pericardial effusion
predominantly apically.
___ ___
1. Deep venous thrombosis in one of the left peroneal veins.
2. No evidence of deep venous thrombosis in the right lower
extremity.
TTE ___
The estimated right atrial pressure is ___ mmHg. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is normal (LVEF>55%). with borderline normal free wall
function. The pulmonary artery systolic pressure could not be
determined due to artifact from ___ from the EKOS ultrasound
probe. There is a trivial/physiologic pericardial effusion.
There are no echocardiographic signs of tamponade.
Compared with the prior study (images reviewed) of ___
this study is focused, but does demonstrate that the right
ventricle appears smaller and function is improved. PASP could
not be calculated due to acoustic artifact.
Brief Hospital Course:
___ admitted for bilateral PEs with evidence of RV strain on CT,
signs of acute-on-chronic thromboembolic pulmonary HTN with RV
dilation on TTE, and LLE DVT on LENIs s/p EKOS catheter
placement with tPA lysis of PEs. On lovenox bridge to Coumadin
for long-term management.
#BILATERAL PEs: transferred from OSH with bilateral PEs and
evidence of RV strain on CT. Pt was hemodynamically stable on
arrival to floor at ___. Doppler US of lower extremities on
admission revealed LLE DVT. s/p EKOS with tPA-directed lysis and
ICU monitoring, pt was then treated with enoxaparin, and
Coumadin was initiated on ___. Being discharged with lovenox
bridge until INR ___ on Coumadin (insurance would not cover
NOAC).
#DMII: on metformin and gliperide at home; held during
admission. On ISS while in house. Will resume home regimen upon
discharge.
#HLD: Continued home Atorvastatin 40mg daily
#HTN: on lisinopril 20mg at home. Held on admission for blood
pressure stabilization. BPs on discharge in 110s-120s. Continue
to hold lisinopril. Can re-assess with primary care doctor.
TRANSITIONAL ISSUES:
# ACUTE-ON-CHRONIC THROMBOEMBOLIC PULMONARY HYPERTENSION: as
evidenced by echocardiography. Will follow-up with Dr ___ in
clinic for this issue.
# BILATERAL PEs: going home with lovenox bridge to Coumadin.
Should stay on lovenox until INR is ___ with Coumadin. Will be
followed by PCP for this.
# UNPROVOKED PEs: this is reportedly the second time patient has
presented like this. Should pursue a hypercoagulable work as an
outpatient, as well as age-appropriate cancer screening (never
had colonoscopy).
# COMMUNICATION: HCP: ___ ___, daughter ___
___
# CODE: Full code, confirmed
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. glimepiride 2 mg oral DAILY
4. Lisinopril 20 mg PO DAILY
5. MetFORMIN (Glucophage) 1000 mg PO BID
6. TraZODone 50 mg PO QHS:PRN insomnia
Discharge Medications:
1. Enoxaparin Sodium 80 mg SC Q12H
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 80 mg/0.8 mL 80 mg subcutaneous twice a day Disp
#*28 Syringe Refills:*0
2. Warfarin 5 mg PO DAILY16
RX *warfarin [Coumadin] 2.5 mg 2 tablet(s) by mouth once a day
Disp #*60 Tablet Refills:*0
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. glimepiride 2 mg ORAL DAILY
6. MetFORMIN (Glucophage) 1000 mg PO BID
7. TraZODone 50 mg PO QHS:PRN insomnia
8. HELD- Lisinopril 20 mg PO DAILY This medication was held. Do
not restart Lisinopril until you see your primary care doctor on
___.
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
- Submassive pulmonary emboli with right heart strain
SECONDARY DIAGNOSES:
- Hypertension
- Type 2 Diabetes Mellitus
- Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms ___,
You were admitted to ___ from
___ to ___ for blood clots in your lungs (called
pulmonary emboli).
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
=============================================
- You had a CT scan of your chest at ___,
which showed blood clots in your lungs.
- You had an ultrasound of your heart (called an
echocardiogram) that showed that your heart was having to work
extra hear because of the blood clots in your lungs.
- You had a catheter placed into your lungs through your neck.
A strong ___ medicine was given through the catheter to
treat the clots in your lungs.
- You received a blood thinner (enoxaparin) by injection while
you were in the hospital. You will continue to take this at home
until your primary care doctor, ___ you to stop.
- You were started on a blood thinner pill, called warfarin
(Coumadin), that you will continue to take once you go home from
the hospital.
WHAT WILL HAPPEN WHEN YOU LEAVE THE HOSPITAL?
=============================================
- You will continue to take warfarin (Coumadin), the blood
thinner, for the clots in your lungs.
- You will see a lung doctor, Dr ___, in the office
for follow-up of your blood clots in a few weeks.
- You will see your primary care doctor, ___, to
follow-up this hospitalization on ___ (see
appointment below). You will also need to have your INR checked
(this tells us about the Coumadin level in your blood and is
very important).
If you have any further questions regarding your care here,
please do not hesitate to contact us. We wish you the best with
your health going forward.
Your ___ Care Team
Followup Instructions:
___
|
10108380-DS-18 | 10,108,380 | 27,148,430 | DS | 18 | 2154-07-13 00:00:00 | 2154-07-13 14:23:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Latex / Lamisil / strawberries
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ h/o left breast papilloma resected ___, followed at ___
for post-operative anxiety, insomnia, decreased appetite, also
h/o acid reflux and possible IBS, s/p laparoscopic
cholecystectomy ___, presents with abdominal pain. To ED, she
c/o 2d LLQ pain with subsequent migration to the upper
epigastrium. Pain comes intermittently, last ___ every few
minutes. Characterized by burning sensation into the back.
Endorses nauses w/o vomiting and anorexia. No fevers, chills,
diarrhea.
Her initial ED vitals were: 98.1 127/78 82 18 99%. Per ED
comments, rectal was guaiac negative. Her lab work was entirely
unremarkable: WBC 4.2, H/H 12.9/40.4, PLT 150. ALT 15/AST 23/AP
80/TBili 0.3. Lipase 32. Chem7 w/o abN. Lactate 0.8. UA with Sm
Leuk, 3 WBCs, 1 RGC, and 4 Epis. UCG negative. CT A/P wetread:
No evidence of acute intra-abdominal pathology by CT exam. She
received GI cocktail, morphine 5mg IV x3, and Zofran 4mg IV x2.
Transfer VS were 98.1 85 143/92 16 98%RA.
On arrival to the floor, VS were: 98.6 123/80 63 16 100%RA.
Patient relates the same story as above. She denies f/c, CP/SOB,
urinary or bowel sx, rashes, muscle or joint pains. She had a
normal bowel movement this morning and is passing gas. She
denies sick contacts or recent travel. Feels that upper abdomen
is larger than usual, has concern for hernia.
REVIEW OF SYSTEMS: See HPI.
Past Medical History:
s/p Intraductal Papilloma Resection ___
s/p CCY ___
s/p Coccyx Fx ___
GERD
Mild Symmetric Goiter w/o Nodules
? Depression
h/o UTIs
h/o Shoulder/Chest Wall Muscle Spasms
h/o Headache, Possible Migraine
Social History:
___
Family History:
Non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS - 98.1 85 143/92 16 98%RA
General: Middle-aged lady lying decubitus in bed, mild distress,
NAD
HEENT: NCAT, no sinus tenderness, EOMI, clear OP, MMM
Neck: supple, no LAD or thyroid abN, no JVD.
CV: RRR, no r/g/m
Lungs: CTA b/l, no w/r/r
Abdomen: Central obesity w/o distention. +BS all quadrants. nl
percussion all quadrants. No fluid wave. Tender to epigastric
palpation. No hernia appreciated. Initially tender to RLQ
palpation w/rebound, but not on repeat exam. Negative obturator
and psoas signs. No peritoneal signs. Able to shift positions on
request.
GU: no Foley. No CVA tenderness.
Ext: WWP, no edema.
Neuro: face symmetric, moving all four limbs appropriately on
request
Skin: 3cm well-healed scars below umbilicus, midline upper
abdomen and RUQ. otherwise, no lesions or bruises noted.
Affect: Mildly depressed affect, but able to relate history,
answers appropriately
DISCHARGE PHYSICAL EXAM:
========================
VS- 97.9 107/66 63 16 100%
General: Middle-aged lady found sleeping but rousable, better
affect today, c/o pain but NAD
CV: RRR, no r/g/m
Lungs: CTA b/l, no w/r/r
Abdomen: Central obesity w/o distention or fluid wave. +BS all
quadrants. Tender to epigastric palpation. No RLQ tenderness.
Able to turn and shift w/o difficulty.
Ext: WWP, no edema.
Neuro: face symmetric, moving all four limbs appropriately on
request
Skin: 3cm well-healed scars below umbilicus, midline upper
abdomen and RUQ. otherwise, no lesions or bruises noted.
Affect: Pleasant affect this AM, inquires after going home.
Pertinent Results:
ADMISSION LABS:
===============
___ 11:30AM BLOOD WBC-4.2 RBC-4.19* Hgb-12.9 Hct-40.4
MCV-97 MCH-30.7 MCHC-31.8 RDW-12.6 Plt ___
___ 11:30AM BLOOD Neuts-65.2 ___ Monos-4.6 Eos-0.9
Baso-1.0
___ 11:30AM BLOOD Glucose-86 UreaN-12 Creat-0.9 Na-139
K-4.2 Cl-103 HCO3-26 AnGap-14
___ 11:30AM BLOOD ALT-15 AST-23 AlkPhos-80 TotBili-0.3
___ 11:30AM BLOOD Lipase-32
___ 11:30AM BLOOD Albumin-4.5
___ 11:38AM BLOOD Lactate-0.8
DISCHARGE LABS:
===============
___ 06:50AM BLOOD WBC-3.5* RBC-3.88* Hgb-12.2 Hct-37.4
MCV-97 MCH-31.3 MCHC-32.5 RDW-12.7 Plt ___
___ 06:50AM BLOOD Glucose-77 UreaN-8 Creat-1.1 Na-143 K-3.9
Cl-106 HCO3-26 AnGap-15
___ 06:50AM BLOOD Calcium-8.7 Phos-3.8 Mg-2.0
EKG:
====
___ NSR, HR 60, nl axis, mildly prolonged PR, few PACs, low
voltage, no ST segment changes, TWI III, aVF, V3. Changes
previously seen on ___ EKG (low voltage new).
Brief Hospital Course:
___ h/o left breast papilloma resected ___, followed at ___
for post-operative anxiety, insomnia, decreased appetite, also
h/o acid reflux and possible IBS, s/p laparoscopic
cholecystectomy ___, presents with non-specific abdominal
pain.
BRIEF HOSPITAL COURSE:
======================
# Abdominal Pain: Unclear etiology. Migration from the LLQ to
the epigastrum per history is unusual for abdominal pain. Vitals
unremarkable throughout her stay. Has epigastric pain with
palpation, but no other remarkable findings on physical exam,
particularly after RLQ tenderness was not repeated on sequential
exams, and other appendiceal physical signs were negative.
Laboratory and radiologic testing were not remarkable for acute
process, though "mild nonspecific fat stranding around the
ascending colon as well as equivocal mild colonic wall edema"
was called in the CT results (wetread). This radiologic finding
is of unclear diagnostic significance, though though her lack of
WBC elevation and elevated lactate, as well as lack of
peritoneal signs on clinical exam, are reassuring. EKG here
unremarkable for ischemic change. Given that she had not been on
her home pantoprazole, this medication was restarted, with GI
cocktail, donnatol and simethecone also administered for
comfort. She had some relief with these measures, and was able
to take PO. For presumed dyspepsia, she was discharged on high
dose pantoprazole, and recommended to take Tylenol and Maalox
for additional comfort.
Medications on Admission:
None.
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
Do not take more than 4000mg (6 tablets) daily.
2. Pantoprazole 40 mg PO Q12H
3. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
abdominal cramping
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Abdominal Pain NOS
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms ___,
It was a pleasure to care for you at the ___
___. You were admitted for abdominal pain. Your
clinical exam, laboratory testing and abdominal imaging were all
reassuring. As you were off your pantoprazole for a while, you
may be experiencing severe dyspepsia, resulting in your pain.
Please take this medication as prescribed; you can use Tylenol
and Maalox OTC for additional comfort. Please be sure to make a
follow-up appointment with your Primary Care Physician in the
next ___ days. Thank you for allowing us to participate in your
care.
Followup Instructions:
___
|
10108433-DS-20 | 10,108,433 | 21,634,827 | DS | 20 | 2123-08-31 00:00:00 | 2123-08-31 14:42:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Head injury
Major Surgical or Invasive Procedure:
Cardioversion
History of Present Illness:
A ___ year old male brought to the hospital after being found by
health aid sitting in his room with bleeding 3 cm laceration to
forehead. Patient has slurred speech and is a poor historian. He
reports no loss of consciousness but is unable to recall the
details surrounding the fall. He reports his last drink was
___ prior to presentation. It is unclear if he has a history
of alcohol withdrawal or seizures. He affirmed that he drinks
daily (2 pints of Vodka). He states he has a history of
Depression, for which he is prescribed Remeron (mirtazapine),
but he has not taken this in more than a month. He is tearful at
times during interview, admits to passive suicidal ideations,
but denies any intent or plan. CT head did not show evidence of
acute intracranial pathology. In the ED, he was found to have
tachycardia that is refractory to diltiazem and adenosine.
On arrival to ___, the patient says he feels good. He is
annoyed that he needs alcohol and he can not get more due to
money problems. He does not have living family members.
Past Medical History:
- alcohol use disorder
- hyperthyroidism ___ thyroid nodules
- atrial flutter
- depression
- hypertension
Social History:
___
Family History:
None significant per patient.
Physical Exam:
ADMISSION EXAM:
===============
VITALS: T 99.4 | HR 144 | BP 189/119 | RR 30 | SpO2 96% on 2L NC
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, head 3 cm laceration with sutures, poor
oral hygiene
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: tachycardic, hard to appreciate murmurs
ABD: tenderness to palpation in the RUQ and epigastric area, no
organomegaly
EXT: Warm, well perfused, 2+ pulses, pedal fungal infection with
onychomycosis
DISCHARGE EXAM:
98.2 PO 100 / 62 L Lying 72 93 Ra
GENERAL: no distress, resting comfortably in bed
HEENT: laceration over temple, no sutures
Eyes: anicteric, PERRL
___: rrr, s1/2, no murmurs
Lungs: CTA b/l, no w/r/r
GI: soft, NT, ND, +BS
Ext: no peripheral edema or cyanosis
Skin: warm, dry, +laceration as above
Psych: calm, cooperative
Pertinent Results:
PERTINENT LABS
=======================
___ 11:59AM BLOOD TSH-<0.01*
___ 10:27AM BLOOD T4-7.5 T3-112 Free T4-2.1*
___ 04:15AM BLOOD PTH-47
___ 11:59AM BLOOD T4-6.3 T3-83 Free T4-1.6
___ 04:34AM BLOOD Cortsol-4.4
___ 08:18PM BLOOD 25VitD-14*
___ 02:43AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
___ 02:43AM BLOOD HIV Ab-NEG
___ 02:43AM BLOOD HCV Ab-NEG
DISCHARGE LABS
============
___ 07:10AM BLOOD WBC-6.5 RBC-4.60 Hgb-11.2* Hct-39.4*
MCV-86 MCH-24.3* MCHC-28.4* RDW-20.2* RDWSD-61.7* Plt ___
___ 07:10AM BLOOD Glucose-77 UreaN-7 Creat-0.7 Na-141 K-4.7
Cl-98 HCO___ AnGap-14
___ 07:10AM BLOOD Calcium-9.0 Mg-1.8
IMAGING
=======
CT C/A/P W/CON (___)
IMPRESSION:
1. No definite acute intrathoracic or intra-abdominal sequela of
trauma.
2. A 2.6 x 1.5 cm peripheral hypodensity in the lateral aspect
of the spleen with peripheral thin calcification is most likely
chronic, potentially prior laceration or infarct.
3. Areas of rounded atelectasis in the lungs bilaterally with a
small right pleural effusion.
4. Multiple compression deformities throughout the thoracic and
lumbar spine without CT evidence of acuity though to be
correlated clinically. Multiple old rib fractures bilaterally.
CT HEAD W/O CON (___)
IMPRESSION:
1. There are no acute intracranial findings, no hemorrhage.
2. Global volume loss. White matter hypodensities which could
represent sequela of prior infarcts or other insult.
3. A 1.1 cm suspected colloid cyst without hydrocephalus.
CT NECK W/O CON (___)
1. No mass or obstruction seen in the upper airway.
2. Severe degenerative changes of C2 to C 5.
3. Ultrasound follow-up is recommended for large heterogeneous
thyroid.
[hospitalist adds that the degenerative of c3 and c4 result in a
huge osteophyte projecting anteriorly directly toward the
hypopharynx/epiglottis, which may explain his tendency to have
profound transient desaturations]
CTA CHEST (___)
-------------------
1. No evidence of pulmonary embolism or aortic abnormality.
2. Similar appearance of the lungs, with multifocal scarring and
rounded
atelectasis at the lung bases.
3. Bilateral subacute-to-chronic rib fractures.
4. Dilated main pulmonary artery is suggestive of pulmonary
arterial
hypertension.
5. Dilated ascending thoracic aorta measuring up to 4.5 cm.
6. Enlarged heterogenous thyroid gland with calcifications and
nodules.
TTE (___)
-------------
CONCLUSION:
The left atrial volume index is normal. The estimated right
atrial pressure is >15mmHg. There is mild symmetric left
ventricular hypertrophy with a mildly increased/dilated cavity.
There is moderate global left ventricular hypokinesis.
Quantitative biplane left ventricular ejection fraction is 36 %.
There is no resting left ventricular outflow tract gradient.
Normal right ventricular cavity size with low normal free wall
motion. The aortic sinus diameter is normal for gender with
normal ascending aorta diameter for gender. The aortic arch
diameter is normal. The aortic valve leaflets (3) appear
structurally normal. There is no aortic valve stenosis. There is
mild [1+] aortic regurgitation. The mitral valve leaflets appear
structurally normal with no mitral valve prolapse. There is
trivial mitral regurgitation. The tricuspid valve leaflets
appear structurally normal. There is mild [1+] tricuspid
regurgitation. The estimated pulmonary artery systolic pressure
is borderline elevated. There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
mildly dilated cavity and moderately reduced global systolic
function. Borderline right ventricular free wall systolic
function. Mild aortic regurgitation.
VIDEO SWALLOW (___)
Penetration of thin liquids without aspiration identified.
Moderate oropharyngeal dysphagia most notable for significantly
reduced base of tongue retraction and significantly reduced
pharyngeal stripping with fairly good airway protection. These
deficits resulted in pharyngeal residue with solids > liquids,
increasing in severity with complexity of texture.
Brief Hospital Course:
___ w/ hyperthyroidism ___ toxic multinodular goiter, a-flutter,
history of inadequate housing but currently domiciled, and heavy
EtOH abuse, who was was found down with head laceration after
presumed fall and admitted for alcohol withdrawal, sow s/p ICU
phenobarbital protocol. Course c/b 2:1 Aflutter s/p TEE/DCCV
___ (now on xarelto) w/ newly diagnosed HFrEF (EF 36%)
-presumed tachycardia-mediated, as well as hyperthyroidism due
to multinodular goiter.
#Aflutter with RVR:
Felt to be somewhat chronic given elevated heart rates at ___
earlier this year. Presented with HR in the 140-150s with 2:1 AF
on EKG. This was in the context of alcohol withdrawal, PNA, and
hypothyroidism. He was initially admitted to the FICU and
managed with multiple nodal agents, including diltiazem gtt, and
ultimately loaded with digoxin. CHADSVASC=1 and felt to be high
risk of fall, so initially did not start anticoagulation.
Cardiology was consulted for help with management. He had a TTE
that showed a newly reduced EF, and so diltiazem was
discontinued in favor of beta blockade. Given continued
difficulty controlling rates w/ digoxin + metoprolol, he
underwent TEE/cardioversion on ___. He was anticoagulated with
rivaroxaban due to this procedure and will need to continue
anticoagulation x1 month. Per cardiology he will need cardiology
follow-up in ___ weeks, which is being arranged by cardiology at
the time of discharge. Per EP he should also have follow-up with
Dr. ___ (EP) within 1 month of discharge to discuss
possible ablation procedure. His metoprolol dose was increased
(now ___ XL daily).
#Cardiomyopathy:
TTE on ___ with dilated cardiomyopathy with global hypokinesis
and EF 36%. Etiology thought to be most likely
tachycardia-induced cardiomyopathy given AF. Other contributing
causes: EtOH and hyperthyroidism. HIV negative. Cardiolgoy
consulted as above. The patient was started on beta blockade
with metoprolol and ACEi. Appeared warm and dry on exam without
diuretic, though noted on CXR to have small bilateral pleural
effusions.
#EtOH Use Disorder
#EtOH Withdrawal
Drinking 2 pints of vodka daily before admission. Denied history
of withdrawal seizures or DTs. Treated in the ICU with
phenobarbital protocol. Social work consulted. Patient expressed
motivation to stop drinking in light of recent cardiac
diagnoses. He is planning to seek support from his outpatient
case manager and therapist as well as weekly AA meetings. He was
started on thiamine, folic acid, MVI.
#Hypoxemia
#c/f Pneumonia
Patient with new O2 requirement while in the FICU, with history
of cough. Treated empirically for CAP with ceftriaxone/azithro
for 5 day course (___). S&S evaluation with concern for
aspiration, as below. He continued to have intermittent
desaturations throughout admission. CXR ___ without pulmonary
edema or infiltrates. He was wheezy on exam raising possibility
of undiagnosed COPD given prior heavy smoking history. His
wheezing resolved with duonebs. He should have PFTs as an
outpatient. There was also concern during hospitalization for
vocal cord dysfunction given hypoxemia and muffled voice. ENT
consulted and did not find any notable findings on scope. They
recommended a CT neck to further evaluate, which showed
"degenerative changes" at C3/C4 with an anterior osteophyte,
which might be etiology.
#Thyroid nodules / hyperthyroidism
Patient has a several-year history of hyperthyroidism, on
methimazole prior to admission but with PCP concerns about
adherence. His last u/s was in ___ which showed multiple
nodules, unchanged from ___. On admission home methimazole 10mg
was resumed. Endocrine was consulted for help with management.
Recommended continued methimazole and BB. FT4, TT3, T3up wnl on
___. There is concern for medication compliance, therefore upon
discharge from rehab he should be set up with a home ___
aide to ensure medication compliance. Plan for endocrine
follow-up in 2 weeks. This appointment is being scheduled by the
endocrine team and not yet finalized by discharge.
#Fall with headstrike
Presented after a fall with head laceration. ___ evaluated
patient and recommended discharge to rehab.
#Dysphagia
Seen by speech and swallow, recommending slow advancement to a
ground diet with thin liquids. Medications crushed in puree
followed by sips of thin liquids. Oral care q4. Aspiration
precautions with strict 1:1 supervision for ALL po intake.
Alternate bites and sips to prevent accumulation of residue. No
straws. Will need continued speech/swallow therapy while at
rehab.
#Vitamin D Deficiency
D2 50,000 IU QWeek
#Hypocalcemia:
Calcium carbonate 500 mg TID
#Depression:
Held home bupropion given concern for reduced seizure threshold
and will not resume on discharge. Continued home doxepin.
Discussed with PCP.
#TRANSITIONAL ISSUES:
[ ] Repeat TFTs on ___
[ ] Thyroid ultrasound as an outpatient
[ ] Recommend outpatient PFTs given wheezing and intermittent
desaturations
[ ] Management of depression - bupropion d/c on admission given
c/f reduced seizure threshold with alcohol use disorder
[ ] Set up with ___ upon d/c from rehab to ensure medication
compliance with regards to methimazole.
[ ] Both endocrine and cardiology appointments are not finalized
by the time of discharge and will need to be confirmed while the
patient is at rehab (both departments are aware of the need for
f/u and are working on appointments)
Time spent: 55 minutes
Discharge communication not sent to PCP as he has none on file.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Methimazole 10 mg PO DAILY
2. Doxepin HCl 150 mg PO HS
3. Omeprazole 20 mg PO DAILY
4. Naltrexone 50 mg PO DAILY
5. Metoprolol Succinate XL 50 mg PO DAILY
6. Cetirizine 10 mg PO DAILY
7. Aspirin 81 mg PO DAILY
8. Fluticasone Propionate NASAL 2 SPRY NU Frequency is Unknown
9. BuPROPion 100 mg PO BID
Discharge Medications:
1. Calcium Carbonate 500 mg PO TID
2. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN shortness of
breath/wheezing
3. Lisinopril 5 mg PO DAILY
4. Multivitamins W/minerals 15 mL PO DAILY
5. Rivaroxaban 20 mg PO DINNER
6. Vitamin D ___ UNIT PO 1X/WEEK (FR)
7. Fluticasone Propionate NASAL 2 SPRY NU DAILY
8. Metoprolol Succinate XL 200 mg PO DAILY
9. Aspirin 81 mg PO DAILY
10. Cetirizine 10 mg PO DAILY
11. Docusate Sodium 100 mg PO BID
12. Doxepin HCl 150 mg PO HS
13. FoLIC Acid 1 mg PO DAILY
14. Methimazole 10 mg PO DAILY
15. Naltrexone 50 mg PO DAILY
16. Omeprazole 20 mg PO DAILY
17. Thiamine 100 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Atrial Flutter
Heart Failure
Alcohol Withdrawal
Hyperthyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital with a large cut on your
scalp, withdrawal from alcohol, an abnormal heart rhythm, and
heart failure.
We treated you for these conditions and you improved. We
encourage you to continue to see your case manager and therapist
for help with alcohol use. You will need to see a cardiologist,
a heart rhythm specialist, and a thyroid doctor after you leave
the hospital to help manage your medical problems.
It was a pleasure taking care of you.
Sincerely,
Your ___ team
Followup Instructions:
___
|
10108435-DS-43 | 10,108,435 | 26,693,769 | DS | 43 | 2191-01-20 00:00:00 | 2191-01-25 16:44:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Compazine / Codeine / Atenolol
Attending: ___.
Chief Complaint:
Leg Swelling
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr ___ is a ___ year old man with PMHx notable for
HCV cirrhosis, CAD, COPD on ___ home O2, polysubstance abuse,
recent punctate L parietal hemorrhage who presents to the ___
ED with worsening lower extremity edema and worsening
spontaneous bleeding in the lower extremity varicosities. He was
seen in the ___ ED on ___ when he presented with orthostasis,
chest pain, lightheadedness, and falls. At that time a pan-scan
including a CT head and chest abdomen pelvis revealed no
evidence of pulmonary emboli, known diffuse subcutaneous veins
second to IVC chronic thrombus, negative cardiac enzymes and
EKG, but did show a suspected left parietal hyperdensity
suspicious for a focus of hemorrhage. He was evaluated by
neurosurgery at that time, with no followup CT recommended.
Since that time he reports recurrent falls, worsening
orthostasis, bruising on upper extremities, and feeling
increasingly tired. He also reports worsening headache,
worsening lower extremity edema, intermittent chest pain with
radiation to left arm, cough, but no fevers, chills, recent
infectious symptoms, nausea, vomiting, decreased p.o. tolerance.
See most recent outpatient note in ___ medical records from
___, MD on ___ describing recent change in
medication regimen, as well as patient's reluctance to accept
outpatient ___ modalities; given increasing symptomatology, and
risk for recurrent falls and hypotension, will be admitting for
titration of medical therapy, specifically anticoagulation and
antihypertensives. EKG stable, CTH neg, INR 6, CXR w/o volume
overload, cr stable.
In the ED, initial vitals were: 98.2 65 128/69 18 100%
Labs were notable for: proBNP: 2145, INR: 6.0, H/H 9.1/29.6, tox
screen positive for urine Benzos, urine Opiates, urine Mthdne.
The patient recieved:
___ 14:50 PO/NG Methadone 55 mg
___ 14:50 PO/NG Gabapentin 800 mg
___ 15:10 PO/NG ClonazePAM 2 mg
Imaging was notable for:
CT Head: The previously described left parietal punctate
hemorrhage is not clearly identified on the current study. No
evidence of acute intracranial hemorrhage.
CXR: No acute cardiopulmonary process
On the floor, he reports pain in bilateral lower extremities.
ROS is positive for hemetemesis last evening, and blood on the
toilet paper when he wiped last evening. No gross blood in his
last BM yesterday (mixture of formed and loose). Some Headache
and nausea.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies 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.
Past Medical History:
- Hepatitis C, denies h/o treatment
- Hepatitis B previous infection, now sAg negative
- s/p STEMI w/ BMS in LAD in ___, due to GI bleed stopped
plavix cont only aspirin
- Malignant hypertension: thought to be secondary to medication
non-compliance, but had hypotension during admission in
___ and BP meds were cut back. (most likely due to Clonidine
effect: overdose/withdrawal)
- Pulmonary embolus: Recurrent VTE s/p IVC filter, previously
not on
coumadin due to noncompliance, but resumed warfarin since last
___ admission and is followed by ___ clinic.
- Heroin abuse: 55mg methadone daily last dose ___ confirmed
with methadone maintenance clinic ___
Phone: ___
- Chronic obstructive pulmonary disease on ___ home O2
- Gastroesophageal reflux disease
- PTSD ___ veteran)
- Anxiety / Depression
- Antisocial personality disorder
- Microcytic anemia
- Vitamin B12 deficiency
- Chronic kidney disease
Social History:
___
Family History:
Father died of myocardial infarction at unknown age. Mother died
of pancreatic cancer.
Physical Exam:
<<<Admission Physical Exam
Vital Signs: T: 98.3 P:60-126 BP: 130-74 RR: 18 Spo2: 100 RA
General: Alert, oriented, in pain
HEENT: Sclera anicteric, MMM, no dentition, EOMI, PERRL, neck
supple,
Chest: Mild gynecomastia, variety of palpable suferficial veins
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear on inspiration, expiratory wheezes bilaterally
Abdomen: Soft, mild RUQ tenderness, negative Murphys sign,
non-distended, bowel sounds present, no rebound or guarding,
mild hepatosplenomegaly
GU: No foley
Rectal: Patient deferred
SKIN: severe venous stasis changes in the skin of the lower
extremities ___ way up the shins, tense 4+ edema, dried blood
interdigitinous spaces on left foot, no active bleeding noted.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, grossly normal sensation, gait deferred.
<<<Discharge Physical Exam
Vitals: t: 98.2, p:83, bp:128/63, rr: 18, Spo2:100% on 2L NC
General: Alert, oriented, in pain
HEENT: Sclera anicteric, MMM, no dentition, EOMI, PERRL, neck
supple
Chest: Mild gynecomastia, variety of palpable superficial veins
CV: Regular rate and rhythm, frequent extra beats, normal S1 +
S2, no murmurs, rubs, gallops
Chest wall tenderness to light palpation over left side of
sternum.
Lungs: Increased air movement, clear inspiratory, short wheezes
lasting ___ expiration. Limited cough with end expiration.
Abdomen: Soft, diffusely, moderately tender to palpation, no
rebound or guarding, bowel sounds present, no rebound or
guarding, mild hepatosplenomegaly
GU: No foley
SKIN: severe venous stasis changes in the skin of the lower
extremities ___ way up the shins, tense 4+ edema, very tender to
palpation, dried blood interdigitinous spaces on left foot
Ext: warm, well perfused, unable to assess pulses in lower
extremities due to edema, 2+ pulses bilaterally upper
extremities, no clubbing, cyanosis
Neuro: grossly normal sensation, non focal
Pertinent Results:
<<<Admission Labs
___ 07:35AM NEUTS-63.6 ___ MONOS-6.2 EOS-5.7
BASOS-1.7* IM ___ AbsNeut-2.57 AbsLymp-0.90* AbsMono-0.25
AbsEos-0.23 AbsBaso-0.07
___ 07:35AM WBC-4.0 RBC-3.33* HGB-9.1* HCT-29.6* MCV-89
MCH-27.3 MCHC-30.7* RDW-14.9 RDWSD-47.7*
___ 07:35AM PLT COUNT-154#
___ 07:35AM ___ PTT-52.8* ___
___ 07:35AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 07:35AM cTropnT-<0.01
___ 07:48AM LACTATE-1.2
___ 07:35AM GLUCOSE-89 UREA N-23* CREAT-1.3* SODIUM-140
POTASSIUM-4.3 CHLORIDE-107 TOTAL CO2-23 ANION GAP-14
___ 01:10PM URINE RBC-2 WBC-1 BACTERIA-FEW YEAST-NONE
EPI-1
___ 01:10PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 01:10PM URINE bnzodzpn-POS barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-POS
<<<Discharge Labs
___ 10:30AM BLOOD WBC-5.9 RBC-3.51* Hgb-9.7* Hct-31.8*
MCV-91 MCH-27.6 MCHC-30.5* RDW-14.8 RDWSD-49.1* Plt ___
___ 10:30AM BLOOD Plt ___
___ 10:30AM BLOOD Glucose-110* UreaN-28* Creat-1.0 Na-142
K-4.4 Cl-104 HCO3-30 AnGap-12
___ 06:31AM BLOOD ALT-12 AST-15 AlkPhos-67
___ 10:30AM BLOOD Calcium-8.5 Phos-3.2 Mg-1.9
___ 10:30AM BLOOD ___ PTT-39.3* ___
<<<Other Significant Labs
___ 06:31AM BLOOD CK-MB-1 cTropnT-<0.01
___ 06:24AM BLOOD ___ PTT-57.4* ___
___ 05:54AM BLOOD ___ PTT-53.7* ___
___ 06:40AM BLOOD ___
___ 06:31AM BLOOD ___ PTT-40.6* ___
<<<Studies
___- Head CT
The previously described left parietal punctate hemorrhage is
not identified
on the current study. No evidence of intracranial hemorrhage.
___- Head CT
No evidence for acute intracranial abnormalities.
___- CXR
No acute cardiopulmonary process.
___
Volume loss versus early infiltrates in the lower lobes
___- TTE
IMPRESSION: Suboptimal image quality. Left ventricular systolic
dysfunction with mild regional variation c/w LAD territory CAD.
Mild mitral regurgitation. Pulmonary artery systolic
hypertension.
Compared with the report of the prior study (images unavailable
for review) of ___, the right ventricle is not
well-visualized. Estimated pulmonary artery systolic pressure is
higher.
Brief Hospital Course:
___ year old man with PMHx notable for HCV cirrhosis, CAD,
chronic IVC clot on warfarin, COPD on ___ home O2,
polysubstance abuse, and recent punctate L parietal hemorrhage
who presents with worsening lower extremity edema and worsening
spontaneous bleeding in the lower extremity varicosities in the
setting of a supretherapeutic INR (6.0).
<<<Active Issues
#Supratherapeutic INR. Warfarin was held. patient did not
experience additional bleeding episodes while inpatient.
Warfarin was restarted at 2mg on ___ to maintain INR ___. On
discharge, INR was therapeutic at 2.2.
#COPD Exacerbation. On admission, he was not requiring O2
(despite stating he uses ___ L at home chronically). On ___ he
developed increased cough, sputum (blood tinged), and oxygen
requirement, and was treated for a presumed COPD exacerbation.
He received DuoNeb treatments q4hrs and was treated with
prednisone 40mg and Levofloxacin 750mg PO for 5 days to be
completed ___.
# NSVT. Given his chronic use of methadone, he was monitored on
telemetry given the potential for levofloxacin and methadone to
prolong QTc. He experienced intermittent runs of NSVT (<5 beats,
self terminating) and chest pain. Multiple EKGs were performed
with non-prolonged QTc, unchanged sinus bradycardia and LAFB,
and some pre-atrial beats. Chest pain was always reproducible on
physical exam, suggestive of MSK pain. Troponin was negative.
Potassium and Magnesium were repleated as needed.
# Chronic lower extremity venous stasis. Diuresied with 20mg IV
2x on admission for edema extending up past knees. We limited
diuresis due to SBP 100s/60s and the risk of hepatorenal failure
given his chronic liver disease. His lisinopril was held after
admission due to SBPs 100s/60s.
# Headache/Blurry Vision/Drowsyness. He developed new onset
blurry vision and headache on the morning of ___ so a
non-contrast head CT to evaluate for hemorrhage was performed
and was negative for any acute intracranial process.
Orthostatics were also negative.
# Dizziness/Falls. He reported increased dizziness and falls
prior to admission. A TTE was done on ___ which showed a mild
increase in pulmonary artery systolic pressure compared with
previous exam from ___. Orthostatics were negative.
# Cirrhois ___ chronic Hepatitis C. Patient did not show signs
of acute hepatic encephalopathy during this admission. Lactulose
was increased to 30mL q4hrs. His home nadolol and omeprazole was
administered.
#Polysubstance Abuse/Dependance. Methadone was continued at 55mg
during this admission. The medical team was concerned that he
was overly sedated with his narcotic regimen so clonazepam was
titrated down from 2mg TID to 1mg TID during the
hospitalization. The patient objected strongly to the suggestion
that he was overly sedated with the narcotics and threatened to
leave the hospital multiple times.
<<< Chronic Issues
# CAD. Continued home Atorvastatin 80 mg PO QPM. Held
Lisinopril 10mg daily.
# BPH. Continued home Tamsulosin 0.4 mg PO QHS
# PTSD. Pt spoke with SW during this admission regarding his
prior military experiences in ___.
<<< Transitional Issues
- Will need hepatology follow up. Care Connections will contact
that patient with the specific appointment information.
- On prednisone & levofloxacin until ___ for COPD flare
- Will follow up with ___ clinic - ___ lab
to draw INR on ___ and ___ - INR on discharge 2.2, will
take 2 mg daily
*** The patient was evaluated by ___ with the recommendation for
home ___ if patient agreeable for home safety evaluation and
dynamic balance training. He refused to have this evaluation
done outside the hospital
*** Attempts were made to set the patient up with ___ services
upon discharge but the patient refused all of these services,
despite the medical recommendation of his treatment team.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB/Wheeze
2. Atorvastatin 80 mg PO QPM
3. ClonazePAM 2 mg PO TID
4. FoLIC Acid 1 mg PO DAILY
5. Furosemide 80 mg PO DAILY
6. Gabapentin 800 mg PO TID
7. Lactulose 30 mL PO TID
8. Lisinopril 10 mg PO DAILY
9. Methadone 55 mg PO DAILY
10. Nadolol 40 mg PO DAILY
11. Omeprazole 20 mg PO BID
12. Tamsulosin 0.4 mg PO QHS
13. Tiotropium Bromide 1 CAP IH DAILY
14. Docusate Sodium 100 mg PO BID
15. Multivitamins 1 TAB PO DAILY
16. Senna 17.2 mg PO QHS
17. Warfarin 5 mg PO DAILY16
Discharge Medications:
1. Atorvastatin 80 mg PO QPM
2. ClonazePAM 1 mg PO Q8H:PRN anxiety
RX *clonazepam 1 mg 1 tablet(s) by mouth every 8 hours, Disp
#*15 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
4. FoLIC Acid 1 mg PO DAILY
5. Gabapentin 800 mg PO TID
6. Lactulose 30 mL PO TID
7. Methadone 55 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. Nadolol 40 mg PO DAILY
10. Omeprazole 20 mg PO BID
11. Senna 17.2 mg PO QHS
12. Tamsulosin 0.4 mg PO QHS
13. Warfarin 2 mg PO/NG DAILY16
RX *warfarin 2 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
14. Levofloxacin 500 mg PO DAILY Duration: 2 Days
RX *levofloxacin 500 mg 1 tablet(s) by mouth daily Disp #*2
Tablet Refills:*0
15. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine 5 % (700 mg/patch) Apply 1 patch to pain over
chest daily Disp #*30 Patch Refills:*0
16. PredniSONE 40 mg PO DAILY Duration: 2 Days
RX *prednisone 20 mg 2 tablet(s) by mouth daily Disp #*4 Tablet
Refills:*0
17. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB/Wheeze
18. Furosemide 80 mg PO DAILY
19. Lisinopril 10 mg PO DAILY
20. Tiotropium Bromide 1 CAP IH DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses: Supratherapeutic INR, COPD exacerbation,
Cirrhois ___ chronic Hepatitis C, Chronic Lower extremity venous
stasis, Polysubstance abuse/ h/o Heroin abuse
Secondary diagnoses: CAD, GERD, Anxiety/Depression, BPH, PTSD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were recently treated here at ___. Briefly, you were
hospitalized with a bleeding foot and INR of 6.0. During your
hospitalization we managed your warfarin dose to ensure that you
were back within your goal range of INR ___. We gave you water
pills through the IV for the swelling in your legs. We also gave
you steroid, antibiotics, and breathing treatments to help with
your COPD. You received a CT scan of your head due to your
blurry vision and headache which was negative for any concerning
processes. Physical Therapy evaluated you and recommended
discharge to home with home ___ services.
Please continue taking your steroids and antibiotics as
directed. Please work with your PCP and the ___
clinic to help cooridnate your warfarin dosing. Please also
weigh yourself every morning and call your MD if weight goes up
more than 3 lbs.
Thank you,
Your ___ Treatment Team
Followup Instructions:
___
|
10108435-DS-44 | 10,108,435 | 24,531,107 | DS | 44 | 2191-07-03 00:00:00 | 2191-07-03 16:35:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Compazine / Codeine / Atenolol
Attending: ___.
Chief Complaint:
fall, confusion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr ___ is a ___ with history of COPD, CHF, STEMI s/p PCI,
cirrhosis, DVT/PE on Coumadin Hep C who presents to the
emergency room after suffering a fall while waiting at ___
___. Pt states that prior to the fall, he did have some CP
(unclear how close this occurred to the fall) as well as SOB
(chronic, but worse than baseline) as well as lightheadedness.
Pt describes the CP as L -sided, substernal, possibly worse with
walking but pt is somewhat unclear on this. Despite this, pt
believes that he just lost his balance when walking through a
construction zone and that is what caused his fall. Denies
focal weakness however states that he does feel weak all over.
Pt states he was recently admitted to ___ for worsening ___,
discharged 1 day ago. At that time they increased his Lasix
dose from 40 to 80 mg.
In the ED, initial vitals were: 10, 97.7, 65, 74/42, 98% RA.
Labs were notable for trop of 0.02, creatinine 2.4, pro-BNP of
704, lactate of 1.8. He was given 2 L of NS with improvement in
his BPs to the 100s. He was admitted to medicine for treatment
___ and further evaluation of falls. They were also
concerned for confusion.
On the floor, pt endorses ongoing leg pain and weakness. He
states that he had a fever to 103.0 3 days ago, without
associated sxs and with no recent fevers. He endorses abd pain
with urination and states that he has difficulty initiating a
stream. He also states that he has HA x ___ m. States he has
had a 30 lb wt loss in 3 wks however belly feels more distended
than usual. Has not been taking lactulose for some time but
does not feel more confused.
Review of systems:
(+) Per HPI
(-) Denies chills, night sweats. Denies sinus tenderness,
rhinorrhea or congestion. Denies cough. Denies chest pain or
tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No dysuria. Denies arthralgias
or myalgias.
Past Medical History:
(per chart, confirmed with pt and updated):
- Hepatitis C, denies h/o treatment
- Hepatitis B previous infection, now sAg negative
- s/p STEMI w/ BMS in LAD in ___, due to GI bleed stopped
plavix cont only aspirin
- Malignant hypertension: thought to be secondary to medication
non-compliance, but had hypotension during admission in
___ and BP meds were cut back. (most likely due to Clonidine
effect: overdose/withdrawal)
- Pulmonary embolus: Recurrent VTE s/p IVC filter, previously
not on coumadin due to noncompliance, but resumed warfarin on
prior admission and is followed by ___ clinic.
- Heroin abuse: pt reports 65 mg methadone daily confirmed
___
with methadone maintenance clinic ___
Phone: ___
- Chronic obstructive pulmonary disease on ___ home O2
- Gastroesophageal reflux disease
- PTSD ___ veteran)
- Anxiety / Depression
- Antisocial personality disorder
- Microcytic anemia
- Vitamin B12 deficiency
- Chronic kidney disease
- ___: punctate L parietal hemorrhage, seen by neurosurg who
did not recommend any f/u or intervention
Social History:
___
Family History:
(per chart, confirmed with pt):
Father died of myocardial infarction at unknown age. Mother died
of pancreatic cancer.
Physical Exam:
Vitals: 97.8 111/64 56 16 96% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
adentulous
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs/chest: Diffuse wheezes, gynocomastia
Abdomen: Obese, soft, non-tender, non-distended, bowel sounds
present, no organomegaly, no rebound or guarding. + Caput. No
fluid wave or shifting dullness.
GU: No foley
Ext: Diffusely TTP. Chronic venous stasis changes bilaterally.
1+ edema to the knees, no e/o skin breakdown or cellulitis.
Bilateral hand tremor.
Neuro: aao x3. CNII-XII intact, ___ strength upper/lower, no
asterixis extremities, gait deferred.
Pertinent Results:
___ 11:20AM BLOOD WBC-4.8 RBC-3.50* Hgb-9.1* Hct-31.1*
MCV-89 MCH-26.0 MCHC-29.3* RDW-15.7* RDWSD-50.2* Plt ___
___ 11:20AM BLOOD Neuts-54.0 ___ Monos-6.9 Eos-8.6*
Baso-1.9* Im ___ AbsNeut-2.56 AbsLymp-1.34 AbsMono-0.33
AbsEos-0.41 AbsBaso-0.09*
___ 11:20AM BLOOD Plt ___
___ 11:20AM BLOOD ___ PTT-51.7* ___
___ 11:20AM BLOOD Glucose-109* UreaN-61* Creat-2.4*# Na-140
K-4.3 Cl-94* HCO3-34* AnGap-16
___ 11:20AM BLOOD ALT-13 AST-20 CK(CPK)-98 AlkPhos-85
TotBili-0.7
___ 11:20AM BLOOD Lipase-19
___ 07:00PM BLOOD cTropnT-<0.01
___ 11:20AM BLOOD cTropnT-0.02*
___ 11:20AM BLOOD CK-MB-2 proBNP-704*
___ 11:20AM BLOOD Albumin-4.0 Calcium-9.3 Phos-4.5 Mg-2.4
___ 11:28AM BLOOD Lactate-1.8
MICRO: blood cx pending
STUDIES:
CT c-spine
No acute fracture or traumatic malalignment.
CT head
No acute intracranial abnormalities.
CXR
Mild pulmonary vascular congestion and mild bibasilar
atelectasis.
EKG: sinus bradycardia with LAFB (old). TWI in V4 (old, no
other acute ST/TW changees
RUQ US:
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The
contour of the
liver is smooth. There is no focal liver mass. The main portal
vein is patent
with hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD
measures 6 mm.
GALLBLADDER: The gallbladder is collapsed.
PANCREAS: The pancreas is not well visualized, largely obscured
by overlying
bowel gas.
SPLEEN: Enlarged spleen with normal echogenicity, measuring
16.5 cm.
KIDNEYS: Limited sagittal views of the right kidney demonstrate
no evidence
of hydronephrosis.
RETROPERITONEUM: Visualized portions of aorta and IVC are within
normal
limits.
IMPRESSION:
Patent portal vein with hepatopetal flow. No ascites.
Splenomegaly.
Brief Hospital Course:
___ year old man with PMHx notable for HCV cirrhosis, CAD, COPD
on ___ home O2, CAD, chronic ___, DVT/PE on Coumadin who
presents to the ___ ED with worsening lower extremity edema
and worsening spontaneous bleeding in the lower extremity
varicosities.
# Hypotension:
Most likely due to overdiuresis in setting of recent up
titration of diuretic, also fits with acute renal failure.
Reports fevers at home but none here and infectious work up was
negative. Troponins flat making cardiogenic cause of hypotension
unlikely. The patients diuretics were held and he was given
gentle IV hydration with improvement in both renal function and
blood pressure. His antihypertensives were held and resumed
prior to discharge, but at lower doses: Lisinopril 5mg daily,
Lasix 60mg daily, Nadolol held
# ___:
Pre-renal in setting of overdiuresis. Improved to baseline with
hydration.
# Fall: Likely due to hypotension, no e/o neurologic etiology,
will w/u cardiac etiology as above. Head CT/c-spine reassuring,
last ECHO ___ without evidence of valvular disease. CT head/
C-spine negative for acute process.
- ___ c/s
# COPD with acute exacerbation:
Patient had productive cough with blood tinged sputum and very
poor air movement on exam. CXR negative for PNA. This was
consistent with a flare of his COPD. He was placed on
Prednisone 40mg daily and Augmentin 875mg BID x5 days in
addition to nebulizers and his chronic meds. Last day of
steroids and antibiotics are ___.
# Chronic diastolic CHF:
# CAD
Patient with low nl EF on last ECHO, BNP now lower than on
prior. Also evidence of severe pulmonary hypertension on recent
ECHO at ___. Taken off nadolol at some pt due to brady, however
pt states that he is taking at home. Diuretics were held in the
setting of hypotension and acute renal failure but were resumed
on discharge at dose listed above. Aspirin was continued. His
Nadolol was held in favor of Carvedilol for cardioprotection.
He has no documentation of varices and his Nadolol may have
contributed to his hypotension, so this was held.
# Lower extremity edema:
Chronic, suspect due to lymphedema due to chronic thrombosis/IVC
thrombosis, as well as possible contributions from volume
overload from HF/liver disease. This was managed with local
wound care
# Cirrhosis: Due to hep C, pt states worsening abd distension
and non-compliance with lactulose however no e/o worsening
encephalopathy at this time. Abdominal ultrasound with doppler
was without thrombosis and was otherwise unremarkable. Lactulose
was continued. Nadolol changed in favor of Carvedilol given no
clear documentation of varices and he has clear cardiac disease.
# Anemia: normocytic, near recent ___, likely AOCD in setting of
CKD, liver disease, possible varices, supertherapeutic INR, will
check iron studies given ferritin WNL at last check. No e/o
active bleeding however pt at high risk given liver disease,
# Chronic Hx PE/DVT: Supertherapeutic INR on admission, coumadin
was held and resumed once INR intherapuetic range, at first at a
lower dose 3mg, and then at 4mg daily. Close INR monitoring is
recommended. Next INR should be drawn ___ or ___.
# History of heroin use:
# Chronic pain:
The patent was continued on his methadone, dose confirmed on
admission. He was also given oxycodone for breakthrough pain as
prescribed by his PCP. Gabapentin was continued.
#Depression:
Patient reports PTSD as well. Ongoing complaint of depression
without SI. Discussed psychiatry evaluation with the patient
which he declined. Mirazapine was continued.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN sob
2. Atorvastatin 40 mg PO QPM
3. ClonazePAM 2 mg PO TID
4. FoLIC Acid 1 mg PO DAILY
5. Furosemide 80 mg PO DAILY
6. Gabapentin 800 mg PO TID
7. Lactulose 15 mL PO BID
8. Lisinopril 10 mg PO DAILY
9. Methadone 65 mg PO DAILY
10. Nadolol 40 mg PO DAILY
11. Omeprazole 20 mg PO DAILY
12. OxycoDONE (Immediate Release) 5 mg PO Q8H:PRN pain
13. Tamsulosin 0.4 mg PO QHS
14. Tiotropium Bromide 1 CAP IH DAILY
15. Warfarin 5 mg PO DAILY16
16. Docusate Sodium 100 mg PO BID
17. Multivitamins 1 TAB PO DAILY
18. Senna 17.2 mg PO QHS
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN sob
2. Atorvastatin 40 mg PO QPM
3. ClonazePAM 2 mg PO TID
4. Docusate Sodium 100 mg PO BID
5. FoLIC Acid 1 mg PO DAILY
6. Furosemide 60 mg PO DAILY
RX *furosemide 20 mg 3 tablet(s) by mouth once a day Disp #*90
Tablet Refills:*0
7. Gabapentin 800 mg PO TID
8. Lactulose 15 mL PO BID
9. Lisinopril 5 mg PO DAILY
RX *lisinopril 5 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
10. Methadone 65 mg PO DAILY
11. Mirtazapine 30 mg PO QHS
12. Multivitamins 1 TAB PO DAILY
13. Omeprazole 20 mg PO DAILY
14. OxycoDONE (Immediate Release) 5 mg PO Q8H:PRN pain
15. Senna 17.2 mg PO QHS
16. Tamsulosin 0.4 mg PO QHS
17. Tiotropium Bromide 1 CAP IH DAILY
18. Warfarin 4 mg PO DAILY16
19. Carvedilol 3.125 mg PO BID
RX *carvedilol 3.125 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
20. Aspirin 81 mg PO DAILY
21. PredniSONE 40 mg PO DAILY Duration: 1 Day
last dose ___
RX *prednisone 20 mg 2 tablet(s) by mouth once a day Disp #*1
Tablet Refills:*0
22. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 1 Day
last day ___
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth twice a day Disp #*3 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
COPD with acute exacerbation
Acute renal failure
Hypotension
Chronic systolic CHF
Depression
Chronic PE
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:
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
You were admitted with fatigue, fall, and shortness of breath.
These symptoms were likely due to several factors: your chronic
conditions, dehydration from too much Lasix, and COPD
exacerbation. With treatment you improved.
Because of your low blood pressure, several of your blood
pressure medications have been lowered or changed.
Please continue your medications as prescribed and finish your
course of Prednisone and Augmentin. Please continue your
Warfarin as well and have your INR repeated in the next ___ days
Followup Instructions:
___
|
10108435-DS-45 | 10,108,435 | 23,827,733 | DS | 45 | 2191-08-14 00:00:00 | 2191-08-14 22:47:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Compazine / Codeine / Atenolol / Penicillins
Attending: ___
Chief Complaint:
Leg swelling
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with COPD, HFpEF, STEMI s/p PCI, HCV cirrhosis, DVT/PE on
Coumadin, Hep C, polysubstance abuse, chronic lymphedema R > L
___ chronic thrombosis and IVC thrombosis presenting from home
with several days of BLE swelling and pain with difficulty
ambulating, dyspnea, orthopnea and several falls at home.
Patient is a poor historian. He states that he has been feeling
progressive pain in his LEs and that they feel cold, with
worsening bilateral swelling; at baseline he has had R > L lower
extremity edema. He lives at home and has a ___ visit to help
with medication administration - he states that he has not been
able to leave the house for several days due to ambulation
difficulty. He reports several falls in the past several days,
and today fell and landed on his buttocks. He does not think he
hit his head. No fever, some intermittent chills. No productive
cough or increase in his baseline wheezing. No abd pain. He
states he has had diarrhea for several weeks without any nausea
or vomiting. No chest pain today, intermittently has transient
sharp chest pain which is self-limited. He reports stable 4
pillow orthopnea and also endorses + PND over the past 3 weeks
as well.
He was recently admitted to ___ in ___ for multiple
falls, worsening lower extremity edema and spontaneous bleeding
of his lower extremity varicosities. His falls were felt to be
___ orthostasis in the setting of overdiuresis as an outpatient.
His home antihypertensives were decreased and he was discharged
on liisnopril 5 mg daily, Lasix 60 mg daily. His home nadolol
was held. Discharge weight was 229 pounds; weight has been as
low as 213.84 pounds in ___.
In the ED, initial vitals were: 98.5 70 149/88 18 100% RA
Labs were notable for: Cr 1.2 (at baseline), BNP 1711, hgb 9.5
(at baseline), lactate 1.7, LFTs wnl, INR 3.2, trop < 0.01, CXR
showed mild vascular congestion and CT head showed no acute
intracranial process. While in the ED, the patient had an
unwitnessed fall; repeat head CT was negative. The patient
received Klonopin and gabapentin prior to transfer to the floor.
On the floor, initial VS 99.2, 147/87, 59, 18, 99% on RA.
Weight at admission 225.1 lbs.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias.
Past Medical History:
- Hepatitis C, denies h/o treatment
- Hepatitis B previous infection, now HBsAg negative
- s/p STEMI w/ BMS in LAD in ___, due to GI bleed stopped
plavix cont only aspirin
- Malignant hypertension: thought to be secondary to medication
non-compliance, but had hypotension during admission in ___
and BP meds were cut back. (most likely due to Clonidine effect:
overdose/withdrawal)
- Pulmonary embolus: Recurrent VTE s/p IVC filter, previously
not on coumadin due to noncompliance, but resumed warfarin on
prior admission and is followed by ___ clinic.
- Heroin abuse: pt reports 65 mg methadone daily confirmed
___
with methadone maintenance clinic ___
Phone: ___
- Chronic obstructive pulmonary disease on ___ home O2
- Gastroesophageal reflux disease
- PTSD ___ veteran)
- Anxiety / Depression
- Antisocial personality disorder
- Microcytic anemia
- Vitamin B12 deficiency
- Chronic kidney disease
- ___: punctate L parietal hemorrhage, seen by neurosurg who
did not recommend any f/u or intervention
Social History:
___
Family History:
Father died of myocardial infarction at unknown age. Mother died
of pancreatic cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: VS 99.2, 147/87, 59, 18, 99% on RA.
Weight at admission 225.1 lbs.
General: Alert, oriented, elderly male agitated, but in no acute
distress
HEENT: MMM, NCAT, EOMI, anicteric sclera, JVP elevated to 8-9 cm
with +hepatojugular reflex
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs/chest: mild bibasilar crackles, + end-expiratory wheezes
throughout, no labored respirations
Abdomen: Obese, soft, non-distended, non-tender, bowel sounds
present, no rebound or guarding. No fluid wave.
GU: No foley
Ext: Diffusely TTP. Chronic venous stasis changes bilaterally.
1+ edema to the knees, no e/o skin breakdown or cellulitis.
Bilateral hand tremor.
Neuro: AOx2 (not to date/day of the week), spontaneously moving
all extremities, no asterixis, gait deferred.
DISCHARGE PHYSICAL EXAM:
VS: Tm 99 Tc 98.5 ___ 56-65 18 99 RA
Weight: 103 kg
General: comfortable appearing, NAD
HEENT: MMM, NCAT, anicteric sclera, no JVP elevation
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs/chest: No crackles, + end-expiratory wheezes throughout
with some decreased air movement
Abdomen: Obese, soft, non-distended, mild tenderness to
palpation diffusely, bowel sounds present, no rebound or
guarding
GU: No foley
Ext: Diffusely TTP. Extensive chronic venous stasis changes
bilaterally. No e/o skin breakdown or cellulitis.
Neuro: MAE, grossly nonfocal
Pertinent Results:
ADMISSION LABS:
___ 08:48PM BLOOD WBC-4.4 RBC-3.63* Hgb-9.5* Hct-31.2*
MCV-86 MCH-26.2 MCHC-30.4* RDW-15.1 RDWSD-47.1* Plt ___
___ 08:48PM BLOOD Neuts-57.8 ___ Monos-5.9 Eos-6.3
Baso-1.4* Im ___ AbsNeut-2.57 AbsLymp-1.26 AbsMono-0.26
AbsEos-0.28 AbsBaso-0.06
___ 10:05PM BLOOD ___ PTT-47.2* ___
___ 08:48PM BLOOD Glucose-89 UreaN-21* Creat-1.2 Na-141
K-5.0 Cl-102 HCO3-26 AnGap-18
___ 08:48PM BLOOD ALT-8 AST-33 AlkPhos-84 TotBili-0.4
___ 08:48PM BLOOD Albumin-4.2
___ 08:48PM BLOOD proBNP-1711*
___ 08:48PM BLOOD cTropnT-<0.01
___ 08:48PM BLOOD TSH-3.2
___ 08:56PM BLOOD Lactate-1.7
DISCHARGE LABS:
___ 06:10AM BLOOD WBC-3.9* RBC-3.58* Hgb-9.4* Hct-31.6*
MCV-88 MCH-26.3 MCHC-29.7* RDW-14.9 RDWSD-47.8* Plt ___
___ 06:10AM BLOOD ___ PTT-49.5* ___
___ 06:10AM BLOOD Glucose-87 UreaN-30* Creat-1.0 Na-139
K-4.4 Cl-102 HCO3-32 AnGap-9
___ 06:10AM BLOOD Calcium-8.6 Phos-4.0 Mg-2.2
MICROBIOLOGY:
___ C. difficile DNA amplification assay (Final ___:
CANCELLED. This test was cancelled because a FORMED stool
specimen was received, and is NOT acceptable for the C.
difficile DNA amplification testing. See discussion in ___
laboratory manual.
IMAGING:
___ Chest X ray: AP upright and lateral views of the chest
provided.
There is no focal consolidation, effusion, or pneumothorax.
Pulmonary
vascular congestion is mild. Cardiomegaly is similar to prior.
Imaged osseous
structures are intact. No free air below the right
hemidiaphragm is seen.
___ CT Head: There is no evidence of infarction, hemorrhage,
edema, or mass. The ventricles and sulci are normal in caliber
and configuration. Calcification of the carotid siphons are
seen bilaterally.
No fracture seen. The paranasal sinuses, mastoid air cells, and
middle ear
cavities are clear. The orbits are unremarkable.
___ CT Head x2 (after fall in ED): There is no evidence of
infarction, hemorrhage, edema, or mass. Calcification of the
carotid siphons is seen bilaterally.
No fracture seen. The paranasal sinuses, mastoid air cells, and
middle ear
cavities are clear. The orbits are unremarkable.
Brief Hospital Course:
___ year old man with PMHx notable for HCV cirrhosis, COPD on
___ home O2, CAD, chronic ___, DVT/PE on Coumadin who presented
to the ___ ED with dyspnea, worsening lower extremity
pain/swelling and falls.
# Chronic diastolic heart failure: Mr. ___ was recently
discharged ___nd was noted to be 104.1 kg
lbs. His admission weight was 102.3 kg. His worsening lower
extremity swelling was not thought to be predominantly caused by
a significant acute on chronic diastolic CHF exacerbation. He
may have had some increased volume given the mild congestion
seen on his chest X ray and his BNP of 1711. He received 40 mg
IV Lasix on admission with resolution of his dyspnea and mild
increase in his creatinine. He did not note any improvement in
his leg pain or swelling. He was discharged on his home dose of
Lasix 60 mg daily.
# Falls: Patient reports many falls at home and also fell once
in the ED. CT scans of the head were negative for hemorrhage.
His falls are likely mechanical as he reports difficulty with
walking given progressive BLE swelling. ___ evaluated the patient
and noted significant weakness and instability, recommending
discharge to rehab.
# Chronic lower extremity venous stasis. Likely related to
lymphedema from recurrent DVT with minor component from ___.
There was no evidence of overlying cellulitis. Wound care was
consulted but the patient refused the consult. He likewise
declined leg wraps.
# Chest pain: Patient described lightning-like chest pain that
awakens him from sleep and lasts a few seconds before
self-resolving. Trop-T x 2 were negative and ECG was repeatedly
without ischemic changes. His pain was also reproducible with
palpation of the left chest, indicating a musculoskeletal source
of the pain.
# Diarrhea: Patient reported that he had been having diarrhea
since his last hospitalization in ___. On further
questioning, he said that he had not had a BM in the three days
prior to presentation. Does say he has not had a BM in 3 days.
LFTs were normal and his abdominal exam was benign. C diff could
not be sent as he did not have a loose BM while in the hospital.
Lactulose was re-started on discharge.
# HCV cirrhosis: Complicated by hepatic encephalopathy in the
past; has no known history of esophageal varices. No evidence of
hepatic encephalopathy at this time. Initially held lactulose in
the setting of diarrhea but when he had no loose BMs in the
hospital, this was restarted.
# Polysubstance abuse: Patient has long history of chronic
narcotics use and heroin abuse. On admission, he claimed to be
prescribed MS ___ 50 mg BID and received this for one day,
but on the second day, he became somewhat somnolent and it was
discovered that this was an expired prescription and it was
discontinued. His methadone use was verified with his ___
clinic (___).
# COPD: At home, patient is on ___ NC. S/p recent COPD
exacerbation in ___ for which he was given a prednisone
burst and 5 day course of Augmentin (last day ___. He was
continued on home albuterol/tiotropium.
# Chronic Hx PE/DVT. INR was supratherapeutic, making recurrent
DVT unlikely.
# Depression/PTSD: Continued home mirtazapine.
Transitional Issues:
- Patient currently on methadone 65 mg daily. He is not
currently being prescribed any other opiates. He claimed to be
receiving MS ___ 30 mg BID but this was an expired
prescription from ___.
- will need to f/u INR on ___ given supratherapeutic INR
in-house
- Weight on discharge: 103 kg
- CODE: full
- CONTACT: patient -- ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB
2. Atorvastatin 40 mg PO QPM
3. ClonazePAM 2 mg PO TID
4. Docusate Sodium 100 mg PO BID
5. FoLIC Acid 1 mg PO DAILY
6. Furosemide 60 mg PO DAILY
7. Gabapentin 800 mg PO TID
8. Lactulose 15 mL PO BID
9. Lisinopril 5 mg PO DAILY
10. Methadone 65 mg PO DAILY
11. Mirtazapine 30 mg PO QHS
12. Multivitamins 1 TAB PO DAILY
13. Omeprazole 20 mg PO DAILY
14. Senna 17.2 mg PO QHS:PRN constipation
15. Tamsulosin 0.4 mg PO QHS
16. Tiotropium Bromide 1 CAP IH DAILY
17. Warfarin 4 mg PO 4X/WEEK (___)
18. Carvedilol 3.125 mg PO BID
19. Warfarin 3 mg PO 3X/WEEK (___)
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB
2. Atorvastatin 40 mg PO QPM
3. Carvedilol 3.125 mg PO BID
4. ClonazePAM 2 mg PO TID
5. Docusate Sodium 100 mg PO BID
6. FoLIC Acid 1 mg PO DAILY
7. Gabapentin 800 mg PO TID
8. Lisinopril 5 mg PO DAILY
9. Methadone 65 mg PO DAILY
10. Mirtazapine 30 mg PO QHS
11. Multivitamins 1 TAB PO DAILY
12. Omeprazole 20 mg PO DAILY
13. Senna 17.2 mg PO QHS:PRN constipation
14. Tamsulosin 0.4 mg PO QHS
15. Tiotropium Bromide 1 CAP IH DAILY
16. Furosemide 60 mg PO DAILY
17. Lactulose 15 mL PO BID
___ hold for loose stools
18. Acetaminophen 500 mg PO Q6H:PRN pain
19. Warfarin 4 mg PO 4X/WEEK (___)
20. Warfarin 3 mg PO 3X/WEEK (___)
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Diastolic congestive heart failure
Post-thrombotic syndrome
Chronic lymphedema
Chronic obstructive pulmonary disease
Secondary diagnosis:
Hypertension
Chronic kidney disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were hospitalized at ___
because you had increased swelling in your legs and were
falling. You were also feeling short of breath. The swelling and
pain in your legs is due to your history of blood clots. Wound
care was consulted to help you take care of your legs but you
did not want to talk to them.
You did have some extra fluid built up in your lungs which we
removed with IV medication. This improved your breathing.
It was a pleasure participating in your care. We wish you all
the best in the future.
Sincerely,
Your ___ team
Followup Instructions:
___
|
10108435-DS-48 | 10,108,435 | 21,831,401 | DS | 48 | 2192-01-16 00:00:00 | 2192-01-16 17:14:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Compazine / Codeine / Atenolol / Penicillins
Attending: ___.
Chief Complaint:
Dyspnea, ___ edema
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Parts of history obtained from ___ as patient was confused at
time of interview.
Mr. ___ is a ___ M with history of CAD s/p STEMI with BMS
___, recurrent DVT/PE s/p IVC filter now thrombosed currently
on Coumadin, HTN, COPD on 2L home O2, PTSD/Depression/ASPD,
chronic lower extremity edema, polysubstance abuse and chronic
pain complicated by narcotics overdose presenting with worsening
of bilateral lower extremity edema and dyspnea.
On arrival, patient stated progressive dyspnea on exertion over
the last 3 days. He stated that he normally has difficulty
ambulating but this is much worse. He also had a non-productive
cough and is unclear if this is new for him. He also stated that
he may have had hemoptysis x2 a few days prior to admission, but
does not remember the quantity or quality of the sputum stating
he is "confused." He had no recent medication changes and no
changes in his diet.
He endorsed intermittent, shooting chest pain that exacerbates
his dyspnea. It is not related to any exacerbation.
He denied nausea, vomiting or diaphoresis, as well as abdominal
pain and dark or bloody stool. He endorsed subjective fevers and
chills, as well as some recent falls without head strikes. He
has difficulty ambulating around his house. He has been offered
case management and assisted living but will not go to a
facility. He had a visiting nurse who helps with his wound care
but this had desisted by the time of admission due to combative
interactions with the patient.
Of note, the patient was recently discharged from ___ on
___ for similar presentation including significant ulcers on
his anterior lower extremities which were attributed to venous
stasis. During that admission his torsemide was increased. In
addition, he was treated for a COPD exacerbation based on
imaging from CTA chest.
In the ED, initial vitals were: Pain 10, T 97.2, HR 68, BP
117/58, RR 20, O2 100% Nasal Cannula
Labs showed baseline hct, INR therapeutic, BNP at baseline
(800). Normal lactate.
Imaging showed: EKG showed no acute ischemia. A chest x-ray
showed persistent cardiomegaly. Mild pulmonary vascular
congestion. A CTA of the chest was performed to rule out PE,
with read pending at time of transfer.
The patient was given:
___ 14:38 PO OxyCODONE SR (OxyconTIN) 40 mg
___ 15:37 PO/NG Gabapentin 800 mg
___ 15:37 PO/NG ClonazePAM 2 mg
The patient desat'ed to 89% on 3L while ambulating. Given the
increased dyspnea and ambulatory desaturation, decision was made
to admit to medicine.
Transfer VS were pain 9, T 97.4, HR 62, BP 123/67, RR 14, O2
100% Nasal Cannula
On arrival to the floor, patient was confused and AAOx1. He was
still endorsing dyspnea and pain in his legs and back.
Past Medical History:
- Hepatitis C, denies h/o treatment, no clear cirrhosis on
imaging; complicated by hepatic encephalopathy in the past
- Hepatitis B previous infection, now HBsAg negative
- s/p STEMI w/ BMS in LAD in ___, due to GI bleed stopped
plavix cont only aspirin
- Malignant hypertension: thought to be secondary to medication
non-compliance, but had hypotension during admission in ___
and BP meds were cut back. (most likely due to Clonidine effect:
overdose/withdrawal)
- Pulmonary embolus: Recurrent VTE s/p IVC filter now
thrombosed, previously not on coumadin due to noncompliance, but
resumed warfarin on prior admission and is followed by ___
___ clinic.
- Heroin abuse: pt reports 65 mg methadone daily confirmed
___ with methadone maintenance clinic ___
Phone: ___
- Chronic obstructive pulmonary disease on ___ home O2
- Gastroesophageal reflux disease
- PTSD ___ veteran)
- Anxiety / Depression
- Antisocial personality disorder
- Microcytic anemia
- Vitamin B12 deficiency
- Chronic kidney disease
- ___: punctate L parietal hemorrhage, seen by neurosurg who
did not recommend any f/u or intervention
Social History:
___
Family History:
Father died of myocardial infarction at unknown age. Mother died
of pancreatic cancer.
Physical Exam:
ADMISSION
Vital Signs: 97.5 134/66 69 18 99 3L
GEN: confused, disheveled
HEENT: sclerae anicteric, pin point pupils. OP clear
___: RRR no MRG. JVP at angle of jaw at 45 degrees
LUNGS: no increased WOB. Diffuse wheezing and rhonchi
ABD: Marked caput medusa. Non-tender, obese. Palpable liver edge
about 4 finger breaths below costal margin
EXT: warm, significant venous stasis changes with open wounds on
anterior shins b/l. Edema to thigh.
NEURO: CN II-XII grossly intact, though patient had poor effort.
Patient may be mumbling words, unclear if baseline. Some
decreased strength in LUE.
DISCHARGE
Vitals: 98 // 119/68 // 54 // 16 // 100%RA
GEN: NAD. Not using oxygen. Cooperative. Eating breakfast. Much
calmer than prior evening.
HEENT: Pin point pupils, anicteric sclerae. OP clear, moist
mucous membranes, poor dentition.
___: RRR no MRG. JVP stable at <6cm from sternal manubrium.
LUNGS: no increased WOB. Diffuse end expiratory wheezing.
Reduced air movement in bilateral bases. Reduced crackles from
prior.
ABD: Marked caput medusa. Mild distension. No palpable liver
edge, no enlarged liver by percussion. Soft, nontender.
EXT: Warm, significant venous stasis changes to distal knee.
Some crusted wounds on anterior shins b/l without active oozing.
Nonpitting edema to thigh.
Pertinent Results:
ADMISSION
___ 11:30AM BLOOD WBC-3.3* RBC-3.38* Hgb-8.1* Hct-28.5*
MCV-84 MCH-24.0* MCHC-28.4* RDW-16.0* RDWSD-49.4* Plt ___
___ 11:30AM BLOOD ___ PTT-31.9 ___
___ 11:30AM BLOOD Glucose-109* UreaN-15 Creat-1.1 Na-138
K-4.2 Cl-100 HCO3-31 AnGap-11
___ 11:30AM BLOOD ALT-5 AST-14 AlkPhos-77 TotBili-0.4
___ 11:30AM BLOOD proBNP-800*
___ 05:00AM BLOOD Calcium-8.6 Phos-4.3 Mg-2.0
___ 11:51AM BLOOD Lactate-1.2
___ 03:45PM URINE Color-Yellow Appear-Clear Sp ___
___ 03:45PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.5 Leuks-TR
___ 03:45PM URINE RBC-1 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-1
PERTINENT
___ 11:30AM BLOOD proBNP-800*
DISCHARGE
___ 05:00AM BLOOD WBC-5.4 RBC-3.63* Hgb-8.4* Hct-29.1*
MCV-80* MCH-23.1* MCHC-28.9* RDW-16.3* RDWSD-47.1* Plt ___
___ 05:00AM BLOOD Plt ___
___ 05:00AM BLOOD Glucose-85 UreaN-38* Creat-1.0 Na-137
K-4.7 Cl-97 HCO3-33* AnGap-12
MICROBIOLOGY
__________________________________________________________
___ 3:44 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.
__________________________________________________________
___ 5:00 am BLOOD CULTURE 2 OF 2.
Blood Culture, Routine (Pending):
__________________________________________________________
___ 5:00 am BLOOD CULTURE 1 OF 2.
Blood Culture, Routine (Pending):
__________________________________________________________
___ 3:45 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: <10,000 organisms/ml.
__________________________________________________________
___ 11:30 am BLOOD CULTURE
Blood Culture, Routine (Pending):
IMAGING
___ Imaging ABDOMEN US (COMPLETE ST
IMPRESSION:
No ascites. Limited evaluation of the liver, however no
morphological features of cirrhosis are identified. Doppler
evaluation of the liver is normal.
Venous collaterals in the abdominal wall are related to
occlusion of the inferior vena cava below the IVC filter.
___ Imaging CHEST (PA & LAT)
IMPRESSION:
Persistent cardiomegaly. Mild pulmonary vascular congestion.
___ Imaging CTA CHEST
IMPRESSION:
1. No evidence of acute pulmonary embolism or aortic
abnormality.
2. Cardiomegaly with mi pulmonary edema.
3. Moderate chronic small airways disease with mucous plugging,
particularly in the lower lobes, worse from ___. Areas of
more confluent opacity in the lower lobes suggest atypical
infection.
4. Dilated main pulmonary artery suggests sequelae of chronic
pulmonary hypertension.
5. Thickened esophageal wall suggests esophagitis.
6. Interval increased size of mediastinal lymph nodes which
could be reactive and related to esophagitis and current
infection. Close interval follow-up to ensure resolution.
7. Mild splenomegaly
___ Imaging CT HEAD W/O CONTRAST
IMPRESSION:
1. Study is mildly degraded by motion.
2. Within this limitation, no evidence of acute intracranial
hemorrhage.
Brief Hospital Course:
___ with history of CAD s/p STEMI with BMS ___, recurrent
DVT/PE s/p IVC filter now thrombosed currently on Coumadin, HTN,
COPD on 2L home O2, PTSD/Depression/ASPD, chronic lower
extremity edema, polysubstance abuse and chronic pain
complicated by narcotics overdose presenting with worsening of
bilateral lower extremity edema and dyspnea.
ACTIVE DIAGNOSES:
#Community Acquired Pneumonia: Patient has been complaining of a
non-productive cough x3 days prior to admission. Also
complaining of subjective fevers/chills. CXR is notable to
vascular congestion but CTA showed possible infection and exam
initially showed hypoxia on room air in addition to diffuse
wheezing and rhonchi. No leukocytosis. Patient completed a 7-day
course of doxycyline ___. Azithromycin and ceftriaxone
were not chosen given prolonged QTc on methadone and penicillin
allergy, respectively.
#COPD exacerbation: Patient had increased dyspnea and cough,
though no increased sputum production. Patient has diffuse
wheezing and rhonchi on exam. Chest imaging as above. Initially
avoided prednisone and azithromycin given concern for volume
status and QTc prolongation, respectively. However, patient
continued to have significant wheezing on exam and was therefore
treated with a 5-day prednisone burst of 40mg QD from ___.
Exacerbating factors likey CHF exacerbation (see below) and
infection (see above). Patient received duonebs q6H and PRN
albuterol while in house. Of note, he only intermittently uses
his supplemental O2.
#Acute on Chronic Diastolic Heart Failure: Last LVEF from TTE
___ was 50%. BNP near baseline but patient has pitting edema on
exam in addition elevated JVP, dyspnea and mild vascular
congestion on CXR. Unclear if patient is compliant with
medications. Per OMR notes it states ___ notes patient is only
compliant with pain medications. Other exacerbating factors
include his previously mentioned pneumonia and COPD. Received
Lasix 40mg IV x2 with large urine output. Crackles and rhonchi
improved on exam in addition of decreased JVP from angle of jaw
to midneck. Patient then started on prednisone (see above) for
COPD exacerbation with increased JVP and crackles in addition to
even fluid balance and new hyponatremia and therefore was
rediuresed with 40IV Lasix x1. Volume status improved with
decreased JVP and crackles. His home furosemide dose was briefly
increased from 40mg to 60mg QD, though ultimately returned to
___ with respiratory improvement following steroids for COPD
exacerbation. Continued on metoprolol and atorvastatin.
#Lower extremity edema: Patient has known venous stasis changes
on his lower extremities requiring wound care and takes Lasix at
home. Review of OMR shows that patient was recently discharged
from home ___ care after being abusive to staff. Patient
does have a diagnosis of dCHF, last LVEF is 50%. BNP is at
baseline but has signs of volume overload on exam evidenced by
pitting edema and elevated JVP. Unclear if patient has been
compliant with medications. No signs of systemic infection. In
addition, patient has known IVC congestion from thrombosis of
IVC filter further evidenced by extensive collaterals on both
imaging and congestion of Periumbilical veins on exam. Discussed
with patient need for rehab and home services, though he was not
agreeable to this plan. Patient's legs were briefly elevated and
wrapped while in house. Diuresed as above.
#Toxic Infectious Encephalopathy: Resolved. Patient was AAOx1 on
initial exam. No obvious neurological deficits, but patient was
not entirely cooperative during evaluation. Patient has history
of recent falls though NCHCT negative for acute process/bleed.
INR is not supratherapeutic. Given caput medusa and ?h/o HCV
there would be concern for cirrhosis though LFTs and abdominal
ultrasound where not concerning for this diagnosis. Venous
collaterals from IVC congestion and have been noted on prior
exams. Mental status now improved s/p Lasix and antibiotics.
CHRONIC, INACTIVE DIAGNOSES:
#CAD s/p MI: s/p STEMI w/ BMS in LAD in ___, due to GI bleed
stopped plavix cont only aspirin. Currently no chest pain though
endorses intermittent, sharp chest pain for many weeks. EKG
shows no active ischemia. Continued ASA, metoprolol and
atorvastatin.
#History of DVT/PE: Patient has history of recurrent VTE s/p IVC
filter which has subsequently clotted. Currently on warfarin
with therapeutic INR. CTA was ordered in ED for dyspnea and was
negative for PE. Patient has impressive venous collaterals on
abdomen and back which have been documented prior, due to to IVC
congestion. Patient was continued on home warfarin dosing with
therapeutic INR.
#History of Hepatitis C: Patient reports h/o HCV though prior VL
negative and reports no history of treatment. Otherwise stable.
LFTs and ultrasound negative as above.
#History of opiate abuse/chronic pain: Patient currently on
methadone, oxycontin and gabapentin. Prior history of heroin use
and overdose. Will avoid increasing pain medications while in
house. Patient was discharged with narcan prescription.
Methadone dose was confirmed with provider.
Methadone Provider: ___ ___
Methadone dose confirmed as: 65 qAM and 10mg qPM
#BPH: stable on tamsulosin.
#Anxiety/Depression: stable
-cont clonazepam and duloxetine
TRANSITIONAL ISSUES
[]Patient previously discharged from home ___ practice, did not
want to wait to have confirmed new service (fired from several,
others not in his insurance). Paperwork submitted to ___ home
visit as of ___. Will need outpatient follow up of status of
visiting nurse service
[]Will require regular INR checks and has means of transport to
a lab if ___ is not set up. Given his difficulty getting to
follow up, we talked about switching to Dabigatran. He initially
agreed so Warfarin was held 1 day and we called ___ to inform
them, though he then changed his mind. We left a voicemail and
emailed ___ that he would not be leaving their service but were
not able to get confirmation as it was a weekend. He is
scheduled for a ___ outpatient appointment including
INR check and we reiterated the importance of attending this
appointment. We also secured a ride via his insurance company.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB
2. Atorvastatin 40 mg PO QPM
3. ClonazePAM 2 mg PO TID
4. Docusate Sodium 100 mg PO BID
5. FoLIC Acid 1 mg PO DAILY
6. Lactulose 30 mL PO BID
7. Methadone 65 mg PO QAM
8. Methadone 10 mg PO NOON
9. Metoprolol Tartrate 12.5 mg PO BID
10. Multivitamins 1 TAB PO DAILY
11. OxyCODONE SR (OxyconTIN) 40 mg PO Q8H
12. Senna 17.2 mg PO QHS:PRN constipation
13. Tamsulosin 0.8 mg PO QHS
14. Furosemide 40 mg PO DAILY
15. Tiotropium Bromide 1 CAP IH DAILY
16. Gabapentin 800 mg PO TID
17. Warfarin 3 mg PO DAILY16
18. DULoxetine 60 mg PO DAILY
19. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN dyspnea
20. Polyethylene Glycol 17 g PO DAILY constipation
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB
2. Atorvastatin 40 mg PO QPM
3. ClonazePAM 2 mg PO TID
RX *clonazepam 2 mg 2 tablet(s) by mouth three times a day Disp
#*15 Tablet Refills:*0
4. Docusate Sodium 100 mg PO BID
5. DULoxetine 60 mg PO DAILY
6. FoLIC Acid 1 mg PO DAILY
7. Gabapentin 800 mg PO TID
8. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN dyspnea
9. Methadone 65 mg PO QAM
RX *methadone 5 mg 13 tablets by mouth qam Disp #*65 Tablet
Refills:*0
10. Methadone 10 mg PO NOON
RX *methadone 10 mg 1 tablet by mouth QNoon Disp #*5 Tablet
Refills:*0
11. Metoprolol Tartrate 12.5 mg PO BID
12. OxyCODONE SR (OxyconTIN) 40 mg PO Q8H
RX *oxycodone [OxyContin] 40 mg 1 tablet(s) by mouth every eight
(8) hours Disp #*15 Tablet Refills:*0
13. Polyethylene Glycol 17 g PO DAILY constipation
14. Senna 17.2 mg PO QHS:PRN constipation
15. Tamsulosin 0.8 mg PO QHS
16. Multivitamins 1 TAB PO DAILY
17. Tiotropium Bromide 1 CAP IH DAILY
18. Lactulose 30 mL PO BID
19. Bisacodyl ___ID
RX *bisacodyl 10 mg 1 suppository(s) rectally daily Disp #*12
Suppository Refills:*0
20. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
21. Warfarin 3 mg PO 3X/WEEK (___)
22. Warfarin 4 mg PO 4X/WEEK (___)
23. Furosemide 40 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY
Community Acquired Pneumonia
Acute on Chronic Diastolic Heart Failure
COPD exacerbation
SECONDARY
History of DVT/PE
Chronic 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:
Dear Mr. ___,
It was a pleasure taking care of you during your
hospitalization. You came to the hospital because you were
having difficulty breathing. You were found to have extra fluid
on your lungs, in addition to a pneumonia. We gave you an
antibiotic to treat your pneumonia in addition to Lasix to help
you remove your extra fluid and steroids to decrease the
inflammation. This made you feel better. We also wrapped and
elevated your legs to help improve their swelling.
We discussed the need for rehab in order for you to get your
strength back while in a safe, observed environment that would
be able to monitor your medical problems. You did not want to go
to rehab, so we worked to find a Visiting Nurse ___. The
case management team put in paperwork to set you up with ___
Home Visiting and we are awaiting approval of those services.
You preferred going home without services, so we arranged close
follow up with Healthcare Associates for ___. When you
see Dr. ___ on ___, please discuss having a
visiting nurse to help manage your symptoms and medications, and
to catch any changes in your health (like leg swelling) before
you get so sick that you need to come to the hospital.
Because you have heart failure it is important that you weigh
yourself every morning, call MD if weight goes up more than 3
lbs.
Your discharge appointments and follow up appointments are
detailed below.
We wish you the best!
Your ___ care team
Followup Instructions:
___
|
10108435-DS-49 | 10,108,435 | 26,448,261 | DS | 49 | 2192-02-05 00:00:00 | 2192-02-05 20:27:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Compazine / Codeine / Atenolol / Penicillins
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with history of CAD s/p STEMI with BMS ___, recurrent
DVT/PE s/p IVC filter now thrombosed currently on Coumadin, HTN,
COPD on 2L home O2, PTSD/Depression/ASPD, chronic lower
extremity edema, polysubstance abuse and chronic pain
complicated by narcotics overdose presents with multiple
complaints. The patient initially called an ambulance after
having poor appetite, inability to eat, and abdominal pain for
about 1 week. On review of systems, he reports having diffuse
abdominal pain, abdominal swelling, poor appetite, nausea,
vomiting, intermittent diarrhea, cough, rhinorrhea, shortness of
breath, pain in the extremities, and lower extremity swelling.
He reports that the abdominal pain is a relatively new symptom
for him, but the respiratory symptoms are ongoing.
Of note, the patient has had multiple recent admissions to
___, most recently on ___ for pneumonia/COPD exacerbation,
AMS, and Acute on chronic diastolic HF.
ED Course:
- Initial vitals 97.8 75 137/76 20 98% RA.
- Exam notable for diffusely diminished breath sounds more
prominent at the base, end expiratory wheezing, diffuse
abdominal pain, very distended abdomen, prominent caput medusa,
2+ pitting edema in left leg and 3+ pitting edema in right.
Oriented to month/year ___, ___, can recite
days of the weeks backwards, similar to prior admissions. Guaiac
negative brown stool.
- Laboratory workup revealed: H/H 7.4/___.2, Utox negative, Chem
10 wnl, ABG wnl, LFT's wnl.
- Patient was given Duonebs for wheezing
- CXR Cardiomegaly is unchanged and there is persistent hilar
engorgement. Mild pulmonary interstitial edema likely present.
No large effusion or pneumothorax. No convincing signs of
pneumonia. Mediastinal contour is unchanged. Bony structures are
intact.
- Bedside ultrasound by ED house staff with no significant
ascites or pocket for paracentesis
Vitals prior to transfer: 97.7 60 139/62 13 98% RA
On the floor, the patient continues to act very somnolent but is
completely arousable and AOx3, complaining of ongoing diffuse
abdominal pain and "falls", although is not cooperative and is
very unclear in his history.
ROS:
(+/-) Per HPI
Past Medical History:
- Hepatitis C, denies h/o treatment, no clear cirrhosis on
imaging; complicated by hepatic encephalopathy in the past
- Hepatitis B previous infection, now HBsAg negative
- s/p STEMI w/ BMS in LAD in ___, due to GI bleed stopped
plavix cont only aspirin
- Malignant hypertension: thought to be secondary to medication
non-compliance, but had hypotension during admission in ___
and BP meds were cut back. (most likely due to Clonidine effect:
overdose/withdrawal)
- Pulmonary embolus: Recurrent VTE s/p IVC filter now
thrombosed, previously not on coumadin due to noncompliance, but
resumed warfarin on prior admission and is followed by ___
___ clinic.
- Heroin abuse: pt reports 65 mg methadone daily confirmed
___ with methadone maintenance clinic ___
Phone: ___
- Chronic obstructive pulmonary disease on ___ home O2
- Gastroesophageal reflux disease
- PTSD ___ veteran)
- Anxiety / Depression
- Antisocial personality disorder
- Microcytic anemia
- Vitamin B12 deficiency
- Chronic kidney disease
- ___: punctate L parietal hemorrhage, seen by neurosurg who
did not recommend any f/u or intervention
Social History:
___
Family History:
Father died of myocardial infarction at unknown age. Mother died
of pancreatic cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vital Signs: 97.5 128/55 65 20 97%ra
General: Somnolent but arousable, AOx3 (___)
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Diffuse wheezing, mild crackles bibasilar. Good air
movement
Abdomen: Tender to deep palpation, normal BS, slightly
distended. Soft, no rebound/guarding. Caput medusae per previous
exams.
GU: No foley
Ext: Warm, well perfused, ___ pulses symmetric b/l. Significant
venous stasis changes and open ulcers that appear dry, slightly
erythematous with no weeping, blood, or pus bilaterally. 2+
edema b/l.
Neuro: Mostly uncooperative. AOx3 (___). Somnolent but
arousable. Moving all four extremities equally. No obvious
facial asymmetry.
DISCAHRGE PHYSICAL EXAM:
========================
Vital Signs: 97.7PO 106 / 62 58 20 100 2L
Wr: 106.8 <- 107.7. (Baseline 108.9) (111 kg on admission)
I/O: 1040/825 (___)
General: Alert, oriented, chronically deconditioned gentleman,
NAD. HEENT: Sclera anicteric, MMM, difficult to visualize
tonsils, but hard palate and soft palate without erythema or
exudates.
Neck: JVP below clavicle with bed at 30 degree angle
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops.
Lungs: Inspiratory phase clear b/l; expiratory phase prolonged
with mainly upper airway wheezes, no appreciable rales or
rhonchi, some upper respiratory transmitted sounds, but good
airflow on inspiration.
Abdomen: NTTP, normal BS, slightly distended. Soft, no rebound
or guarding. Caput medusae per previous exams.
Ext: Warm, well perfused, ___ pulses symmetric b/l. Significant
venous stasis changes, hyperpigmentation and open shallow ulcers
that appear dry, slightly erythematous with no weeping, blood,
or pus bilaterally. 2+ lower extremity swelling up to his knees.
Neuro: A+Ox3. CN II-XII intact, ___ bilateral upper and lower
extremities.
Pertinent Results:
ADMISSION LABS:
===============
___ 07:36PM PO2-90 PCO2-48* PH-7.40 TOTAL CO2-31* BASE
XS-3
___ 07:36PM LACTATE-1.3
___ 07:00PM GLUCOSE-121* UREA N-19 CREAT-1.0 SODIUM-141
POTASSIUM-4.2 CHLORIDE-102 TOTAL CO2-28 ANION GAP-15
___ 07:00PM ALT(SGPT)-10 AST(SGOT)-21 ALK PHOS-68 TOT
BILI-0.3
___ 07:00PM LIPASE-15
___ 07:00PM cTropnT-<0.01 proBNP-692*
___ 07:00PM ALBUMIN-3.7 CALCIUM-8.2* PHOSPHATE-3.6
MAGNESIUM-2.2
___ 07:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 07:00PM WBC-5.3 RBC-3.22* HGB-7.4* HCT-26.2* MCV-81*
MCH-23.0* MCHC-28.2* RDW-17.2* RDWSD-50.0*
___ 07:00PM NEUTS-69.5 LYMPHS-18.1* MONOS-7.4 EOS-4.2
BASOS-0.6 IM ___ AbsNeut-3.65# AbsLymp-0.95* AbsMono-0.39
AbsEos-0.22 AbsBaso-0.03
___ 07:00PM PLT COUNT-173
___ 07:00PM ___ PTT-44.9* ___
MICRO LABS:
===========
Blood culture (___): No growth
Blood culture (___): No growth
Sputum culture (___): Inadequate sample (> 10 epithelial cells)
DISCHARGE LABS:
===============
___ 07:48AM BLOOD WBC-4.1 RBC-3.42* Hgb-7.9* Hct-27.9*
MCV-82 MCH-23.1* MCHC-28.3* RDW-16.3* RDWSD-48.6* Plt ___
___ 07:48AM BLOOD Glucose-80 UreaN-27* Creat-0.9 Na-138
K-4.4 Cl-96 HCO3-35* AnGap-11
___ 07:48AM BLOOD Calcium-9.0 Phos-3.8 Mg-2.2
IMAGING:
========
CHEST (PA & LAT) ___: AP upright and lateral views of the chest
provided. Cardiomegaly is unchanged and there is persistent
hilar engorgement. Mild pulmonary interstitial edema likely
present. No large effusion or pneumothorax. No convincing signs
of pneumonia. Mediastinal contour is unchanged. Bony structures
are intact.
ECG (___): Old anterior infarct, sinus bradycardia
RUQ US (___): 1. Limited evaluation of the left lobe of the
liver however, no focal lesions or parenchymal abnormalities are
seen. 2. Mild splenomegaly. 3. Normal biliary tree.
Abdominal xray (___): Nonspecific bowel gas pattern.
CXR (___): Pulmonary vascular congestion has improved, but there
is now mild interstitial edema. Mild cardiac enlargement is
stable. There is no pleural effusion. There are no focal
pulmonary abnormalities to suggest pneumonia and no appreciable
pleural effusion or evidence of pneumothorax.
EKG (___): Sinus bradycardia, old anteroseptal infarct, and no
STE/STD/TWI suggestive of ischemia.
EKG (___): NSR, QTc 408
Brief Hospital Course:
Mr. ___ is a medically complex ___ M h/o CAD, CHF, DVT on
couamdin, multiple recent admissions for dyspnea, difficulty
ambulating, who presented again with altered mental status,
dyspnea, diffuse abdominal pain, and difficulty ambulating, in
the setting of mild decompensated heart failure.
ACUTE MEDICAL PROBLEMS:
=======================
#Acute on chronic diastolic heart failure: On admission, based
on b/l pitting edema, worsening dyspnea, and pulmonary edema on
CXR, concern for mild decompensated heart failure. Ischemic
heart disease less likely in setting of negative troponin x1. Pt
takes meds at home and reports med compliance, but concern for
overall poor social situation suggest that med or diet
noncompliance are possible. Weight on last hospital discharge
was 108.9 kg. Weight on admission was 111 kg and he was given
Lasix IV until he reached his baseline weight, when he was
restarted on his home Lasix 40 mg PO. He was net negative on
this and he described an episode when he fell (see below), so
Lasix was held the following 3 days. He was sent home on 20 mg
Lasix PO ___ of his home dose).
#COPD exacerbation: On admission, patient's lung exam is
diffusely wheezy, suggesting mild COPD exacerbation as well.
Patient is satting well on home 2L O2 and does not report any
new cough or sputum production. It is possible that in the
setting of altered mental status, failure to thrive, he has not
been using his inhalers as prescribed. He was given prednisone
40 mg qd for 5 days, standing duonebs, and home tiotropium.
Initially, antibiotics were held to avoid QTc prolongation.
However, since is still complained of sputum production, he was
started on levofloxacin on ___ and his QTc was 408 on ___. He
completed this course on ___ (6 days).
#URI: Throughout his admission, he has been complaining of
increased mucus production, weakness, sore throat, and headache.
This was thought to be due to a common cold that could
exacerbate his underlying reactive airway. He was started on
fluticasone 2 puff BID and cepacol lozenges. He will go home
with fluticasone, nasal spray, and cepacol lozenges.
#Subacute Abdominal Pain: The patient has provided a very
unclear history about his abdominal pain, but he reports that
his abdomen has been distended and tender for one week, and he
reports that he has not been eating for one week as well. All
initial LFT's, lipase, CBC wnl, and his exam is only moderately
tender to palpation. His abdominal swelling is likely due to
mild CHF exacerbation causing abdominal swelling since he had no
ascites on ED US. He has caput medusa on exam and a history of
IVC filter thrombosis in the past. Unclear if this can
contribute to pain. RUQ US on ___ showed no focal lesions and
normal biliary tree and KUB showed no obstruction. He is no
longer complaining of abdominal pain.
#Altered mental status: Was somnolent on admission, but became
alert by the morning. Apparently due to psychiatric history he
has waxing/waning sensorium and has presented similarly to this
prior. Unclear the cause but so far metabolic workup negative,
infectious workup so far negative, no leukocytosis, no h/o liver
disease to suggest HE. He is on many sedating medications which
are likely to contribute. Initially held gabapentin, but was
restarted after two days due to complaints of leg pain. He was
continued on his pain regimen as stated below.
#Fall: On ___, had a fall while going to the bathroom. He does
not know what time this occurred, but denies LOC or hitting his
head. Denied palpitations or any neurologic deficits. He felt
graying out and then landed on his knees. He used the sink to
help himself up. He did not notify any nursing staff at this
time. No concern for neurological or cardiac abnormalities, but
given his diuresis (below his baseline weight by ___ kg) and
borderline low BP, hypovolemia is a possibility. Orthostatic VS
were normal. We held his Lasix 2 days after. ___ saw him and
recommended home with ___, but he has refused ___ in the past.
#Chest pain: He had chest pain in the ED with negative troponin
and an EKG not concerning for active ischemia. On ___, he also
complained of ___ sharp, nonpleuritic, left sternal chest pain
that was slightly tender to palpation. CXR showed improved
pulmonary vascular congestion, but interstitial edema and no
evidence to suggest PNA. EKG showed no evidence of active
ischemia. Low concern for PE (no increased oxygen requirement or
pleuritis), ACS (EKG at baseline without signs of active
ischemia), or intrapulmonary process (no evidence of PNA). Thus,
it is likely musculoskeletal pain or radiation from his
abdominal discomfort. This resolved on its own.
CHRONIC MEDICAL ISSUES:
=======================
#Frequent hospitalizations and noncompliance: This patient has
had multiple recent admissions. While he says he takes his
medications, he has multiple complex medical issues and it does
not seem like he can ___ for himself adequately. He claims he
does not have a ___, but past documentation has suggested that
he did, but he refuses working with them when they visit. He
also refuses to work with ___ and he has stated that he refuses
to see anyone in clinic other than Dr. ___ on ___. An
appointment was made for him at ___ on ___, but it
questionable if he will show up.
#Anemia: Patient has a history of anemia with baseline
hemoglobin in mid 7 to 8 range. Unclear reason for this in the
past. Iron studies suggest iron deficiency anemia (low ferritin,
high/normal TIBC). No evidence of bleeding and guaiac negative
stool
#Chronic Venous Stasis: Likely related to lymphedema from
recurrent DVT with minor component from ___. There were no
signs of acute infection. He denied any improvement in his leg
pain while hospitalized, but his baseline is difficult to assess
given his vague descriptions. He continued on his home
gabapentin and was given Lasix throughout his hospital stay with
significant improvement of his lower extremity edema. He never
had signs of bleeding or infection of his ulcers.
#CAD s/p STEMI with BMS to LAD: He was continue on his home
aspirin and atorvastatin.
#Chronic Hx PE/DVT: He was continued on his home warfarin and
did not require much adjustment throughout his hospital stay.
#Chronic pain: He was continued on his home methadone 65 mg and
10 mg qd as well as his home oxycodone SR 40 mg q8h. There were
several episodes when he accused nursing staff of not giving him
his medication, so two nurses had to give it and watch him take
it. For constipation, he was continued on his home bowel
regimen.
#HTN: He had borderline blood pressures during his hospital
stay, so his home metoprolol was held.
#HLD: He was continued on his home atorvastatin
#Depression/PTSD: He was continued on his home ClonazePAM 2 mg
PO TID and duloxetine
#BPH: He was continue on his home Tamsulosin 0.4 mg PO QHS
#GERD and history of GI bleeding: He was continued on his home
Omeprazole 20 mg PO DAILY
#Nutritional supplementation: He was continued on his home
folate and multivitamin
TRANSITIONAL ISSUES:
====================
-His home metoprolol tartrate 12.5 BID was held in the setting
of low BP. Consider restarting it if his BP starts to rise.
-His home Lasix 40 mg was cut to 20 mg in the setting of
borderline low BP.
-Compliance on his medications needs to be addressed, especially
with his Lasix.
-He may become a danger to himself due to noncompliance and
refusal of services.
-He conveyed some abuse-type behavior with his methadone while
in the hospital. Consider weaning as an outpatient.
-His weight on discharge was 106.8 kg (235.45 lb)
-He will follow-up with Dr. ___ on ___ at ___ at ___.
-CODE: Full
-CONTACT: none, should have a discussion about HCP
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB
2. Atorvastatin 40 mg PO QPM
3. ClonazePAM 2 mg PO TID
4. Docusate Sodium 100 mg PO BID
5. DULoxetine 60 mg PO DAILY
6. FoLIC Acid 1 mg PO DAILY
7. Gabapentin 800 mg PO TID
8. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN dyspnea
9. Methadone 65 mg PO QAM
10. Methadone 10 mg PO NOON
11. Metoprolol Tartrate 12.5 mg PO BID
12. OxyCODONE SR (OxyconTIN) 40 mg PO Q8H
13. Polyethylene Glycol 17 g PO DAILY constipation
14. Senna 17.2 mg PO QHS:PRN constipation
15. Tamsulosin 0.8 mg PO QHS
16. Multivitamins 1 TAB PO DAILY
17. Tiotropium Bromide 1 CAP IH DAILY
18. Lactulose 30 mL PO BID
19. Bisacodyl ___ID
20. Omeprazole 40 mg PO DAILY
21. Warfarin 3 mg PO 3X/WEEK (___)
22. Warfarin 4 mg PO 4X/WEEK (___)
23. Furosemide 40 mg PO DAILY
Discharge Medications:
1. Cepacol (Sore Throat Lozenge) 2 LOZ PO Q4H
RX *dextromethorphan-benzocaine [Cepacol Sorethroat-Cough] 5
mg-7.5 mg 2 lozenge(s) by mouth Every 4 hours as needed Disp
#*32 Lozenge Refills:*0
2. Fluticasone Propionate NASAL 2 SPRY NU BID
RX *fluticasone 50 mcg/actuation 2 sprays nasally 4 times a day
as needed Disp #*1 Spray Refills:*1
3. Sodium Chloride Nasal ___ SPRY NU QID:PRN mucus/congestion
RX *sodium chloride [Saline Nasal] 0.65 % ___ sprays nasally 4
times a day Disp #*1 Spray Refills:*0
4. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
5. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB
6. Atorvastatin 40 mg PO QPM
7. Bisacodyl ___ID
8. ClonazePAM 2 mg PO TID
9. Docusate Sodium 100 mg PO BID
10. DULoxetine 60 mg PO DAILY
11. FoLIC Acid 1 mg PO DAILY
12. Gabapentin 800 mg PO TID
13. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN dyspnea
14. Lactulose 30 mL PO BID
15. Methadone 65 mg PO QAM
16. Methadone 10 mg PO NOON
17. Metoprolol Tartrate 12.5 mg PO BID
18. Multivitamins 1 TAB PO DAILY
19. Omeprazole 40 mg PO DAILY
20. OxyCODONE SR (OxyconTIN) 40 mg PO Q8H
21. Polyethylene Glycol 17 g PO DAILY constipation
22. Senna 17.2 mg PO QHS:PRN constipation
23. Tamsulosin 0.8 mg PO QHS
24. Tiotropium Bromide 1 CAP IH DAILY
25. Warfarin 3 mg PO 3X/WEEK (___)
26. Warfarin 4 mg PO 4X/WEEK (___)
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
-COPD exacerbation
-Acute exacerbation of diastolic congestive heart failure
-Community acquired pneumonia
SECONDARY DIAGNOSES:
-Hepatitis C
-History of pulmonary emboli
-Anemia
-Chronic venous stasis
-Coronary artery disease
-Hypertension
-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:
Mr ___,
It was a pleasure meeting you and taking ___ of you during your
hospitalization at ___.
You were admitted with several symptoms, including worsening leg
swelling and pain, cough, shortness of breath, abdominal pain
and distention. You were diagnosed with an exacerbation of
congestive heart failure, which can cause trouble breathing,
abdominal swelling and pain, and leg swelling. You were also
diagnosed with an exacerbation of COPD and heart failure. You
were treated with a diuretic called Lasix to help remove excess
fluid in the body, and with steroids, nebulizers, and
antibiotics to treat your COPD. For concern for superimposed
pneumonia, you were also treated with an antibiotic called
levofloxacin.
You also have an appointment set up with Dr. ___ of Dr.
___ on ___ at 2:30 pm. The only change we made to
your home medications was in your Lasix (water pill). Instead of
40 mg daily, you will take 20 mg daily. We urge you to continue
taking all of your prescribed medications at home, as missing
doses of medications can lead to a return of your symptoms.
Finally, please weigh yourself daily and if you weight > 3 lbs
more than your baseline (around 240 lbs), then call your doctor.
Regards,
Your ___ Team
Followup Instructions:
___
|
10108435-DS-50 | 10,108,435 | 25,239,067 | DS | 50 | 2192-03-21 00:00:00 | 2192-03-22 16:18:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Compazine / Codeine / Atenolol / Penicillins
Attending: ___.
Chief Complaint:
chest pain, dyspnea, lower extremity edema
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ with complicated PMH including PE on
Coumadin and Hep C presenting with abdominal pain and
distension. + a week of abdominal and chest pain. Both stabbing
and pressure type of pain associated with dry heaves. Also with
SOB and increasing BLE edema. Has had multiple admissions in
past for abdominal pain related to his CHF exacerbations.
In the ED initial vitals were 97.9 80 140/95 18 97% RA. EKG with
stable Q's in V1-V4, no ischemic ST/T changes. Labs/studies
notable for INR 2.7, lactate 1.0, troponin <0.01, normal chem 7,
BNP 2478, and CBC with pancytopenia below his usual baseline.
Patient was given 40 IV Lasix, Albuterol neb, and ipratropium
bed. Vitals on transfer 98.1 73 135/68 15 100% Nasal Cannula.
On the floor,
-chest pain is still present and runs across upper chest. SOB
and lower extremity edema remains unchanged from yesterday.
Asking for pain medication for his chronic pain.
Past Medical History:
1. CARDIAC RISK FACTORS:
- Malignant hypertension
2. CARDIAC HISTORY:
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: s/p STEMI w/ BMS in LAD
in ___, due to GI bleed stopped plavix cont only aspirin
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
- Hepatitis C, denies h/o treatment, no clear cirrhosis on
imaging; complicated by hepatic encephalopathy in the past
- Pulmonary embolus: Recurrent VTE s/p IVC filter now
thrombosed, previously not on coumadin due to noncompliance,
but resumed warfarin on prior admission and is followed by ___
___ clinic.
- Heroin abuse on methadone
- Chronic obstructive pulmonary disease on ___ home O2
- Gastroesophageal reflux disease
- PTSD ___ veteran)
- Anxiety / Depression
- Antisocial personality disorder
- Microcytic anemia
- Vitamin B12 deficiency
- Chronic kidney disease
- ___: punctate L parietal hemorrhage, seen by neurosurg who
did not recommend any f/u or intervention
Social History:
___
Family History:
Father died of myocardial infarction at unknown age. Mother died
of pancreatic cancer.
Physical Exam:
ADMISSION EXAM:
===============
Last discharge weight: 106.8 kg
VS: 97.8 73 133/84 20 95%RA
GENERAL: agitated mood and affect, alert and answers q's
appropriately
HEENT: NCAT
NECK: JVP to midneck
CARDIAC: RRR
LUNGS: inspiratory crackles to midback bilaterally
ABDOMEN: Distended
EXTREMITIES: Chronic venous stasis changes to patella. Skin is
hardened. Difficult to assess pitting edema given stasis changes
DISCHARGE EXAM:
===============
Weight at discharge: 99.1 kg (with 1+ pitting edema)
Vitals: 98.4, 61-65, 103-123/50-55, 18, 93-95% RA
General: nontoxic, no acute distress, interactive but does not
voice
HEENT: NCAT, EOMI
NECK: JVP about 9-10 cm H2O
Lungs: mild inspiratory crackles in bilateral lung bases,
diffuse expiratory wheezes
CV: Irregular, S1/S2, systolic ejection murmur, no rubs or
gallops
Abdomen: non-tender, non-distended, no guarding or rebound
Ext: severe venous stasis changes to patella with hardened skin,
edema improved. Right leg diameter > left leg diameter
Pertinent Results:
ADMISSION LABS:
==============
___ 09:55PM BLOOD WBC-3.7* RBC-3.05* Hgb-6.7* Hct-25.4*
MCV-83 MCH-22.0* MCHC-26.4* RDW-17.2* RDWSD-52.0* Plt ___
___ 09:55PM BLOOD Neuts-71.1* Lymphs-16.8* Monos-7.5
Eos-3.5 Baso-0.8 Im ___ AbsNeut-2.66 AbsLymp-0.63*
AbsMono-0.28 AbsEos-0.13 AbsBaso-0.03
___ 09:55PM BLOOD Plt ___
___ 09:55PM BLOOD Glucose-91 UreaN-16 Creat-0.7 Na-138
K-4.0 Cl-101 HCO3-28 AnGap-13
___ 09:55PM BLOOD ALT-<5 AST-13 AlkPhos-61 TotBili-0.5
___ 09:55PM BLOOD Lipase-9
___ 09:55PM BLOOD proBNP-2478*
___ 09:55PM BLOOD Albumin-3.8 Calcium-8.2* Phos-3.3 Mg-1.8
___ 10:15PM BLOOD Lactate-1.0
MICROBIOLOGY:
=============
Blood Culture, Routine (Final ___: NO GROWTH.
IMPORTANT STUDIES:
=================
___ CT ABD & PELVIS WITH CO IMPRESSION:
1. Mild cardiomegaly with interstitial pulmonary edema partially
visualized in
the lower lungs. Trace right pleural effusion.
2. Chronic occlusion of the IVC in this patient with filter with
extensive
venous collaterals in the body wall.
3. Mild body wall edema extending into the lower extremities,
right greater
than left.
4. Unchanged splenomegaly.
5. Prominent retroperitoneal and pelvic sidewall lymph nodes
likely reactive.
Please note, these do not meet size criteria for pathologic
enlargement.
6. Chronic L1 compression deformity.
7. Apparent thickening of the distal esophagus appears
unchanged, correlate
for esophagitis.
___ CXR IMPRESSION:
- Worsening bilateral pulmonary edema.
___ EKG:
- Sinus bradycardia. Left axis deviation. Left anterior
fascicular block.
DISCHARGE LABS:
===============
___ 07:50AM BLOOD Calcium-8.8 Phos-4.9* Mg-2.5
___ 07:50AM BLOOD Glucose-86 UreaN-54* Creat-1.3* Na-137
K-4.3 Cl-92* HCO3-36* AnGap-13
___ 07:50AM BLOOD ___ PTT-41.1* ___
___ 07:50AM BLOOD WBC-3.8* RBC-3.65* Hgb-8.0* Hct-29.5*
MCV-81* MCH-21.9* MCHC-27.1* RDW-18.1* RDWSD-52.6* Plt ___
Brief Hospital Course:
Mr. ___ is a medically complex ___ M h/o CAD, HFpEF, DVT/PE
on coumadin, multiple admissions for dyspnea, difficulty
ambulating, who initially presented with chest pain, dyspnea,
and lower extremity edema.
# Acute on Chronic HFpEF: chief complaint of dyspnea and lower
extremity edema, likely secondary to medicine/diet
noncompliance. Troponin and EKG were not concerning for
ischemia. Was initially diuresed with IV lasix adequately and
transitioned to PO torsemide as he approached euvolemia. He was
discharged on torsemide 80 mg PO daily. His weight upon
discharge was 99.1 kg (standing). At this weight, he still had
pitting edema in his lower extremities but this was deemed not
able to be mobilized (creatinine rose with further diuresis
attempts) in setting of his known chronically occluded IVC
secondary to clotted IVC filter. Creatinine was 1.3 on day of
discharge. He will have labs checked on ___ and faxed to his
PCP.
# COPD: patient's home regimen included albuterol and and
tiotropium. Given his multiple admissions for dyspnea and PE
revealing diffuse wheezes, we increased his regimen to include
advair with adequate response. Patient was weaned down to room
air with oxygen saturation of 93-95% at rest. He uses 2L NC home
oxygen.
# H/O PE/DVT on coumadin: His home regimen of coumadin was
continued at discharge. He will need close follow up of his
warfarin dosing by his PCP ___ his INR trend. Labs
to be drawn on ___ and faxed to his PCP.
CHRONIC ISSUES:
===============
# GERD: no changes to home regimen
# DEPRESSION/PTSD: no changes to home regimen
# CAD S/P STEMI: no changes to home regimen
# CHRONIC VENOUS STASIS: no changes to home regimen
# CHRONIC PAIN: no changes to home regimen
TRANSITIONAL ISSUES:
====================
[ ] PCP to follow up on Chem-10 and INR which will be drawn on
___. Creatinine on discharge was 1.3. INR on discharge was 2.0.
[ ] Last dose of methadone was 65 mg on ___ at 0924 AM.
[ ] Weight upon discharge: 99.1 kg standing (218.5 pounds) with
1+ edema on exam
[ ] Torsemide new home regimen: 80 mg PO daily
# CODE: Full
# CONTACT: None
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN
2. Atorvastatin 40 mg PO QPM
3. ClonazePAM 2 mg PO TID
4. DULoxetine 60 mg PO DAILY
5. FoLIC Acid 1 mg PO DAILY
6. Furosemide 40 mg PO DAILY
7. Gabapentin 800 mg PO TID
8. Lactulose 30 mL PO BID
9. Methadone 65 mg PO QAM
10. Methadone 10 mg PO DAILY
11. Metoprolol Tartrate 12.5 mg PO BID
12. OxyCODONE SR (OxyconTIN) 40 mg PO Q8H
13. Tamsulosin 0.8 mg PO QHS
14. Tiotropium Bromide 1 CAP IH DAILY
15. Warfarin 3 mg PO 3X/WEEK (___)
16. Warfarin 4 mg PO 4X/WEEK (___)
17. Docusate Sodium 100 mg PO BID
18. Senna 17.2 mg PO QHS
The Preadmission Medication list is accurate and complete.
1. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN
2. Atorvastatin 40 mg PO QPM
3. ClonazePAM 2 mg PO TID
4. DULoxetine 60 mg PO DAILY
5. FoLIC Acid 1 mg PO DAILY
6. Furosemide 40 mg PO DAILY
7. Gabapentin 800 mg PO TID
8. Lactulose 30 mL PO BID
9. Methadone 65 mg PO QAM
10. Methadone 10 mg PO DAILY
11. Metoprolol Tartrate 12.5 mg PO BID
12. OxyCODONE SR (OxyconTIN) 40 mg PO Q8H
13. Tamsulosin 0.8 mg PO QHS
14. Tiotropium Bromide 1 CAP IH DAILY
15. Warfarin 3 mg PO 3X/WEEK (___)
16. Warfarin 4 mg PO 4X/WEEK (___)
17. Docusate Sodium 100 mg PO BID
18. Senna 17.2 mg PO QHS
Discharge Medications:
1. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth qday Disp
#*30 Tablet Refills:*0
2. Torsemide 80 mg PO DAILY
RX *torsemide [Demadex] 20 mg 4 tablet(s) by mouth qday Disp
#*120 Tablet Refills:*0
3. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN
4. Atorvastatin 40 mg PO QPM
5. ClonazePAM 2 mg PO TID
6. Docusate Sodium 100 mg PO BID
7. DULoxetine 60 mg PO DAILY
8. FoLIC Acid 1 mg PO DAILY
9. Gabapentin 800 mg PO TID
10. Lactulose 30 mL PO BID
11. Methadone 65 mg PO QAM
12. Methadone 10 mg PO DAILY
13. OxyCODONE SR (OxyconTIN) 40 mg PO Q8H
14. Senna 17.2 mg PO QHS
15. Tamsulosin 0.8 mg PO QHS
16. Tiotropium Bromide 1 CAP IH DAILY
17. Warfarin 3 mg PO 3X/WEEK (___)
18. Warfarin 4 mg PO 4X/WEEK (___)
19.Outpatient Lab Work
ICD-10: I48.0, I50.3
Please draw Chem-10, INR, ___, and PTT on ___ and fax results
to Dr. ___ at ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
==================
- Acute exacerbation of HFrEF
SECONDARY DIAGNOSES:
=====================
- COPD
- H/O PE/DVT on coumadin
- Chronic pain
- CAD
- Chronic venous stasis
PRIMARY DIAGNOSES:
==================
- Acute exacerbation of HFpEF
SECONDARY DIAGNOSES:
=====================
- COPD
- H/O PE/DVT on coumadin
- Chronic pain
- CAD
- Chronic venous stasis
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 to care for you at the ___
___.
Why did you come to the hospital?
- You were concerned about your abdominal pain, chest pain,
shortness of breath and increasing lower leg edema.
- You were found to be having a heart failure exacerbation and a
worsening of your underlying COPD
What did you receive in the hospital?
- You received IV lasix to take fluid off your lungs and legs
which improved your breathing and leg edema.
- We also started you on another breathing medication, advair,
for your severe COPD which helped improve your breathing.
- We continued your methadone and oxycontin home regimen while
you were in the hospital
What will you need to do when you leave the hospital?
- Please take your new fluid pill regimen torsemide as
prescribed
- Please continue taking your COPD medications in addition to
your new medication, advair, to help control your COPD symptoms.
It will be important for you to follow up with your primary
physician or pulmonologist regarding your COPD.
- Please follow up with the ___ clinic within a few days
after you leave the hospital, as your INR levels during your
stay were difficult to control.
- Please weigh yourself every morning, and call your primary
physician if your weight goes up more than 3 lbs
- Your weight upon discharge was 218.5 pounds (99.1 kg) still
with 1+ edema on exam
Followup Instructions:
___
|
10108435-DS-55 | 10,108,435 | 21,003,300 | DS | 55 | 2192-07-14 00:00:00 | 2192-07-14 20:17:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Compazine / Codeine / Atenolol / Penicillins
Attending: ___.
Chief Complaint:
inguinal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with PMH of CAD, CHF (latest EF 45% ___, COPD on 2L
oxygen at home intermittently, recurrent blood clots on
Warfarin, history of heroin abuse, recent admission for ___
edema, falls, and ___ on CKD who represents with recurrent
falls, inguinal pain, nausea and vomiting.
Patient has had frequent hospitalizations recently. Most
recently, he was admitted from ___ to ___ where he
presented for ___ edema and ulcerations in the setting of
numerous falls as outpatient. His chronic venous stasis changes
are thought to be secondary to decreased blood return to the
right side of the heart from the completely clotted IVC filter.
He was treated with wound care. He was also having falls prior
to admission but refused ___ and was discharged with ___
services. Per review of chart patient was non-compliant with ___
only intermittently allowing them into his apartment. His
apartment was unkempt. Per ___ OMR Note:
"Call from ___, Case Manager - ___
___ NP ___ (cell)who was finally able to get into
the pt's home by accompanying the nurse who goes to fill his
methadone locked box. Of note the box has been tampered with
(but
was unable to be breached). She is most concerned about the
state
of his apartment. There are cigarette butts everywhere (pt uses
oxygen "all the time" per pt and to sleep). States there are
pill
bottles everywhere, in every room, on all the surfaces and
floor.
Pt is on several waiting lists for assisted living housing but
she is concerned if they come to interview him they will not
accept him - she has a heavy house cleaner scheduled to come in
today to try to clean the apt. She is hoping he will agree to
assisted living housing so he can get meals, supervision, med
management.....
States if pt will not agree to accept her calls and visits she
cannot continue to prescribe the methadone for pain management.
But knows he can no longer go to the ___ clinic daily
because he keeps falling (that is why she took over
prescribing)
She is putting in referrals to ___ - pt
reused to see them today but might see them on ___. Also
placed a referral to ___ and Protective
Services."
Patient reports R inguinal pain, 1 week of n/v, weakness and
frequent falls. He denies headstrike or LOC. Patient reports
pain in his right inguinal area, that is worse with moving or
standing up. He has had multiple episodes of nausea and vomiting
daily. He denies any fevers. No diarrhea. No abdominal
distention. No headaches or confusion. Patient reports unable to
tolerate p.o. due to his nausea and vomiting, and abdominal pain
in the ED, though is hungry and requesting food on arrival. He
also reports noting blood in his urine 2 days ago. Denies
dysuria or urinary frequency.
Past Medical History:
-STEMI w/ BMS in LAD in ___, due to GI bleed stopped plavix
continued aspirin
- Hepatitis C, denies h/o treatment, no clear cirrhosis on
imaging; complicated by hepatic encephalopathy in the past
- Pulmonary embolus: Recurrent VTE s/p IVC filter now
thrombosed, previously not on coumadin due to noncompliance,
but resumed warfarin on prior admission and is followed by ___
___ clinic.
- Heroin abuse; currently on methadone
- Chronic obstructive pulmonary disease on ___ home O2
- Gastroesophageal reflux disease
- PTSD ___ veteran)
- Anxiety / Depression
- Antisocial personality disorder
- Microcytic anemia
- Vitamin B12 deficiency
- Chronic kidney disease
- ___: punctate L parietal hemorrhage, seen by neurosurg who
did not recommend any f/u or intervention
Social History:
___
Family History:
Father died of myocardial infarction at unknown age. Mother died
of pancreatic cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
Vital Signs: 97.4 PO 125 / 75 60 18 100 2 L NC
General: Disheveled looking male. Alert, oriented, no acute
distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding. Prominent varicosed
veins on trunk
GU: No foley. Right inguinal area with soft bulge with
overlying prominent veins but without bowel sounds on clear
hernia. Non-TTP.
Ext: Bilateral 3+ edema with dark staining of skin and multiple
bilateral ulcerations. TTP
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
DISCHARGE PHSYICAL EXAM
=======================
Vital Signs: 97.4 PO 113 / 66 61 16 95 RA
General: Disheveled looking male. Crumbs diffusely on hospital
gown and in bed. Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, forced expiratory
wheeze, rales, rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding. Prominent varicosed
veins on trunk
GU: No foley. Right inguinal area with soft bulge with overlying
prominent veins but without bowel sounds on clear hernia.
Non-TTP.
Ext: Bilateral 3+ edema with dark staining of skin wrapped in
ACE bandages, severely TTP, venous stasis changes on posterior
thighs bilaterally, mild bruising on R posterior thigh.
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
Pertinent Results:
ADMISSION LAB RESULTS
=====================
___ 12:06AM BLOOD WBC-3.3* RBC-2.91* Hgb-7.0* Hct-24.4*
MCV-84 MCH-24.1* MCHC-28.7* RDW-16.8* RDWSD-51.6* Plt ___
___ 12:06AM BLOOD Neuts-52.7 ___ Monos-7.2 Eos-7.2*
Baso-1.2* Im ___ AbsNeut-1.76 AbsLymp-1.05* AbsMono-0.24
AbsEos-0.24 AbsBaso-0.04
___ 12:06AM BLOOD ___ PTT-35.3 ___
___ 12:06AM BLOOD Glucose-80 UreaN-19 Creat-1.1 Na-137
K-5.7* Cl-101 HCO3-25 AnGap-17
___ 12:06AM BLOOD ALT-9 AST-54* AlkPhos-50 TotBili-0.4
___ 12:06AM BLOOD Albumin-3.6 Calcium-8.5 Phos-4.0 Mg-2.2
___ 12:25AM BLOOD Lactate-1.0 K-4.4
INR
===
___ 12:06AM BLOOD ___ PTT-35.3 ___
___ 08:00AM BLOOD ___ PTT-37.3* ___
___ 07:32AM BLOOD ___ PTT-37.2* ___
___ 07:51AM BLOOD ___ PTT-41.8* ___
___ 06:50AM BLOOD ___ PTT-43.4* ___
___ 06:46AM BLOOD ___ PTT-42.6* ___
___ 05:53AM BLOOD ___ PTT-43.1* ___
___ 06:35AM BLOOD ___
DISCHARGE LAB RESULTS
=====================
___ 06:05AM BLOOD WBC-3.0* RBC-3.23* Hgb-7.7* Hct-26.6*
MCV-82 MCH-23.8* MCHC-28.9* RDW-15.9* RDWSD-47.6* Plt ___
___ 06:05AM BLOOD ___ PTT-45.5* ___
___ 06:05AM BLOOD Glucose-81 UreaN-13 Creat-0.9 Na-133
K-4.4 Cl-95* HCO3-29 AnGap-13
IMAGING
=======
___ CXR:
1. Elevated pulmonary vascular congestion, with no frank
pulmonary edema. 2. Patchy opacity at the right lung base may
represent atelectasis or pneumonia.
___ CT Abdomen/Pelvis:
1. No acute process in the abdomen or pelvis. 2. Splenomegaly,
similar to prior. 3. Chronic occlusion of the IVC, with a filter
in place, and extensive venous collaterals.
___ CT C-spine:
No fracture or traumatic malalignment.
___ CT Head:
No fracture or intracranial process
Brief Hospital Course:
___ with past medical history of CAD, CHF (latest EF 45%
___, COPD on 2L oxygen at home intermittently, recurrent
blood clots on Warfarin iso non-adherence, DVT/PE with
thrombosed, irretrievable IVC filter, history of heroin abuse,
who presented with recent falls and right inguinal pain.
#Subtherapeutic INR: Patient with history of PE and clotted IVC
filter, presented with INR of 1.5. He was started on Lovenox
80mg BID on ___. His warfarin dose was increased to 3.5 mg
daily, and then 4mg daily so that his INR would be therapeutic.
Goal INR between ___ because of history of PE and known clotted
IVC filter. His INR was 1.9 on ___, so the Lovenox injections
were discontinued, and he was changed back to his home dose of
warfarin. His INR should be monitored closely.
# Falls: Patient with chronic falls that are well documented in
previous hospitalizations. Most likely mechanical. Use of
sedating meds like high dose narcotics is likely contributing.
Patient has refused rehab in the past three hospitalizations,
and then he re-presents to the hospital several days after
discharge. EKG unchanged, orthostatics negative. ___ recommends
rehab.
# Right inguinal pain, bulge: The patient presented with a
painful bulge in right inguinal area without clear hernia
palpated. CT abdomen/pelvis was negative for any abdominal
hernia. The bulge was attributed to increased collateral dilated
veins in the area, likely from occluded IVC. Non tender on exam.
#HCP: The patient does not have an HCP. The importance of
obtaining one was discussed with him. He is considering his
friend ___
# ___ edema, skin ulcerations: Consistent with previous
descriptions. No signs of infection on exam. The wound care team
was consulted, and the wounds were bandanged with ACE bandages
daily.
#Trouble urinating: On admission, the patient reported increased
trouble urinating. This was thought secondary to the high dose
of opiates that the patient was taking. Patient also reports a
history of BPH. UA unremarkable. CT scan shows L1 deformity
unchanged from before, so low concern for spinal etiology. He
was started on finasteride during this admission.
# CKD: Cr at recent baseline
# Anemia: Previous w/u c/w anemia of chronic disease. Hgb is 7
on admission and consistent with recent baseline.
CHRONIC ISSUES
==============
# Chronic diastolic heart failure: The patient presented
without evidence of volume overload on exam and CXR without
edema but with prominent vasculature and enlarged heart. He was
continued on home metoprolol and torsemide.
# CAD: Continued home metoprolol and aspirin.
# Chronic pain/Polysubstance abuse: Continue on home methadone,
gabapentin, clonazepam, and oxycontin. Consider weaning off
narcotics in the setting of falls.
# COPD: On ___ at home. Continued home albuterol sulfate,
tiotropium
# Hepatitis C: No history of treatment, no cirrhosis on prior
imaging but history of hepatic encephalopathy
# History of pulmonary embolism: continued home warfarin.
Lovenox bridge as discussed above because of sub-therapeutic INR
# Depression/Post-traumatic stress disorder: Continue
duloxetine and clonazepam.
# BPH: Continued home tamsulosin. Started finasteride during
this amission
TRANSITIONAL ISSUES
=================
- Please monitor the patient's INR closely
- It is very important that the patient name ___ healthcare proxy.
During his hospitalization, he expressed interested in reaching
out to his friend ___. He did not have the phone number with
him during the hospitalization.
- Patient deemed unsafe to live at home
NEW MEDICATIONS
- Finasteride
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. ClonazePAM 2 mg PO TID
5. Docusate Sodium 200 mg PO BID
6. DULoxetine 60 mg PO DAILY
7. FoLIC Acid 1 mg PO DAILY
8. Gabapentin 800 mg PO TID
9. Lactulose 30 mL PO BID
10. Methadone 65 mg PO QAM
11. Methadone 10 mg PO QPM
12. OxyCODONE SR (OxyconTIN) 40 mg PO Q8H
13. Senna 17.2 mg PO QHS
14. Tamsulosin 0.8 mg PO QHS
15. Tiotropium Bromide 1 CAP IH DAILY
16. Torsemide 20 mg PO DAILY
17. Warfarin 3.5 mg PO 2X/WEEK (___)
18. Warfarin 2.5 mg PO 5X/WEEK (___)
19. Metoprolol Succinate XL 25 mg PO DAILY
20. Lactic Acid 12% Lotion 1 Appl TP DAILY Apply to lower
extremity wounds daily
Discharge Medications:
1. Finasteride 5 mg PO DAILY
2. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. ClonazePAM 2 mg PO TID
6. Docusate Sodium 200 mg PO BID
7. DULoxetine 60 mg PO DAILY
8. FoLIC Acid 1 mg PO DAILY
9. Gabapentin 800 mg PO TID
10. Lactic Acid 12% Lotion 1 Appl TP DAILY Apply to lower
extremity wounds daily
11. Lactulose 30 mL PO BID
12. Methadone 65 mg PO QAM
13. Methadone 10 mg PO QPM
14. Metoprolol Succinate XL 25 mg PO DAILY
15. OxyCODONE SR (OxyconTIN) 40 mg PO Q8H
16. Senna 17.2 mg PO QHS
17. Tamsulosin 0.8 mg PO QHS
18. Tiotropium Bromide 1 CAP IH DAILY
19. Torsemide 20 mg PO DAILY
20. Warfarin 3.5 mg PO 2X/WEEK (___)
21. Warfarin 2.5 mg PO 5X/WEEK (___)
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Primary diagnosis:
=============
Right inguinal pain
Subtherapeutic INR
Secondary diagnosis
===============
Falls
Chronic lower extremity edema
Urinary retention
CKD
Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You were hospitalized at ___.
Why did you come to the hospital?
=========================
- You came to the hospital because of pelvic pain and because
you could not take care of yourself at home.
What did we do for you?
==================
-We took a picture of your abdomen and you have no hernia in
your abdomen
-You also complained of difficulty urinating so we started you
on a new medication called finasteride.
What do you need to do?
==================
-You will be discharged to the ___ Rehab
-Continue taking all of your medications as prescribed and go to
all of your doctor appointments
It was a pleasure caring for you. We wish you the best!
Sincerely,
Your ___ Medicine Team
Followup Instructions:
___
|
10108435-DS-56 | 10,108,435 | 24,751,909 | DS | 56 | 2193-01-03 00:00:00 | 2193-01-03 21:45:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Compazine / Codeine / Atenolol / Penicillins
Attending: ___.
Chief Complaint:
Fever and leg pain
Major Surgical or Invasive Procedure:
EGD/colonoscopy
History of Present Illness:
___ w/ complex PMH including CAD, HFrEF, PTSD, chronic pain,
opiate dependence on MMT, and a thrombosed IVC filter with
severe chronic lower extremity venous congestion, who was sent
from ___ with fevers.
The patient had chills and sweats this morning and had a fever
to ___. This was associated with increased pain in his legs
R>L, although this is already a chronic issue for him. He has
bleeding skin tears on the right leg, but is not able to give a
history of whether there was any trauma to the leg. He was
recently diagnosed with pneumonia but has finished his course of
levaquin and pulmonary symptoms are all resolving.
In the ___ ED vitals were: temp 101.3 (104 rectal), HR 105, BP
103/83, RR 18, 95% on RA. Labs were fairly unremarkable. One
blood culture was collected, he was given vancomycin, and was
admitted to medicine.
REVIEW OF SYSTEMS
GEN: as per HPI
CARDIAC: denies chest pain or palpitations
PULM: denies new dyspnea or cough
GI: denies n/v, denies change in bowel habits
GU: denies dysuria or change in appearance of urine
MSK: multiple pain complaints, but none that are clearly new
Full 14-system review of systems otherwise negative and
non-contributory.
Past Medical History:
CAD s/p STEMI w/ BMS in LAD in ___
HFrEF
Recurrent VTE and chronic RLE DVT,
suspected antiphospholipid syndrome
Thrombosed IVC filter with severe chronic venous congestion of
the lower extremities
venous ulcers, with prior superficial wound culture growing MRSA
Strep bacteremia in the setting of pneumonia ___
CKD (b/l Cr 1.1-1.3)
HCV, never treated
IV heroin use, in remission on methadone
History of methadone overdose causing PEA arrest
COPD
GERD
PTSD ___ veteran)
Anxiety / Depression
Microcytic anemia
Vitamin B12 deficiency
Chronic kidney disease
Punctate L parietal hemorrhage
BPH
Recurrent falls
MRSA carrier
s/p shoulder replacement
s/p cervical laminectomy
Social History:
___
Family History:
Father died of myocardial infarction at unknown age. Mother died
of pancreatic cancer.
Physical Exam:
VITALS: last 24-hour vitals were reviewed.
GEN: chronically ill appearing man in mild distress from
multiple pain complaints
EYE: EOMI, sclerae anicteric
ENT: MMM, OP clear, not tender over sinuses
NECK: No LAD, no JVD. Supple.
CARDIAC: RRR, no M/R/G
PULM: normal effort, no accessory muscle use, LCAB
GI: soft, NT, ND, NABS. Negative ___.
GU: no flank pain, prostate enlarged but not boggy or tender.
MSK: No visible joint effusions or deformities. Point tenderness
at several points along the spine of unclear chronicity.
NEURO: AAOx3. Speech is mumbling and a bit dysarthric (chronic).
No facial droop, moving all extremities.
PSYCH: blunted affect, gruff interaction
PERIPHERAL VASCULAR: veins are engorged over legs and abdomen,
especially the bilateral hypogastrics, which create a vermiform
fullness in the bilateral inguinal regions.
LYMPHATIC: no inguinal, axillary or cervical LAD
DERM: Bilateral brawny erythema of lower extremities to the
level of the upper calf. Skin tears on the R tibial plateau are
bleeding. No bright red erythema, no warmth, no induration, no
purulent discharge.
Pertinent Results:
****************
ADMISSION LABS:
****************
___ 01:55PM WBC-7.1# RBC-3.39* HGB-8.8* HCT-29.1* MCV-86
MCH-26.0 MCHC-30.2* RDW-17.0* RDWSD-53.9*
___ 01:55PM PLT COUNT-107*
___ 01:55PM NEUTS-89.6* LYMPHS-3.3* MONOS-5.5 EOS-0.9*
BASOS-0.3 IM ___ AbsNeut-6.32*# AbsLymp-0.23* AbsMono-0.39
AbsEos-0.06 AbsBaso-0.02
___ 01:55PM GLUCOSE-98 UREA N-21* CREAT-1.4* SODIUM-136
POTASSIUM-5.0 CHLORIDE-97 TOTAL CO2-22 ANION GAP-22*
___ 02:15PM LACTATE-2.7*
****************
IMAGING:
****************
# Head CT ___ No acute intracranial process.
# RLE CT (___): No evidence of a soft tissue infection or
abscess in the right lower limb. Diffuse circumferential skin
thickening/edema.
# RUQ U/S (___): . Echogenic liver is most likely from
steatosis. More advanced liver disease including
steatohepatitis, hepatic fibrosis, and cirrhosis cannot be
excluded on this study.
2. No focal concerning hepatic lesions identified.
3. Stable mild splenomegaly. No ascites.
# TTE (___): EF 50-55%, TR grad 29, mild LVH, mild dilated
LV/RV, AK apex
# Abd/Pelvic CT (___): 1. Chronic occlusion of the IVC, with
extensive collaterals the subcutaneous tissues of the abdominal
wall.
2. Mildly enlarged pelvic and retroperitoneal lymph nodes,
measuring up to 13 mm, unchanged. 3. Splenomegaly.
# EGD (___): Normal mucosa in the esophagus. Erythema and
friability in the antrum compatible with gastritis. Normal
mucosa in the duodenum
Erosions in the fundus (endoclip). Otherwise normal EGD to third
part of the duodenum
# Colonoscopy (___): Normal mucosa in the hepatic flexure,
transverse colon, descending colon, sigmoid colon and rectum.
Due to a long and patulous/redundant colon, cecum was not
reached. No lesions or polyps were seen from the rectum to the
hepatic flexure. Otherwise normal colonoscopy to hepatic flexure
# CTC Virtual Colonography (___):
IMPRESSION:
No significant polyp or mass identified (greater than 1 cm),
though there is a
5-7 cm segment of descending colon that was collapsed and a mass
small or flat
mass here cannot be excluded. The sensitivity of CT colonography
for polyps
greater than 1 cm is 85-90%. The sensitivity for polyps 6-9 mm
is about
60-70%. Flat lesions may be missed with CT Colonography.
DC LABS:
___ 05:07AM BLOOD WBC-3.4* RBC-2.66* Hgb-7.6* Hct-24.2*
MCV-91 MCH-28.6 MCHC-31.4* RDW-14.8 RDWSD-49.1* Plt ___
___ 05:07AM BLOOD ___ PTT-77.0* ___
___ 05:07AM BLOOD Glucose-90 UreaN-21* Creat-1.0 Na-137
K-3.9 Cl-98 HCO3-32 AnGap-11
H. Pylori PENDING
Brief Hospital Course:
___ ___ vet with PTSD and h/o substance abuse and additional
PMH notable for CAD s/p STEMI (w/BMS in LAD ___, sCHF, s/p
shoulder replacement + cervical laminectomy, BPH, recurrent
falls, Punctate L parietal hemorrhage and recent course of
Levofloxacin for pneumonia, Recurrent VTE (?antiphospholipid
syndrome) w/ chronic RLE DVT s/p IVC filter c/b severe chronic
venous congestion of the lower extremities, who was admitted for
high fevers and subsequently managed for severe chronic venous
insufficiency c/b acroangiodermatitis and bleeding from leg
ulcers.
Admitted on ___ from ___ rehab with 1 day fevers upto ___
with no clear localizing symptoms. On presentation to rectal
temp of 104, HR 105, BP 103/83, RR 18, 95% on RA. One blood
culture was collected, he was given vancomycin, and was admitted
to medicine where IV levofloxacin was initially added. RLE
extremity noted to have severe chronic stasis dermatitis with
emacirated bleeding skin erosions. CT of RLE was obtained which
did not show any evidence soft tissue infection or abscess. CT
head was non acute and CXR was noted for stable cardiomegaly and
mild vascular congestion.
Admitted to the floor and started on empiric abx with
ceftriaxone, Flagyl and vanco. Did not have any more fever
spikes. Started weaning off Abx on ___ by stopping Flagyl and
Ceftriaxone. Dermatology was consulted and felt that his skin
lesions were c/w acroangiodermatitis related to his venous
stasis; the mainstay of treatment is compression with which the
patient has initially not been amenable to.
On ___, pt triggered for hypotension with Hct drop down to 17.2
and transferred to the FICU where he received PRBC X7. Hemolysis
labs were negative as were stool guiacs and his Hct eventually
stabilized. The only known source of bleeding was his leg which
had somewhat increased bleeding that morning in the setting of
therputic SQ lovenox. He did not undergo any further evaluation
for occult bleed. Lovenox was held. Given his hypotension and
some hypoxia he was evaluated and ruled out for MI per trops neg
X2 and TTE in the FICU showed LVEF 50-55 w/o WMA. He was
continued on IV vancomycin and resumed on his home torsamide
given intermittent ___ O2 requirement. PICC was placed and
CXR showed cleared lung fields. He remained afebrile and
antibiotics were not expanded. He did not require presors.
He was transferred back to the medical floor in stable condition
on ___. IV vanco held on ___. Continued management for
bleeding leg ulcers and had intermittent PRBC requirements for
low Hct. CT abd/pelvis non-con ___ did not show any other
obvious site of bleeding. Here are the following issues
addressed during his stay:
- Fever: single spike on admission thus far RLE only potential
source identified, ? portal for bacteremia though Bcx NTD.
Initially on IV Vanco + Levofloxacin, switched to IV ceftriaxone
+ PO Mtronidazole Subsequently as Bcx NTD and afebrile stopped
IV ceftriaxone + Flagyl (last doses ___ and continued IV
Vanco. IV vanco held on ___ after completion of 8 day course.
No further abx given blood cultures were negative and fevers
never recurred. The suspicion for cellulitis in his leg was low
from the outset
- Acute on Chronic Blood Loss Anemia: requiring 7 blood
transfusions on ___. Likely ___ to blood loss from bleeding RLE
wounds. CT abd/pelvis non-con ___ did not show any other
obvious site of bleeding. However does report some BRBPR and
very likely to have colonic varrices/hemmoroids. The degree of
anemia and PRBC requirement (10 units thus far during this
admission) suggested that beyond his legs wound there may be
another ongoing source of slow blood loss which is most likely
to be in his lower GI tract. He was reviewed by gastroenterology
consult who ultimately decided to do EGD/colonoscopy. Due to
the large fecal load, he required several days of preparation.
The EGD showed signs of linear erosion with oozing (endoclipped)
- and gastritis. Colonoscopy was unremarkable although could
not reach cecum. A CTC virtual colonography revealed no
suspicious lesions. For this bleed, Mr. ___ was placed on
PPI BID. HPYlori serologies and stool Ag were PENDING ON DC
but treatment is recommended if serology is POSITIVE.
- severe macerated stasis dermatitis of lower extremities:
bleeding skin lesions c/w acroangiodermatitis related to his
venous stasis. Warfarin and SQ lovenox continue to be held
given ongoing bleeding. SQ heparin was trialed and caused
significantly worsened bleeding and was held again on ___ with
subsequent improvement.
He was reviewed by dermatology and per their recs underwent
intensive wound care with vaseline impregnated gauze or Adaptic
covered by absorptive dressing covered by Kerlix as well as
compressive ACE raps and elevation for bilateral lower
extremities. Compression is considered to be the mainstay of
treatment for his underlying skin condition.
- Chronic VTE/Thrombosis/Embolism risk: discussed with
hematology consult and Vascular surgery given his high risk of
DVT and embolism in the setting of holding of anticoagulation
and an in-situ old IVC filter which is likely not protecting him
from PE anymore and can even serve as a nidus for a down stream
clot. Per vascular there are no available surgical interventions
for his venous stasis and the IVC filter can not be safely
removed. Hematology team agreed that anticoagulation be held
initially. After the gastric bleed was identified and treated,
Mr. ___ was placed back on anticoagulation with heparin gtt
sliding scale. He was stable for >48hrs on IV heparin and
warfarin was resumed with goal INR ___. On Discharge he is to
be transitioned to Lovenox ___ q12 as a bridge to warfarin
until INR >2. Please given Lovenox upon arrival to the facility
and dose from there. Please check INR again on ___.
- Hypotension: likely ___ to fluid shifts and unstable
intravascular volume due to bleeding and torsamide. These
responded to fluid boluses and PRBC transfusion and resolved
with holding of home torsamide and anticoagulation. His
torsemide was resumed on DC but his Lisinopril continues to be
HELD. This can be re-evaluated in the future
- Constipation: managed with agresive bowl regimen and enemas.
- ___. Bland UA except for elevated SG. resolved with IVF
- Elevated lactate, low BP's, ___: ? low circulating volume in
the setting of SIRS. resolved
- mild pulmonary congestion and hypoxia in the setting of being
off his home torsamide. resolved.
- long standing pancytopenia: B12, Folate, Ferritin checked
during this admission and not low.
- Known splenomegaly: no obvious cirrhosis on . Abdominal CT
___ showed splenomegaly. Liver was unremarkable. Stable
- h/o recurrent falls and poor functional status
- chronic pain syndrome/opiates: on MMT for years, but it
appears that ___ rehab is tapering him down; his dose was 60
mg daily which he tolerated well per rehab nursing and records.
Until ___, the patient was on oxycontin 40 mg TID for his
chronic pain. It appears that this has been stopped at some
point during his recent hospitalizations and rehab stays. Has
not visited his ___ clinic since ___. During this
admission he was ultimately placed on methadone 85 mg day for
his aute on chronic pain (leg and abdomen). No additional
opiates are needed otherwise at this baseline.
- HIS METHADONE IS CURRENTLY FOR CHRONIC PAIN AT THE DOSE
RECOMMENDED. Can wean as tolerated
- Social issues: Until recently, the patient has lived alone
where he is somewhat unsafe and often falls. He has frequent
hospitalizations, partially caused by failures of self-care for
his multiple chronic illnesses. However, he has fairly bad PTSD
and an independent spirit, so he likes being left alone and
usually refuses any rehab placements or skilled home care.
Recently he has been in ___ rehab. Patient has previously
declined to complete an HCP as he has no friends or relatives
involved in his care.
chronic:
-PTSD
- CAD s/p STEMI (w/BMS in LAD ___: on atorvastatin, BB and
warfarine. ASA 81 mg dropped off his med rec during a recent
hospitalization and was held given his severe bleeding.
- PLEASE RESUME ASPIRIN 81MG DAILY ONCE INR THERAPEUTIC IF NO
EVIDENCE OF FURTHER BLEEDING
- Chronic systolic CHF (echo ___ LVEDD 56, EF 45%, Mod MR + TR,
Mod PHTN) on lisonopril metoprolol and torsamide at home.
Asymtomatic during this admission.
HCV: Never treated. ? cirrhosis given his anemia,
thrombocytopenia and known splenomegaly, but imaging during this
admission did not show any findings in his liver suggestive of
cirrhosis.
TRANSITIONAL ISSUES:
1. Lovenox bridge to warfarin, goal INR ___. Wound care to legs
3. Methadone for chronic pain
4. H. plyori PENDING at discharge, should treat if positive
5. Lisinopril held on discharge given low blood pressure, can
consider restarting
6. Aspirin 81mg daily held during hospitalization given
bleeding. Please restart this if he remains stable for next
___ hrs
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN
2. Atorvastatin 40 mg PO QPM
3. ClonazePAM 2 mg PO TID
4. Docusate Sodium 200 mg PO BID
5. DULoxetine 60 mg PO DAILY
6. FoLIC Acid 1 mg PO DAILY
7. Gabapentin 800 mg PO TID
8. Methadone 60 mg PO QAM
9. Metoprolol Succinate XL 25 mg PO DAILY
10. Senna 17.2 mg PO QHS
11. Tamsulosin 0.8 mg PO QHS
12. Tiotropium Bromide 1 CAP IH DAILY
13. Torsemide 20 mg PO DAILY
14. Warfarin 3.5 mg PO 3X/WEEK (MO,FR,SA)
15. Warfarin 3 mg PO 5X/WEEK (___)
16. Omeprazole 40 mg PO DAILY
17. Lisinopril 10 mg PO DAILY
18. Ascorbic Acid ___ mg PO DAILY
19. Ferrous Sulfate 325 mg PO BID
20. Multivitamins 1 TAB PO DAILY
21. Cyanocobalamin 1000 mcg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Bisacodyl ___AILY:PRN constipation/stool impaction
3. Enoxaparin Sodium 100 mg SC Q12H
Start: Today - ___, First Dose: Next Routine Administration
Time
please start on arrival to ___, ___ of ___. Hydrocortisone Cream 1% 1 Appl TP QID:PRN pruritus right
lower extremity
5. Lactulose 30 mL PO DAILY:PRN constipation
6. Polyethylene Glycol 17 g PO DAILY:PRN constipation
7. Methadone 85 mg PO DAILY
FOR CHRONIC PAIN
RX *methadone 10 mg 8.5 tablets by mouth once a day Disp #*17
Tablet Refills:*0
8. Omeprazole 40 mg PO Q12H
9. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN
10. Ascorbic Acid ___ mg PO DAILY
11. Atorvastatin 40 mg PO QPM
12. ClonazePAM 2 mg PO TID
13. Cyanocobalamin 1000 mcg PO DAILY
14. Docusate Sodium 200 mg PO BID
15. Ferrous Sulfate 325 mg PO BID
16. FoLIC Acid 1 mg PO DAILY
17. Gabapentin 800 mg PO TID
18. Iron Polysaccharides Complex ___ mg PO DAILY
19. Metoprolol Tartrate 12.5 mg PO BID
20. Multivitamins 1 TAB PO DAILY
21. Senna 17.2 mg PO QHS
22. Tiotropium Bromide 1 CAP IH DAILY
23. Torsemide 20 mg PO DAILY
24. Warfarin 3.5 mg PO 3X/WEEK (MO,FR,SA)
25. Warfarin 3 mg PO 5X/WEEK (___)
26.Outpatient Lab Work
Please check INR on ___ and periodically thereafter for INR
monitoring, goal INR ___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Gastrointestinal Bleeding
Acroangiodermatitis
Chronic Venous Insufficiency
Blood loss anemia
Chronic VTE
Chronic 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:
Mr. ___,
you were admitted to ___ due to a febrile illness which may
have resulted from a skin infection. Your fever resolved with
antibiotic treatment.
You were also managed for the chronic skin condition on your
legs which was complicated by bleeding from your leg wounds as a
result of the high pressure and poor circulation in your veins.
This condition is a complication of blood clots and your IVC
filter. You will need continued management with careful wound
care and compressive dressings. Surgery is, unfortunately, not
an option.
You also were found to be anemic and received a total of nearly
10 units of RBC transfusion. To identify the source of the
bleed, you underwent endoscopic procedures (EGD and
colonoscopy). The EGD revealed bleeding in the stomach - this
was stopped using endoscopic procedures. Please continue with
the Prilosec to protect your stomach lining.
You will need to be on blood thinners indefinitely, given the
risk of clots. The Coumadin levels will need to be monitored at
your rehab.
We wish you the best of luck,
Your ___ Team
Followup Instructions:
___
|
10108435-DS-58 | 10,108,435 | 27,447,491 | DS | 58 | 2193-03-31 00:00:00 | 2193-04-10 11:10:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Compazine / Codeine / Atenolol / Penicillins
Attending: ___.
Chief Complaint:
eye pain, s/p fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ male with history of opioid
dependence on methadone, AF on Coumadin, CAD s/p PCI, diastolic
heart failure and recurrent falls who presented to the ED with
right eye pain and swelling following fall.
States he fell out of bed yesterday morning with brief LOC but
unknown how long. He endorses significant head and eye pain, but
cannot open the right eye due to swelling to know about vision
changes. He also endorses neck pain and abdominal pain. He notes
baseline leg pain and swelling for the past ___ years that are
taken care of by ___. He denies chest pain or SOB, cough,
fainting or near fainting, heart palpitations, N/V/D.
In the ED: AF, P 60-80, BP 143 --> 108, satting well on RA. Exam
notable for right eye with significant overlying edema and
ecchymosis unable to look down on exam. Workup included labs
notable for CK 2800, Cr 1.7, INR 4. CT head and Cspine,
Abdomen/Pelvis and CT maxillofacial all pursued and without
acute
traumatic changes except for right eye hematoma found to be
confined to extraocular structures. Ophtho advised supportive
care only. He was evaluated by trauma team in the ED and it was
felt that given exam and reassuring imaging, no further concern
from an ortho/spine perspective. He was admitted to medicine for
IV hydration given ___ and concern for rhabdo, and for ___ for
dispo planning. He was given IV dilaudid for pain control in the
ED as well as 2L NS and all his home medications for the day.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Of note, he states that he fell during his last day in rehab,
but noted the eye swelling after returning home, and that this
prompted his ER visit.
Past Medical History:
ANEMIA
DEEP VENOUS THROMBOPHLEBITIS
HEPATITIS
IVC FILTER
MURAL THROMBUS
PULMONARY EMBOLISM
THROMBOCYTOPENIA
NARCOTICS AGREEMENT
HOME SERVICES
___
Social History:
___
Family History:
Reviewed and found to be not relevant to this
illness/reason for hospitalization.
Physical Exam:
VITALS: Afebrile and vital signs stable (see eFlowsheet)
GENERAL: Alert and in no apparent distress
EYES: large area of swelling and ecchymosis involving right
upper
eyelid / orbit. Area of swelling extends up to forehead.
Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: no S3, no S4. No JVD.
RESP: scattered expiratory wheezes with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: chronic venous stasis changes in ___ bilaterally up to
knees
with dry scaling areas of dry blood.
EXTREMITIES: 3+ pitting edema in ___ b/l with venous stasis
NEURO: Alert, somewhat slowed speech but awake and conversant,
answering appropriately though slightly irritable, oriented,
face
symmetric, gaze conjugate with EOMI, speech fluent, moves all
limbs, sensation to light touch grossly intact throughout
PSYCH: pleasant, appropriate affect
Pertinent Results:
___ 07:30AM BLOOD WBC-6.0 RBC-2.90* Hgb-7.7* Hct-25.6*
MCV-88 MCH-26.6 MCHC-30.1* RDW-15.2 RDWSD-48.8* Plt ___
___ 08:15AM BLOOD WBC-8.3# RBC-2.97* Hgb-8.1* Hct-25.9*
MCV-87 MCH-27.3 MCHC-31.3* RDW-15.2 RDWSD-49.1* Plt ___
___ 07:30AM BLOOD Neuts-77.8* Lymphs-12.3* Monos-6.5
Eos-2.8 Baso-0.3 Im ___ AbsNeut-4.67 AbsLymp-0.74*
AbsMono-0.39 AbsEos-0.17 AbsBaso-0.02
___ 07:30AM BLOOD Plt ___
___ 07:30AM BLOOD ___ PTT-55.4* ___
___ 08:15AM BLOOD Plt Smr-LOW* Plt ___
___ 08:15AM BLOOD ___ PTT-46.7* ___
___ 07:30AM BLOOD Glucose-71 UreaN-40* Creat-1.3* Na-141
K-4.1 Cl-100 HCO3-28 AnGap-13
___ 09:00PM BLOOD Glucose-77 UreaN-39* Creat-1.3* Na-142
K-4.5 Cl-100 HCO3-26 AnGap-16
___ 07:30AM BLOOD ALT-12 AST-46* LD(LDH)-233 CK(CPK)-2557*
AlkPhos-58 Amylase-19 TotBili-0.4
___ 09:00PM BLOOD ALT-11 AST-53* CK(CPK)-3432* AlkPhos-61
___ 02:14PM BLOOD ALT-11 AST-52* AlkPhos-63 TotBili-0.9
___ 08:15AM BLOOD ALT-9 AST-41* CK(CPK)-2867* AlkPhos-66
TotBili-0.7
___ 07:30AM BLOOD Lipase-11
___ 02:14PM BLOOD Lipase-9
___ 08:15AM BLOOD Lipase-10
___ 02:14PM BLOOD cTropnT-<0.01
___ 08:15AM BLOOD cTropnT-<0.01
CT abd/pelvis:
IMPRESSION:
1. No acute sequela of trauma. No retroperitoneal hematoma.
2. Retroperitoneal and right pelvic and inguinal lymphadenopathy
is similar
since the most recent examination, but more prominent than on
remote priors.
3. Extensive body wall collateral vessels, the sequela of known
IVC occlusion,
with IVC filter in place.
4. Stable splenomegaly.
5. Chronic compression fracture of the L1 vertebral body with
similar
retropulsion.
.
CT spine:
IMPRESSION:
No acute fracture or subluxation.
CT head:
IMPRESSION:
1. Large right frontal and periorbital hematoma without
underlying fracture.
Globes intact without retrobulbar hematoma.
2. No acute intracranial abnormality including no intracranial
hemorrhage or
mass effect.
Discharge Labs
___ 07:09AM BLOOD ___
___ 08:20AM BLOOD Glucose-115* UreaN-19 Creat-0.8 Na-138
K-4.5 Cl-98 HCO3-29 AnGap-11
___ 08:30AM BLOOD CK(CPK)-254
All blood and urine cultures negative at time of discharge
Brief Hospital Course:
Mr. ___ is a ___ male with past medical history of DVT/PE,
chronic pain who presented s/p fall with orbital hematoma and
concern for ___.
# Hematoma of right eye - Currently improved significantly prior
to discharge. Seen by optho in the ED and underwent extensive
imaging. No interventions beyond supportive care indicated at
this time. According to ophtho recs: warm compresses for the
right upper eyelid; no specific recommendations regarding
coumadin, the hemorrhage appears to be confined to the
extraocular structures. Follow up with regular eye doctor upon
discharge within ___ weeks, earlier if any worsening vision or
double vision.
# Fall / Elevated CK / Concern for rhabdomyolysis - CK elevated
on admission after recent fall and now back to normal prior to
discharge. Restarted home torsemide and metoprolol on ___ given
recovery of Creatinine
# Supratherapeutic INR on admission went as high as 6.3 in the
setting of chronic anticoagulation therapy. Coumadin initially
held and restarted on ___. Despite large hematoma, no e/o
ongoing bleeding and thus was
not reversed. Continued Coumadin for INR goal ___.
# ___: Resolved. Admission Creatinine 1.7. Was likely pre-renal
and after fall. Discharge Creatinine was 0.8
#Chronic venous ulcers, bilateral - extensive - evaluated by
wound consult; BLE have significant chronic venous changes and
he has some superficial ulcerations that appeared to be healing
well as wound care continued while hospitalized.
#Methadone use: During ___ admission to ___ he was taken
off oxycontin for pain and changed to methadone for pain. He
tells me that he has "pain everywhere" and that he was asked to
"leave" methadone clinics. Given that he was on methadone for
chronic pain he was discharged with a prescription for 80 mg a
day (was on 85 mg a day; dose reduced for ease of
administration)
# Hypoxia
# COPD- chronic, on baseline 2L. No respiratory complaints this
hospitalization
# Chronic diastolic heart failure/CAD: continue home meds.
Restarted torsemide and metoprolol as above.
# Anemia: Was at baseline.
# R knee swelling: Xray reassuring. Likely inflamed due to fall
vrs hemarthrosis due to fall.
# Anxiety: Continued on home dose of kconazepam 2 mg po tid.
No signs of sedation seen while taking this dose of clonazepam
# Emergency contact/HCP: Patient reports he has no emergency
contact. ___ in medical records according to patient is
a friend who passed away and he states he has no other family
members or friends to resort to. Refused to sign HCP inpatient
and will need to be re-evaluated.
# Home Safety: All members of his medical team had grave
concerns about his safety at home. OT felt that he was safe to
return home but with maximal services to ensure safe and proper
medication administration. Despite extensive counseling he was
adamant on discharge home and refused return to rehab. He was
cleared for return home by ___ and he demonstrated steady gait
while hospitalized.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Torsemide 20 mg PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. Multivitamins 1 TAB PO DAILY
4. Tiotropium Bromide 1 CAP IH DAILY
5. Ascorbic Acid ___ mg PO BID
6. Methadone 85 mg PO DAILY
7. Omeprazole 40 mg PO DAILY
8. Docusate Sodium 200 mg PO BID
9. Ferrous Sulfate 325 mg PO BID
10. ClonazePAM 2 mg PO TID
11. Gabapentin 800 mg PO TID
12. Atorvastatin 40 mg PO QPM
13. Enoxaparin Sodium 100 mg SC Q12H
14. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
15. Lactulose 30 mL PO DAILY:PRN constipation
16. Cyanocobalamin 1000 mcg PO DAILY
17. Hydrocortisone Cream 1% 1 Appl TP QID:PRN pruritus right
lower extremity
18. Senna 17.2 mg PO QHS
19. Warfarin 5 mg PO DAILY DVTs
20. Bisacodyl ___AILY:PRN constipation/stool impaction
21. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN
22. Polyethylene Glycol 17 g PO DAILY:PRN constipation
23. Metoprolol Succinate XL 25 mg PO DAILY
Discharge Medications:
1. Methadone 80 mg PO DAILY
2. Warfarin 2.5 mg PO DAILY DVTs
3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
4. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN
5. Ascorbic Acid ___ mg PO BID
6. Atorvastatin 40 mg PO QPM
7. Bisacodyl ___AILY:PRN constipation/stool impaction
8. ClonazePAM 2 mg PO TID
9. Cyanocobalamin 1000 mcg PO DAILY
10. Docusate Sodium 200 mg PO BID
11. Ferrous Sulfate 325 mg PO BID
12. FoLIC Acid 1 mg PO DAILY
13. Gabapentin 800 mg PO TID
14. Hydrocortisone Cream 1% 1 Appl TP QID:PRN pruritus right
lower extremity
15. Lactulose 30 mL PO DAILY:PRN constipation
16. Metoprolol Succinate XL 25 mg PO DAILY
17. Multivitamins 1 TAB PO DAILY
18. Omeprazole 40 mg PO DAILY
19. Polyethylene Glycol 17 g PO DAILY:PRN constipation
20. Senna 17.2 mg PO QHS
21. Tiotropium Bromide 1 CAP IH DAILY
22. Torsemide 20 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
___:
Primary diagnosis
- Fall
- Orbital hematoma
- Supratherapeutic INR
- 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 Mr ___,
You were admitted due to fall and having a very high INR. You
had a R periorbital injury and had a swollen right eye. This
improved with monitoring. All your labwork improved before you
were discharge (mainly your kidney function and INR).
According to the eye doctors, you should follow up with regular
eye doctor upon discharge within ___ weeks, or earlier if any
worsening vision or double vision. If you do not have an eye
care provider, please call ___.
Our case manager worked very closely with your insurance company
and with your ___ pharmacy to make sure that we have a safe
discharge plan for you. I have faxed several prescriptions to
your ___ and we are giving you a prescription for methadone.
Between these prescriptions and the medicines that you brought
to the hospital, you will have enough medicine to fill your
needs. I have given you a prescription for methadone. You must
go to your PCP visit on ___ to get a refill for additional
methadone.
If you are unable to manage your medical needs safely at home,
we recommend that you return to rehab, as we have made all
possible arrangements to ensure a safe discharge home for you
Followup Instructions:
___
|
10108435-DS-59 | 10,108,435 | 23,333,218 | DS | 59 | 2193-04-21 00:00:00 | 2193-04-21 18:00:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Compazine / Codeine / Atenolol / Penicillins
Attending: ___.
Chief Complaint:
leg pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ PMH of CAD s/p STEMI, HFpEF (EF 50-55%), recurrent VTE
c/b
chronic venous stasis ulcers, opioid dependence on methadone,
CAD
s/p stents, Diastolic Heart Failure, COPD who presented for
worsening bilateral leg pain.
Patient reports that for the past week he has experienced
worsening of his chronic bilateral leg pain and is having
difficulty walking secondary to his pain. He denies any recent
falls. Patient also reports a 3 day history of nonbilious
emesis,
nonbloody diarrhea, and decreased PO intake. Denies any new
abdominal pain, fever, cough, chest pain or chest pressure. Does
endorse chills. States he is not compliant with warfarin.
In the ED, initial VS were: 96.8 62 110/60 14 97% RA
Labs showed:
3.4 > ___ < ___ 20 AGap=12
-------------< 95
4.7 26 1.3
ALT 8, AST 15, Tb 0.4
INR 1.6
Imaging showed:
CXR
Worsening mild to moderate pulmonary edema with increased
bibasilar atelectasis.
___
1. High velocity pulsatile flow in the right common femoral vein
reflective of an AV fistula.
2. Calf veins bilaterally not well evaluated. Otherwise, no
evidence of deep venous thrombosis in the imaged portion of the
right or left lower extremity veins.
Patient received: methadone 10 mg, 1L NS, dilaudid 1 mg
Vascular surgery was consulted. "Pt seen and evaluated.
Waveforms
are similar to prior ultrasounds. No acute surgical intervention
but would recommend further workup of bilateral lower extremity
leg pain."
Transfer VS were: 97.7 79 138/74 18 97% RA
On arrival to the floor, patient reports extreme pain in his
legs
bilaterally which is ___. Patient would not allow me to touch
his legs. He reports he has some cough, also noted that he has
pain with urination and hasn't urinated a significant amount of
urine since arrival to the ED. History was limited due to
patient's pain. He did confirm that he has not been taking his
Warfarin.
REVIEW OF SYSTEMS:
10 point ROS reviewed and negative except as per HPI
Past Medical History:
CAD s/p STEMI w/ BMS in LAD in ___
HFrEF
Recurrent VTE and chronic RLE DVT,
suspected antiphospholipid syndrome
Thrombosed IVC filter with severe chronic venous congestion of
the lower extremities venous ulcers, with prior superficial
wound
culture growing MRSA
Strep bacteremia in the setting of pneumonia ___
CKD (b/l Cr 1.1-1.3)
HCV, never treated
IV heroin use, in remission on methadone
History of methadone overdose causing PEA arrest
COPD
GERD
PTSD ___ veteran)
Anxiety / Depression
Microcytic anemia
Vitamin B12 deficiency
Chronic kidney disease
Punctate L parietal hemorrhage
BPH
Recurrent falls
MRSA carrier
s/p shoulder replacement
s/p cervical laminectomy
Social History:
___
Family History:
Per records, family history of cardiovascular disease.
Physical Exam:
ADMISSION PHYSICAL:
=====================
VS: 102.0 PO 120/72 L Lying 80 18 90 RA
GENERAL: Patient appeared uncomfortable, noting significant
pain.
Patient's level of consciousness fluctuating, but oriented.
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MM
dry
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: Limited exam due to patient preference. Mild expiratory
wheezes present in anterior lung fields
ABDOMEN: distended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly. Minimal bowel sounds
present.
EXTREMITIES: Significant chronic changes with bilateral erythema
to knee, skin break down present with dusky appearance of
extremities.
PULSES: Patient would not allow me to palpate for pulses
NEURO: A&Ox3, moving all 4 extremities with purpose
DISCHARGE PHYSICAL EXAM
VITALS: 97.8 102/64 105 20 88 RA
GENERAL: Patient walking, in no significant pain. agitated.
Oriented and alert.
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MM
dry
NECK: supple, no LAD, no JVD
HEART: mild tachycardic, RR, S1/S2, no murmurs, gallops, or rubs
LUNGS: Limited exam due to patient preference. Mild expiratory
wheezes present in anterior lung fields
ABDOMEN: distended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly. Bowel sounds +
EXTREMITIES: Significant chronic changes with bilateral erythema
to knee, skin break down present with dusky appearance of
extremities. Excoriated region of knee
NEURO: A&Ox3, moving all 4 extremities with purpose
Pertinent Results:
ADMISSION LABS:
___ 08:37PM BLOOD WBC-3.4* RBC-2.91* Hgb-7.5* Hct-26.0*
MCV-89 MCH-25.8* MCHC-28.8* RDW-15.7* RDWSD-50.9* Plt ___
___ 09:18AM BLOOD WBC-12.1*# RBC-2.95* Hgb-7.6* Hct-26.1*
MCV-89 MCH-25.8* MCHC-29.1* RDW-15.7* RDWSD-50.5* Plt ___
___ 07:38AM BLOOD WBC-7.4 RBC-2.91* Hgb-7.5* Hct-26.2*
MCV-90 MCH-25.8* MCHC-28.6* RDW-16.1* RDWSD-53.3* Plt ___
___ 08:37PM BLOOD ___ PTT-34.6 ___
___ 09:18AM BLOOD ___ PTT-24.1* ___
___ 04:50AM BLOOD ___ PTT-35.0 ___
IMAGING:
Lower Extremity US ___. High velocity pulsatile flow in the right common femoral vein
reflective of an AV fistula.
2. Calf veins bilaterally not well evaluated. Otherwise, no
evidence of deep venous thrombosis in the imaged portion of the
right or left lower extremity veins.
___ CXR: Worsening mild to moderate pulmonary edema with
increased bibasilar atelectasis.
___ CT AP:
1. No acute intra-abdominal or pelvic process.
2. Enlarged retroperitoneal and pelvic sidewall lymphadenopathy
which
demonstrates shorts term stability, but have increased in size
from more
remote prior examinations.
3. Extensive abdominal wall varicosities.
4. Splenomegaly.
___ CT Chest:
1. Limited examination secondary to respiratory motion. Within
these
limitations, no acute thoracic process identified.
2. Enlarged main pulmonary trunk suggesting underlying pulmonary
hypertension.
3. CT findings of anemia.
___ RUQ US:
1. Images were limited due to the patient's right lateral
decubitus position and inability to move for better acoustic
windows. Within this limitation, no evidence of gallstones or
gallbladder distention.
2. No intrahepatic or extrahepatic biliary dilatation.
3. Splenomegaly measuring up to 15.1 cm.
CXR ___:
IMPRESSION:
Compared to chest radiographs since ___ most recently ___.
Severe consolidation right mid and lower lung has worsened
substantially since ___ probably pneumonia. Hemorrhage
is not excluded. Mild
cardiomegaly stable. No definite left lung abnormality. No
pneumothorax or pleural effusion.
MICRO:
___ 9:52 am 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.
___ 1:00 pm Blood (CMV AB)
**FINAL REPORT ___
CMV IgG ANTIBODY (Final ___:
NEGATIVE FOR CMV IgG ANTIBODY BY EIA.
<4 AU/ML.
Reference Range: Negative < 4 AU/ml, Positive >= 6 AU/ml.
CMV IgM ANTIBODY (Final ___:
NEGATIVE FOR CMV IgM ANTIBODY BY EIA.
INTERPRETATION: NO ANTIBODY DETECTED.
Greatly elevated serum protein with IgG levels ___ mg/dl
may cause
interference with CMV IgM results.
___ 7:59 pm URINE Source: ___.
**FINAL REPORT ___
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
A negative result does not rule out infection due to other
L.
pneumophila serogroups or other Legionella species.
Furthermore, in
infected patients the excretion of antigen in urine may
vary.
DISCHARGE LABS:
___ 04:40AM BLOOD WBC-4.1 RBC-2.95* Hgb-7.5* Hct-25.6*
MCV-87 MCH-25.4* MCHC-29.3* RDW-16.0* RDWSD-50.5* Plt ___
___ 04:40AM BLOOD ___ PTT-42.3* ___
___ 04:40AM BLOOD Glucose-105* UreaN-23* Creat-1.1 Na-138
K-4.2 Cl-97 HCO3-32 AnGap-9*
___ 04:40AM BLOOD Calcium-8.7 Phos-4.5 Mg-1.9
Brief Hospital Course:
This is a ___ year old male with past medical history of CAD,
diastolic CHF, chronic hypoxic respiratory failure secondary to
COPD on 2L home O2, chronic VTE on Warfarin, opiate dependence
and chronic pain on methadone, anxiety, admitted ___ with
leg pain and hypoxia secondary to pneumonia, now status post
course of antibiotics with resolution of respiratory symptoms,
spontaneous improvement in leg pain without evidence of new
acute pathology, able to be discharged home with services.
# Acute on chronic hypoxic respiratory failure secondary to
acute bacterial pneumonia
# COPD
Patient initially was admitted for leg pain management, but
found to be febrile on admission to the floor. Initial source
of fever was unclear as CT Torso was without evidence of
infection, but subsequent chest xray subsequently demonstrated
a developing pneumonia. Patient initially on unasyn for broad
coverage given subsequent persistent fever and progressive
hypoxia with intermittent blood streaked sputum (thought to be
from pneumonia and anticoagulation as admission chest imaging
did not show other potential causes). Antibiotics were
transitioned to vancomycin and levaquin, with subsequent slow
improvement in respiratory status over several days. Slow
improvement felt to relate to his significant underlying lung
disease. He was able to be weaned to home RA to 2LNC and
completed an 8 day course of levofloxacin. Would repeat Chest
CT in ___ weeks to ensure resolution of pneumonia--could
consider repeating sooner if hemoptysis were to persist.
Continued tiotropium, nebulizers. Patient frequently declined
bronchodilators during this admission, occasionally resulting
in episodes of hypoxia that would then resolve with use of a
bronchodilator.
# R leg pain
# Chronic R lower extremity DVT
Presented for worsening bilateral leg pain. Patient was
evaluated by vascular surgery while in the emergency department
who noted no evidence of deep venous thrombosis in the imaged
portion of the right or left lower extremity veins based on
ultrasound of the lower extremities. Remainder of workup did
not reveal fracture or other serious acute process. Pain
improved with home pain medications and patient was able to
ambulate at time of discharge.
# ___ on CKD stage 3
Cr peaked at 1.6 following admission for above acute processes;
improved with holding home diuresis; restarted home diuresis
without issue;
# Home situation / Social supports
Of note patient was evaluated by ___ who recommended discharge
to rehab, however patient adamantly refused to go to rehab.
There was concern about sending patient home because he often
refuses services and often refuses help. Team and Psychiatry
evaluated patient; no inpatient mental health needs and patient
was able to demonstrate understanding of risks of discharge
home plan; he verbally contracted to allow home services into
his home. Social work contacted patient's landlord as well as
elder services to ensure safe plan in place, in addition to
work by case manager to optimize home services. Overall,
team's impression was of a patient with history of poor
decisions with respect to health and self-care, as well as a
difficult personality, but of a person who had capacity to make
these decisions. At future outpatient and/or inpatient visits
would continue to have ongoing dialogue about safest home
situation with periodic reassessments to ensure he maintains
the capacity to make these decisions.
# Acute metabolic encephalopathy
# Chronic Pain
# Opioid Use Disorder
# Anxiety
Hospital course was initially notable for patient's somnolence
which was felt to be a result of methadone, gabapentin and
clonazepam use in setting of his acute illness and ___. During
this time, gabapentin and Clonazepam were reduced with
subsequent improvement in mental status. They were
subsequently able to be returned to home dosing. Continued
patient's methadone, although patient frequently requested dose
increases, reporting ongoing craving and withdrawal symptoms.
See below transitional issues regarding recommendations from
psychiatry.
# Chronic diastolic CHF
# Coronary artery disease
Continued statin, metoprolol, torsemide
# GERD
Continued omeprazole
# Chronic lower extremity DVT
Patient continued on 2.5mg Warfarin with a goal INR of ___ for
management of DVTs.
# Urinary retention
Started tamsulosin for urinary retention this admission;
consider outpatient follow-up.
#Leukopenia:
Patient with a history of anemia and borderline leukopenia,
both at baseline this admission. A UPEP showed "MULTIPLE
PROTEIN BANDS SEEN, WITH ALBUMIN PREDOMINATING OLIGOCLONAL FREE
KAPPA LIGHT CHAIN NOTED ON IFE RECOMMEND REPEAT UPEP IN ___
WEEKS IF CLINICALLY INDICATED". Would consider this.
TRANSITIONAL ISSUES:
===================================
- Discharged home with services
- As above, would consider ongoing dialog re: safest living
situation for him, as well as have periodic assessments of his
capacity to make these decisions.
- Would consider repeat UPEP within ___ weeks of discharge
- Warfarin was dosed 2.5mg with goal INR of ___. Continue
outpatient INR management
- Would consider repeat CT chest at ___ weeks to ensure
resolution of consolidation
- Given potential for respiratory depression and black box
warning re: coadministration, would consider
weaning/downtitration of opiate and benzodiazepine regimen as
outpatient; additionally, as per psychiatry consultation, given
that patient reports issues related to methadone cravings and
withdrawal, referral of patient to a ___ clinic for
opiate use disorder may be recommended;
Code Status: Full Code
HCP: Not designated - would consider asking patient to designate
one
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN
3. Bisacodyl ___AILY:PRN constipation/stool impaction
4. ClonazePAM 2 mg PO TID
5. Cyanocobalamin 1000 mcg PO DAILY
6. Docusate Sodium 200 mg PO BID
7. FoLIC Acid 1 mg PO DAILY
8. Gabapentin 800 mg PO TID
9. Hydrocortisone Cream 1% 1 Appl TP QID:PRN pruritus right
lower extremity
10. Lactulose 30 mL PO DAILY:PRN constipation
11. Multivitamins 1 TAB PO DAILY
12. Omeprazole 40 mg PO DAILY
13. Polyethylene Glycol 17 g PO DAILY:PRN constipation
14. Senna 17.2 mg PO QHS
15. Tiotropium Bromide 1 CAP IH DAILY
16. Torsemide 20 mg PO DAILY
17. Warfarin 2.5 mg PO DAILY DVTs
18. Atorvastatin 40 mg PO QPM
19. Methadone 80 mg PO DAILY
20. Ascorbic Acid ___ mg PO BID
21. Metoprolol Succinate XL 25 mg PO DAILY
22. Ferrous Sulfate 325 mg PO BID
Discharge Medications:
1. Ipratropium-Albuterol Neb 1 NEB NEB Q4H
2. Tamsulosin 0.4 mg PO QHS
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*6
3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
RX *acetaminophen [Arthritis Pain Relief (acetam)] 650 mg 1
tablet(s) by mouth q6hr:PRN Disp #*120 Tablet Refills:*5
4. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN
RX *albuterol sulfate [Ventolin HFA] 90 mcg ___ puff INH
q4hr:PRN Disp #*1 Inhaler Refills:*6
5. Ascorbic Acid ___ mg PO BID
RX *ascorbic acid (vitamin C) 500 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*5
6. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth qpm Disp #*30 Tablet
Refills:*6
7. Bisacodyl ___AILY:PRN constipation/stool impaction
8. ClonazePAM 2 mg PO TID
RX *clonazepam 2 mg 1 tablet(s) by mouth three times a day Disp
#*40 Tablet Refills:*0
9. Cyanocobalamin 1000 mcg PO DAILY
RX *cyanocobalamin (vitamin B-12) 1,000 mcg 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*6
10. Docusate Sodium 200 mg PO BID
RX *docusate sodium 100 mg 2 capsule(s) by mouth twice a day
Disp #*120 Capsule Refills:*6
11. Ferrous Sulfate 325 mg PO BID
RX *ferrous sulfate [Feosol] 325 mg (65 mg iron) 1 tablet(s) by
mouth twice a day Disp #*60 Tablet Refills:*6
12. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*6
13. Gabapentin 800 mg PO TID
RX *gabapentin 800 mg 1 tablet(s) by mouth three times a day
Disp #*180 Tablet Refills:*6
14. Hydrocortisone Cream 1% 1 Appl TP QID:PRN pruritus right
lower extremity
RX *hydrocortisone 1 % apply to lower extremity QID:PRN
Refills:*4
15. Lactulose 30 mL PO DAILY:PRN constipation
RX *lactulose 10 gram/15 mL (15 mL) 1 package by mouth daily:PRN
Disp #*30 Packet Refills:*6
16. Methadone 80 mg PO DAILY
17. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*6
18. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*6
19. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*6
20. Polyethylene Glycol 17 g PO DAILY:PRN constipation
RX *polyethylene glycol 3350 [ClearLax] 17 gram/dose 17 gm by
mouth daily:PRN Disp #*30 Package Refills:*6
21. Senna 17.2 mg PO QHS
RX *sennosides [Senna Lax] 8.6 mg 2 tablets by mouth at bedtime
Disp #*60 Tablet Refills:*6
22. Tiotropium Bromide 1 CAP IH DAILY
RX *tiotropium bromide [Spiriva with HandiHaler] 18 mcg 1 cap
INH daily Disp #*30 Capsule Refills:*6
23. Torsemide 20 mg PO DAILY
RX *torsemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*6
24. Warfarin 2.5 mg PO DAILY DVTs
RX *warfarin 2.5 mg 1 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*60
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
# Acute on chronic hypoxic respiratory failure secondary to
acute bacterial pneumonia
# COPD
# ___ on CKD stage 3
# Chronic diastolic CHF
# Chronic R lower extremity DVT
# Opioid Use Disorder
# Coronary artery disease
# Anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
Why did you come to the hospital?
- You were admitted to the hospital because you were having
increasing pain in your legs and you developed a fever
What did you receive in the hospital?
- You had an ultrasound taken of your legs that showed that you
did not have a clot
- You had a CT scan of your lungs that showed that you had
pulmonary hypertension.
- You had several x-rays of your chest, the last of which
demonstrated that you had pneumonia
- You had a CT scan of your abdomen and pelvis that showed that
you did not have an infection in your abdomen
What should you do once you leave the hospital?
- Please continue taking your medications at the new doses
prescribed
- You should continue working with physical therapy
- You should follow up with your primary care provider as
described below
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
10108435-DS-60 | 10,108,435 | 27,067,429 | DS | 60 | 2193-05-17 00:00:00 | 2193-05-17 21:42:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Compazine / Codeine / Atenolol / Penicillins
Attending: ___.
Chief Complaint:
Leg Pain
Major Surgical or Invasive Procedure:
N/A
History of Present Illness:
___ h/o CAD s/p STEMI, HFpEF (EF 50-55%), recurrent VTE c/b
chronic venous stasis ulcers (on Coumadin),
opioid dependence on methadone, CAD s/p stents, HFpEF, COPD on
home O2, recent admission for ___ leg pain felt to be due to
venous stasis presenting again with worsening bilateral leg
pain. Patient is a poor historian, but states that he has not
been able to walk due to pain since a few days after his
discharge at end
of ___. He says that his legs look different as well but
is not able to say how. The pain goes up into his ___ thighs. His
respiratory status at baseline.
Per review of records, pt had ___ arranged at home but has not
been letting them do his wound care. He states that they"only
put on cream, do not do the wrapping."
-In the ED, initial VS were: 98.7 90 160/78 17 99% RA
-Exam notable for: ___ legs hyperpigmented with skin plaques. ___
feet warm, pulses not easily palpable. No ulcers or draining
wounds. Lungs with scattered rhonchi, NC in place.
-Labs showed: Hgb 8.6, normal WBC, INR 1.3 (on Coumadin)
-Patient received: PO Dilaudid 2 mg x2, Warfarin 2.5 mg x1
Transfer VS were: ___ pain 97.8 70 155/83 16 100% 2L NC
Patient was seen at ___ for post discharge followup on ___,
after admission ___. He continued on home 3L O2 at
night. He still reported exertional dyspnea but overall
respiratory status improved. He stated he had not taken his
Coumadin as his medications were stolen. Although it was
recommended that he be discharged to a rehabilitation facility,
he refused and was therefore discharged home.
On arrival to the floor, patient reports continued severe leg
pain up to his thighs bilaterally. He overall is upset at his
functional status, also that he needs high doses of narcotics
given that he got addicted to narcotics in ___. He is
circumferential in his thought process, unable to give linear
history. He reports urinary retention for 2 days, non specific
abdominal pain. His breathing feels about the same, worsens
intermittently. He is tearful about his experiences in ___
during interview. He says the ___ only visited once, and was not
helpful. At home, has cane and walker for help.
In the morning, accepting team:
Per chart review, admission ___ for leg pain, pneumonia.
Non-invasive venous studies no evidence for thrombosis but
showed apparent RCF AV fistula. Vascular surgery was consulted
and felt this likely to be collateral. During this admission, it
was recommended that he be discharged to a rehabilitation
facility, he refused and was therefore discharged home with
nursing services. Psychiatry determined him to have capacity to
make this decision.
He has been evaluated by vascular surgery on multiple past
admissions in ___ for concern chronic occluded IVC filter
might be contributing to venous stasis/pain syndrome however due
to collaterals and clot burden it was determined there were no
surgical options for removal of filter.
At home, he would allow visiting nurses to enter his home but
did not allow wound care to dress his legs. He describes running
out of medications at home when it was robbed. He reports
inconsistently taking his Coumadin.
Past Medical History:
CAD s/p STEMI w/ BMS in LAD in ___
HFrEF
Recurrent VTE and chronic RLE DVT,
suspected antiphospholipid syndrome
Thrombosed IVC filter with severe chronic venous congestion of
the lower extremities venous ulcers, with prior superficial
wound
culture growing MRSA
Strep bacteremia in the setting of pneumonia ___
CKD (b/l Cr 1.1-1.3)
HCV, never treated
IV heroin use, in remission on methadone
History of methadone overdose causing PEA arrest
COPD
GERD
PTSD ___ veteran)
Anxiety / Depression
Microcytic anemia
Vitamin B12 deficiency
Chronic kidney disease
Punctate L parietal hemorrhage
BPH
Recurrent falls
MRSA carrier
s/p shoulder replacement
s/p cervical laminectomy
Social History:
___
Family History:
Per records, family history of cardiovascular disease.
Physical Exam:
ADMISSION:
==========
VS: 98.3 153/77 73 18 100 2L
GENERAL: NAD, irritable through interview, emotionally labile
with tearful in talking about ___
HEENT: pinpoint pupils reactive to light, nasal cannula on,
moist mucous membranes
NECK: supple, no LAD, JVD below angle of jaw at 30 degrees
HEART: RRR, S1/S2, grade II/VI systolic murmur at the ___
LUNGS: poor air entry at bases, with prolonged expiratory phase
and wheezes, clear on above lung fields
ABDOMEN: nondistended, nontender in all quadrants, + varicose
veins
EXTREMITIES: chronic venous stasis changes below knees
bilaterally, with dark/purple skin changes, visible bleeding
b/l, L>R edema, tender to touch diffusely
SKIN: warm and well perfused, unable to palpate DP and ___ pulses
DISCHARGE:
==========
VITALS: 98.9 PO 151 / 78 69 18 94 Ra
GENERAL: NAD, somnolent but arousable
HEENT: pinpoint pupils reactive to light, moist mucous membranes
NECK: supple, no LAD, JVD below angle of jaw at 30 degrees
HEART: RRR, S1/S2, grade II/VI systolic murmur at the ___
LUNGS: decreased at bases, diffuse mild expiratory wheezes
ABDOMEN: nondistended, nontender in all quadrants
EXTREMITIES: chronic venous stasis changes below knees
bilaterally, with dark/purple skin changes, visible bleeding
b/l, bilateral edema, tender to touch diffusely
SKIN: warm and well perfused, unable to palpate DP and ___ pulses
NEURO: oriented to person, place, date, impaired attention
PSYCH: irritable, tangential speech
Pertinent Results:
ADMISSION LABS:
___ 09:05PM BLOOD WBC-4.5 RBC-3.37* Hgb-8.6* Hct-30.1*
MCV-89 MCH-25.5* MCHC-28.6* RDW-16.3* RDWSD-53.2* Plt ___
___ 09:05PM BLOOD Neuts-63.6 ___ Monos-5.5 Eos-8.4*
Baso-0.9 Im ___ AbsNeut-2.89 AbsLymp-0.97* AbsMono-0.25
AbsEos-0.38 AbsBaso-0.04
___ 09:05PM BLOOD ___ PTT-31.2 ___
___ 09:05PM BLOOD Glucose-83 UreaN-11 Creat-0.9 Na-141
K-4.9 Cl-103 HCO3-26 AnGap-12
___ 06:40AM BLOOD Calcium-8.3* Phos-3.3 Mg-1.4*
___ 09:10PM BLOOD Lactate-0.8
DISCHARGE LABS:
___ 06:40AM BLOOD WBC-4.0 RBC-3.21* Hgb-8.3* Hct-28.0*
MCV-87 MCH-25.9* MCHC-29.6* RDW-16.0* RDWSD-50.6* Plt ___
___ 06:40AM BLOOD ___ PTT-33.8 ___
___ 06:40AM BLOOD Glucose-78 UreaN-14 Creat-0.9 Na-141
K-4.3 Cl-101 HCO3-31 AnGap-9*
IMAGING:
___ LENIS:
No evidence of deep venous thrombosis in the right or left lower
extremity
veins. Right common femoral AV fistula again noted.
Brief Hospital Course:
___ w/ PMH of CAD s/p STEMI, HFpEF (EF 50-55%), recurrent VTE
c/b chronic venous stasis ulcers (on Coumadin), occluded IVC
filter (since ___ opioid dependence on methadone, CAD s/p
stents, HFpEF, COPD on home O2, recent admission for ___ leg pain
felt to be due to venous stasis presenting again with worsening
bilateral leg pain.
DISCHARGE:
Patient was noted to be sedated on home regimen of methadone and
clonazepam. Clonazepam dose was reduced to prevent this.
On ___ patient escalated with aggressive behavior. Patient
walked down 7 flights of stairs to the basement, and would not
speak to resident or attending to assess capacity. Given
concerns of multiple outpatient providers as well as elder
services representative, this was deemed critical prior to
discharge. Code purple was called. Subsequently psychiatry
conducted capacity evaluation and determined he had capacity. He
was discharged without prescriptions.
# Bilateral Leg Pain
# Extensive Venostasis with superficial bleeding
# Chronic R lower extremity DVT
# Thrombosed IVC filter
Has had recent workup without acute process, chronic pain and
swelling, without evidence of new infection. Has known chronic
RLE DVT with IVC filter thrombosis. Given reports of increased
pain, assessed for growing clot burden in the setting of
subtherapeutic INR showed no DVT. It is unclear if this will
have treatment ramifications as he is not a candidate for
removal of IVC. He was given home methadone 80 mg daily,
gabapentin 800 TID, scheduled Tylenol, aggressive bowel regimen.
Wound care was consulted and he refused dressings and care by
nursing.
#Chronic Pain
#Opioid Use Disorder
#Anxiety
#PTSD
Reports of sedation on previous admissions, as well as requests
for escalating doses of methadone. Requested to transfer
methadone to clinic; reportedly patient has reached out to 2
clinics but they have not returned his calls. He was again noted
to be somnolent this admission. PRN dosing clonazepam at 1mg
TID, dose reduction from home with home methadone given.
Monitored on telemetry.
#Social supports/home living condition:
Of note patient was evaluated by ___ who recommended discharge to
rehab, however patient adamantly refused to go to rehab. During
last admission, psychiatry evaluated patient; no inpatient
mental health needs and patient was able to demonstrate
understanding of risks of discharge to home. Patient resistant
to psychiatric evaluation outpatient for PTSD as well. Case open
with Elder Services who was informed of admission and discharge.
Social work consulted and work appreciated.
#Urinary retention:
Complained of this on presentation; noted to be at risk of this
in setting of chronic high dose opiate use. Had no evidence of
this on this admission urinated well. No infectious cause, UA
unremarkable. Continued Tamsulosin.
CHRONIC ISSUES:
===============
# Chronic diastolic CHF EF 50-5%
# Coronary artery disease
Continued statin, metoprolol, torsemide. Not decompensated.
# COPD: On home O2 recent admission for COPD exacerbation, given
vancomycin and levofloxacin, completed antibiotics. Decreased
breath sounds at bases on exam, no focal findings. Of note,
patient was able to descend 7 flights of stairs without dyspnea
on day of discharge. Continued tiotropium and albuterol PRN.
# Chronic Anemia
# Pancytopenia
Stable at Hgb about ___. Previous anemia work up while inpatient
not indicative of iron deficiency or hemolysis. Has been
transfusion dependent in past.
# GERD
Continued omeprazole
Transitional Issues From prior discharge:
=========================================
- would consider ongoing dialog re: safest living situation for
him, as well as have periodic assessments of his
capacity to make these decisions.
- Would consider repeat UPEP within ___ weeks of discharge
- Warfarin was dosed 2.5mg with goal INR of ___. Continue
outpatient INR management
- Would consider repeat CT chest at ___ weeks to ensure
resolution of consolidation
- Given potential for respiratory depression and black box
warning re: coadministration, would consider
weaning/downtitration of opiate and benzodiazepine regimen as
outpatient; additionally, as per psychiatry consultation, given
that patient reports issues related to methadone cravings and
withdrawal, referral of patient to a ___ clinic for opiate
use disorder may be recommended
>30 minutes spent on discharge planning
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Ascorbic Acid ___ mg PO BID
3. Atorvastatin 40 mg PO QPM
4. Bisacodyl ___AILY:PRN constipation/stool impaction
5. Cyanocobalamin 1000 mcg PO DAILY
6. Docusate Sodium 200 mg PO BID
7. Ferrous Sulfate 325 mg PO BID
8. FoLIC Acid 1 mg PO DAILY
9. Gabapentin 800 mg PO TID
10. Hydrocortisone Cream 1% 1 Appl TP QID:PRN pruritus right
lower extremity
11. Lactulose 30 mL PO DAILY:PRN constipation
12. Methadone 80 mg PO DAILY
13. Metoprolol Succinate XL 25 mg PO DAILY
14. Multivitamins 1 TAB PO DAILY
15. Omeprazole 40 mg PO DAILY
16. Polyethylene Glycol 17 g PO DAILY:PRN constipation
17. Senna 17.2 mg PO QHS
18. Warfarin 2.5 mg PO DAILY DVTs
19. Ipratropium-Albuterol Neb 1 NEB NEB Q4H
20. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN
21. Tiotropium Bromide 1 CAP IH DAILY
22. Torsemide 20 mg PO DAILY
23. ClonazePAM 2 mg PO TID
24. Tamsulosin 0.4 mg PO QHS
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN
3. Ascorbic Acid ___ mg PO BID
4. Atorvastatin 40 mg PO QPM
5. Bisacodyl ___AILY:PRN constipation/stool impaction
6. ClonazePAM 2 mg PO TID
7. Cyanocobalamin 1000 mcg PO DAILY
8. Docusate Sodium 200 mg PO BID
9. Ferrous Sulfate 325 mg PO BID
10. FoLIC Acid 1 mg PO DAILY
11. Gabapentin 800 mg PO TID
12. Hydrocortisone Cream 1% 1 Appl TP QID:PRN pruritus right
lower extremity
13. Ipratropium-Albuterol Neb 1 NEB NEB Q4H
14. Lactulose 30 mL PO DAILY:PRN constipation
15. Methadone 80 mg PO DAILY
16. Metoprolol Succinate XL 25 mg PO DAILY
17. Multivitamins 1 TAB PO DAILY
18. Omeprazole 40 mg PO DAILY
19. Polyethylene Glycol 17 g PO DAILY:PRN constipation
20. Senna 17.2 mg PO QHS
21. Tamsulosin 0.4 mg PO QHS
22. Tiotropium Bromide 1 CAP IH DAILY
23. Torsemide 20 mg PO DAILY
24. Warfarin 2.5 mg PO DAILY DVTs
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Chronic pain
Opioid Use disorder
Chronic DVT
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
10108435-DS-61 | 10,108,435 | 29,537,226 | DS | 61 | 2193-10-08 00:00:00 | 2193-10-08 17:56:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Compazine / Codeine / Atenolol / Penicillins
Attending: ___.
Chief Complaint:
diarrhea
fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ male with history of CAD S/p STEMI, recurrent VTE,
chronic pain on methadone, chronic bilateral leg swelling who
presents with diarrhea. The patient reports a few week history
of
diarrhea. Diarrhea is watery. Non-bloody and up to 20 episodes
per day. He reports he took 2 Lomotil he had from a previous
bowel infection (?C. diff- no positive tests in our system) and
his diarrhea did not improve. He also reports one episode of
vomiting but has been able to eat since being in the hospital.
He
also reports crampy abdominal pain which he associates with
taking torsemide.
He is unsure of his medications and if he has been taking his
warfarin. He also tells me he's been falling a lot in his
apartment and he feels weak overall. He also complains of
shortness of breath but has difficulty specifying when he feels
SOB most. He denies PND or orthopnea. He feels like he is "on
his
deathbed". When asked to elaborate why, he tells me he has been
sick and he recently had a conversation with his PCP about his
poor health.
In the emergency department, he was checked for flu which was
negative. He had a CT scan which showed mild pulmonary edema,
chronic left ventricular apical infarct with associated aneurysm
and thrombus and chronic IVC occlusion. His INR was 1.5 and he
was started on a heparin drip and admitted for evaluation of
diarrhea and management if subtherapeutic INR.
Past Medical History:
CAD s/p STEMI w/ BMS to LAD in ___
HFrEF
Recurrent VTE and chronic RLE DVT, suspected antiphospholipid
syndrome
Thrombosed IVC filter with severe chronic venous congestion of
the lower extremities venous ulcers
Strep bacteremia in the setting of pneumonia ___
CKD (b/l Cr 1.1-1.3)
HCV, never treated
IV heroin use, in remission on methadone
History of methadone overdose causing PEA arrest
COPD
GERD
PTSD ___ veteran)
Anxiety / Depression
Microcytic anemia
Vitamin B12 deficiency
Chronic kidney disease
Punctate L parietal hemorrhage
BPH
Recurrent falls
s/p shoulder replacement
s/p cervical laminectomy
Social History:
___
Family History:
Father- deceased- heart disease ___
Mother- deceased- heart disease
Physical Exam:
Admission EXAM(8)
VITALS: 98.0 BP:135/71 HR: 60 18 98 2L
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 expiratory wheezing in all lung fields.
GI: Abdomen soft, distended, non-tender. visible distended
superficial vessels.
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: Chronic venous stasis changes on lower extremities with
tense edema R>L
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs
PSYCH: pleasant, appropriate affect
DISCHARGE PHYSICAL EXAM
Vitals: 98.5 PO 108 / 59 R Lying 60 16 94 Ra
GENERAL: Sleeping but easily arouses to verbal stimuli
HEENT: NC/AT
CV: Heart regular, no murmur, no S3, no S4.
RESP: Limited as patient refused posterior exam. Some scattered
wheezing and rhonchi noted throughout; however, pt's breathing
appears comfortable and non-labored.
GI: Abdomen soft, non-distended. Bowel sounds present. Mild
diffuse TTP (pt attributes to having just ate). No r/g.
EXT: Chronic hyperpigmentation of the BLEs.
NEURO: intermittently sedated appearing. global slowing responds
to voice, appropriate and coherent during interactions.
non-focal
PSYCH: calm
Pertinent Results:
Admission Labs:
================
___ 06:26PM BLOOD WBC-4.4 RBC-3.29* Hgb-8.9* Hct-29.6*
MCV-90 MCH-27.1 MCHC-30.1* RDW-16.7* RDWSD-54.2* Plt ___
___ 06:26PM BLOOD ___ PTT-28.3 ___
___ 06:26PM BLOOD Glucose-85 UreaN-9 Creat-0.9 Na-140 K-4.5
Cl-100 HCO3-30 AnGap-10
___ 06:26PM BLOOD cTropnT-<0.01
___ 11:40AM BLOOD proBNP-5005*
___ 06:26PM BLOOD Albumin-3.5 Calcium-8.6 Phos-3.5 Mg-2.0
___ 06:28PM BLOOD Lactate-1.0
CT CSpine - IMPRESSION:
No evidence of cervical spinal fracture or traumatic
malalignment.
CT Head - IMPRESSION:
No evidence of acute intracranial hemorrhage.
CTA Chest, CT A/P - IMPRESSION:
1. No evidence of pulmonary embolism or acute aortic pathology.
2. No acute intra-abdominal or intrapelvic process to explain
the patient's symptoms.
3. New small bilateral pleural effusions. Mild pulmonary
edema.
4. Chronic left ventricular apical infarct with associated
aneurysm and thrombus.
5. Chronic L1 compression deformity, similar in appearance
since at least ___.
6. Thickening of the bladder wall for which correlation with
urinalysis is recommended to exclude infection.
7. Multiple other chronic findings include extensive collateral
veins related to chronic IVC occlusion at the occluded IVC
filter, prominent lymph nodes, chronic airways disease.
TTE - IMPRESSION (suboptimal): Moderately dilated left ventricle
with mildly depressed function, including hypokinesis of the
distal anterior wall and dyskinesis of the true apex. Increased
left ventricular filling pressure. Mild to moderate mitral and
tricuspid regurgitation. Moderate pulmonary hypertension.
Compared to the previous study (images reviewed - ___,
the severity of mitral and tricuspid regurgitation has
increased. The pulmonary pressure is higher (previously 29 mmHg
+RAP).
OTHER NOTABLE LABS:
___ 07:01AM BLOOD WBC-3.3* RBC-3.21* Hgb-8.9* Hct-29.0*
MCV-90 MCH-27.7 MCHC-30.7* RDW-15.6* RDWSD-51.6* Plt ___
___ 07:01AM BLOOD Plt ___
___ 07:01AM BLOOD ___ PTT-46.6* ___
___ 07:01AM BLOOD Glucose-88 UreaN-25* Creat-0.9 Na-134*
K-4.6 Cl-95* HCO3-31 AnGap-8*
___ 07:01AM BLOOD
___ EKG: Sinus bradycardia with no significant change compared
to the tracing done on ___.
Brief Hospital Course:
___ male with history of CAD s/p STEMI, recurrent VTE,
chronic pain on methadone, chronic bilateral leg swelling who
initially p/w diarrhea, which has since resolved. Found to have
an LV thrombus of unclear chronicity on imaging and is now s/p
Lovenox bridge to Coumadin. His course was complicated by acute
hypoxic and hypercarbic respiratory failure requiring FICU
transfer for BiPAP on ___, as well as intermittent
encephalopathy.
# ACUTE ON CHRONIC HYPOXIC AND HYPERCAPNIC RESPIRATORY FAILURE
# CENTRAL HYPOVENTILATION DUE TO SEDATING MEDICATIONS
# MODERATE PULMONARY ARTERY SYSTOLIC HYPERTENSION
# CONCERN FOR OSA
# COPD
Suspect acute hypoxia on ___ was due to a combination of central
hypoventilation from home methadone/klonopin/gabapentin with
possible aspiration and COPD exacerbation given wheezing and
productive cough. Pt required brief ICU stay and was started on
nocturnal BiPAP. TTE this admission showed interval worsening of
pHTN with now moderate pHTN and worsening TR and MR, which is
also likely contributing to his hypoxia and made worse by
possible underlying central hypoventilation. At baseline, pt at
2L nocturnal O2. While pt has been intermittently refusing his
torsemide, he does not have significant evidence of pulmonary
edema on CXR with lower BNP than prior and his hypoxia has
actually improved. This makes CHF exacerbation less likely. S/p
doxy for COPD flare. Initiated taper of patient's multiple
sedating medications. He will need a formal sleep evaluation
following discharge. He will also need outpatient follow up for
recent TTE findings with worsening PAH/MR/TR. prior to discharge
his clonazepam dose was reduced to 1 mg 3 times daily. On the
day of discharge the patient was not in respiratory distress and
he was satting well on room air.
# ACUTE ENCEPHALOPATHY: Pt with acute obtundation ___, about
___ hours after receiving multiple sedating medications. Mental
status improved with transient bipap and no other intervention.
Suspect the most likely cause of obtundation is his multiple
sedating medications and long term tapering is crucial to
optimize both his mental and respiratory status. Delirium
secondary to hospitalization and medications also likely
contributing. Mental status improved to baseline prior to
discharge.
The patient insistent to go home on several occations. We
explained that we had serious reservations about the safety of
going home given his deconditioning and multiple sedating
medications. While he disagreed with us about the severity of
the
risks of being discharged home, he does express a clear
understanding of the risks and of our degree of concern. He is
able to provide a cogent plan for what he will do after being
discharged, knew that he needed a chair car to get home, reports
access to money/food/shelter, and has close friends that he is
planning on staying with (he declined to provide me with their
contact information). We further discussed his elevated INR, and
he understood this and the risks associated with it, and was
able
to articulate how his warfarin/INR is managed at home and that
he
needed to look out for signs of bleeding without being prompted.
This suggests to us that he does understand fairly complex
medical issues and decisions. Given all of this, and the
psychiatric evaluation on ___ with similar conclusions, we
believe he does have the capacity to leave the hospital at this
time. He has PCP follow up the on ___ which he is aware of and
plans to follow through with. He stated he was able to call his
home ___ services to have the re-established after his
discharge. We will also contacted them in the morning. He was
able to get out of bed and ambulate using a cane with the RN
this afternoon prior to discharge.
# LV THROMBUS
# H/O DVT/PE
# CLOTTED IVC FILTER
Patient with history of clotted filter since at least ___.
Previously evaluated by vascular surgery who determined there
was no way to remove filter. CTA showing chronic LV apical
thrombus. TTE was suboptimal but did not show thrombus. The
patient follows with HCA ACMS but seems to be non-compliant with
INR checks. TTE with suboptimal quality though did not show any
LV thrombus. Given subtherapeutic INR on presentation, he was
treated with Lovenox bridge. However his INR was
supratherapeutic prior to discharge and warfarin was held. On
the day of discharge the patient declined blood tests and we
were not able to measure his INR on discharge or make warfarin
adjustments. Patient should follow-up with outpatient
anticoagulation provider for further titration of his warfarin
dose.
# CAD
# CHRONIC SYSTOLIC HEART FAILURE
Patient reports that he is not taking his torsemide as it makes
him urinate. Despite this, he appeared euvolemic on exam, and
BNP, while elevated, was improved from prior values. Pt endorsed
chronic heaviness in his chest; but serial cardiac enzymes and
ECG's were reassuring with only non-specific T wave changes on
ECG during trigger on ___ pm.
# CHRONIC PAIN / ANXIETY: Patient on high dose methadone,
gabapentin and clonazepam at home. Doses confirmed in OMR and
___ (last filled scripts on ___. Gabapentin and
clonazepam doses have been down titrated during this admission.
# MULTIPLE FALLS
# GOALS OF CARE
On previous admissions there has been concern that he is not
safe at home and ___ has recommended rehab which he refuses. PCP
has also been addressing alternative living situations with the
patient including ___ house. Pt has capacity to decline rehab
option (see above) and therefore based on his wishes he was
discharged home with ___ services.
# PASSIVE SI: Pt reportedly expressed a desire "to end it all"
early in hospitalization and would not further elaborate. Psych
consulted, felt this did not represent true SI after discussion
with pt (see psych consult note for details). Found no
psychiatric contraindication to discharge. Could consider
outpatient neuropsych evaluation.
# DIARRHEA: Resolved, with subsequent complaints of
constipation.
# CHRONIC SYSTOLIC HEART FAILURE
EF 50% on TTE this admission. Patient complained of dyspnea on
exertion and reports that he is not taking his torsemide as it
makes him urinate. Despite this, he appeared euvolemic on exam,
and BNP, while elevated, was improved from prior values. He
continued to refuse his torsemide intermittently while inpatient
but resrtarted prior to discharge.
# COPD: Patient reports he uses O2 at home at night. On
Albuterol and Spiriva.
# BPH: On tamusulosin
# Pancytopenia: Chronic issue. ? underlying MDS. ___. Will
need outpatient f/u.
Transitional issues
====================
The patient has worsening pulmonary hypertension, mitral
regurgitation, tricuspid regurgitation based on inpatient
transthoracic echo. Consider consulting with cardiology for
further workup.
Patient requires urgent evaluation with sleep medicine for
possible BiPAP/CPAP at home at night.
Patient was noted to have a thrombosed IVC with severe chronic
venous congestion of the lower extremities. Vascular surgery
was consulted and anticipated difficulty in removing the IVC
filter and no need for acute surgical intervention. Consider
referral to vascular surgery as an outpatient
due to supratherapeutic INR noted on the day prior to discharge
the patient did not receive warfarin on the day of the discharge
and 1 day prior to discharge. Please follow-up on INR levels
and dose warfarin accordingly.
Patient reportedly expressed desire to "end it all" early in
hospitalization. Consider outpatient neuropsychiatric
evaluation for SI.
On the day prior to discharge the patient had pancytopenia
which has been ___ for the last 5 days. Please repeat CBC in
1 week.
The patient has bibasilar atelectasis seen on chest x-ray from
___. Please repeat chest x-ray in 1 month to confirm
resolution of these findings.
The patient was discharged on his home metoprolol succinate
12.5 twice daily. Consider consolidating that to 25 mg once
daily for ease of administration.
We reduced his clonazepam dose to 1 mg 3 times daily and his
gabapentin dose to 600 3 times daily due to sedation effect
leading to respiratory failure. Please titrate these
medications as an outpatient.
We discharged the patient on naloxone nasal spray in case of
opiate overdose.
Would consider ongoing dialogue regarding the safest living
situation for him.
**Patient was seen and examined today prior to discharge. See
above regarding discharge despite our concerns. Greater than 30
minutes were spent on discharge planning and coordination.**
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
2. Atorvastatin 40 mg PO QPM
3. ClonazePAM 2 mg PO TID
4. FoLIC Acid 1 mg PO DAILY
5. Gabapentin 800 mg PO TID
6. Methadone 100 mg PO DAILY
7. Metoprolol Succinate XL 12.5 mg PO BID
8. Omeprazole 40 mg PO DAILY
9. Tamsulosin 0.4 mg PO QHS
10. Tiotropium Bromide 1 CAP IH DAILY
11. Torsemide 20 mg PO DAILY
12. Warfarin Dose is Unknown PO DAILY16
13. Ferrous Sulfate 325 mg PO BID
Discharge Medications:
1. Naloxone 0.4 mg Subcut DAILY:PRN opioid reversal
RX *naloxone [Narcan] 4 mg/actuation 1 puff in once Disp #*1
Spray Refills:*0
2. ClonazePAM 1 mg PO TID
3. Gabapentin 600 mg PO TID
4. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
5. Atorvastatin 40 mg PO QPM
6. Ferrous Sulfate 325 mg PO BID
7. FoLIC Acid 1 mg PO DAILY
8. Methadone 100 mg PO DAILY
9. Metoprolol Succinate XL 12.5 mg PO BID
10. Omeprazole 40 mg PO DAILY
11. Tamsulosin 0.4 mg PO QHS
12. Tiotropium Bromide 1 CAP IH DAILY
13. Torsemide 20 mg PO DAILY
14. HELD- Warfarin Dose is Unknown PO DAILY16 This medication
was held. Do not restart Warfarin until You check you INR on
___. Based on INR value you medication may be restarted
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
acute hypoxic hypercapnic respiratory failure
acute encephalopathy
CAD
LV thrombus
Hypercarbic respiratory failure
Acute encephalopathy
Diarrhea
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 taking care of you at the ___.
You were admitted with diarrhea and a fall. Your diarrhea
improved. You were found to have a blood clot in your heart for
which you were started on Lovenox to help stabilize your blood
clot while your INR become therapeutic.
While you were here, you were also found to have difficulty with
your breathing and confusion with sedation. Because of this you
were started on a breathing mask and stayed a short duration in
the intensive care unit. Your difficulty breathing is likely due
to taking multiple sedating medications (gabapentin, klonapin,
methadone) and sleep apnea. Therefore, you were initiated on
Cpap and some of your medication doses were decreased for your
safety. We discharged you without the breathing mask and you
would need to follow up with the sleep medicine specialty clinic
early next week to have a sleep study. This sleep study will
help decide if you need a sleep mask at home.
We noted that your INR was higher than target on the day of
discharge. Therefore, we were holding you warfarin and you
should follow up with the ___ clinic on ___ for an INR
check and possibly restarting you warfarin.
Please follow up with your primary care provider on ___.
Please take you medications as prescribed.
It was a pleasure taking care of you at the ___. We wish you
all the best.
Your ___ team
Followup Instructions:
___
|
10108435-DS-64 | 10,108,435 | 21,634,956 | DS | 64 | 2194-01-31 00:00:00 | 2194-02-01 17:20:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Compazine / Codeine / Atenolol / Penicillins
Attending: ___
Chief Complaint:
chest pain, dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HISTORY OF PRESENT ILLNESS:
___ gentleman with complex past medical history
including
coronary artery disease status post bare-metal stent in ___,
profound bilateral venous stasis with multiple chronic ulcers,
poor self-care at home with difficulty engaging with medical
providers, history of heroin use disorder now on chronic
methadone for chronic pain, multiple DVTs and PEs, presented to
___ office without appointment today and was referred to ED.
Patient gives history of several vague concerns that are
inconsistently reported to different providers. States he has
chest pain that started at rest, while having his feet up
watching TV, initially stated it radiated only once down his
left
arm, then stated it was consistently radiating through to his
back. Pain does not change with exertion. Also states that he is
having bilateral leg pain, and noted right leg swelling that has
been new over the past several days since discharge from ___.
Of note, patient with recent admission on ___. At
that time, with abdominal pain, diarrhea but with negative c
diff, unremarkable CTA A/P, and abdominal pain resolved on own.
Course complicated by HCAP treated with IV ceftazidime then PO
levaquin. It was also noted that patient had long standing
history of venous stasis with ulcerations and poor self care.
Per
prior notes, patient had been noncompliant with allowing ___ for
wound care at home. There had been multiple attempts to help
arrange for placement/safer living situation but patient
refused.
CM looked for long-term placement while in the hospital as the
patient was initially agreeable but when his opiate and benzo
medications would not be escalated he insisted on leaving AMA.
He
was given prescriptions for non-controlled medicine (no
clonazepam or methadone and for intranasal narcan.
In the ED, initial VS were:
97.2 89 163/80 18 97% RA
Exam notable for:
Exam notable for stable vitals, somewhat oriented (patient
thought he was at ___, thought the month was ___ and year
was ___, systolic ejection murmur at left upper sternal
border,
regular heart rhythm, profound Medusa across abdomen that is
tender to palpation diffusely without rigidity, profound lower
extremity venous stasis changes with dark pigmentation,
innumerable areas of scabbing, right greater than left trace
pitting edema. Patient jittery and has coarse jaw tremor.
Patient then developed bleeding from left lower extremity, and
he
soaked through 3 separate dressings applied by RNs over the past
4 hours, and in discussing this with him, he reported that last
time this happened, he was admitted to ___ and required 5 units
of blood. On examination, he continued to bleed despite direct
pressure applied with 1 finger over the wound.
ECG:
Rates ___, SR, left axis, no ST changes or TWI
Labs showed:
normal BMP: Cr 0.8 (1.0)
trop <0.01 x3 , MB 2
hgb 9.2 (8.6), plt 127
INR 2.3 (2.8), ___ 25.2, PTT 39.7
Imaging showed:
CTA chest:
1. No evidence of pulmonary embolism or acute aortic
abnormality.
2. Mild peribronchial thickening suggestive of chronic airways
disease. No
focal consolidation.
3. Unchanged dilatation of the main pulmonary artery which could
suggest underlying pulmonary arterial hypertension.
4. Similar right hilar and mediastinal lymphadenopathy.
5. Redemonstration of chronic left ventricular apical infarct
with associated aneurysm and thrombus.
___:
1. No evidence of deep venous thrombosis in the right lower
extremity veins.
2. Right common femoral arteriovenous fistula, similar to prior.
CXR with:
Mild interstitial pulmonary edema.
Consults:
Social work:
Patient reports extended history of substance use, stating he
began using heroin while deployed in ___. Patient states
he's
been prescribed methodone for several years and cites
frustration
re: limited access to methodone following recent ___ from ___.
Per MD, pt's PCP provided ___ paperwork detailing pt's daily
methodone dosing. Should pt be admitted, SW will alert primary
SW
on the unit to pt's case (pt is well-known to inpatient SW from
previous admissions).
Patient received:
Methadone 40 mg
PO/NG ClonazePAM 1 mg
PO Aspirin 324 mg
PO/NG Gabapentin 800 mg
PO Tamsulosin .4 mg
PO/NG Atorvastatin 40 mg
Transfer VS were:
74 138/79 17 99% RA
On arrival to the floor, patient reports that his legs have been
throbbing, stinging and bleeding since 2 am. He denies recent
falls or trauma to the legs that precipitated the bleeding. He
also reports ___ episodes of sharp chest pain per day,
exacerbated by movement. The chest pain is reproducible to
touch.
He also reports headache. He reports that he uses 2L of O2 by NC
supplemental oxygen at home all the time and walks with a cane.
He has home health, who visit several times per week. He denies
fevers, chills, cough.
REVIEW OF SYSTEMS: 10 point ROS reviewed and negative except as
per HPI
Past Medical History:
CAD s/p STEMI w/ BMS to LAD in ___
HFrEF
Recurrent VTE and chronic RLE DVT, suspected antiphospholipid
syndrome
Thrombosed IVC filter with severe chronic venous congestion of
the lower extremities venous ulcers
Strep bacteremia in the setting of pneumonia ___
CKD (b/l Cr 1.1-1.3)
HCV, never treated
IV heroin use, in remission on methadone
History of methadone overdose causing PEA arrest
COPD
GERD
PTSD ___ veteran)
Anxiety / Depression
Microcytic anemia
Vitamin B12 deficiency
Chronic kidney disease
Punctate L parietal hemorrhage
BPH
Recurrent falls
s/p shoulder replacement
s/p cervical laminectomy
Social History:
___
Family History:
Father- deceased- heart disease ___
Mother- deceased- heart disease
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: ___ 1127 Temp: 98.2 PO BP: 141/79 HR: 60 RR: 18 O2 sat:
99% O2 delivery: 2L NC Dyspnea: 0 RASS: 0 Pain Score: ___
GENERAL: NAD, resting comfortably in bed
HEENT: EOMI, PERRLA, anicteric sclera, MMM
NECK: supple, no LAD
CV: RRR, S1/S2, no murmurs, gallops, or rubs
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
GI: abdomen soft, nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ radial pulses bilaterally
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric
DERM: lower extremities poorly perfused, severe venous stasis
disease with diffuse plaques and violaceous appearance on
bilateral calves, bilateral legs with multiple cm/sub-cm lesions
oozing bright red blood. c/d/i gauze wrapping to bilateral
calves.
DISCHARGE PHYSICAL EXAM:
___ ___ Temp: 98.4 PO BP: 103/61 HR: 68 RR: 16 O2 sat: 91%
O2 delivery: RA
GENERAL: NAD, resting comfortably in bed
HEENT: EOMI, PERRLA, anicteric sclera, MMM
NECK: supple, no JVD
CV: II/VI SEM at left upper sternal border, S1/S2, no murmurs,
gallops,rubs
PULM: mild expiratory wheezing ___, rales, rhonchi, breathing
comfortably without use of accessory muscles on RA
GI: abdomen soft, nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no edema
PULSES: 2+ radial pulses bilaterally
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric
DERM: lower extremities poorly perfused, severe venous stasis
disease with diffuse plaques and violaceous appearance on
bilateral calves, bilateral legs with multiple cm/sub-cm lesions
oozing bright red blood. c/d/i gauze wrapping to bilateral
calves.
Pertinent Results:
ADMISSION LABS:
___ 04:11PM BLOOD WBC-4.4 RBC-3.11* Hgb-8.6* Hct-28.7*
MCV-92 MCH-27.7 MCHC-30.0* RDW-16.5* RDWSD-55.6* Plt ___
___ 04:11PM BLOOD Neuts-72.9* Lymphs-16.5* Monos-5.7
Eos-3.6 Baso-1.1* Im ___ AbsNeut-3.22 AbsLymp-0.73*
AbsMono-0.25 AbsEos-0.16 AbsBaso-0.05
___ 04:02PM BLOOD ___ PTT-36.3 ___
___ 04:25AM BLOOD Ret Aut-1.7 Abs Ret-0.06
___ 04:11PM BLOOD Glucose-100 UreaN-24* Creat-1.0 Na-139
K-5.2 Cl-98 HCO3-20* AnGap-21*
___ 12:15AM BLOOD CK(CPK)-148
___ 04:11PM BLOOD CK-MB-1.8
___ 04:11PM BLOOD cTropnT-<0.01
___ 04:29PM BLOOD CK-MB-2 cTropnT-<0.01 proBNP-976*
___ 12:15AM BLOOD CK-MB-2 cTropnT-<0.01
___ 05:30AM BLOOD CK-MB-2 cTropnT-<0.01
___ 04:11PM BLOOD Calcium-9.1 Phos-4.1 Mg-2.0
___ 04:25AM BLOOD calTIBC-351 VitB12-506 Folate->20
Ferritn-337 TRF-270
___ 05:10PM BLOOD pO2-76* pCO2-45 pH-7.39 calTCO2-28 Base
XS-1
DISCHARGE LABS:
___ 04:30AM BLOOD WBC-3.8* RBC-2.79* Hgb-7.7* Hct-25.7*
MCV-92 MCH-27.6 MCHC-30.0* RDW-14.7 RDWSD-49.7* Plt ___
___ 04:30AM BLOOD ___ PTT-40.2* ___
___ 04:30AM BLOOD Glucose-111* UreaN-33* Creat-1.1 Na-138
K-4.3 Cl-94* HCO3-31 AnGap-13
___ 04:30AM BLOOD Calcium-8.9 Phos-4.9* Mg-2.1
MICRO: none
IMAGING AND STUDIES:
___ ECG
Rate 72, NSR, QTc 422, right axis deviation, no ST changes
concerning for ischemia
___ CXR
Mild interstitial pulmonary edema.
___ Unilat lower ext veins
1. No evidence of deep venous thrombosis in the right lower
extremity veins.
2. Right common femoral arteriovenous fistula, similar to prior.
___ CTA Chest
1. No evidence of pulmonary embolism or acute aortic
abnormality.
2. Mild peribronchial thickening suggestive of chronic airways
disease. No
focal consolidation.
3. Unchanged dilatation of the main pulmonary artery which could
suggest
underlying pulmonary arterial hypertension.
4. Similar right hilar and mediastinal lymphadenopathy.
5. Redemonstration of chronic left ventricular apical infarct
with associated
aneurysm and thrombus.
Brief Hospital Course:
___ gentleman with complex past medical history
including coronary artery disease status post bare-metal stent
in ___, profound bilateral venous stasis with multiple chronic
ulcers, poor self-care at home with difficulty engaging with
medical providers, history of heroin use disorder now on chronic
methadone for chronic pain, multiple DVTs and PEs, who presented
to the ED with vague complaints of chest pain and ___ pain.
ACTIVE ISSUES:
=============
# Bilateral lower extremity venous stasis with ulceration,
history of recurrent DVT with known occluded IVC filter, on
Coumadin: Patient with bleeding ___ wound in ED without evidence
of infection (no leukocytosis, afebrile, no purulent drainage or
infectious symptoms). Wound care was consulted for further
management of wounds and recommended a daily regimen of:
applying Soothe and Cool to intact, dry skin, applying Melgisorb
AG to open areas, covering with large soft sorbsponge, wrapping
with Kerlex and securing with take. Warfarin originally DC'ed
due to active bleeding. it was restarted on ___. We have been
dosing it daily according to INR. Due to low INRs, we have
increased Warfarin dose to 7.5mg and kept him on lovenox bridge.
# Chest pain: Patient with chest pain and negative ___ and CTA
for PE. Troponins negative x 3, EKG without new ischemic
changes. Of note, CTA did reveal chronic LV apical infarct with
aneurysm and thrombus dating back to at least ___. His chest
pain is reproducible on exam, consistent with
MSK/costochondritis etiology. He was treated with home
gabapentin 800 mg PO TID, acetaminophen 650mg PO Q6H PRN,
lidocaine 5% patch QAM. Pain Management was consulted and
recommended gabapentin and standing Tylenol.
# Anemia, normocytic: Hgb 9.1 on admission, MCV 91. Work up
included: iron studies, B12 and folate, retic count notable for
low reticulocyte index (0.85), consistent with nutritional
deficiency. Iron studies, B12, folate were within normal limits.
Due to the patient's ongoing bleeding from leg wounds, Hgb was
monitored throughout the admission. Discharge Hgb 7.7.
# Hemoptysis: Patient with complaint of hemoptysis without clots
during this stay. Per chart review worked up at ___ in prior
admission in ___, thought to be due to anticoagulation in the
setting of existing lung disease +/- community acquired
pneumonia (treated with ceftriaxone and azithromycin), with
recommendation for outpatient imaging and pulmonary follow up.
CTA here only notable for mild peribronchial thickening
suggestive of chronic airways disease, no focal consolidation.
Discharge Hgb 7.7. ___ consider further work up as an
outpatient.
CHRONIC ISSUES:
===============
# HFpEF: LVEF 50% ___ with hypokinesis of the distal anterior
wall and dyskinesis of the true apex. No evidence of current
decompensation; patient continued on home torsemide. Held home
metoprolol due to bradycardia.
# History of heroin abuse, on methadone: Home methadone 85 mg PO
daily was continued.
# COPD: continued home albuterol, tiotropium.
# Opioid dependence: continued home methadone.
# Anxiety: continued home clonazepam.
# HTN: continued home metoprolol.
# HLD: continued home statin.
# BPH: continued home tamsulosin.
# GERD: continued home omeprazole.
# Iron deficiency anemia: continued home ferrous sulfate.
# Thrombocytopenia: chronic, was stable during hospitalization,
was monitored.
TRANSITIONAL ISSUES:
==================
[] Warfarin dose was increased to 7.5 mg. Patient was also sent
out on lovenox bridge. Discharge INR 1.5. Please follow up INR
at appointment on ___ and adjust at your discretion.
[] Held metoprolol succinate at discharge because SBPs 90-100s
off this medication, please restart as able.
[] Gave him two days of methadone 85mg (total 170mg) until
follow up appointment with PCP
[] ___ consider switch to DOAC as outpatient
[] We arranged for visiting nursing for further wound
management.
[] At the PCP's discretion, consider splitting methadone dose
into 3 times daily or 4 times daily to optimize analgesic
effects, if the primary intention of the methadone is for pain
(vs. substance abuse)
[] On CTA chest, patient noted to have prominent main pulmonary
artery. On admission, breathing is at baseline, on 2L O2 by NC
(same O2 requirement as at home). Further workup can be
considered as an outpatient if persists.
#CODE: Full (confirmed)
#CONTACT: ___
Relationship: Other
Phone: ___
>30 minutes spent on discharge planning and coordination
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
2. Atorvastatin 40 mg PO QPM
3. ClonazePAM 1 mg PO BID
4. Gabapentin 800 mg PO TID
5. Methadone 85 mg PO DAILY
6. Metoprolol Succinate XL 25 mg PO DAILY
7. Omeprazole 40 mg PO DAILY
8. Tamsulosin 0.4 mg PO QHS
9. Tiotropium Bromide 1 CAP IH DAILY
10. Warfarin 2.5 mg PO 5X/WEEK (___)
11. Acetaminophen 650 mg PO QID
12. Ascorbic Acid ___ mg PO DAILY
13. Docusate Sodium 100 mg PO BID
14. Multivitamins W/minerals 1 TAB PO DAILY
15. Zinc Sulfate 220 mg PO DAILY
16. Ferrous Sulfate 325 mg PO DAILY
17. Narcan (naloxone) 4 mg/actuation nasal ASDIR
18. Warfarin 1.25 mg PO 2X/WEEK (MO,FR)
19. Senna 17.2 mg PO BID
20. Lidocaine 5% Patch 1 PTCH TD QAM
21. FoLIC Acid 1 mg PO DAILY
22. Torsemide 20 mg PO DAILY
Discharge Medications:
1. Enoxaparin Sodium 90 mg SC Q12H
RX *enoxaparin 100 mg/mL 90 mg SC twice a day Disp #*10 Syringe
Refills:*0
2. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *polyethylene glycol 3350 17 gram/dose 1 powder(s) by mouth
daily Refills:*0
3. Warfarin 7.5 mg PO DAILY16
further management per ___ clinic
4. Acetaminophen 650 mg PO QID
5. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
6. Ascorbic Acid ___ mg PO DAILY
7. Atorvastatin 40 mg PO QPM
8. ClonazePAM 1 mg PO BID
9. Docusate Sodium 100 mg PO BID
10. Ferrous Sulfate 325 mg PO DAILY
11. FoLIC Acid 1 mg PO DAILY
12. Gabapentin 800 mg PO TID
13. Lidocaine 5% Patch 1 PTCH TD QAM
14. Methadone 85 mg PO DAILY Duration: 2 Days
Consider prescribing naloxone at discharge
RX *methadone 10 mg/5 mL 85 mg by mouth daily Disp #*85
Milliliter Refills:*0
15. Multivitamins W/minerals 1 TAB PO DAILY
16. Narcan (naloxone) 4 mg/actuation nasal ASDIR
17. Omeprazole 40 mg PO DAILY
18. Senna 17.2 mg PO BID
19. Tamsulosin 0.4 mg PO QHS
20. Tiotropium Bromide 1 CAP IH DAILY
21. Torsemide 20 mg PO DAILY
22. Zinc Sulfate 220 mg PO DAILY
23. HELD- Metoprolol Succinate XL 25 mg PO DAILY This
medication was held. Do not restart Metoprolol Succinate XL
until your doctor tells you to
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
Chest pain, likely musculoskeletal
Bilateral ___ venous stasis with ulceration
SECONDARY DIAGNOSIS
Acute on chronic normocytic anemia
Recurrent DVT with known occluded IVC filter
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ for chest pain and lower extremity
wounds.
While you were here, we did multiple studies to investigate the
cause of your chest pain. Reassuringly, your EKG was normal and
you did not have any labs to suggest injury to your heart
muscle. A CTA of your chest was performed and did not show any
evidence of clot in your lungs. At this time, we suspect that
your chest pain is possibly musculoskeletal in nature.
For your lower extremity wounds, we asked our wound care nurses
to come see you and make recommendations for wound management.
Please take care, we wish you the best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10108435-DS-66 | 10,108,435 | 20,850,610 | DS | 66 | 2194-08-28 00:00:00 | 2194-08-28 23:47:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Compazine / Codeine / Atenolol / Penicillins
Attending: ___.
Chief Complaint:
Bilateral leg swelling, weakness, dehydration
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ with CAD (BMS to LAD ___, HFrEF (EF 45% on ___,
bilateral venous stasis c/b chronic ulcers, COPD, CKD, history
of
heroin use now on chronic methadone for chronic pain, multiple
DVTs/PEs (on warfarin), history of atraumatic subdural hematoma
with craniotomy (___) who presents with bilateral lower
extremity weakness and swelling.
He presented to his PCP office today and reported "I can't
survive like this" due to weakness and "at least a dozen" falls
at home with multiple headstrikes but no LOC. This has been
accompanied by inability to eat or drink for 4 days due to
nausea.
He was recently hospitalized at ___ ___ for vomiting
blood, with admission INR of 13. He was given vitamin K, and his
INR came down 5.6 before he eloped on ___. He was then
hospitalized again at ___ from ___ - ___ for
supratherapeutic
INR, at which time it was recommended he go on a factor X
inhibitor which he refused.
He had a recent hospitalization at ___ ___ for
shortness of breath, bilateral lower extremity pain consistent
with CHF exacerbation. Respiratory symptoms improved with
diuresis and inhaler treatment. Course was complicated by one
episode of somnolence and respiratory rate of 5. At that time
his
home methadone was switched from 90 liquid daily to 30 mg TID in
tablet form with no further episodes of somnolence or bradypnea.
He had initially requested placement at a nursing home, but
later
refused.
Currently, he is complaining of bilateral lower extremity pain,
worse in the left leg. He says that he fell because his legs
were
hurting, and because he was feeling dizzy when he stood up. He
also notes that he hasn't eaten or had anything to drink for ___
days because he has been vomiting. He reports that the last time
he vomited was in the ED.
In the ED, vitals were: T 98.2 HR 58 BP 124/71 RR 16 O2sat 99%
RA
Exam:
Chronic venous stasis changes with some bleeding ulcerations of
the legs. 2+ pulses bilaterally. Patient with varices on the
abdomen, which is soft nontender nondistended, without signs of
trauma.
No JVD
Labs:
- Trop < 0.01, CK 120
- proBNP 3940
- INR 2.8
Studies:
CT CAP w/o contrast ___
1. Subcutaneous stranding at the right upper thigh at the level
of the right greater trochanter, likely related to trauma.
Otherwise, no evidence of acute intrathoracic or intraabdominal
injury within the limitation of an unenhanced scan.
2. Extensive varices in the subcutaneous tissue, likely
secondary
to IVC filter thrombosis.
CT c-spine w/o contrast ___
No traumatic malalignment or acute fracture.
CT head w/o contrast ___
No acute intracranial abnormalities on the noncontrast head CT.
They were given:
___ 11:41 PO/NG Methadone 30 mg
___ 15:25 PO/NG ClonazePAM 1 mg
___ 15:25 PO/NG Acetaminophen 650 mg
___ 15:25 PO/NG Gabapentin 800 mg
___ 18:16 PO/NG Methadone 30 mg
Past Medical History:
CAD s/p STEMI w/ BMS to LAD in ___
HFrEF
Recurrent VTE and chronic RLE DVT, suspected antiphospholipid
syndrome
Thrombosed IVC filter with severe chronic venous congestion of
the lower extremities venous ulcers
Strep bacteremia in the setting of pneumonia ___
CKD (b/l Cr 1.1-1.3)
HCV, never treated
IV heroin use, in remission on methadone
History of methadone overdose causing PEA arrest
COPD
GERD
PTSD ___ veteran)
Anxiety / Depression
Microcytic anemia
Vitamin B12 deficiency
Chronic kidney disease
Punctate L parietal hemorrhage
BPH
Recurrent falls
s/p shoulder replacement
s/p cervical laminectomy
Social History:
___
Family History:
Father- deceased- heart disease ___
Mother- deceased- heart disease
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS:
___ 2225 Temp: 98.3 PO BP: 146/75 HR: 67 RR: 18 O2 sat: 96%
O2 delivery: Ra
GENERAL: Awake and interactive. In no acute distress but
intermittently annoyed around medication administration, slow to
speak.
HEENT: PERRL, EOMI. small pupils. MMM.
NECK: No cervical lymphadenopathy. No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Wheezes throughout lung fields, no rhonchi or rales. No
increased work of breathing.
BACK: No CVA tenderness, but diffuse tenderness to palpation of
spine
ABDOMEN: Obese with prominent varicose veins throughout abdomen
and pubic area. Sensitive to palpation. Normal bowels sounds,
non
distended.
EXTREMITIES: Bilateral lower extremities purple from knees down
with chronic stasis changes and various scabs, none currently
bleeding. No open ulcers, no ulcers on feet. Feet warm and
well-perfused, palpable DP pulses bilaterally.
SKIN: Warm, legs as above.
NEUROLOGIC: AOx3. Moving all 4 limbs spontaneously. CN2-12
intact. ___ strength throughout. Normal sensation. Gait not
assessed.
DISCHARGE PHYSICAL EXAM
========================
VITALS: 24 HR Data (last updated ___ @ 616)
Temp: 98.3 (Tm 98.5), BP: 104/60 (92-113/58-68), HR: 64
(61-71), RR: 18 (___), O2 sat: 96% (93-96), O2 delivery: Ra,
Wt: 208.77 lb/94.7 kg
GENERAL: NAD, but very easily agitated. At times, will not speak
to providers/ignore them.
CARDIAC: RRR, nml s1 s2, no mrg.
LUNGS: No increased work of breathing. Not on O2. Diffuse
wheezing throughout.
ABDOMEN: Soft with prominent varicose veins throughout abdomen
and pubic area. nd, nt.
EXTREMITIES: bilateral lower venous stasis ulcers
NEUROLOGIC: AOx3. No focal neurologic deficits.
Pertinent Results:
ADMISSSION LABS:
___ 09:38AM BLOOD WBC-3.3* RBC-3.60* Hgb-9.6* Hct-31.7*
MCV-88 MCH-26.7 MCHC-30.3* RDW-16.0* RDWSD-51.8* Plt ___
___ 09:38AM BLOOD Neuts-60.9 ___ Monos-6.1 Eos-2.7
Baso-1.5* Im ___ AbsNeut-2.01 AbsLymp-0.94* AbsMono-0.20
AbsEos-0.09 AbsBaso-0.05
___ 09:38AM BLOOD ___ PTT-37.2* ___
___ 09:38AM BLOOD Glucose-94 UreaN-13 Creat-1.0 Na-140
K-4.2 Cl-104 HCO3-24 AnGap-12
___ 09:38AM BLOOD ALT-7 AST-18 CK(CPK)-120 AlkPhos-79
TotBili-0.5
___ 09:38AM BLOOD Lipase-19
___ 07:55PM BLOOD cTropnT-<0.01
___ 09:38AM BLOOD cTropnT-<0.01 proBNP-3940*
___ 09:38AM BLOOD Albumin-4.0 Calcium-9.2 Phos-3.5 Mg-1.9
DISCHARGE LABS:
___ 08:25AM BLOOD WBC-3.0* RBC-3.98* Hgb-10.6* Hct-35.4*
MCV-89 MCH-26.6 MCHC-29.9* RDW-15.1 RDWSD-49.6* Plt ___
___ 08:25AM BLOOD Glucose-154* UreaN-29* Creat-1.0 Na-141
K-4.1 Cl-97 HCO3-30 AnGap-14
___ 08:25AM BLOOD Calcium-8.9 Phos-3.6 Mg-1.9
INR:
___ 09:38AM BLOOD ___ PTT-37.2* ___
___ 07:50AM BLOOD ___
___ 07:15AM BLOOD ___
___ 07:35AM BLOOD ___
___ 07:55AM BLOOD ___
___ 07:45AM BLOOD ___
___ 08:25AM BLOOD ___
MICRO:
___ 1:48 pm URINE ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ NCHCT: No acute intracranial abnormalities on the
noncontrast head CT.
___ C-SPINE: No traumatic malalignment or acute fracture.
___ CT TORSO W/O CONTRAST:
1. Subcutaneous stranding at the right upper thigh at the level
of the right greater trochanter, likely related to trauma versus
nonspecific subcutaneous edema. Otherwise, no evidence of acute
intrathoracic or intraabdominal injury within the limitation of
an unenhanced scan.
2. Extensive varices in the subcutaneous tissue, likely
secondary to IVC
filter thrombosis.
Brief Hospital Course:
___ with CAD (BMS to LAD ___, HFrEF (EF 45% on ___,
bilateral venous stasis c/b chronic ulcers, COPD, CKD, history
of heroin use now on chronic methadone for chronic pain,
multiple DVTs/PEs (s/p clotted IVC filter, now on warfarin),
history of atraumatic subdural hematoma with craniotomy (___)
who presents with bilateral lower extremity weakness and
swelling and multiple falls at home.
ACUTE ISSUES:
=============
# Multiple falls
Patient reports multiple falls over past few weeks (ambulates
with cane), most recently this morning ___, with multiple head
strikes but no loss of consciousness. Unclear etiology though
ddx includes: orthostatic hypotension (poor po intake + on
tamsulosin) vs. arrhythmia (h/o CAD) vs. ?seizure activity (per
pt, h/o of this in the past) vs. mechanical vs. sedating
medications (methadone, clonazepam, gabapentin). He refused to
have orthostatics obtained multiple times and initially refused
to work with ___ however, later was amenable with working with
___ after a long discussion. He was extremly defensive about
discontinuing or lowering the dose of multiple sedating
medications he is currently taking, so these were continued.
Overall feel that falls most likely secondary to deconditioning
with contribution from his multiple sedating medications.
#Leukopenia
#Anemia
#Thrombocytopenia
Has had low counts in the past since ___, though this will
fluctuate. Last HIV ___ negative. No known h/o MDS. On ___,
pt agreed to checking HIV again. He denied any recent illicit
drug use or sexual activity in the past year; however, he
refused to discuss further and clarify. HIV screen was negative.
# Inappropriate behavior
# Agitation
Pt refused to work with physical therapy and repeatedly refused
attempts to work with providers in working up the etiology for
his falls (e.g., lowering the dose of sedating meds, working
with ___. On one occasion, he was inappropriate with staff
members, threatening to sue providers for fictitious reasons
(e.g., providers are threatening pt), and throwing medication
wrappers at nursing staff while calling them inappropriate
names. ___ was not called by nursing, and pt was thereafter
slightly more willing to cooperate with staff.
==============
CHRONIC ISSUES
==============
# Bilateral lower extremity wounds
# Lower extremity lymphedema
Chronic lymphedema from chronic thrombosis of IVC distal to
renal veins. Wound care was consulted.
# Chronic HFrEF (EF 45% on ___
ProBNP 3940 on admission, though appears euvolemic. Unclear dry
weight due to refusal of standing weights last admission,
although perhaps ~199 lbs, admission weight 216 lbs. Continued
home torsemide 20mg qd.
# COPD
Per patient, his home oxygen saturation drops to 81-84% with
ambulation if he does not use his home oxygen. SpO2 wnl on RA;
however, patient repeatedly demanded being able to use oxygen
despite SpO2 being >92% on RA. Continued home Tiotropium Bromide
1 CAP IH DAILY, Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing.
# History multiple DVTs and PEs
# Thrombosed IVC filter
# History of atraumatic subdural hematoma s/p craniotomy
(___)
# History of supratherapeutic INR
Patient was admitted to ___ ___ and
underwent craniotomy for atraumatic subdural hematoma. During
previous hospitalization, neurosurgery was consulted for
recommendations regarding restarting the patient's home
warfarin, and recommended restarting anticoagulation, so he was
bridged to warfarin and at the time of discharge was receiving
2.5mg daily for goal INR 2.0-3.0 for chronic bilateral iliac
vein occlusions and recurrent DVT prophylaxis. He was admitted
twice to ___ earlier in ___ for supratherapeutic INR (see
HPI). Per patient, he was supposed to be alternating 4 and 5 mg,
but missed his last two days. His INR on admission was 2.8.
Continued daily warfarin dosing.
# History of IV heroin use, in remission on methadone
# Chronic pain
During previous admission ___, patient's home 90 mg of
methadone was fractionated to 30 TID after period of somnolence
and decreased respiratory rate with concern for patient taking
his own methadone in addition to hospital prescribed. Patient
was
initially upset about this transition, but was content when
methadone changed from liquid to pill form. Due to concern from
previous hospitalization, patient's belongings were searched by
nursing on arrival, and his empty methadone bottle (as well as
cigarettes and lighters) were put into safe-keeping. Continued
home methadone 30 mg tablet TID, Gabapentin 800 mg PO/NG TID.
# CAD s/p STEMI s/p bare-metal stent to LAD.
- Continued home atorvastatin 40 mg QPM. Not on ASA (subdural
hemorrhage) or b-blocker (bradycardia).
# Constipation
-Continued home Polyethylene Glycol, Senna and docusate sodium.
# Microcytic anemia.
- at baseline
# GERD
- Continued home Omeprazole 40 mg PO DAILY
# CKD
___ ___.
- monitored Cr.
# Anxiety/Depression
# PTSD
- continued home ClonazePAM 1 mg PO/NG TID
CORE MEASURES
#CODE: Full Code
#CONTACT: None documented
TRANSITIONAL ISSUES
==================
[]Outpatient stress test given chest pain.
[]Consider starting ACE-I, spironolactone for HFrEF.
[]Monitor CBC, though appears to have chronic leukopenia,
anemia, thrombocythemia.
This patient was prescribed, or continued on, an opioid pain
medication at the time of discharge (please see the attached
medication list for details). As part of our safe opioid
prescribing process, all patients are provided with an opioid
risks and treatment resource education sheet and encouraged to
discuss this therapy with their outpatient providers to
determine if opioid pain medication is still indicated.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ascorbic Acid ___ mg PO BID
2. Atorvastatin 40 mg PO QPM
3. ClonazePAM 1 mg PO TID
4. Cyanocobalamin 1000 mcg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. FoLIC Acid 1 mg PO DAILY
7. Gabapentin 800 mg PO TID
8. Methadone 30 mg PO TID
9. Multivitamins W/minerals 1 TAB PO DAILY
10. Omeprazole 40 mg PO DAILY
11. Senna 17.2 mg PO BID
12. Tamsulosin 0.4 mg PO QHS
13. Tiotropium Bromide 1 CAP IH DAILY
14. Torsemide 20 mg PO DAILY
15. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
16. Narcan (naloxone) 4 mg/actuation nasal ASDIR
17. Warfarin ___ mg PO ASDIR
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
2. Ascorbic Acid ___ mg PO BID
3. Atorvastatin 40 mg PO QPM
4. ClonazePAM 1 mg PO TID
5. Cyanocobalamin 1000 mcg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. FoLIC Acid 1 mg PO DAILY
8. Gabapentin 800 mg PO TID
9. Methadone 30 mg PO TID
Consider prescribing naloxone at discharge
10. Multivitamins W/minerals 1 TAB PO DAILY
11. Narcan (naloxone) 4 mg/actuation nasal ASDIR
12. Omeprazole 40 mg PO DAILY
13. Senna 17.2 mg PO BID
14. Tamsulosin 0.4 mg PO QHS
15. Tiotropium Bromide 1 CAP IH DAILY
16. Torsemide 20 mg PO DAILY
17. Warfarin ___ mg PO ASDIR
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
#Recurrent falls
#Weakness
#Nausea
#Poor appetite
#Pancytopenia
Secondary Diagnoses:
# Bilateral lower extremity wounds
# Lower extremity lymphedema
# Chronic diastolic heart failure
# Chronic obstructive pulmonary disease
# History multiple DVTs and PEs
# Thrombosed IVC filter
# History of atraumatic subdural hematoma s/p craniotomy
(___)
# History of supratherapeutic INR
# History multiple DVTs and PEs
# Thrombosed IVC filter
# CAD s/p STEMI s/p bare-metal stent to LAD.
# Constipation
# Microcytic anemia
# History of atraumatic subdural hematoma s/p craniotomy
(___)
# GERD
# CKD
# Anxiety/Depression
# PTSD
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 Mr. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You came to the hospital because you had multiple falls at
home.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- While you were in the hospital, we had our physical therapists
see you.
- We monitored your heart for any irregular rhythm. Your heart
rhythm was normal.
- We tried to do additional testing to see what was causing your
falls, but you refused on multiple occasions.
- We gave you IV fluids.
- We tried to lower your dose of some sedating medications you
are currently taking, but you refused.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- Try to drink and eat adequate amounts of food at home. We were
concerned you did not have enough fluids to drink. This may have
caused you to lose consciousness and fall.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10109025-DS-9 | 10,109,025 | 29,389,462 | DS | 9 | 2136-12-29 00:00:00 | 2136-12-29 17:42:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Zosyn
Attending: ___.
Chief Complaint:
ABDOMINAL PAIN
Major Surgical or Invasive Procedure:
- Endoscopic placement of nasojejunal feeding tube (___)
- Gastrostomy with AXIOS stent placement into pancreatic
pseudocyst (___)
- PICC insertion (___)
History of Present Illness:
HISTORY OF PRESENT ILLNESS
___ presenting with two days of abdominal pain. The pain is
located in two places: in the epigastrium, and in the lower
central abdomen. Per the patient, the pain occurs in either one
place or the other, but not in both places at once and is ___
sharp, non-radiating pain. The pain began on ___ in the
evening, and was accompanied by anorexia. The anorexia was
concerning for her parents, and they brought her to ___.
Of note, On ___, the patient returned home from ___, where she had been treated with antibiotics,
NPO, and TPN for post-ERCP pancreatitis. Her abdominal began
pain in late ___, when she had abdominal pain at work and was
brought to ___. There she was diagnosed with
pancreatitis and gallstones. One week later she had an ERCP
which was negative. Later that day she developed abdominal pain
and was brought to ___. There she was NPO, TPN,
antibiotics for ___ days before eventually being discharged on
___. Per note there was a fluid collection around her
pancreas.
On ___, she had worsening abdominal pain and on discussion with
her parents, and her family decided to bring her to ___ for
further evaluation. No nausea, no vomiting, no diarrhea, no
fevers. No changes in color of stool. No blood in stool. Chills
in the AM of ___. Last BM on ___.
Past Medical History:
choledocholithiasis
post-ERCP pancreatitis
Social History:
___
Family History:
diabetes in her father's side of the family, material
grandfather (deceased) with MI
Physical Exam:
=========================================
ADMISSION PHYSICAL EXAM
=========================================
VS: 98.5 102/66 62 18 98 RA
GEN: Alert, lying in bed quietly with hands folded over lower
abdomen, no acute distress. Mother at bedside.
HEENT: Moist MM, anicteric sclerae, no conjunctival pallor
NECK: Supple without LAD
PULM: Generally CTA b/l without wheeze or rhonchi
COR: RRR (+)S1/S2 no m/r/g
ABD: epigastric tenderness and mild abdominal distension. No
rebound tenderness or guarding, no bowel sounds appreciated.
EXTREM: Warm, well-perfused, no edema
NEURO: CN II-XII grossly intact, motor function grossly normal
=========================================
DISCHARGE PHYSICAL EXAM
=========================================
VITALS: 98.8, 98 / 65, 79, 18, 97% RA
General: A&Ox3. No longer with NJT.
HEENT: scelerae anicteric, MMM, oropharynx clear
Lungs: clear anteriorly, without wheezes, rhonchi, or stridor.
CV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: no abdominal tenderness to palpation or rebound
tenderness or guarding. soft, NTND.
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. Hives no longer present.
Pertinent Results:
ADMISSION LABS
==========================================
___ 08:42PM BLOOD WBC-14.3* RBC-3.79* Hgb-9.6* Hct-31.6*
MCV-83 MCH-25.3* MCHC-30.4* RDW-14.7 RDWSD-44.6 Plt ___
___ 08:42PM BLOOD Neuts-75.9* Lymphs-14.5* Monos-6.9
Eos-1.3 Baso-0.6 Im ___ AbsNeut-10.81* AbsLymp-2.07
AbsMono-0.99* AbsEos-0.18 AbsBaso-0.09*
___ 08:42PM BLOOD ___ PTT-30.6 ___
___ 08:42PM BLOOD Glucose-102* UreaN-12 Creat-0.7 Na-138
K-4.3 Cl-98 HCO3-28 AnGap-16
___ 08:42PM BLOOD ALT-85* AST-37 AlkPhos-372* TotBili-0.7
___ 08:42PM BLOOD Lipase-136*
___ 03:49PM BLOOD Albumin-3.3* Calcium-8.9 Phos-3.6 Mg-1.9
___ 06:45AM BLOOD calTIBC-247* Ferritn-216* TRF-190*
___ 03:49PM BLOOD Triglyc-79
___ 07:29PM BLOOD ___ pO2-97 pCO2-46* pH-7.39
calTCO2-29 Base XS-1
___ 04:24PM BLOOD Lactate-1.0
DISCHARGE LABS
==================
___ 05:59AM BLOOD WBC-15.6* RBC-3.71* Hgb-9.2* Hct-30.3*
MCV-82 MCH-24.8* MCHC-30.4* RDW-15.1 RDWSD-44.4 Plt ___
___ 05:20AM BLOOD Neuts-74.4* Lymphs-16.5* Monos-7.7
Eos-0.2* Baso-0.1 Im ___ AbsNeut-9.06* AbsLymp-2.01
AbsMono-0.94* AbsEos-0.03* AbsBaso-0.01
___ 05:59AM BLOOD Glucose-102* UreaN-14 Creat-0.8 Na-138
K-4.6 Cl-98 HCO3-22 AnGap-23*
___ 05:59AM BLOOD ALT-85* AST-67* LD(LDH)-385* AlkPhos-383*
TotBili-0.2
___ 05:59AM BLOOD Albumin-3.8 Calcium-9.7 Phos-4.3 Mg-2.1
IMAGING
==========================================
CXR ON ___:
FINDINGS:
The lungs are clear without consolidation, effusion, or edema.
Cardiomediastinal silhouette is within normal limits. No acute
osseous
abnormalities. Curvilinear lucency below the left hemidiaphragm
is compatible With gastric air bubble with compression due to
adjacent pancreatic cyst.
CT ABDOMEN/PELVIS ON ___:
PERTINENT FINDINGS:
HEPATOBILIARY: The liver is normal in size and attenuation.
There is mild, mostly central intrahepatic biliary ductal
dilatation. There is partially occlusive thrombus within the
extrahepatic portal vein (02:34). The intrahepatic portal vein
and its branches are widely patent. There are numerous
calcified gallstones within a decompressed gallbladder.
SPLEEN: The spleen is normal in size and enhancement.
PANCREAS: The patient is status post recent episode of
pancreatitis after
ERCP. Arising from the pancreatic body and tail is a 9.6 x 11.2
x 12.4 cm
fluid collection. This collection exerts mass effect displaces
the stomach anteriorly and narrows the portal vein at the level
of portal confluence. An additional smaller fluid collection in
the area of the pancreatic tail inferiorly measures 1.3 x 3.0 cm
(02:43). Finally, a collection is identified within the
pancreatic head measuring 0.8 x 2.3 cm.
Of note, the pancreatic head and uncinate process are well seen
and the
pancreatic body and tail are largely compressed by the
peripancreatic fluid collection. However, the pancreatic body
and tail enhance normally and there is no definite evidence of
pancreatic necrosis.
GASTROINTESTINAL: There is no bowel obstruction. Colon is
within normal
limits.
VASCULAR: The aorta is normal in caliber. Again there is a
small, partially occlusive thrombus involving the extrahepatic
main portal vein just distal to the portal/SMV confluence.
Splenic vein is not visualized suggesting thrombosis.
Additionally, a dilated collateral vein adjacent to the greater
curvature of the stomach along the anterior abdominal wall is
identified.
IMPRESSION:
1. 12.4 cm fluid collection arising from the pancreatic body and
tail within the lesser sac which exerts mass effect upon
adjacent structures and displaces the stomach anteriorly.
Additional smaller peripancreatic collections as described
above. These collections are most consistent with pseudocysts.
The pancreatic parenchyma enhances normally and there is no
definite evidence of necrosis.
2. Mild, mostly central intrahepatic ductal dilatation.
3. Small, partially occlusive thrombus within the main portal
vein, just
distal to the portal/SMV confluence. Thrombus formation is
likely related to mass effect by the large adjacent pancreatic
pseudocyst. The intrahepatic portal vein and its branches are
patent. Splenic vein is not visualized.
4. No bowel obstruction. No free air.
5. Cholelithiasis without evidence of cholecystitis.
CXR ON ___
IMPRESSION:
New left basal opacity is concerning for pneumonia.
MRCP ON ___
IMPRESSION:
1. Arising anteriorly from the body and tail of the pancreas
there is a
multiloculated thick walled 13 x 13 x 10 cm fluid collection
which extends
into the lesser sac and abuts the posterior aspect of the
stomach compressing the stomach anteriorly, it also extends into
the left anterior pararenal space. There is some debris noted
at the dependent aspect of the collection consistent with mildly
complex walled off necrosis.
In the pancreatic head there is a 1.1 x 1.4 cm fluid collection
with some
debris in it. This is also consistent with focal walled off
necrosis.
2. Large pancreatic walled off necrosis exerts mass effect on
the SMV at the confluence with the main portal vain with a small
amount of intraluminal thrombus at the confluence which is less
conspicuous when compared to prior CT. Apparent splenic vein
occlusion.
3. Bilateral mild striated nephrograms are noted. This may be
due to
medication causing ATN. There is no infarct, perinephric
abnormality, or
renal mass.
4. Gallbladder is contracted around numerous gallstones. No
evidence of acute cholecystitis. No choledocholithiasis.
EGD (___):
Normal mucosa in the whole esophagus
Normal mucosa in the whole stomach
The previously placed NJ tube was noted in the stomach with the
tip of the tube passed the pylorus into the small intestine.
EUS was performed using a linear echoendoscope at ___ MHz
frequency:
A large 16 cm X 12 cm complex fluid collection consistent with
WOPN was noted in the body/tail of the pancreas. The largest
portion of the pancreatic collection was identified in the
proximal gastric body and thus this was the location selected
for puncture. Color doppler was used to determine an avascular
path for Axios stent deployment. Electrocautery enhanced Axios
was performed creating a tract between the gastric wall and the
pseudocyst.
Under EUS imaging the axios stent was deployed successfully. A
straight-tip 0.035 in x ___ cm Jagwire was introduced through
the axios stent under fluoroscopic guidance. The cystgastrostomy
tract was dilated with a CRE ballon up to 12 mm. After stent
deployment a large amount of fluid and debris were seen coming
out of the necrotic collection. Approximately 1,250 mL were
removed. No evidence of bleeding post procedure was noted.
Brief Hospital Course:
=============================================
BRIEF HOSPITAL COURSE
=============================================
Ms ___ is a ___ with hx of recent post-ERCP pancreatitis
(discharged from ___ ___, who presented to
___ on ___ with 2 days of abdominal pain and inability to
tolerate PO intake and mild nausea and vomiting. She had
returned home just recently from ___ on ___ where
she had been treated with IV antibiotics and had been on TPN for
post-ERCP pancreatitis. ERCP had been done because of concern
for choledocholithiasis.
# PANCREATIC PSEUDOCYST: On admission on ___, imaging was
notable for 12.4 cm fluid collection arising from the pancreatic
body and tail within the lesser sac which exerted mass effect
upon adjacent structures and displaces the stomach anteriorly.
This was most consistent with pseudocyst. The cyst had increased
in size by 6 cm since a CT abdomen/pelvis at an outside hospital
in early ___. There was mild, mostly central intrahepatic ductal
dilatation. The ERCP team was consulted and an NJ tube was
placed endoscopically on ___ and enteral nutrition was started,
given an albumin of 2.7 and concern for poor PO intake over the
last few weeks. Pain was managed with IV Dilaudid initially, and
she received IVF and electrolyte repletion. On ___, MRCP showed
a multiloculated thick walled 13 x 13 x 10 cm cyst with walled
off necrosis. A PICC line was placed in the evening of ___
given poor PIV access, need to administer IV antibiotics, and
concern for secure access prior to drainage of the pseudo-cyst.
On ___, she underwent and EGD with EUS and pancreatic
pseudocyst drainage via Axios stent placement. Approximately
1,250 mL were removed. There was no e/o bleeding or other
complications. Post-operatively, advancement of diet to clear
liquids, full liquids, and then a regular low-fat was
well-tolerated without abdominal pain. On ___, the NJ tube was
removed. On day of discharge, patient had been tolerating PO
intake for >48 hours and abdominal pain was controlled with
Tylenol alone. At the request of the ERCP team she will complete
a total of 7 days of post-procedure antibiotics which will be
done with ciprofloxacin (last day = ___.
# PORTAL VEIN THROMBUS: A small, partially occlusive thrombus
was also identified within the main portal vein, just distal to
the portal/SMV confluence. Thrombus formation is likely related
to mass effect by the large adjacent pancreatic pseudocyst. The
intrahepatic portal vein and its branches were patent. Splenic
vein was not visualized. There was cholelithiasis without
evidence of cholecystitis. Patient was treated with a heparin
drip upon admission. Heparin gtt was stopped prior to and
following the pseudocyst drainage procedure on ___ given ERCP
team's concern for her being at very high risk of bleeding if
therapeutically anticoagulated. Hematology was consulted who
recommended full dose anticoagulation for her multiple venous
thrombi, however the ERCP team felt that the risk of bleeding
outweighed the benefits, especially since decompression of the
pseudocyst should restore normal venous return decreasing her
propensity to form additional clot. After multidisciplinary
discussion, a decision was reached regarding anticoagulation:
she will remain on Lovenox 40 mg daily, beginning on ___ and
ending on ___ (i.e. hold ___ and ___ dose) prior to her
repeat endoscopy with Dr. ___ on ___. Further decision
regarding ongoing anticoagulation to be made by Dr. ___
(___) and Dr. ___ in follow up.
# PNEUMONIA: On ___, the patient triggered for chest pain, back
pain, tachycardia to 130s-140s, hypoxia to 85 RA, placed on 2L.
EKG showed sinus tachycardia. The abdominal exam was unchanged,
with no peritoneal signs. Her lungs were clear, though WBC was
18k. CXR was suggestive of pneumonia, and the patient was
started on vancomycin and Zosyn, with improvement in O2 sats.
She remained afebrile throughout. She was treated for a total of
6 days of antibiotics (course abbreviated due to drug reaction -
alternative agent deferred due to clinical resolution).
# DRUG REACTION TO ZOSYN: On ___ the patient noted itchiness
and the appearance of hives, which acutely worsened during
pre-operative infusion of Zosyn (day 6 of treatment for
pneumonia, described above). She received Benadryl and
dexamethasone, Zosyn was discontinued. The hives improved until
the morning of ___, when the pruritus and hives worsened,
appearing on her legs, abdomen, face, and arms. She was treated
with IV Benadryl, IV solumedrol, cetirizine, and famotidine, and
her symptoms resolved. Zosyn was added as a drug allergy in the
___ OMR.
# LFT ABNORMALITIES: Low grade Alkaline Phosphatase and ALT
elevation (without AST elevation) into 300s and ___ respectively
on admission. This downtrended to nadir on ___, but then began
to increase again. ALT/AST/AlkPhos/TBili on discharge were
85/67/383/0.2. Etiology for this is not clear but may include
residual effect of drug reaction (see above) or significant
intra-abdominal process (although this is improving by all other
metrics). No abdominal pain or tenderness (markedly different
from admission). Plan is to repeat labs at follow up with Dr.
___.
# CHOLELITHIASIS: inciting event for abdominal pain and workup
at OSH in ___, leading to gallstone pancreatitis, ERCP at
OSH, and then pancreatic pseudocyst. Gallstones noted again in
imaging at ___. Will need cholecystectomy when recovered from
EGD.
# ANEMIA: improved since ___, with iron studies demonstrating
effects from chronic inflammation.
=============================================
TRANSITIONAL ISSUES
=============================================
# PANCREATIC PSEUDOCYST:
- Needs repeat CT abdomen/pelvis with (venous) contrast on
___ prior to EGD/necrosectomy. This has been ordered
- Scheduled to undergo repeat EGD/necrosectomy in on ___ with
Dr. ___ at ___.
# LFT ABNORMALITIES:
- Will have repeat LFTs done on ___ when she undergoes repeat
endoscopy with Dr. ___.
# CHOLELITHIASIS:
- Once more acute issues related to her pancreatic pseudocyst
have been further addressed, patient should be referred for
elective cholecystectomy.
# ANTICOAGULATION:
- Continue Lovenox 40 mg SC daily, but HOLD dose on ___ and ___
prior to repeat endoscopy with Dr. ___ on ___.
- Dr ___ and Dr ___ to decide on future
anticoagulation plan. Follow up with both has already been
scheduled.
# ZOSYN ALLERGY:
- Please ensure this is documented in her electronic medical
record outside of ___.
CONTACT: father, ___ ___
CODE: Full
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
RX *acetaminophen 650 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*30 Tablet Refills:*0
2. Ciprofloxacin HCl 500 mg PO Q12H Duration: 3 Doses
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*3 Tablet Refills:*0
3. Enoxaparin Sodium 40 mg SC DAILY
HOLD dose on ___ and ___. Confirm with Dr ___ prior to
resuming after procedure on ___.
RX *enoxaparin [___] 40 mg/0.4 mL 40 mg SC daily Disp #*30
Syringe Refills:*0
Discharge Disposition:
Home with Service
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Pancreatic pseudocyst
Post-ERCP pancreatitis
Splenic vein thrombosis
Portal vein thrombosis
Healthcare associated pneumonia (HCAP)
Cholelithiasis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital with abdominal pain, following
treatment for pancreatitis at an outside hospital. On admission,
you were found to have a 14cm pancreatic pseudocyst (collection
of fluid). The pancreatic pseudocyst was drained with surgery,
and 1.5 liters of fluid were removed from the cyst.
There was also a blood clot that was partially blocking one of
the veins supplying blood to your liver, as well as a clot in a
vein near the spleen. The blood clot was treated with blood
thinners. Due to increased bleeding risk after your pancreatic
pseudocyst drainage, you cannot tolerate the full dose of blood
thinning medication so we have prescribed a lower dose for you.
You will take Lovenox 40 mg daily. Please DO NOT take this
medication on ___ or ___. The need for this medication will
then be reassessed when you see Dr. ___ for repeat
endoscopy/procedure on ___.
While you were here, you developed an allergic reaction to an
antibiotic called "Zosyn" (also called
"piperacillin-tazobactam"). You developed itchy red hives on
your legs, arms, face, and abdomen. The antibiotic was
discontinued, you were treated with Benadryl and steroids, and
the rash resolved. You should NOT receive this medication in the
future.
You also have gallstones. Take care to avoid fatty foods as
these can worsen gallstone pain.
It has been a pleasure to be involved in your care!
Your ___ Care Team
Followup Instructions:
___
|
10109085-DS-6 | 10,109,085 | 28,083,201 | DS | 6 | 2187-08-31 00:00:00 | 2187-09-04 16:19:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Plavix / Hydrochlorothiazide / Midazolam / tamsulosin
Attending: ___.
Chief Complaint:
hip pain, falls
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with a history of coronary disease, hypertension, peripheral
vascular disease, metastatic lung cancer with metastases to the
brain, who presented to the ED after a fall.
He fell onto the right hip and has since had pain. He was not
lightheaded or dizzy surrounding the fall. He did not lose
consciousness. He does feel very weak. He did not have
palpitations, or chest pain. He denies striking his head, no
neck pain.
Past Medical History:
1. Rheumatoid arthritis
2. Carotid stenosis - L total stenosis, R s/p endarterectomy
___
3. Gout
4. Colonic Polyps- s/p sigmoid polypectomies in ___ and ___.
Bx in
___ revealed adenomas and suggestion to repeat in ___ years
5. HTN- on clonidine, amlodipine, metoprolol, lisinopril
6. Chronic Back Pain- on Oxycodone
7. Lung cancer - Mult pulm nodules, growing on CT. s/p RFA on
___. Peripheral Vascular Disease - Iliac artery stenosis s/p b/l
EIA stents.
9. CAD - s/p MI in the 1980s with circumflex and RCA occlusion
10. CHF - EF 40% in ___
Social History:
___
Family History:
NC
Physical Exam:
Exam on day of discharge (Dr. ___
GENERAL: NAD, awake and alert, oriented x3
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva,
patent nares, MMM
NECK: nontender and supple, no LAD, no JVD
BACK: no spinal process tenderness, no CVA tenderness
CARDIAC: RRR, nl S1 S2, no MRG
LUNG: CTAB, no rales wheezes or rhonchi, no accessory muscle use
ABDOMEN: +BS, soft, non-tender, non-distended, no rebound or
guarding, no HSM
EXT: warm and well-perfused, no cyanosis, clubbing or edema
PULSES: 2+ DP pulses bilaterally
NEURO: strength ___ throughout, sensation grossly normal
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
==================================
Labs
==================================
___ 05:01PM BLOOD WBC-8.2 RBC-3.28* Hgb-11.6* Hct-37.2*
MCV-113* MCH-35.4* MCHC-31.2 RDW-16.3* Plt ___
___ 05:01PM BLOOD Neuts-80.4* Lymphs-11.4* Monos-6.0
Eos-1.6 Baso-0.5
___ 09:14PM BLOOD ___ PTT-32.8 ___
___ 05:01PM BLOOD Plt ___
___ 05:01PM BLOOD Glucose-100 UreaN-19 Creat-1.0 Na-139
K-4.1 Cl-105 HCO3-22 AnGap-16
==================================
Radiology
==================================
femur xray
FINDINGS:
Frontal views of the pelvis with frontal and cross-table lateral
views of the
right hip and AP and lateral views of the distal right femur.
There is a lucency through the cortex of the lateral greater
trochanter
compatible with an acute fracture. Extent of this fracture is
uncertain,
whether it is isolated to the greater trochanter or extends
through the
femoral neck. The bones are osteopenic. No other fractures
visualized.
Pubic symphysis and SI joints are unremarkable. Vascular stent
projects over
the right iliac region. Vascular calcifications are identified.
Distally,
the femur is unremarkable
IMPRESSION:
Lucency through the right greater trochanter worrisome for acute
fracture.
The extent of this fracture is uncertain, whether it is isolated
to the
trochanter or involves the femoral neck.
CT head
FINDINGS:
There is no evidence of acute intracranial hemorrhage, diffuse
edema, or shift
of normally midline structures. Hypodensity in the right
parietal region near
the vertex with trace internal hyperdensity corresponds to the
patient's known
cerebral metastasis seen on prior MR of ___. Cerebellar
lesions are
better assessed on the prior MR. ___ periventricular ___
matter
hypodensities are compatible with sequelae of mild chronic
microvascular
ischemic disease. The gray-white matter interface is preserved
without
evidence of acute major vascular territorial infarct. The
ventricles and
sulci are slightly prominent but normal in configuration,
compatible with age
related parenchymal volume loss. Vascular calcification of the
bilateral
carotid siphons and vertebral arteries is incidentally noted.
The orbits and
globes are intact. There is trace fluid in the left sphenoid
sinus. The
remainder of the imaged paranasal sinuses, middle ear cavities
and mastoid air
cells are clear bilaterally. The bony calvaria appear intact.
IMPRESSION:
1. No evidence of acute intracranial process.
2. Evidence of mild chronic microvascular ischemic disease and
atrophy.
3. Right parietal hypodensity corresponds to known cerebral
metastasis seen
on prior MR. ___ lesions are better seen by MRI.
CT pelvis
FINDINGS:
CT PELVIS: There is diffuse atherosclerotic disease at the
iliac vessels
bilaterally. The right external iliac artery contains a stent.
There is
severe atherosclerosis at the left common iliac artery with
proximal ectasia
measuring 1.6 x 1.4 cm (2:12). The urinary bladder, prostate,
seminal
vesicles and rectum are within normal limits. Diffuse
diverticulosis is seen
in the sigmoid colon and distal descending colon. Trace
mesenteric fluid is
seen along the left paracolic gutter. No free pelvic fluid or
inguinal/pelvic
lymphadenopathy is detected.
OSSEOUS STRUCTURES AND SOFT TISSUES: A small fat-containing
right inguinal
hernia is incidentally noted. There is no soft tissue hematoma.
There is an acute fracture of the right greater trochanter
without significant
distraction of the fracture fragment. There is no extension of
the fracture
line into the femoral neck. No additional fracture is detected.
There is
evidence of mild degenerative change in the right
femoroacetabular joint with
joint space narrowing, endplate sclerosis and peripheral
osteophyte formation.
Irregularity of the pubic symphysis is likely degenerative.
There is no pubic
symphysis diastasis or widening of either sacroiliac joint.
Facet joint
arthropathy is noted in the imaged lower lumbar spine.
IMPRESSION:
1. Acute fracture of the right greater trochanter without
significant
distraction of the fracture fragment. No fracture involvement
of the femoral
neck.
2. Colonic diverticulosis without evidence of diverticulitis.
3. Severe atherosclerotic disease with left common iliac artery
ectasia
measuring 1.6 cm.
CXR
FINDINGS: As compared to the previous radiograph, there is no
relevant
change. Elevation of the right hemidiaphragm, caused by
slightly distended
right bowel loops. Atelectasis at the right lung bases and mild
parenchymal
opacities in the lateral parts of the right upper lobe base.
These have not
substantially changed as compared to the prior image. Moderate
cardiomegaly
with moderate tortuosity of the thoracic aorta. No pleural
effusions.
Brief Hospital Course:
___ with a history of coronary disease, hypertension, peripheral
vascular disease, metastatic lung cancer with metastases to the
brain, who presented to the ED after a fall. He had hip pain and
on workup he was found to have a nondisplaced R trochanter
fracture. He was seen by orthopedics and the recommendation was
for nonoperative management. He was cleared to work with ___ and
was able to ambulate with a walker. He received oral oxycodone
for pain with good relief and will be discharged home with a
script for percocet. Upon talking with his wife, the patient had
fallen several times on the day of admission (the patient
himself reported he only fell once after he slipped) and had
altered mental status "like a TIA" (wife is a nurse here). We
discussed that multiple falls certainly brings up the concern
that he may be having coordination issues related to his
cerebellar mets, and as such he would continue to be at risk of
fall going forward. The patient had met with Dr. ___
week prior and had refused any treatment for his cancer,
including whole brain radiation or chemotherapy. We again
discussed the risks/benefits of getting treatment versus not
getting any treatment, and asked radiation oncology to visit
with him here to provide further details. The patient says he
will think about it, but is not interested in starting any
treatment now because he needs to get home to supervise his
marinated mushroom business. I urged him to come to a decision
within 1 week, as any benefit he might derive from treatment
will likely diminish as his disease progresses and causes
symptoms. There was some concern about competency, but he was
able to understand and repeat back key points of our
conversations, including the following day. He will touch base
with radiation oncology next week and with Dr. ___ as
needed based on his decisions regarding chemotherapy. For now
his wife will arrange for 24 hour care at home until he is able
to function safely and independently. He was offered home
nursing or ___ services but says he doesn't want them.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Allopurinol ___ mg PO DAILY
2. Aspirin 325 mg PO DAILY
3. Labetalol 100 mg PO BID
4. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN pain
5. Hydroxychloroquine Sulfate 200 mg PO BID
6. Amlodipine 10 mg PO DAILY
7. LeVETiracetam 500 mg PO BID
8. Atorvastatin 40 mg PO DAILY
9. CloniDINE 0.2 mg PO DAILY
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Amlodipine 10 mg PO DAILY
3. Aspirin 325 mg PO DAILY
4. Atorvastatin 40 mg PO DAILY
5. Hydroxychloroquine Sulfate 200 mg PO BID
6. Labetalol 100 mg PO BID
7. LeVETiracetam 500 mg PO BID
8. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*60 Capsule Refills:*0
9. Senna 1 TAB PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*60 Tablet Refills:*0
10. CloniDINE 0.2 mg PO DAILY
11. oxyCODONE-acetaminophen ___ mg oral q4h pain
RX *oxycodone-acetaminophen 10 mg-325 mg 1 tablet(s) by mouth
every four (4) hours Disp #*120 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
R trochanter traumatic 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:
Dear Mr. ___,
It was a pleasure taking care of you during your stay at ___
___. You were admitted for a broken hip
after you fell at home. The bone is still aligned and you were
seen by an orthopedic surgeon who recommended that you do not
need surgery. Your pain has been well controlled with oxycodone
pills and you will be given a prescription for pain medications
at home. While you were here we discussed that your fall may
have been due to cancer metastases to your brain. We discussed
that getting radiation to your brain may help control these
metastases and help prevent new ones. You met with the radiation
oncologist. You indicated that you are not ready to start yet,
that you would like to go home and think about it. I recommended
that you do not delay this decision more than 1 week.
At home, you should only get up with help and with your walker.
Good luck, Merry Christmas, and happy birthday!
Followup Instructions:
___
|
10109398-DS-12 | 10,109,398 | 23,860,604 | DS | 12 | 2112-06-28 00:00:00 | 2112-06-28 11:47:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
codeine
Attending: ___.
Chief Complaint:
right foot wound
Major Surgical or Invasive Procedure:
___: Open right transmetatarsal amputation of ___, and ___ digits with extension of incision up into distal
calf.
___: Right below-the-knee amputation.
History of Present Illness:
This patient is a ___ man with a
history of diabetes who presents after a 3 day long bus ride,
with gangrene and spreading infection in the right foot. The
infection involves the distal aspect of the ___, and ___
toes, and its presence on the dorsum of the foot. There was
evidence of gas in the tissues on CT scan. For this reason,
I he was taken for urgent operative intervention. The procedure
and
risks were explained to the patient. He understood and
wished to proceed.
Past Medical History:
CAD, DMII, hypothyroid, HTN, systolic CHF, HLD
PSH: cardiac cath (no stents placed)
Social History:
___
Family History:
nc
Physical Exam:
Gen: Overweight man in NAD, alert and oriented
CV: RRR
Lungs: CTA bilat
Abd: Soft, non tender
Ext: RLE with BKA. Stump c/d/i. LLE with mild edema, dopplerable
signals.
Pertinent Results:
___ 05:45PM BLOOD WBC-6.1 RBC-3.54* Hgb-10.7* Hct-31.4*
MCV-89 MCH-30.3 MCHC-34.2 RDW-13.4 Plt ___
___ 05:45PM BLOOD Glucose-198* UreaN-26* Creat-1.5* Na-134
K-4.2 Cl-95* HCO3-28 AnGap-15
___ 05:45PM BLOOD Calcium-8.8 Phos-4.1 Mg-2.1
___ 12:50PM BLOOD %HbA1c-11.1* eAG-272*
Brief Hospital Course:
Mr. ___ was admitted from an OSH and taken urgently to the ___.
Broad spectrum antibiotics were started and he underwent open
right transmetatarsal amputation of ___, and ___ digits
with extension of incision up into distal calf. He did well post
operatively but it was determined that unfortuantely the
infection had progressed and his foot could not be salvaged. He
was ultimately taken for a BKA on ___. He did well and followed
the amputation pathway post operatively. He completed a course
of antibitoics for his group b strep/mssa infection on ___. He
was quite upset initially give how serious his disease was, and
how quickly he lost his leg once admitted to us. Psychiatry saw
him and recommended he see an outpatient counselor. He had
___ follow him for his thyroid and diabetes. They adjusted
his synthroid dose, and also started him on insulin. He worked
with physical therapy and was felt to be in need of a rehab
facility to further help in his recovery.
He will follow up with Dr. ___ in a month. He should see an
___ for follow up on his thyroid disease and
diabetes in the next month as well. He is encouraged to seek
out patient psycholgical counseling as soon as possible.
Staples should stay in until his follow up with vascular
surgery.
Medications on Admission:
lasix 80', potassium, lisinopril 20', glyburide, synthroid ___
(recently stopped according to pt)
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN PAIN
2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
3. Calcium Carbonate 500 mg PO QID:PRN heartburn
4. Docusate Sodium 100 mg PO BID
5. Furosemide 80 mg PO DAILY
6. Heparin 5000 UNIT SC TID
7. TraZODone 25 mg PO HS:PRN insomnia
8. Metoprolol Tartrate 25 mg PO BID
9. Lisinopril 20 mg PO DAILY
10. Levothyroxine Sodium 200 mcg PO DAILY
11. Glargine 45 Units Lunch
Insulin SC Sliding Scale using HUM Insulin
12. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
13. Glucose Gel 15 g PO PRN hypoglycemia protocol
14. Gabapentin 300 mg PO Q8H
15. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
16. STOPPED
your oral diabetes medications and started insulin
17. Blood Glucose
to be checked before meals and at bedtime
18. Potassium Chloride 20 mEq PO DAILY
Hold for K >4.5
19. LABS
please check chem 7 once a week - pt with renal insufficency and
on lasix - should monitor SCr and K
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Gangrene with ascending infection,
right lower extremity.
Gangrene with nonhealing open
wound, left foot.
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:
DIVISION OF VASCULAR AND ENDOVASCULAR SURGERY
AMPUTATION DISCHARGE INSTRUCTIONS
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:
Staples will be removed at your follow up.
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.
Followup Instructions:
___
|
10109413-DS-21 | 10,109,413 | 28,210,277 | DS | 21 | 2189-06-10 00:00:00 | 2189-06-10 22:21:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Back pain, weight loss, abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with h/o DM2, HL, HTN, GERD, Parkinsons presented with
thoracic back pain and weight loss. She was feeling well until 3
weeks prior to admission when she had trouble urinating and went
to ___. She was diagnosed with a UTI for which she
took an oral antiB for 5 days. At that time, she began to
develop thoracic back pain that radiated around her bilateral
chest to her abdomen. The pain was ___ at its worst,
intermittent, sharp, not positional, not exertional, not worse
with deep breathing. Nothing made it worse or better. No sensory
changes. She tried ibuprofen without relief. Around the same
time, she began to lose her appetite. She reports eating no
solids in 3 weeks. She complained of nausea and vomiting,
difficulty swallowing with a recnet 30 lb weight loss.
Past Medical History:
- glaucoma
- HTN
- hyperlipidemia
- diabetes
- GERD
- likely tremor dominant ___ disease
- s/p appendectomy
- h/o LBP treated w/ corticosteroid injections
Social History:
___
Family History:
Her parents both died when she was young of unknown cause.
Physical Exam:
ADMISSION:
Vitals: 98.0 64 143/56 20 100% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated
Lungs: sits up easily, Clear to auscultation bilaterally, no
wheezes, rales, ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: obese, soft, TTP in LUQ - reports mild pain diffusely,
non-distended, bowel sounds present, no rebound tenderness or
guarding, no organomegaly
Back: TTP in low thoracic spine, no step offs; also tender along
muscle groups on either side of thoracic spine
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: full strength in ___ bilaterally, EOMI
DISCHARGE:
VS 98.0 145/62 70 18 100% RA
Gen: obese female, sitting in bed, in NAD
HEENT: NCAT, oropharynx clear, PERRL
CV: RRR, no m/r/g
Resp: CTAB, moving air well ___
Abd: soft, TTP in LUQ, no masses or organomegaly
Ext: No ___ edema, sensation intact
Pertinent Results:
ADMISSION:
___ 05:50PM BLOOD WBC-6.1 RBC-3.69* Hgb-10.8* Hct-32.2*
MCV-87 MCH-29.3 MCHC-33.7 RDW-11.6 Plt ___
___ 05:50PM BLOOD Glucose-115* UreaN-23* Creat-1.3* Na-128*
K-4.0 Cl-89* HCO3-30 AnGap-13
___ 05:50PM BLOOD ALT-16 AST-20 LD(LDH)-104 AlkPhos-64
TotBili-0.5
___ 05:50PM BLOOD Albumin-4.6 Calcium-10.6* Phos-3.8 Mg-2.4
REPORTS:
Micro:
UCx ___ x 2 - Alpha hemolytic colonies consistent with alpha
streptococcus or Lactobacillus sp.
Studies:
MRI T-spine
1. No space-occupying mass, abnormal focus of enhancement or
significant spinal canal narrowing.
2. Apparent diffuse enlargement of the thyroid gland; correlate
with clinical and laboratory data.
Barium swallow ___:
Small pulsion diverticulum in the distal esophagus and a tiny
Preliminary Reportsubmucosal filling defect in the mid esophagus
of doubtful clinical Preliminary Reportsignificance
CXR ___
No acute cardiopulmonary process
If there is clinical concern for vascular pathology (aorta) as a
cause of the patient's pain, recommend CTA of the chest for
further assessment.
T spine X ray ___
There is minimal scoliosis of the thoracic spine convex to the
right and centered at approximately T6. Minimal hypertrophic
spurring is seen at several levels. However, the intervertebral
disc spaces are quite well maintained.
Specifically, no evidence of compression fracture.
CT abd/pelvis ___. Normal caliber bowel loops with scattered colonic
diverticulosis without diverticulitis. Stool filled colon.
2. Markedly distended urinary bladder without wall thickening.
3. Status post hysterectomy. Neither ovary is visualized.
DISCHARGE:
___ 07:30AM BLOOD WBC-5.8 RBC-3.24* Hgb-9.4* Hct-28.8*
MCV-89 MCH-28.9 MCHC-32.6 RDW-12.4 Plt ___
___ 07:30AM BLOOD Glucose-115* UreaN-6 Creat-0.8 Na-135
K-3.5 Cl-101 HCO3-23 AnGap-15
___ 07:30AM BLOOD Calcium-9.0 Phos-2.6* Mg-1.5*
Brief Hospital Course:
___ with h/o DM2, HL, HTN, GERD, Parkinsons presents with
thoracic back pain and weight loss, as well as abdominal pain.
Active issues:
# Abdominal pain/back pain: LLQ abdominal pain with thoracic
back pain. Could be two separate etiologies or could be related.
Etiologies at this point unclear--CT abd/pelvis, ___, MRI
spine, and barium swallow all unremarkable. Most likely
diagnosis at this point is pain relating to depressed mood.
Although she is still having pain, her pain seems to be
manageable with PO pain medications and many of the most
worrisome diagnoses at this point have been ruled out. We
recommned she continue her work up with her PCP.
#UTI : The patient had 3 urine cultures that grew alpha
hemolytic colonies consistent with alpha streptococcus or
Lactobacillus sp. She was started on bactrim DS for 7 days, to
be finished on ___.
#Urinary retenion: Etiology unclear--likely related to UTI vs.
diabetic neuropathy. Had foley in place during most of admission
but was able to voluntarily void at discharge.
#Dysphagia/anorexia: Etiology unclear. Barium swallow and EGD
unremarkable. Possibly related to mood vs. GERD. Pathology
results of stomach biopsies are still pending. The patient had
limited PO intake at discharge but was able to tolerate some
solid foods and ensure.
#Hyponatremia: The patient was hyponatremic with sodium of 128
during admission. The hyponatremia was likely caused by HCTZ and
poor Po intake. It resolved with cessation of HCTZ and IVF.
Chronic issues:
# DM2: Her blood sugars were well controlled during admission.
She was restarted on her home metformin at discharge.
# HL: No active issues. We continued her statin during the
admission.
# GERD: No active issues. We continued her omeprazole.
# Parkinsons: No active issues. We continued her sinemet TID
# HTN: We held her HCTZ during the admission and did not restart
it at discharge due to concern for hyponatremia. Her pressures
were moderately well controlled during admission.
Transitional issues:
#Full code
#Stomach biopsies pending
#Has appointment with gastroenterology:
Department: GASTROENTEROLOGY
When: ___ at 3:45 ___
With: ___
Building: ___
Campus: ___ Best Parking: ___
#Will f/u with her PCP within one week
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Carbidopa-Levodopa (___) 1 TAB PO TID
2. Hydrochlorothiazide 25 mg PO DAILY
3. Omeprazole 20 mg PO DAILY
4. Simvastatin 20 mg PO DAILY
5. MetFORMIN (Glucophage) 500 mg PO BID
6. Dorzolamide 2% Ophth. Soln. 1 DROP RIGHT EYE BID
7. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
8. Brimonidine Tartrate 0.15% Ophth. 1 DROP RIGHT EYE BID
Discharge Medications:
1. Carbidopa-Levodopa (___) 1 TAB PO TID
2. Omeprazole 20 mg PO DAILY
3. Simvastatin 20 mg PO DAILY
4. MetFORMIN (Glucophage) 500 mg PO BID
please discuss the dosing of this with your PCP
5. Brimonidine Tartrate 0.15% Ophth. 1 DROP RIGHT EYE BID
6. Dorzolamide 2% Ophth. Soln. 1 DROP RIGHT EYE BID
7. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
8. Multivitamins 1 TAB PO DAILY
RX *multivitamin [Daily Multi-Vitamin] one tablet(s) by mouth
daily Disp #*30 Capsule Refills:*0
9. Sulfameth/Trimethoprim DS 1 TAB PO BID UTI Duration: 7 Days
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg one
tablet(s) by mouth twice a day Disp #*6 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Urinary tract infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ for evaluation of abdominal and back
pain. You had several imaging studies to evaluate your pain. A
CT of your abdomen showed diverticulosis and an enlarged
bladder, but was otherwise unremarkable. An upper endoscopy and
colonoscopy did not show anything that would be causing your
pain. An MRI of your thoracic spine was completed which was
also unremarkable. At this point we do not know what is causing
your pain. Continue Tylenol and flexeril for your back pain.
You also were having difficulty swallowing. We completed a
barium swallow study that examined your esophagus. It showed a
small diverticulum in the distal esophagus that is likely not
significant. We encourage you to try to eat and drink as
tolerated.
You also developed urinary retention during the admission, which
caused the bladder to be enlarged on CT scan. You had a foley
catheter in for a while to relieve the retention. However, by
discharge you were able to void without difficulty. You were
found to have a urinary tract infection, which may have
contributed to the urinary retention. You will be on bactrim
until ___.
Please follow up with your primary care physician for further
evaluation and management of these issues.
Followup Instructions:
___
|
10109413-DS-22 | 10,109,413 | 23,642,706 | DS | 22 | 2190-08-04 00:00:00 | 2190-08-04 17:01:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal Pain, unexplained weight loss
Major Surgical or Invasive Procedure:
U/S guided liver biopsy (___)
History of Present Illness:
___ y/o F PMH significant for glaucoma, DVT diagnosed last month
on Coumadin, who comes into the hospital from her outpatient GI
appointment for significant weight loss and abdominal pain.
The following history has been obtain from both the patient and
the patient's daughter who lives with her. The patient
reportedly has lost 60 pounds in the past year. She reports that
___ years ago when she had her son she developed ___ ___
sharp/dull nonradiating abdominal pain that is worse when she is
hungry. The pain has been constant since that time. She takes
ibuprofen, unclear exactly how much she takes for the pain which
alleviates it. She cannot report any other alleviating or
aggravating symptoms. She reports decrease po intake that she
attributes to not being hungry. Her daughter reports a 60 pound
weight loss in ___ years. She was evaluated as an outpatient in
surgery for possible hernia, but was found to have DVT and was
started on Coumadin. Three days ago, the patient reports some
diarrhea ___ episodes of watery loose stools without melena or
hematochezia which have completely resolved. Denies any fevers,
chills, nightsweats, N/V, constipation, CP, SOB, cough.
In the ED initial vitals were:98.2, 85, 122/84, 18, 97% RA
- Labs were significant for Chem 7 WNL except K of 3.1. WBC 5.2
with normal differential H&H 9.1/28.8. LFTs significnt for ALT
53/AST 64 Tbili 0.8, albumin 3.3. UA was grossly positive.
- Patient was given ceftriaxone.
Vitals prior to transfer were:5 98.1, 71, 134/73, 19, 98% RA
.
ROS: 10 point ROS negative except as mentioned above in HPI
Past Medical History:
- glaucoma
- DVT
- s/p appendectomy
- h/o LBP treated w/ corticosteroid injections
- ___
Social History:
___
Family History:
Her parents both died when she was young of unknown cause.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vitals - T:97.7 BP:137/64 HR:75 RR:16 02 sat:100%RA
GENERAL: NAD AOx2 (place and person), unable to count backwards,
thin
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
ABDOMEN: nondistended, +BS, minimal tenderness in LLQ without
rebound or guarding, no appreciable bruits
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
PULSES: 2+ DP pulses bilaterally
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
=========================
Vitals:98.9, 124/60, 79, 18, 96RA
General: Cachectic woman laying comfortably in hospital bed
HEENT: NCAT, EOMI, MMM
Lymph: No cervical or supraclavicular LAD
Lungs: Decreased lung sounds on right. Crackles at right base.
CV: RRR w/o MRG
MSK: Mild tenderness over lumbar spine, including left CVA
tenderness.
Abdomen: +BS. Tender in LUQ, LLQ w/guarding. Palpable thrill
left of midline.
Ext: WWP. Prominent edema of left thigh and lower extremity. No
palpable cords.
Neuro: A&O x3. Strength and sensation in tact bilterally.
Pertinent Results:
ADMISSION LABS:
==================
___ 07:15PM BLOOD WBC-5.2 RBC-3.18* Hgb-9.1* Hct-28.8*
MCV-91 MCH-28.7 MCHC-31.6 RDW-14.5 Plt ___
___ 07:15PM BLOOD Neuts-63.3 ___ Monos-5.0 Eos-1.9
Baso-0.3
___ 07:15PM BLOOD Plt ___
___ 06:00AM BLOOD ___
___ 07:15PM BLOOD Ret Aut-1.8
___ 07:15PM BLOOD Glucose-98 UreaN-8 Creat-0.8 Na-139
K-3.1* Cl-105 HCO3-23 AnGap-14
___ 07:15PM BLOOD ALT-53* AST-64* AlkPhos-277* TotBili-0.8
___ 07:15PM BLOOD Lipase-17
___ 07:15PM BLOOD Albumin-3.3* Iron-30
___ 07:15PM BLOOD calTIBC-144* Ferritn-741* TRF-111*
___ 07:15PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-POSITIVE
___ 06:00AM BLOOD CEA-529* AFP-3.6
___ 07:19PM BLOOD Lactate-1.5
___ 04:15PM URINE Color-DkAmb Appear-Cloudy Sp ___
___ 04:15PM URINE Blood-MOD Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.5 Leuks-LG
___ 04:15PM URINE RBC-27* WBC->182* Bacteri-MANY Yeast-NONE
Epi-4
___ 04:15PM URINE WBC Clm-FEW Mucous-MANY
Test Result Reference
Range/Units
CA ___ 5 <34 U/mL
DISCHARGE LABS:
==================
___ 06:25AM BLOOD WBC-5.8 RBC-3.29* Hgb-9.5* Hct-30.7*
MCV-93 MCH-28.7 MCHC-30.8* RDW-15.4 Plt ___
___ 06:25AM BLOOD ___ PTT-32.0 ___
___ 06:25AM BLOOD Glucose-71 UreaN-6 Creat-0.6 Na-134 K-3.7
Cl-98 HCO3-25 AnGap-15
___ 06:30AM BLOOD ALT-62* AST-74* AlkPhos-425* TotBili-0.9
___ 06:25AM BLOOD Calcium-8.6 Phos-3.2 Mg-1.9
MICROBIOLOGY:
================
___ URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH
SKIN
AND/OR GENITAL CONTAMINATION.
___ BLOOD CULTURES (X2): No growth
___ 6:35 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
IMAGING:
=============
___ RUQ U/s IMPRESSION:
1. Numerous hepatic masses as described. Given that these are
new since theexaminations from ___, recommend multiphasic MRI
if possible, or
alternatively a multiphasic CT for further assistance. The
peripancreatic lesion and IVC filling defect can be evaluated at
the same time.
2. Moderate right-sided pleural effusion.
___ CT Chest w/ con IMPRESSION:
1. Large right pleural effusion with bilateral pulmonary,
pleural and osseous metastatic disease.
2. Abdominal findings reported separately.
___ CT Abdomen & Pelvis w/ and w/o con IMPRESSION:
-Large irregular hypodense pancreatic body/tail lesion, as
detailed above, concerning for pancreatic adenocarcinoma. The
mass appears to invade the splenic vein, surrounds the SMA and
celiac arterial branches, and also invades the left adrenal
gland. Soft tissue extends to the porta hepatis, with narrowing
of the main portal vein, which maintains patency.
-Metastatic disease throughout the liver, bones and visualized
portion of the lower chest.
-Thrombus within the infrarenal IVC, enhancing, likely tumor
thrombus. Additional thrombus is visualized within the cephalad
right saphenous vein into the common femoral vein.
-Mural thickening and mucosal hyperenhancement of the cecum.
Findings may be related to upstream venous congestion from
neoplastic burden as noted above.
___ U/S Liver Biopsy IMPRESSION:
Uncomplicated 18-gauge targeted liver biopsy x 2, with specimen
sent to pathology.
PATHOLOGY:
=============
___ LIVER BIOPSY PATHOLOGIC DIAGNOSIS:
Liver, targeted needle core biopsies:
Adenocarcinoma with ductal phenotype and focal necrosis,
morphologically consistent with a tumor of pancreas/biliary
system primary site.
Note: The finding of a large mass lesion in the pancreas
supports a pancreatic origin of the tumor in this particular
patient setting.
PENDING LABS AT TIME OF DISCHARGE:
====================================
___ Stool campylobacter culture: pending
Brief Hospital Course:
Ms. ___ is a lovely ___ with HTN, HLD, ___, and
recent DVT on Coumadin initially admitted for ongoing chronic
abdominal pain and 60 pound weight loss over the past year, now
found to have metastatic pancreatic cancer per imaging studies
and confirmed on liver biopsy pathology. CEA elevated to 529,
___. She will follow-up with hematology-oncology
specialists for further workup.
# Metastatic pancreatic cancer:
Ms. ___ was admitted directly from the outpatient office of
her GI provider ___ with vague abdominal pain and
significant unexplained weight loss. On admission, her initial
labwork was concerning for mild transaminitis and an elevated
alk phos. Follow-up RUQ u/s showed "numerous liver masses" and
recommended follow-up imaging. After GI consult, CT torso was
ordered, revealing a number of lung, liver, pancreatic and bone
lesions, suggesting metastatic malignancy of unknown primary,
likely metastatic pancreatic cancer. Pt underwent liver biopsy
on ___ and a bump in LFT s/p liver biopsy. Liver biopsy showed
adenocarcinoma with ductal phenotype and focal necrosis
consistent with pancreatic cancer. Patient will follow-up with
hematology/oncology for further outpatient work-up (see below
for appointments).
# LLE DVT: Diagnosed in ___ during outpatient follow-up
for previous admission, had been anticoagulated on Coumadin. No
clear risk factors initially on diagnosis. Concern for
malignancy in setting of new weight loss and chronic abdominal
pain with suggestive findings on CT scan (see above). New
thromboses noted in R. saphenous vein into common femoral. We
initially started the patient on a heparin gtt for
anticoagulation given need for biopsy, but transitioned to
lovenox sc prior to d/c, on 30mg SC BID given patient's low
weight of 40kg.
# Positive UA: Patient has a chronic foley for urinary retention
placed about a year ago as per daughter. She had no systemic
signs/symptoms or physical exam findings that are consistent
with infection and thus positive UA most likely is colonization.
Held antibiotics given lack of systemic symptoms. BCx negative
x2, Urine culture contaminated, and patient remained afebrile.
# Anemia: Found to be anemic during admission with no overt
source of bleeding, as per her baseline. Normocytic anemia with
low/normal transferrin saturation, high ferritin consistent with
anemia of chronic inflammation.
#Depression:
Patient reported feeling down recently on admission. On
sertraline per daughter, re-started ___. No formal dx of
depression. In setting of new diagnosis, SW consulted during
inpatient admission.
# Urinary Retention: Stable, continued with chronic Foley
catheter.
# Glaucoma: Stable, continued home eye drops.
TRANSITIONAL ISSUES
-f/u oncological care for management of new pancreatic cancer
diagnosis
-anticoagulation: patient with known DVTs in LLE, also with
hypercoagulable state given cancer, discharged on slightly lower
Lovenox dose of 30mg BID, however given weight loss, will need
to consider alternative DVT treatment if continues to lose
weight, as increased potential for life threatening bleed.
Consider rivaroxaban if weight continues to drop potentially as
outpatient.
-given poor appetite this admission, likely related to her
malignancy, consider appetite stimulant as an outpatient.
-should be referred to Palliative Care Clinic given new
diagnosis of metastatic disease with poor prognosis
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Brimonidine Tartrate 0.15% Ophth. 1 DROP RIGHT EYE BID
2. Warfarin 3 mg PO DAILY16
3. Ibuprofen 600 mg PO Q8H:PRN pain
4. Multivitamins 1 TAB PO DAILY
5. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP RIGHT EYE BID
6. Latanoprost 0.005% Ophth. Soln. 1 DROP RIGHT EYE HS
7. Ferrous Sulfate 325 mg PO DAILY
8. Sertraline 50 mg PO DAILY
Discharge Medications:
1. Brimonidine Tartrate 0.15% Ophth. 1 DROP RIGHT EYE BID
2. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP RIGHT EYE BID
3. Latanoprost 0.005% Ophth. Soln. 1 DROP RIGHT EYE HS
4. Multivitamins 1 TAB PO DAILY
5. Sertraline 50 mg PO DAILY
6. Ferrous Sulfate 325 mg PO DAILY
7. Ibuprofen 600 mg PO Q8H:PRN pain
8. Acetaminophen 650 mg PO Q6H pain/fever
This is a new medication to treat your pain.
9. Enoxaparin Sodium 30 mg SC BID DVT
Start: Today - ___, First Dose: Next Routine Administration
Time
This is a new medication to treat your blood clot in your left
leg.
10. Ondansetron 4 mg PO Q8H:PRN nausea
This is a new medication to treat your nausea.
11. OxycoDONE (Immediate Release) 2.5-5 mg PO Q6H:PRN
breakthrough pain
This is a new medication to treat your pain.
12. Polyethylene Glycol 17 g PO DAILY:PRN constipation
This is a new medication to treat your constipation.
13. Docusate Sodium 100 mg PO BID:PRN constipation
This is a new medication to treat your constipation.
14. Senna 8.6 mg PO BID:PRN constipation
This is a new medication to treat your constipation.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Metastatic pancreatic cancer
Secondary diagnoses:
DVT
Depression
Urinary retention
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 treating you at ___. You were admitted for
further workup of your abdominal pain and recent unexplained
weight loss. Unfortunately, imaging performed during your
inpatient stay, including an ultrasound of your abdomen and a CT
scan of your body, revealed a number of abnormal areas in
different part of your body concerning for cancer. You underwent
a liver biopsy that revealed pancreatic cancer. Its important
that you're scheduled for follow-up with a
Hematologist/Oncologist--we will contact you regarding this
appointment. If you do not hear from use within a few days,
please call ___ and an appointment will be created for
you.
Until then, you should continue the medication provided to thin
your blood to prevent further clots from developing, in addition
to your regular home medications.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10109555-DS-14 | 10,109,555 | 24,579,922 | DS | 14 | 2120-06-22 00:00:00 | 2120-06-22 21:15:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
___ - Left Chest Tube Placement
___ - Left TPC Placement
History of Present Illness:
Mr. ___ is a ___ male with history of
metastatic RCC on nivolumab, hypercalcemia of malignancy who
presents with shortness of breath and found to have large left
pleural effusion s/p chest tube placement.
Patient noted that for the past 3 days he has had worsening
shortness of breath, pleuritic chest pain with deep breathing,
productive cough with yellow sputum, and right sided chest
discomfort. He noted that he had rhinorrhea as well, but thought
it was related to his recent oral surgery, as he noted that
whatever he drank would come out his nose. He noted that he
believed he had defect in upper gums s/p debridement by oral
surgeon.
Patient noted that he has had normal stooling, but has felt very
weak and is eating/drinking very little. He noted that he
continues to have chronic pain from his malignant bony lesions,
for which he is wheelchair bound. He noted that when he
presented to OSH initially they found that he had a pleural
effusion and sent him to ___ without "doing anything".
In the ED, initial vitals: 97.4 113 ___ 98%. WBC 9.0, Hgb
10.3, plt 223, LFTs wnl except AP 152, Alb 3.4, CHEM with HCO3
21, lactate wnl, trop <0.01, VBG 7.38/42. Chest tube drainage
had 350 WBC (22% poly, many RBC, prot 3.6, glucose 85, LDH 303).
Initial CXR revealed increased size of bilateral pleural
effusions, large on the left and small to moderate on the right.
Bibasilar airspace opacities could reflect compressive
atelectasis, though infection or aspiration cannot be excluded
in the correct clinical setting. Repeat CXR s/p chest tube
placement revealed Left chest tube in place without change in
pleural effusion despite having 500cc removed. EKG sinus without
STEMI. Patient was given duonebs and fentanyl then admitted to
oncology. By time of transfer patient was on room air, with
adequate saturation.
After chest tube placement patient noted that right sided chest
discomfort had completely resolved but he now had left sided
chest discomfort. Pleuritic symptoms remain unchanged. He noted
that shortness of breath is better however.
Past Medical History:
PAST ONCOLOGIC HISTORY:
- ___: Presented with abdominal pain and hematuria. CT
abdomen showed a 7cm right renal mass
- ___: right radical nephrectomy. Pathology showed 5.7 x 5.5
x 5.0cm grade I clear cell carcinoma. No capsular invasion.
Intrarenal small vein invasion identified. No lymph nodes
resected. Staged as pT1bNx.
- ___: Surveillance CT with multiple tiny pulmonary nodules,
largest being 3.5mm.
- ___: 3 pulmonary nodules demonstrate interval growth, up
to 6 mm. New 15 mm lytic lesion in T9 vertebra.
- ___: bone scan: non-specific abnormality at T9
- ___: MRI spine: 1.5cm T9 lesion consistent with metastasis
- ___: CT guided T9 biopsy, pathology negative for
malignancy
- ___: CT torso showed several pre-existing pulmonary
nodules are either stable or have slightly grown since ___, and most show new calcification. No new nodules. Stable T9
vertebral body metastasis.
- ___: CT torso w/o contrast showed mild interval growth of
several pulmonary nodules and enlargement of known T9 lytic
lesion, now with cortical destruction posteriorly, but no
retropulsion or central canal narrowing.
- ___: MRI brain negative for metastases
- ___: Wedge resection x 3 of RCC metastases in RLL
- ___: completed cyberknife to T9 lesion
- ___: CT torso showed slight interval growth of 2 left lower
lobe lung nodules and left hilar lymph node. No new lung,
nodal, or pleural metastases. Slight regression of T9 lytic
metastasis.
- ___: Initiated zometa which provided significant relief of
back pain after 1 dose. Also initiated cyclobenzaprine and
renewed oxycodone.
- ___: CT torso with minimal decrease in size of the
pre-existing pulmonary nodules and stable appearance of a
predominantly lytic T9 lesion. ongoing back pain, prescribed
diclofenac cream which has helped.
- ___: Worsening back pain. Extensive imaging work-up and
Ortho spine eval most consistent with DJD with no evidence of
new metastatic disease. Seen in ___ by Dr. ___ with
dramatic improvement in pain with addition of tizanidine to pain
regimen.
- ___: CT torso with stable pulmonary nodules, no disease
progression
- ___: Zometa; CT with findings c/f disease
progression(enlarging intrathoracic LAD and increase in lower
lobe nodules; mixed sclerotic/lytic lesions in T9), ___ in
abdomen
- ___: Screen failure clinical trial ___, pazopanib and
pembrolizumab
- Week of ___ started pazopanib
- ___: CT with decrease in size of pulmonary nodules and
thoracic lymphadenopathy
- ___: Held pazopanib due to LGIB, patient had colonoscopy
which revealed hemorrhoids
- ___: Restarted pazopanib
- ___: XRT to RT ribs and L3-5
- ___: Hypertension, attributed to poorly controlled pain,
improved after radiation
- ___: Zometa; on pazopanib
- Scans show overall stable disease with minimal progression at
L4.
- ___: Hospitalization for headache, ataxia, and vomiting
status post fall with headstrike but no loss of consciousness,
likely secondary to concussion/post-concussive symptoms.
Hematochezia with stable H&H attributed to hemorrhoids
- ___: Hospitalization at ___ due to
headaches and syncope. Headaches were thought to be ___
migraines and improved after a non-opioid medication shot
(unknown which medication). He restarted pazopanib after
discharge.
- ___: Progression of disease on re-staging scans. Extensive
new and progression of bone lesions - right iliac bone and
thoracolumbar spine. New left lower lobe lung nodule.
Symptomatic spinal mets. Received Zometa
- ___: Decided to switch pazopanib to cabozantinib
- ___: MRI cervical and thoracic spine showed extensive
metastatic disease throughout.
- ___: Started palliative radiation therapy to upper
cervical and lower thoracic spinal fields. This was complicated
by nausea/vomiting and sore throat.
- ___: Started cabozantinib 20 mg daily
- ___: Treatment break off cabozantinib for 1 week. Stopped
radiation therapy after obtaining only 6 out of planned 10
courses due to excessive side effects. Noticed improvement in
neck and lower back pain after radiation.
- ___: Re-start of cabozantinib 20 mg daily
- ___: Self-stopped cabozantinib due to poor quality of
life and severe adverse effects. Decided to go ahead with his
request for treatment break. Arranged palliative care services
at home.
- ___: Hospitalized at outside hospital (___
___, ___) for symptomatic hypercalcemia. Received
IV fluids and zometa.
- ___: Hospitalized for hematemesis. EGD on ___
showed gastric ulcer. Biopsies returned positive for metastatic
RCC. Also found to have community acquired pnuemonia.
Persistently hypercalcemic for which he received zometa on ___,
and denosumab. Also received IV fluids, lasix and calcitonin.
- Re-started cabozantinib at 20 mg every other day
- ___: Increased cabozantinib to 20 mg daily; Denosumab
- ___: Cabozantinib increased to 40 mg daily
- ___: Cabozantinib increased to 60 mg daily
- ___: Cabozantinib dose decreased to 40 mg daily because of
GI side effects and intolerance
- ___: CT scan at ___ showed extensive metastatic disease
predominantly involving the axial skeleton, new pleural
effusions, new 0.5 cm LUL nodule, new 1.5 cm nodule lateral to
enlarged left hilum; and new splenic lesions.
- ___: Xgeva
- Decided to take him off pazopanib due to progression.
Insurance denied request for treatment of extensive bony
metastatic disease with radium-223
PAST TREATMENT:
1. Right radical nephrectomy
2. Resection of lung metastases
3. Cyberknife to T9
4. XRT to right ribs and ___. Pazopanib
6. EBRT to upper and lower spine fields
PAST MEDICAL HISTORY:
- Hyperlipidemia
- s/p Inguinal Hernia Repair
- s/p Umbilical Hernia Repair
- Hypercalcemia of malignancy
- Erosion of upper maxillary post s/p debridement by oral surgen
- Malignant gastric ulcer, on PPI
Social History:
___
Family History:
No family history of malignancy.
Physical Exam:
========================
Admission Physical Exam:
========================
VS: Temp 98.1, BP 123/80, HR 107, RR 20, O2 sat 95% RA.
GENERAL: sitting in bed, appears uncomfortable when moving
around, is breathing without distress.
EYES: PERRLA, anicteric.
HEENT: Patient with mucosal defect above front teeth in midline
with exposed post and necrotic tissue surrounding it with foul
smell, has maxillary sinus tenderness.
LUNGS: CTA on right, has decreased breath sounds globally on
left but are audible, has no cough, has left sided chest tube in
place with serosanguinous drainage (1L prior to being clamped).
CV: RRR no murmur, no significant edema.
ABD: Soft, NT, ND, normoactive BS.
GENITOURINARY: No foley.
EXT: Slow to move around in bed, notes that he has back pain
with movement, extremities with poor muscle bulk.
SKIN: Oral mucosal defect as above.
NEURO: AOx3, fluent speech.
ACCESS: Left chest wall port without erythema.
========================
Discharge Physical Exam:
========================
VS: Temp 97.6, BP 107/73, HR 111, RR 16, O2 sat 95% RA.
PULM: Bibasilar inspiratory crackles, no wheezing. Left TPC
catheter in place.
Remainder of exam unchanged.
Pertinent Results:
===============
Admission Labs:
===============
___ 04:00PM BLOOD WBC-9.0 RBC-3.36* Hgb-10.3* Hct-32.4*
MCV-96 MCH-30.7 MCHC-31.8* RDW-17.7* RDWSD-62.7* Plt ___
___ 04:00PM BLOOD Neuts-71.1* Lymphs-7.5* Monos-19.2*
Eos-0.8* Baso-0.4 NRBC-0.2* Im ___ AbsNeut-6.37*
AbsLymp-0.67* AbsMono-1.72* AbsEos-0.07 AbsBaso-0.04
___ 04:00PM BLOOD ___ PTT-28.3 ___
___ 04:00PM BLOOD Glucose-90 UreaN-12 Creat-0.6 Na-138
K-4.4 Cl-99 HCO3-21* AnGap-18
___ 04:00PM BLOOD ALT-11 AST-19 AlkPhos-152* TotBili-0.4
___ 04:00PM BLOOD Lipase-8
___ 04:00PM BLOOD cTropnT-<0.01
___ 04:00PM BLOOD Albumin-3.4*
___ 04:09PM BLOOD ___ pO2-48* pCO2-42 pH-7.38
calTCO2-26 Base XS-0 Intubat-NOT INTUBA
___ 04:09PM BLOOD Lactate-1.1
===============
Discharge Labs:
===============
___ 05:51AM BLOOD WBC-7.4 RBC-3.22* Hgb-9.8* Hct-30.6*
MCV-95 MCH-30.4 MCHC-32.0 RDW-16.6* RDWSD-57.6* Plt ___
___ 05:51AM BLOOD Glucose-109* UreaN-10 Creat-0.5 Na-136
K-4.9 Cl-99 HCO3-25 AnGap-12
___ 05:51AM BLOOD Calcium-11.9* Phos-2.4* Mg-2.4
=============
Microbiology:
=============
___ Blood Culture - Pending
___ Pleural Fluid Gram Stain - 3+ PMNs, no microorganisms;
Culture - No Growth
___ Urine Culture - < 10,000 CFU/mL
=========
Cytology:
=========
___ Pleural Fluid Cytology - Pending
___ Pleural Fluid Cytology - Pending
========
Imaging:
========
CXR ___
Impression: Increased size of bilateral pleural effusions, large
on the left and small to moderate on the right. Bibasilar
airspace opacities could reflect compressive atelectasis, though
infection or aspiration cannot be excluded in the correct
clinical setting.
CXR ___
Impression: Left chest tube in place without change in pleural
effusion.
CXR ___
Impression: Comparison to ___. Minimal decrease in extent
of the left pleural effusion with subsequent improved
ventilation of the left lung. The left pleural pigtail catheter
is in stable position. On the right, the effusion has minimally
increased.
CT Sinus/Mandible/Maxillofacial w/o Contrast ___
1. Fracture through the maxillary spine with anterior
displacement of medial incisor equivalents of the recently
placed dental implants. There is also anterior displacement of
the left first premolar equivalent of the dental implants
without maxillary bone fracture. Stranding is noted in this area
without drainable collection.
2. Mild mucosal thickening the bilateral maxillary sinuses and
anterior ethmoid air cells.
3. Lytic metastatic lesions within the visualized cervical spine
without evidence of vertebral body height loss. Osseous
destruction is seen involving the left foramen transversarium at
C1 and bilaterally at C4, new since the MRI dated ___.
A CTA of the neck is recommended to evaluate the vertebral
artery integrity.
CXR ___
Impression: Comparison to ___. The pigtail catheter in
the left pleural space is in stable position. Large amounts of
the pre-existing left pleural effusion have been drained. There
is a relatively substantial basal pneumothorax on the left, at
the site of tube insertion, without evidence of tension. The
size of the cardiac silhouette and the extent of the right
pleural effusion is stable.
CXR ___
1. Removal of left basilar pleural pigtail catheter which has
been replaced by a left basilar PleurX catheter. A small volume
left basal pneumothorax has replaced the previously seen small
left pleural effusion.
2. Moderate right pleural effusion, increased in size compared
to prior study.
CTA Neck ___
1. The carotid and vertebral arteries are patent.
2. No ICA stenosis by NASCET criteria.
3. Extensive bony metastatic disease is again noted most notably
involving the transverse neural foramina of C1 left and C4
bilateral and abutting the vertebral arteries in these
positions, but no evidence of vertebral artery
invasion/abnormality.
4. For a full description of bony metastatic disease please
refer to CT C-spine report done ___.
5. Large right-sided pleural effusion, left upper lung
metastatic nodule and loculated left pneumothorax/bullae is
incompletely imaged and if clinically indicated dedicated chest
imaging should be performed.
Brief Hospital Course:
Mr. ___ is a ___ male with history of
metastatic RCC on nivolumab, hypercalcemia of malignancy who
presents with shortness of breath and found to have large left
pleural effusion s/p chest tube placement followed by TPC
placement.
# Shortness of Breath:
# Bilateral Pleural Effusions: Shortness of breath and pleuritic
chest pain prior to admission are likely ___ pleural effusions.
Likely malignant effusion, cytology pending. Left chest tube
placed in ED. Studies from ED with low neutrophil count of 77,
but normal glucose and high LDH/protein, with serosanguinous
color is suggestive of exudate/malignancy. His chest tube put
out almost 4L of fluid and his breathing improved and he was
weaned off of oxygen. IP was consulted for management and placed
left TPC prior to discharge. Discussed right pleural effusion
with IP, no plan to drain at this time and will monitor in
clinic. Will need to follow-up pleural fluid cytology. Also will
need to monitor respiratory status and right pleural effusion as
may need intervention in the future. He will follow-up in ___
clinic.
# Oral Erosion/Infection: Patient with erosion of dental implant
screw through his mandible/gums with obviously necrotic tissue
and likely extension into sinsues. CT maxillofacial showed
maxillary spine fracture with multiple malpositioned dental
implants. ___ saw patient and will likely need removal of all
implants. He will complete a 7 day course of antibiotics with
augmentin. He will follow-up in ___ Oral Surgery Clinic.
# Metastatic Renal Cell Carcinoma: Metastatic to lung, lymph
nodes, liver, spleen, and bones. His disease has progressed on
pazopanib and cabozantinib, with extensive painful bony
metastatic disease. He received radiation therapy to spine but
tolerated it very poorly, although with improvement of pain. He
is s/p recent switch to nivolumab. CT maxillofacial incidentally
noted osseous destruction involving the left foramen
transversarium at C1 and bilaterally at C4 for which a CTA neck
was done and showed no evidence of vertebral artery invasion. He
will follow-up next week with his Oncologist.
# Malignant Hypercalcemia: Noted in outpatient setting which
improved with twice weekly outpatient fluids and monthly
denosumab (last dose ___. His calcium was 11.9 uncorrected
prior to discharge. We recommended that he receive IV
pamidronate but he declined as he did not want to wait for the
infusion. He understood and was able to verbalize the risks
involved with a worsening calcium. He will receive denosumab in
clinic next week. He will continue IVF at home.
# Cancer-Related Pain: Continued home oxycodone and oxycontin.
# Malignant Gastric Ulcer: He underwent EGD at ___
on ___ for hematemesis, and was found to have gastric
ulcer. Biopsies returned positive for metastatic RCC. Continued
home pantoprazole.
# Anemia: Likely secondary to malignancy. No evidence of active
bleeding. Required no transfusions.
# Hypophosphatemia: Repleted and improved.
# Solitary Kidney: No evidence of kidney disease.
# Dysuria: UA and urine culture negative. No further symptoms.
# BILLING: 45 minutes were spent in preparation of discharge
summary and coordination with outpatient providers.
====================
Transitional Issues:
====================
- Patient admitted with shortness of breath and was found to
have large left pleural effusion. Interventional Pulmonary was
consulted and a chest tube was placed initially followed by a
Pleurx catheter. Patient will continue drainage at home. He will
need to follow-up in ___ clinic. Please continue to monitor
respiratory status and known right pleural effusion.
- Patient found to have multiple dental implant problems for
which he was seen by ___. He will follow-up in Oral Surgery
Clinic at ___ per his request for further
management. He was also found to have likely dental infection
for which he was discharged on Augmentin to complete a 7-day
course (Day ___, to be completed ___.
- Please follow-up pleural fluid cytology from ___ and
___.
- Please follow-up blood culture from ___.
- Please follow-up pleural fluid culture from ___.
Left PleurX Catheter Management
1. Please drain Pleurx catheter: ___ (3
times weekly)
2. Keep a daily log of drainage amount and color, have the
patient bring it with them to their next pleural appointment.
2. Do not drain more than 1000 ml per drainage.
3. Stop draining for pain, chest tightness, or cough.
4. Do not manipulate catheter in any way.
5. You may shower with an occlusive dressing
6. If the drainage is less than 50cc for three consecutive
drainages please call the office for further instructions.
7. Please call ___ if there are any questions.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. OxyCODONE SR (OxyconTIN) 30 mg PO Q8H
2. OxyCODONE (Immediate Release) ___ mg PO Q3H:PRN Pain -
Moderate
3. Pantoprazole 40 mg PO Q12H
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
Plan for 7-day course (Day ___, to be completed ___.
RX *amoxicillin-pot clavulanate 875 mg-125 mg Take 1 tablet by
mouth twice daily. Disp #*7 Tablet Refills:*0
2. OxyCODONE (Immediate Release) ___ mg PO Q3H:PRN Pain -
Moderate
3. OxyCODONE SR (OxyconTIN) 30 mg PO Q8H
4. Pantoprazole 40 mg PO Q12H
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
- Shortness of Breath
- Left Pleural Effusion
- Oral Erosion/Infection
- Metastatic Renal Cell Carcinoma
- Cancer-Related Pain
- Malignant Hypercalcemia
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 ___
___. You were admitted to the hospital for
shortness of breath. You were found to have a large left pleural
effusion (fluid around your lung). You had a tube placed to
drain this fluid and your breathing improved. You will continue
to drain this fluid at home 3 times per week ___,
and ___ with assistance from a visiting nurse. Please call
___ if there are any questions. Other instructions
include:
1. Please drain Pleurx catheter: ___ (3
times weekly)
2. Keep a daily log of drainage amount and color, have the
patient bring it with them to their next pleural appointment.
2. Do not drain more than 1000 ml per drainage.
3. Stop draining for pain, chest tightness, or cough.
4. Do not manipulate catheter in any way.
5. You may shower with an occlusive dressing
6. If the drainage is less than 50cc for three consecutive
drainages please call the office for further instructions.
You will need to follow-up in the Interventional Pulmonary
clinic for further management of your drain and monitoring of
the fluid in your right lung.
Your calcium was found to be elevated. We recommended that you
receive a medication to help lower your calcium but you
declined. Please continue your IV fluids at home. You will
follow-up with Dr. ___ in clinic to receive your calcium
lowering medication.
You were also found to have malpositioned dental implants and a
likely dental infection. You were seen by the Oral Surgeons at
___ and you wished to follow-up with them for
further treatment. You were started on antibiotics and will
finish a course at home.
Please continue your other home medications.
Please follow-up with your appointments as below.
All the best,
Your ___ Team
Followup Instructions:
___
|
10109613-DS-17 | 10,109,613 | 23,183,024 | DS | 17 | 2132-01-16 00:00:00 | 2132-01-16 12:03:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
gabapentin
Attending: ___
Chief Complaint:
Headaches, patient with concern for worsening clot burden of
previously diagnosed venous sinus thrombosis.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ woman with a past medical
history of recently diagnosed factor V Leiden deficiency
heterozygous, DVT status post IVC filter, history of shingles,
migraine headaches, and traumatic brain injury with
intraparenchymal hemorrhage, well-known to our service and
admitted ×2 in the past few months. She has a history of
recently diagnosed cerebral venous thrombosis in her SSS, right
transverse sinus, right sigmoid, and straight dural venous sinus
that was found in ___. She currently is on Coumadin for
treatment. She presents with 3 days of persistent headache
that feels very similar to when she was first diagnosed with her
cerebral venous thrombosis.
She states that three days ago she started to develop a tight
throbbing pain on the vertex of her head that radiated down
which is very similar to her headache in the past. No neck
pain, no photophobia or phonophobia but she does have blurry
vision. She states that the headache has been getting
progressively worse in nature over the past 3 days. The patient
states that she has been compliant with her Coumadin. Her last
INR check was 2 days ago in the 2 range. Approximately 2 weeks
ago, the patient was sub therapeutic at her INR check and was
placed on Lovenox for short duration but has recently come off
this. Otherwise, patient denies any other neurologic symptoms
such as focal
deficits, seizure activity. No other changes to her history.
On neuro ROS, the patient denies loss of vision, diplopia,
dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or
hearing difficulty. Denies difficulties producing or
comprehending speech. Denies focal weakness, numbness,
parasthesiae. No bowel or bladder incontinence or retention.
On general review of systems, the patient 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:
factor V Leiden (heterozygous), TBI (hx of being on
Coumadin and sustaining IPH), depression/anxiety, migraines, h/o
DVT s/p IVC filter placement, R knee cap removal, L ___ toe
surgery, TIAs, shingles involving likely R T10 area.
Social History:
___
Family History:
father and brother died of blood clots ___ Factor
V Leiden deficiency
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
Physical Exam:
Vitals: T 98.5, HR 72, BP 103/69, RR 16
General: awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: supple, no nuchal rigidity
Pulmonary: breathing comfortably on room air
Cardiac: RRR, normal
Abdomen: soft, NT/ND
Extremities: warm, well perfused
Skin: no rashes or lesions noted
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Pt was able to name both high and low frequency objects. Able
to
read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. Pt was able to
register 3 objects and recall ___ at 5 minutes. 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. Fundoscopic
exam revealed bilateral papilledema
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination:
No intention tremor, no dysdiadochokinesia noted. No dysmetria
on FNF or HKS bilaterally.
-Gait:
Deferred
DISCHARGE PHYSICAL EXAM:
Temperature: 97.9
Blood pressure: 111/58
Heart rate: 67
Respiratory rate: 16
Oxygen saturation: 97%
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM
Pulmonary: breathing comfortably on room air, no accessory
muscle use of increased WOB
Cardiac: warm and well perfused
Abdomen: soft, nontender and nondistended, no guarding
Extremities: No ___ edema.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Awake and alert, cooperative. Able to relate
history without difficulty. Language is fluent with intact
repetition and comprehension. Normal prosody. No paraphasic
errors. Speech was not dysarthric. There was no evidence of
apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch
VII: No facial droop, facial musculature symmetric, symmetric
smile and activation
VIII: Hearing intact to conversation
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally
XII: Tongue protrudes in midline
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
No asterixis noted.
Delt Bic Tri WrE FE IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5
R 4+ ___ 4+ ___ 5 5 5
R deltoid and R finger extensors pain limited.
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF bilaterally
-Gait: deferred
Pertinent Results:
MRI/MRA Brain ___:
IMPRESSION:
1. Slight interval increase in thrombus within the right
sigmoid/transverse sinus and unchanged trace residual thrombus
in the superior sagittal sinus cyst above the confluence.
2. Otherwise there has been improvement in the multiple
associated abnormal intracranial findings including improved
pachymeningeal
thickening/enhancement, improved areas of leptomeningeal
enhancement, decrease in the previously described areas of
tubular/sulcal susceptibility and FLAIR/diffusion signal
abnormality
3. Irregular narrowing of the left common carotid artery on the
MRA neckis
likely secondary to adjacent susceptibility artifact and less
likely stenosis. This could be further evaluated with a
nonurgent carotid ultrasound.
4. Normal MRA head.
5. Unchanged moderate amount of fluid within the left mastoid
air cells.
Brief Hospital Course:
Patient ___ was admitted ___ with complaints of
headaches with concern that her known venous sinus thrombosis
was worsening. Patient reported taking her warfarin as
prescribed and noted that at appointment prior to admission her
INR was therapeutic. Patient's INR on admission was 1.9.
Patient had MRI brain with MP rage and overall her clot burden
had improved compared to prior imaging from ___. Patient
was encouraged to continue to take her warfarin as prescribed,
but we did make some changes to her headache regimen. Patient
previously was taking fioricet and sumatriptan and she was told
to discontinue these medications. Patient was instead to told
to take acetaminophen 1000 mg when she was having a headache and
oxycodone when having severe headaches. Patient also encouraged
to avoid bearing down and advised to continue current bowel
regimen and add milk of magnesia if it worsens.
35 minutes were spent on discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ascorbic Acid ___ mg PO DAILY
2. BuPROPion XL (Once Daily) 150 mg PO DAILY
3. ClonazePAM 0.25 mg PO BID
4. Docusate Sodium 200 mg PO BID
5. DULoxetine 90 mg PO DAILY
6. Ferrous Sulfate 325 mg PO DAILY
7. HydrOXYzine 10 mg PO QHS:PRN Sleep
8. Omeprazole 40 mg PO DAILY
9. Propranolol 10 mg PO BID
10. Psyllium Powder 1 PKT PO BID
11. Senna 8.6 mg PO BID
12. Vitamin D ___ UNIT PO BID
13. Warfarin 7.5 mg PO EVERY OTHER DAY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H Headache
RX *acetaminophen 500 mg 2 tablet(s) by mouth As needed, every 8
hours Disp #*60 Tablet Refills:*5
2. AcetaZOLamide 250 mg PO Q12H
Please increase dose of medication as noted in your discharge
information.
RX *acetazolamide 250 mg 2 tablet(s) by mouth Twice daily Disp
#*120 Tablet Refills:*5
3. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Severe
RX *oxycodone [Oxaydo] 5 mg 1 tablet(s) by mouth As needed Disp
#*15 Tablet Refills:*0
4. Ascorbic Acid ___ mg PO DAILY
5. BuPROPion XL (Once Daily) 150 mg PO DAILY
6. ClonazePAM 0.25 mg PO BID
7. Docusate Sodium 200 mg PO BID
8. DULoxetine 90 mg PO DAILY
9. Ferrous Sulfate 325 mg PO DAILY
10. HydrOXYzine 10 mg PO QHS:PRN Sleep
11. Omeprazole 40 mg PO DAILY
12. Propranolol 10 mg PO BID
13. Psyllium Powder 1 PKT PO BID
14. Senna 8.6 mg PO BID
15. Vitamin D ___ UNIT PO BID
16. Warfarin 7.5 mg PO EVERY OTHER DAY
Discharge Disposition:
Home
Discharge Diagnosis:
Headache in the setting of sinus venous thrombosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
During this admission, you presented with headache and we were
concerned that your sinus venous thrombosis had worsened with
increase in clot burden. However, we did specialized imaging of
your brain and your clot burden is actually improving. You will
continue to take your warfarin at the previously prescribed dose
to continue to keep your blood thin to prevent further clotting.
For your headaches we are changing up your management.
Firstly, we are discontinuing your fioricet and sumatriptan.
The fioricet may be causing rebound headaches and the
sumatriptan is not indicated in your type on headache. When you
do have a headache please take tylenol ___ mg every 8 hours as
needed and if it becomes severe take an oxycodone 5 mg.
Finally, we have started you on a medication called
acetazolamide. You will titrate up on this medication as
follows. From discharge til ___ please take 250 mg twice
daily. From ___ til ___ please take 500 mg in the morning
and 250 mg at night. On ___ and thereafter please take 500 mg
twice daily.
In addition to the above, it is important to avoid activities
that can increase pressure in the head. Please take a
medication to soften your stools to prevent bearing down. We
recommend milk of magnesia, which is over the counter, if your
current bowel regimen is not working as needed.
Followup Instructions:
___
|
10109613-DS-19 | 10,109,613 | 23,526,345 | DS | 19 | 2132-09-16 00:00:00 | 2132-09-17 19:25:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
gabapentin
Attending: ___
Chief Complaint:
Pre-syncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with a past medical history of
TBI, factor 5 leiden with prior DVT & venous sinus thrombosis,
hiatal hernia, depression and anxiety, presents today with
elevated INR, headaches, weakness, and multiple other
complaints.
Over the last few days, she reports worsening of her chronic
headaches, which are a pressure-like sensation from the occiput
to the front of her head, more on the left side. She has scalp
tenderness. No nausea, vomiting, phonophobia, change w/
position, or early morning headahces. She is using tylenol.
Her
HA is made worse by stress. She was last seen in ___ with her
neurologist, who recommended she start Topamax, which is
currently being uptitrated, currently on 50mg daily.
She also notes worsening of chronic dizziness and imbalance, is
using her walker more, and feels worse when going from lying to
standing. No vertigo. She was recently told she was
orthostatic. Her appetite is poor. She also has dysphagia for
solid foods, which tend to get stuck in her mid-chest area. She
is drinking lots of water and feels thirsty, as well as
nauseated. She had diarrhea which she attributed to Linzess,
which she has stopped taking. She is in between Psychiatrists
right now and does not have a regular provider for her
___.
She recent has been treated for a UTI, after she presented to
PCP
with urinary symptoms ___, started on Macrobid, later
prescribed
Bactrim. Urine culture was no growth in Atrius records.
She also endorses recent subjective fever, sweats, 4 pound
weight
loss, productive cough hacking cough with bloody streaks,
occasional abdominal pain, muscle aches, fatigue. She has also
noted blood in her urine and epistaxis.
She got her INR checked ___, and was told to present to the ED
because of elevated level.
Past Medical History:
factor V Leiden (heterozygous)
- cerebral venous thrombosis (___) with involvement of the
superior sagittal sinus, right transverse sinus, right sigmoid
and straight dural venous sinus
- DVT s/p IVC filter placement
traumatic brain injury TBI (hx of being on Coumadin and
sustaining IPH)
transient ischemic attacks
depression/anxiety
migraines
R patella removal
L ___ toe surgery
shingles involving likely R T10 area.
factor V Leiden (heterozygous)
- cerebral venous thrombosis (___) with involvement of the
superior sagittal sinus, right transverse sinus, right sigmoid
and straight dural venous sinus
- DVT s/p IVC filter placement
traumatic brain injury TBI (hx of being on Coumadin and
sustaining IPH)
transient ischemic attacks
depression/anxiety
migraines
R patella removal
L ___ toe surgery
shingles involving likely R T10 area.
Social History:
___
Family History:
father and brother died of blood clots ___ Factor
V Leiden deficiency
Physical Exam:
ADMISSION EXAM:
================
VS: 97.6, BP 121 / 68, HR 61, RR 20, 100 Ra
GENERAL: NAD female resting in bed, conversive
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, OP clear. Nasal
passages without erythema or blood.
NECK: supple
CV: RRR
PULM: CTAB, no wheezes
GI: abdomen nondistended, nontender
EXTREMITIES: no edema
PULSES: 2+ radial pulses bilaterally
NEURO: A&O grossly, moving all 4 extremities with purpose, face
symmetric
SKIN: warm and well perfused
DISCHARGE EXAM:
=================
VS: ___ 0408 Temp: 99.7 PO BP: 121/67 R Lying HR: 61 RR: 20
O2 sat: 100% O2 delivery: Ra
GENERAL: NAD female resting in bed
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, OP clear. Nasal
passages without erythema or blood.
NECK: supple
CV: RRR, no murmurs
PULM: CTAB, no wheezes rales or rhonchi
GI: abdomen nondistended, nontender
EXTREMITIES: no edema. Nodular deformity of distal
intraphalyngeal joints bilaterally.
PULSES: 2+ radial pulses bilaterally
NEURO: A&O grossly, moving all 4 extremities with purpose, face
symmetric
SKIN: warm and well perfused
Pertinent Results:
ADMISSION LABS:
================
___ 04:25PM BLOOD WBC-5.4 RBC-4.38 Hgb-12.5 Hct-38.2 MCV-87
MCH-28.5 MCHC-32.7 RDW-16.3* RDWSD-51.4* Plt ___
___ 04:25PM BLOOD ___ PTT-74.0* ___
___ 04:25PM BLOOD Glucose-90 UreaN-21* Creat-1.2* Na-135
K-4.4 Cl-102 HCO3-17* AnGap-16
___ 04:25PM BLOOD ALT-17 AST-29 CK(CPK)-450* AlkPhos-74
TotBili-0.3
___ 04:25PM BLOOD CK-MB-16* MB Indx-3.6
___ 04:25PM BLOOD Albumin-4.1 Calcium-9.1 Phos-3.7 Mg-2.0
___ 04:55AM BLOOD calTIBC-280 ___ Ferritn-53 TRF-215
___ 04:25PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
DISCHARGE LABS:
================
___ 06:40AM BLOOD WBC-6.0 RBC-3.98 Hgb-11.5 Hct-34.7 MCV-87
MCH-28.9 MCHC-33.1 RDW-16.2* RDWSD-51.5* Plt ___
___ 04:25PM BLOOD Neuts-50.0 ___ Monos-8.1 Eos-0.0*
Baso-0.7 Im ___ AbsNeut-2.71 AbsLymp-2.21 AbsMono-0.44
AbsEos-0.00* AbsBaso-0.04
___ 06:40AM BLOOD ___ PTT-38.8* ___
___ 06:40AM BLOOD Glucose-98 UreaN-16 Creat-0.8 Na-142
K-4.5 Cl-110* HCO3-21* AnGap-11
___ 04:55AM BLOOD LD(LDH)-312* CK(CPK)-369* TotBili-0.5
___ 04:55AM BLOOD CK-MB-15* MB Indx-4.1
___ 06:40AM BLOOD Calcium-9.1 Phos-3.5 Mg-1.9
___ 04:55AM BLOOD calTIBC-280 ___ Ferritn-53 TRF-215
IMAGING:
========
CTA HEAD AND CTA NECK
1. No evidence for acute hemorrhage or large acute infarction.
2. Stable areas of encephalomalacia/gliosis in the right
inferior frontal and
anterior temporal lobes.
3. Cervical spine hardware related streak artifacts limit
evaluation of the
left mid common carotid and bilateral mid internal carotid
arteries, and of
the V1 and proximal V2 vertebral artery segment. Otherwise, no
evidence for
carotid stenosis by NASCET criteria or flow-limiting vertebral
stenosis.
4. Normal CTA of the circle of ___.
5. Nonocclusive filling defect involving the right transverse
sinus, right
sigmoid sinus, and right jugular fossa appears slightly larger
than on the ___ and ___ MRI, but differences in
appearance may in
part be secondary to differences in modalities.
6. Stable nonocclusive filling defect in the superior sagittal
sinus,
consistent with chronic thrombus.
Brief Hospital Course:
___ with a h/o TBI, factor 5 leiden with prior DVT & venous
sinus thrombosis, hiatal hernia, depression and anxiety,
admitted for an INR of 10 found at her ___ clinic.
#Supratherapeutic INR: The patient was admitted with an INR of
10. She had no evidence of bleeding on arrival to the hospital.
She got 2.5mg vitamin K in the ED, and her INR dropped to 6.6,
then 1.7 on subsequent days. Given her active thrombosis, she
was started on a heparin drip for bridging. She was then
transitioned to Lovenox 80mg SQ BID. She received her home
warfarin dose of 10mg on ___, and 7.5mg on ___ and was
discharged with an INR of 1.4. She was discharged on Lovenox for
bridging with the plan to have her INR checked on ___ at her
___ clinic.
#Anemia: The patient had a drop in her hemoglobin from 12 to
10.6. Given her supratherapeutic INR, there was some initial
concern for bleeding, however she demonstrated no signs of
bleeding, her hemolysis labs were all negative, and her
hemoglobin was stabilized. Her hemoglobin on discharge was 11.5.
___: Cr 1.2 on admission. She received one liter of IV fluids
in the ED, and another upon arrival to the floor. Her creatinine
improved to 0.8, so this was likely pre-renal in the setting of
some decreased PO intake. Her creatinine was 0.8 on discharge.
Notably, she takes HCTZ for lower extremity edema. Given her ___
and ___ PO intake (discussed below) this was held while she was
in patient, and was held on discharge as well.
#Hiatal hernia
#H/o gastritis and GERD: The patient has a history of a hiatal
hernia and gastritis. She has had continued nausea and
intermittent vomiting with PO intake over the last 6 months.
This has caused her a great deal of distress. She is being
evaluated by Dr. ___ for a possible
fundoplication, however she feels that the surgery would be too
high risk. Given this, we recommend that she follows up with
gastroenterology as an outpatient to discuss other less invasive
treatment options for her hiatal hernia. She was continued on
her anti-emetic regimen with TUMS PRN, Famotidine and
Pantoprazole.
#Factor V Leidin
#Sinus Venous Thrombosis: Pt with known sinus venous thrombosis.
She had repeat imaging with a CT-A of her brain on presentation.
Neurology was consulted to discuss continued sinus venous
thrombosis and felt that she should remain anticoagulated, but
that there was no appreciable change in the size of her clot.
She should continue to follow with neurology as an outpatient,
but there were no changes to this while she was inpatient.
Anticoagulation bridging with Lovenox as above.
STABLE/CHRONIC:
================
#Elevated troponin: Low concern for ACS given lack of exertional
sx, no concerning EKG changes. Would benefit from non-invasive
coronary evaluation as an outpatient.
#Assymptomatic bacteruria: She was not having urinary symptoms
while inpatient, so she was not felt to have a true UTI. Given
this, she was continue on her suppressive antibiotics in house
and on discharge.
#Failure to thrive: Much of her decline in abilities seems
related to poor PO intake as above. ___ was consulted in patient
and recommended home with home ___. She should continue to have
workup for her hiatal hernia as above.
#Headaches: She is being followed closely by neurology as an
outpatient. Topiramate was started at 50mg PO daily, and was
continue in house. She should continue to increase this with
neurology's guidance as an outpatient.
#Urinary incontinence: Continued on home Oxybutynin.
#Depression/Anxiety: Continued home Escitalopram and Clonazepam
#Vitamin D deficiency: Continued home Vitamin D
TRANTISIONAL ISSUES:
====================
[] Discharge INR 1.4: Bridging with Lovenox 80mg SQ BID
- INR check on ___ with ___ clinic
[] Discharge hemoglobin: 11.5, please repeat CBC at first follow
up to ensure stable
[] Cr 0.8 on discharge: Please repeat BMP at first follow up to
ensure stable
[] Please ensure patient has follow up to establish care with a
gastroenterologist at ___: was discharged with phone number
for GI clinic
[] Neurology follow up scheduled for monitoring of sinus venous
thrombosis
[] Consider non-invasive coronary evaluation as an outpatient,
has cardiology follow up scheduled
[] HCTZ held on discharge: Patient reporting some unsteadiness
on feet and was not needed for HTN
#CODE: Full (presumed)
#CONTACT:
Name of health care proxy: ___
Relationship: daughter
Cell phone: ___
>30 minutes spent in discharge planning and coordination
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Calcium Carbonate 500 mg PO QID:PRN heartburn
2. ClonazePAM 1 mg PO BID:PRN anxiety
3. Escitalopram Oxalate 10 mg PO DAILY
4. Famotidine 40 mg PO BID
5. Ferrous Sulfate 325 mg PO DAILY
6. Pantoprazole 40 mg PO Q12H
7. Vitamin D 1000 UNIT PO DAILY
8. Oxybutynin 15 mg PO QHS
9. Warfarin 10 mg PO 3X/WEEK (___)
10. Cephalexin 250 mg PO DAILY
11. Topiramate (Topamax) 50 mg PO DAILY
12. Prochlorperazine 5 mg PO Q8H:PRN nausea
13. Hydrochlorothiazide 25 mg PO DAILY:PRN swelling
14. Warfarin 7.5 mg PO 4X/WEEK (___)
Discharge Medications:
1. Enoxaparin Sodium 80 mg SC Q12H
RX *enoxaparin 80 mg/0.8 mL 80 mg SQ Twice daily Disp #*14
Syringe Refills:*0
2. Multivitamins 1 TAB PO DAILY
RX *multivitamin [Daily Multiple] 1 tablet(s) by mouth Daily
Disp #*30 Tablet Refills:*0
3. Calcium Carbonate 500 mg PO QID:PRN heartburn
4. Cephalexin 250 mg PO DAILY
5. ClonazePAM 1 mg PO BID:PRN anxiety
6. Escitalopram Oxalate 10 mg PO DAILY
7. Famotidine 40 mg PO BID
8. Ferrous Sulfate 325 mg PO DAILY
9. Oxybutynin 15 mg PO QHS
10. Pantoprazole 40 mg PO Q12H
11. Prochlorperazine 5 mg PO Q8H:PRN nausea
12. Topiramate (Topamax) 50 mg PO DAILY
13. Vitamin D 1000 UNIT PO DAILY
14. Warfarin 10 mg PO 3X/WEEK (___)
15. Warfarin 7.5 mg PO 4X/WEEK (___)
16. HELD- Hydrochlorothiazide 25 mg PO DAILY:PRN swelling This
medication was held. Do not restart Hydrochlorothiazide until
you discuss it with your primary care doctor
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
- Supratherapeutic INR
Secondary diagnosis:
- Hiatal hernia
- Migraine headaches
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital because:
- The level of blood thinning from your coumadin was too high
- You were at risk of bleeding
- You were also having worsening headaches and dizziness with
standing and walking
While you were admitted:
- You had imaging of your head which showed no new changes
- Your coumadin was held so that your blood thinning levels
returned to a safe range
- You were seen by our neurologists who agreed to continue the
Topiramate for headaches
- You worked with physical therapy who recommended that you go
home with physical therapy
When you leave:
- Please attend all of your follow up appointments as scheduled
for you
- Please take all of your medications as prescribed
It was a pleasure to care for your during your hospitalization!
- Your ___ care team
Followup Instructions:
___
|
10109613-DS-20 | 10,109,613 | 29,052,334 | DS | 20 | 2133-02-26 00:00:00 | 2133-02-27 07:03:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
gabapentin
Attending: ___.
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ with PMH of TBI, Factor V Leiden w/ prior DVT and venous
sinus thrombosis (VST) on coumdin and IVF filter, who presented
with three days of worsening head pain. She was treated with a
migraine cocktail in the ED (IV acetaminophen, Benadryl, fluids,
and Reglan). Neurology was consulted given c/f thrombosis. VST
ruled out on MR head W & W/O contrast with ___ negative for DVT
and CTA negative for PE. Started on lovenox bridge to Coumadin
and originally planned for discharge home but concerns for trops
uptrending (-Trop 0.08 --> 0.09 --> 0.11, MB 14 --> 16 -->
15)and
reportedly 1 month history of chest pain. EKG with new TWI's in
V1-V3. Recent stress echo was wnl.
Upon interview, patient endorsed continued headache worse than
prior, says headaches are responsive to topamax. Per patient,
she
has experienced several months of chest pain, worse in the last
month. The pain is located near the lower chest
wall/mid-epigastrium, sharp, pleuritic, and intermittent,
worsened with exertion and improved by rest. Each chest pain
episodes last < 5 minutes. Once the pain radiated to ___ L jaw
but no radiation to arms. Endorses chronic shortness of breath
with worsening dyspnea on exertion. Denies history of MI or
heart
failure.
Also says she has chronic constipation requiring frequently self
manual extraction. Last BM was 5 days ago. Denies bloody stool
unless after manual extraction. Recalls some nausea in ED but no
vomiting. No dysuria or hematuria but says she suffers chronic
UTIs. Endorses chronic for several months with sensation of dry
throat and productive copious phlegm initially dark but now
white.
So far patient has received IV fluids, IV Tylenol, IV benedryl,
IV reglan, IV toradol, IV heparin, PO topiramate 50mg x 2,
escitalopram 20mg, pantoprazole 40mg, clonazepam 0.5mg,
famotidine 20mg, prochlorperazine 5mg, enoxaparin 70mg, warfarin
5mg
Past Medical History:
factor V Leiden (heterozygous)
- cerebral venous thrombosis (___) with involvement of the
superior sagittal sinus, right transverse sinus, right sigmoid
and straight dural venous sinus
- DVT s/p IVC filter placement
traumatic brain injury TBI (hx of being on Coumadin and
sustaining IPH)
transient ischemic attacks
depression/anxiety
migraines
R patella removal
L ___ toe surgery
shingles involving likely R T10 area.
factor V Leiden (heterozygous)
- cerebral venous thrombosis (___) with involvement of the
superior sagittal sinus, right transverse sinus, right sigmoid
and straight dural venous sinus
- DVT s/p IVC filter placement
traumatic brain injury TBI (hx of being on Coumadin and
sustaining IPH)
transient ischemic attacks
depression/anxiety
migraines
R patella removal
L ___ toe surgery
shingles involving likely R T10 area.
Social History:
___
Family History:
father and brother died of blood clots ___ Factor
V Leiden deficiency
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: T 98.1, BP 99/65, HR 62, O2 97 on RA
GENERAL: Alert and interactive. In no acute distress.
HEENT: NCAT. Sclera anicteric and without injection.
NECK: Supple
CARDIAC: RRR Audible S1 and S2. No murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Soft, non distended, diffusely tender to deep palpation
especially in lower abdomen, no organomegaly
EXTREMITIES: No clubbing, cyanosis, non-pitting edema in
bilateral ___. good distal pulses
SKIN: WWP. No rash.
NEUROLOGIC: Alert, answers questions appropriately, moves all
extremities
Psych: Affect is anxious and somewhat depressed appearing
==============================
DISCHARGE PHYSICAL EXAM:
24 HR Data (last updated ___ @ 710)
Temp: 97.8 (Tm 98.3), BP: 132/78 (104-132/62-78), HR: 57
(52-68), RR: 18 (___), O2 sat: 97% (96-97), O2 delivery: Ra
GENERAL: Alert and interactive. In no acute distress.
CARDIAC: RRR Audible S1 and S2. No murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Soft, non distended, non-tender.
EXTREMITIES: No clubbing, cyanosis, non-pitting edema in
bilateral ___. good distal pulses
SKIN: WWP. No rash.
NEUROLOGIC: Alert, answers questions appropriately, moves all
extremities
Pertinent Results:
ADMISSION LABS:
___ 05:00PM BLOOD WBC-5.3 RBC-4.13 Hgb-12.2 Hct-38.1 MCV-92
MCH-29.5 MCHC-32.0 RDW-15.2 RDWSD-51.7* Plt ___
___ 05:00PM BLOOD Neuts-44.8 ___ Monos-7.2 Eos-0.2*
Baso-0.6 Im ___ AbsNeut-2.36 AbsLymp-2.46 AbsMono-0.38
AbsEos-0.01* AbsBaso-0.03
___ 05:00PM BLOOD ___ PTT-31.7 ___
___ 05:00PM BLOOD Glucose-87 UreaN-16 Creat-0.8 Na-139
K-7.3* Cl-105 HCO3-21* AnGap-13
___ 05:00PM BLOOD Albumin-4.4 Calcium-9.4 Phos-3.6 Mg-2.1
___ 05:00PM BLOOD ALT-22 AST-72* AlkPhos-36 TotBili-0.4
___ 06:00AM BLOOD %HbA1c-5.2 eAG-103
___ 06:00AM BLOOD Triglyc-103 HDL-59 CHOL/HD-3.0 LDLcalc-97
___ 09:43PM BLOOD ___ pO2-206* pCO2-32* pH-7.38
calTCO2-20* Base XS--4
TROPONINS/CK:
___ 12:30AM BLOOD CK(CPK)-329*
___ 12:00PM BLOOD CK(CPK)-300*
___ 05:00PM BLOOD CK-MB-14* cTropnT-0.08*
___ 12:30AM BLOOD CK-MB-16* MB Indx-4.9
___ 12:30AM BLOOD cTropnT-0.09*
___ 12:00PM BLOOD CK-MB-15* MB Indx-5.0 cTropnT-0.11*
___ 09:38PM BLOOD CK-MB-10 cTropnT-0.17*
___ 02:52AM BLOOD CK-MB-10 cTropnT-0.14*
___ 06:00AM BLOOD CK-MB-10 cTropnT-0.13*
___ 12:54PM BLOOD cTropnT-0.10*
INR:
___ 05:00PM BLOOD ___ PTT-31.7 ___
___ 12:00PM BLOOD ___ PTT-150* ___
___ 06:00AM BLOOD ___ PTT-60.9* ___
___ 06:35AM BLOOD ___
___ 06:40AM BLOOD ___ PTT-37.6* ___
___ 06:15AM BLOOD ___
___ 06:03AM BLOOD ___
DISCHARGE LABS:
___ 06:03AM BLOOD WBC-5.5 RBC-3.33* Hgb-9.9* Hct-31.2*
MCV-94 MCH-29.7 MCHC-31.7* RDW-15.5 RDWSD-53.3* Plt ___
___ 06:03AM BLOOD Plt ___
___ 06:03AM BLOOD ___
___ 06:03AM BLOOD Glucose-92 UreaN-13 Creat-0.6 Na-146
K-3.9 Cl-110* HCO3-23 AnGap-13
___ 06:03AM BLOOD Calcium-9.2 Phos-4.2 Mg-2.0
MICROBIOLOGY:
___ 4:44 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
==========================================================
___ 3:49 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE
IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMIKACIN-------------- <=2 S
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- =>16 R
IMAGING:
___ CTA CHEST:
1. No pulmonary embolus or acute aortic abnormality.
2. New bilateral lower lobe opacification may reflect mild
interstitial edema.
3. Large hiatal hernia.
___ CORONARY CTA:
IMPRESSION:
1. CAD-RADS 0- No plaque or stenosis.
2. Moderate to large hiatal hernia.
3. Mild bibasilar ground-glass opacities and mild bronchial wall
thickening
may be secondary to aspiration, atelectasis and/or mild
interstitial edema.
Brief Hospital Course:
Ms. ___ is a ___ with PMH of TBI, Factor V Leiden w/
prior DVT and venous sinus thrombosis (VST) on coumdin and IVF
filter, who presented with three days of worsening head pain,
VST ruled out on MR. ___ hospital course has been complicated by
E. coli UTI and chest pain for which a coronary CTA was
performed. The final read was still pending at the time of
discharge.
ACUTE ISSUES:
=============
#Atypical, intermittent chest pain
#Elevated troponins
#Concern for NSTEMI
Patient reports intermittent chest pain for the past few months
that is positional in nature; she reports she experiences the
pain when she is at rest, lying on ___ side and shrugging. Of
note, she never experiences the chest pain with exertion. She
was found to have elevated troponins that peaked at 0.17 at
admission and downtrended thereafter. Reassuringly, EKGs
appeared similar to prior EKGs (V1-V3 TWIs); also, recent
___ stress echo was neg for ischemic changes. She was
hypotensive at admission, so it is possible ___ troponin leak
may have been ___ Type 2 NSTEMI. Alternatively, given ___ pain
is located near ___ mid-epigastrium, it was felt ___ chest pain
may have been related to ___ hiatal hernia/GERD vs. h/o anxiety
c/b panic disorder. ___ CTA was neg for PE. ___ coronary CTA
prelim read showed no e/o clinically significant coronary artery
calcifications or severe coronary artery stenosis. Per the
radiologist, it would take ___ days for the final report. Given
___ low cardiac risk, the patient was discharged and ___
cardiologist (Dr. ___ was emailed for close follow-up.
She was started on statin 20mg qhs (per Cardiology), with a plan
to add b-blocker if she began to have more concerning sx.
Aspirin was held, as she was already being anticoagulated with
warfarin.
#Hypotension
Patient triggered for Doppler BP of 69 which improved to ___
on ___. Patient was mentating well without lightheadedness and
other acute complaints. Unclear etiology, though may have been
___ poor po intake given pt's history of frequent
nausea/vomiting. CTA ruled out PE, and patient was afebrile
without infectious symptoms, lowering the concern for sepsis.
___ BCx showed NGTD. Lactate initially elevated at 2.6, but
downtrended on ___ to nml limits. She received 1L LR on ___
and BPs improved to 110-130s systolic thereafter.
#Nausea, Vomiting
#Hiatal hernia
#Tortuous esophagus
Reports progressive inability to tolerate solid foods over the
past few months. Also reports ~20% weight loss in past 6 months,
per Nutrition. ___ EGD notable for hiatal hernia, tortuous
esophagus which is likely causing ___ inability to swallow foods
(reports food gets stuck in ___ chest). No e/o malignancy on
prior EGD. She was continued on Famotidine 40 mg PO BID,
Pantoprazole 40 mg PO Q12H, and IV Compazine initially. She was
switched to PO home Compazine when she was able to tolerate po
intake. We recommend she contact ___ PCP to schedule ___ GI
appointment. She has seen a GI doctor in the past, but would
prefer to see another GI doctor.
#Constipation
Reports having to manually disimpact herself at times due to
hard stool. Likely causing diffuse abdominal pain. Has BM
usually every other day and uses OTC laxatives. Last BM ~5 days
prior to admission, but had multiple BMs on ___. She was given
Senna bid standing, Miralax bid standing, Milk of Magnesia.
#Headache:
Etiology is likely migraine vs tension headache vs TBI. VST was
ruled out on ___ MR. ___ discussed with Dr. ___
outpatient ___ and increased ___ home topiramate from
75mg qd > 100mg qd. She was continued on PO Tylenol, as well as
Compazine.
#Factor V Leiden
#Prior DVT and venous sinus thrombosis (VST)
Patient was subtherapeutic with INR 1.3 on presentation. During
this admission, she was bridged from lovenox to warfarin. No PE
seen on CTA and ___ without DVT. ___ ___ clinic
was contacted and will contact patient for an INR recheck within
___ days of discharge.
#Severe chronic malnutrition
Reports unintentional weight loss (~20% in past 6 months),
likely due to frequent vomiting ___ episodes of emesis
throughout the week). Nutrition was consulted and she was
started on MVI with minerals.
#Acute E. Coli UTI
#Chronic UTI
___ UCx was negative at admission and home Keflex ___ qd for
ppx UTI was subsequently held. We initiated ___ on Keflex and
pyridium, as she began to experience dysuria, urinary
incontinence. ___ UCx was notable for E. Coli UTI, sensitive
to Keflex. She was increased from 250mg qd to Keflex ___ bid.
#Hypernatremia
She was briefly hypernatremia, but this resolved after we
encouraged increased po fluid intake.
CHRONIC ISSUES:
===============
#Urinary incontinence:
Continued Oxybutynin 5 mg PO TID
#Depression/Anxiety:
Continued Escitalopram Oxalate 20 mg PO DAILY and Clonazepam 0.5
mg PO/NG BID:PRN anxiety.
======================
MEDICATION CHANGES
======================
[]Increased home topiramate from 75mg once daily to 100mg once
daily.
[]Started atorvastatin 20mg qhs for intermittent chest pain. ASA
81mg was not started as she was already being AC with warfarin.
___ home Keflex ___ daily was increased to 500mg bid x3 days
due to ___ UCx notable for E. coli. Antibiotic course
(___).
[]Started multivitamin with minerals for malnutrition.
[]Held Strattera during admission, as pt said she did not like
the side effects of Straterra. She plans on following up with
___ outpatient Psychiatrist to discuss switching Straterra >
Adderall.
======================
TRANSITIONAL ISSUES
======================
[] Re-check INR in 3 days (___). Modify warfarin dosing as
needed.
[] Monitor headache symptoms.
[] Monitor for UTI symptoms.
[] Follow-up with neurology, cardiology.
#CODE: DNR/DNI (confirmed with patient and daughter on
___
#CONTACT: ___ (___), phone: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Cephalexin 250 mg PO DAILY
2. ClonazePAM 0.5 mg PO BID:PRN anxiety
3. Escitalopram Oxalate 20 mg PO DAILY
4. Famotidine 40 mg PO BID
5. Oxybutynin 5 mg PO TID
6. Pantoprazole 40 mg PO Q12H
7. Topiramate (Topamax) 50-75 mg PO DAILY
8. Warfarin 5 mg PO DAILY16
9. Ferrous Sulfate 325 mg PO DAILY
10. Prochlorperazine 5 mg PO Q8H:PRN nausea
11. atomoxetine 40 mg oral DAILY
Discharge Medications:
1. Atorvastatin 20 mg PO QPM
Take one tablet (20mg) every night.
RX *atorvastatin 20 mg one tablet(s) by mouth every evening Disp
#*30 Tablet Refills:*0
2. Cephalexin 500 mg PO Q12H Duration: 3 Days
Don't take your cephalexin 250 mg daily while taking this.
Resume it after completing this regimen.
RX *cephalexin 500 mg one capsule(s) by mouth every 12 hours
Disp #*4 Capsule Refills:*0
3. Multivitamins W/minerals Chewable 1 TAB PO DAILY
4. Phenazopyridine 200 mg PO TID Duration: 3 Days
RX *phenazopyridine 200 mg one tablet(s) by mouth three times
daily Disp #*6 Tablet Refills:*0
5. Polyethylene Glycol 17 g PO BID
RX *polyethylene glycol 3350 17 gram/dose 1 powder(s) by mouth
twice daily as needed for constipation Refills:*0
6. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg one tablet by mouth twice daily as
needed for constipation Disp #*30 Tablet Refills:*0
7. Topiramate (Topamax) 100 mg PO DAILY
8. atomoxetine 40 mg oral DAILY
9. Cephalexin 250 mg PO DAILY
10. ClonazePAM 0.5 mg PO BID:PRN anxiety
11. Escitalopram Oxalate 20 mg PO DAILY
12. Famotidine 40 mg PO BID
13. Ferrous Sulfate 325 mg PO DAILY
14. Oxybutynin 5 mg PO TID
15. Pantoprazole 40 mg PO Q12H
16. Prochlorperazine 5 mg PO Q8H:PRN nausea
17. Warfarin 5 mg PO DAILY16
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Headache
Atypical chest pain
Hypotension
Nausea
Vomiting
Hiatal Hernia
Constipation
Factor V Leidin
DVT
Venous ___ thrombosis
Severe chronic malnutrition
Hypernatremia
Acute on chronic urinary tract infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
======================
DISCHARGE INSTRUCTIONS
======================
Dear Ms. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You came to the hospital for 3 days of worsening head pain.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- We increased your Topamax from 75mg once daily to 100mg once
daily. We discussed this with your Neurologist, who agreed with
this change.
- We obtained imaging of your heart vessels. The final report
was still pending at the time of your discharge. We started you
on a new medication, called atorvastatin to help reduce the risk
of heart disease.
- We increased your Keflex dose from 250mg once daily to 500mg
twice daily for a urinary tract infection that grew a type of
bacteria called E. coli. Take the 500mg twice daily dose until
___. Thereafter, you can resume your daily 250mg dose.
- We gave you additional medications to help with your
constipation.
- We continued you on your home warfarin.
- We started you on a multivitamin, as this will help with your
nutrition.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- The ___ clinic will contact you about
checking your INR within ___ days of leaving the hospital.
- Ask your primary care doctor to refer you to a ___
Vanguard GI doctor for your hiatal hernia.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10109613-DS-21 | 10,109,613 | 24,933,592 | DS | 21 | 2133-08-14 00:00:00 | 2133-09-08 08:59:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
gabapentin
Attending: ___.
Chief Complaint:
Right Sided Chest Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with PMH of DVT, Factor 5 leiden, and cerebral venous sinus
thromboisis on warfarin (last dose yesterday) s/p fall from
standing height, + head strike, no LOC. CT head, neck, and abd
were negative at OSH. She suffered 3 right sided rib fx and had
a 30% PTX. A chest tube was placed at OSH which showed
resolution
of the PTX. At bedside, the patient is alert, oriented, and in
no acute distress. She has shallow breathing with a weak cough
and is on 2L NC. Her CT is to suction with no air leak.
Past Medical History:
factor V Leiden (heterozygous)
- cerebral venous thrombosis (___) with involvement of the
superior sagittal sinus, right transverse sinus, right sigmoid
and straight dural venous sinus
- DVT s/p IVC filter placement
traumatic brain injury TBI (hx of being on Coumadin and
sustaining IPH)
transient ischemic attacks
depression/anxiety
migraines
R patella removal
L ___ toe surgery
shingles involving likely R T10 area.
factor V Leiden (heterozygous)
- cerebral venous thrombosis (___) with involvement of the
superior sagittal sinus, right transverse sinus, right sigmoid
and straight dural venous sinus
- DVT s/p IVC filter placement
traumatic brain injury TBI (hx of being on Coumadin and
sustaining IPH)
transient ischemic attacks
depression/anxiety
migraines
R patella removal
L ___ toe surgery
shingles involving likely R T10 area.
Social History:
___
Family History:
father and brother died of blood clots ___ Factor (age ___
V Leiden deficiency
Physical Exam:
Physical Exam upon admission: ___:
VS: 98.8 76 116/58 20 98% 2L NC
Gen: Alert, oriented, in NAD. shallow breathing
HEENT: EOMI, no palpable LAD
CV: RRR
Resp: CTAB, no inc WOB. Right sided CT to suction, no air leak
Abd: Soft, NT, ND.
Extrem: no c/c/e
Neuro: Grossly intact
Psyc: Appropriate mood/affect
Discharge Physical Exam:
VS: 98.3, 122/77, 57, 18, 95 RA
Gen: A&O x3
CV: [x] RRR, [] murmur
Resp: [x] breaths unlabored, [x] CTAB, [] wheezing, [] rales
Abdomen: [x] soft, [] distended, [] tender, [] rebound/guarding
Ext: [x] warm, [] tender, [] edema
Pertinent Results:
___ 05:59AM BLOOD Plt ___
___ 05:59AM BLOOD ___ PTT-35.5 ___
___ 06:25PM BLOOD ___ PTT-31.6 ___
___ 05:59AM BLOOD Glucose-96 UreaN-19 Creat-0.9 Na-143
K-5.1 Cl-108 HCO3-18* AnGap-17
___: CXR:
No definite pneumothorax. Tip of right-sided pigtail catheter
projects over the right upper lung on this frontal only view.
___: CXR:
Trace probably unchanged right apical pneumothorax. Status post
chest tube removal.
___: CXR:
Very small right apical pneumothorax.
___: CXR:
There is interval increase in right pneumothorax in both apical
and basal
component. Basal air might potentially communicated between the
pleura and the chest wall, with to the size of 12 x 6 cm, R
adjacent to rib fractures.
No pleural effusion is seen. Lungs overall clear. Moderate
hiatal hernia is re-demonstrated.
___: CXR:
No substantial change in the appearance of the apical
pneumothorax on the
right although minimal decrease is a possibility as well as the
air bubble
projecting over the right lower lung. Hiatal hernia. No new
findings
otherwise.
___ CXR: Minimally displaced fractures at the right lower rib
cage is again seen. There there is a moderate sized
pneumothorax at the right lateral base. Also a tiny right
apical pneumothorax. These are unchanged.
Brief Hospital Course:
___ year old female admitted to an OSH hospital after she
sustained a fall from standing. Upon review of imaging she was
reported to have right sided rib fractures and a right apical
pneumothorax. A pigtail catheter was placed for lung
re-expansion. The patient was transferred here for trauma
evaluation.
The pigtail catheter reportedly fell out upon transfer. The
patient's repeat chest x-ray showed a trace apical
pneumothorax. She was placed on nasal cannula to help aid with
lung re-expansion and she was instructed in the use of incentive
spirometry. She underwent daily chest x-rays. These showed
stable unchanged moderate pneumothorax. The patient's pain was
controlled with oral analgesia and she resumed her home
medications including Coumadin. She underwent daily monitoring
of ___. She was placed on a regular diet and was voiding
without difficulty. In preparation for discharge, the patient
was evaluated by physical therapy.
The patient was cleared for discharge home with ___ supervision.
The patient was discharged home on HD #5 in stable condition.
A follow-up appointment was made in the Acute care clinic with a
chest x-ray prior to the visit. The patient will follow-up in
her ___ clinic for monitoring of her INR and dosing of
Coumadin. Discharge instructions were reviewed and questions
answered.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. BusPIRone 10 mg PO BID
2. FLUoxetine 30 mg PO DAILY
3. HydrOXYzine 25 mg PO BID PRN anxiety
4. ClonazePAM 0.5 mg PO BID
5. Calcium Carbonate 1000 mg PO DAILY
6. Pantoprazole 40 mg PO Q12H
7. Oxybutynin 15 mg PO QHS
8. Atorvastatin 20 mg PO QPM
9. Ferrous Sulfate 325 mg PO DAILY
10. Polyethylene Glycol 17 g PO DAILY
11. Oxybutynin 5 mg PO QAM
12. Topamax (topiramate) 100 mg oral BID
13. ___ MD to order daily dose PO DAILY16
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen [Acetaminophen Extra Strength] 500 mg 2
tablet(s) by mouth every eight (8) hours Disp #*30 Tablet
Refills:*0
2. Famotidine 40 mg PO Q12H
3. Lidocaine 5% Patch 1 PTCH TD QPM
RX *lidocaine [Lidocaine Pain Relief] 4 % 1 patch to right chest
wall once a day Disp #*14 Patch Refills:*0
4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*25 Tablet Refills:*0
5. Senna 8.6 mg PO BID:PRN Constipation - First Line
RX *sennosides 8.6 mg 1 tablet(s) by mouth twice a day Disp #*20
Tablet Refills:*0
6. Topiramate (Topamax) 100 mg PO BID
7. FLUoxetine 60 mg PO DAILY
8. Warfarin 4 mg PO ONCE Duration: 1 Dose
9. Atorvastatin 20 mg PO QPM
10. BusPIRone 10 mg PO BID
11. Calcium Carbonate 1000 mg PO DAILY
12. Ferrous Sulfate 325 mg PO DAILY
13. HydrOXYzine 25 mg PO BID PRN anxiety
14. Oxybutynin 15 mg PO QHS
15. Oxybutynin 5 mg PO QAM
16. Pantoprazole 40 mg PO Q12H
17. Polyethylene Glycol 17 g PO DAILY
18. Topiramate (Topamax) (topiramate) 100 mg oral BID
19. ___ MD to order daily dose PO DAILY16
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Right Rib Fractures
Right 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 hospital after a fall resulting in
right sided rib fractures and collapse of the right lung
necessitating placement of a chest tube. You were transferred
to ___ for medical management. The chest tube was removed and
your rib pain is being controlled with pain medication. You
were evaluated by physical therapy and cleared for discharge
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 ___ until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Followup Instructions:
___
|
10109613-DS-22 | 10,109,613 | 25,772,481 | DS | 22 | 2134-02-21 00:00:00 | 2134-02-24 22:59:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
gabapentin
Attending: ___.
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
DISCHARGE LABS
==============
___ 06:18AM BLOOD WBC-4.1 RBC-3.47* Hgb-10.9* Hct-32.9*
MCV-95 MCH-31.4 MCHC-33.1 RDW-14.6 RDWSD-50.4* Plt ___
___ 06:18AM BLOOD ___ PTT-48.1* ___
___ 06:18AM BLOOD Glucose-93 UreaN-20 Creat-0.6 Na-132*
K-4.9 Cl-99 HCO3-24 AnGap-9*
___ 06:18AM BLOOD Calcium-9.0 Phos-4.5 Mg-2.0
ADMISSION LABS
==============
___ 09:11PM BLOOD WBC-6.6 RBC-3.89* Hgb-12.2 Hct-36.2
MCV-93 MCH-31.4 MCHC-33.7 RDW-14.3 RDWSD-48.7* Plt ___
___ 09:11PM BLOOD Neuts-46.6 ___ Monos-8.5 Eos-0.0*
Baso-0.5 Im ___ AbsNeut-3.05 AbsLymp-2.89 AbsMono-0.56
AbsEos-0.00* AbsBaso-0.03
___ 09:11PM BLOOD ___ PTT-38.1* ___
___ 09:11PM BLOOD Glucose-90 UreaN-11 Creat-0.5 Na-138
K-4.7 Cl-101 HCO3-23 AnGap-14
___ 09:11PM BLOOD Calcium-9.2 Phos-3.7 Mg-2.0
___ 06:18AM BLOOD TSH-1.3
___ 06:42AM BLOOD CRP-0.8
RENAL U/S
=========
1. No sonographic evidence of renal artery stenosis..
2. Thinning of the cortex bilaterally suggestive of underlying
chronic
medical renal disease.
CAROTID U/S
===========
Right ICA <40% stenosis.
Left ICA <40% stenosis.
MRI HEAD
========
1. No new dural venous sinus thrombosis. No evidence of new
gradient echo
susceptibility artifact or diffusion-weighted signal
abnormality.
2. Resolved thrombosis within the right internal jugular vein
with similar
trace residual filling defect in the sigmoid sinus and posterior
aspect of the
superior sagittal sinus near the confluence of sinuses.
3. Persistent increased T2/FLAIR signal intensity along the
superior sagittal
right transverse and right sigmoid sinus consistent with slow
flow with
unchanged regional collateral vessels.
4. Similar chronic encephalomalacia and gliosis involving the
anterolateral
right temporal lobe and primarily right anterior frontal lobe.
5. No acute territorial infarction or intracranial hemorrhage.
CT HEAD
=======
1. No acute intracranial process.
2. Chronic small vessel ischemic disease.
3. Small foci of encephalomalacia in the right inferior frontal
and temporal lobes unchanged from prior MRI.
Brief Hospital Course:
TRANSITIONAL ISSUES
===================
[ ] Follow up BPs at next visit and adjust BP medications as
needed
[ ] Needs INR drawn on ___ and may require warfarin adjustment
[ ] Consider medication adjustments-- given patient is elderly
and has had multiple falls, her regimen of fluoxetine 60mg PO QD
and Buspirone 15 TID may be contributing to her symptoms
[ ] Need to follow up with neurology as outpatient
[ ] Patient supposed to be on mirabegron for urinary
incontinence, however, patient had issues affording this as an
outpatient, so she had not been taking it. Should discuss
options for paying for this or alternate medication regimens.
[ ] Follow up renin and aldosterone levels
[ ] Follow up serum metanephrines - negative as of ___
[ ] Needs ENT follow up - appointment with Mass Eye and Ear
scheduled for the week after discharge
ASSESSMENT AND PLAN
===================
___ is a ___ year old woman with a Factor V Leiden c/b
prior cerebral venous sinus thrombosis and DVT (on Coumadin),
anxiety, and migraines who presented with acute on subacute
headache.
ACUTE ISSUES
=============
#Dizziness
#Headache
The patient has a known history of cerebral sinus venous
thrombosis (on warfarin), who initially presented with acute
worsening of subacute 2-week headache which was similar to her
prior CVST headache. MRI brain with resolved CVST. Head imaging
was otherwise negative for masses, bleed, or acute infarction.
The patient had recently been weaned off topiramate due to
cognitive side effects. In the ED, she received fluids, Tylenol,
antiemetic, and IV cocktail but ultimately had no improvement in
her symptoms. The inpatient Neurology team was consulted and
felt her HA were tension type vascular headaches. Per
neurology's recommendations, she was started on Meclizine 25mg
PO Q6hrs, Baclofen 10 mg PO/NG BID and continued on
Acetaminophen and zofran PRN. After discussion with the
patient's outpatient neurologist (who had discussed the case
with her outpatient psychiatrist), she was started on clonazepam
to 1.0mg PO BID and Amitriptyline 10mg PO QHS with some
improvement in her symptoms. She was also seen by physical
therapy who recommended outpatient ___ rehab. Given
complaints of her temporal pain, an ESR and CRP were checked--
ESR 2, CRP 0.8 (wnl). TSH was 1.3. Given her new HTN in
association with her headaches, she was started on amlodipine
and captopril with improvement in her BPs (see below). A work up
for secondary HTN was conducted as discussed below. She noted
improvement in her symptoms and was discharged with plans to
follow up with Dr. ___ in neurology.
#Hypertension:
Presented hypertensive SBP 180s-190s. Patient's BPs had been
persistently elevated throughout the first 3 days of her
hospitalization(averaging 150s-160s). Per review of her
outpatient records, she has never been HTN before and baseline
BPs are in 110-120s. It was unclear why she developed HTN at age
___, so a work up for secondary cause of HTN was conducted. This
included a renal ultrasound negative for renal artery stenosis
and normal TSH. Renin, aldosterone, and metanephrines were sent
and pending at the time of discharge (at the time of this
discharge summary, ___ still pending but metanephrines
negative). She was discharged on amlodipine to 10mg PO QD and
her Captopril 12.5mg TID was converted to Lisinopril 7.5mg PO
QD.
CHRONIC ISSUES:
==============
#Factor V Leiden
#Prior DVT and venous sinus thrombosis (VST)
Patient subtherapeutic with INR 1.8 on presentation. Initially
received 9mg Warfarin, then 7.5 x2 days and then 6mg x2 days.
INR at discharge 2.8. Will discharge with warfarin 6mg PO QD.
Goal INR ___. She will need follow up with her PCP to ___
an INR and adjust warfarin.
#Depression/Anxiety:
- Continued Fluoxetine 60mg PO DAILY
- Continued Buspirone as noted above
- Started Clonazepam and amitriptyline as noted above
#Hyperlipidemia:
- Continued atorvastatin 20mg
#Urinary incontinence:
- Held the patient's home mirabegron given non-formulary and
that patient had issues affording this as an outpatient, so she
had not been taking this.
#Recurrent UTI:
- Continued Keflex daily
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 20 mg PO QPM
2. BusPIRone 15 mg PO BID
3. Ferrous Sulfate 325 mg PO DAILY
4. FLUoxetine 60 mg PO DAILY
5. Pantoprazole 40 mg PO Q12H
___ MD to order daily dose PO DAILY16
7. Acetaminophen 1000 mg PO Q8H:PRN Headache
8. Famotidine 40 mg PO Q12H
9. Calcium Carbonate 500 mg PO BID
10. Magnesium Oxide 400 mg PO DAILY
11. Cephalexin 250 mg PO Q24H
12. mirabegron 50 mg oral DAILY
13. Triamcinolone Acetonide 0.025% Ointment 1 Appl TP DAILY
14. Tretinoin 0.025% Cream 1 Appl TP QHS
Discharge Medications:
1. Amitriptyline 10 mg PO QHS
2. amLODIPine 10 mg PO DAILY
3. Baclofen 10 mg PO BID
4. ClonazePAM 1 mg PO BID
5. Lisinopril 7.5 mg PO DAILY
6. Meclizine 25 mg PO QID dizziness
7. Acetaminophen 1000 mg PO Q8H:PRN Headache
8. Atorvastatin 20 mg PO QPM
9. BusPIRone 15 mg PO BID
10. Calcium Carbonate 500 mg PO BID
11. Cephalexin 250 mg PO Q24H
12. Famotidine 40 mg PO Q12H
13. Ferrous Sulfate 325 mg PO DAILY
14. FLUoxetine 60 mg PO DAILY
15. Magnesium Oxide 400 mg PO DAILY
16. mirabegron 50 mg oral DAILY
17. Pantoprazole 40 mg PO Q12H
18. Tretinoin 0.025% Cream 1 Appl TP QHS
19. Triamcinolone Acetonide 0.025% Ointment 1 Appl TP DAILY
20. ___ MD to order daily dose PO DAILY16
21.Outpatient Lab Work
Test: ___ level
Dx: Cerebral venous sinus thrombosis, ICD-10: ___.6
Send results to: ___, MD. ___: ___, ___. Phone: ___. Fax: ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Headache
Vertigo/Dizziness
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
==========================
- You were admitted to the hospital because you were having
severe head pain/headache as well as light headedness and
dizziness.
WHAT HAPPENED TO ME IN THE HOSPITAL?
====================================
- You had an MRI done which showed nothing acute or new on it
- You were seen by the neurology team who recommended some
medications (see below) to help your symptoms
- You were seen by the physical therapists who recommended that
you see physical therapy as an outpatient for ___ rehab.
- Your outpatient neurologist saw you and made recommendations
for specific medications to help with your dizziness and
headache
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
============================================
- On ___, Please go to the lab on the second floor of
the ___ building (where your primary care doctor is) and
have your INR checked. The address is ___,
___, ___. Phone: ___. You have a prescription
for outpatient lab work/INR check in your discharge paperwork.
- Continue to take all your medicines and keep your
appointments.
- Please take all of the medications that are listed below
- You need to see your primary care doctor and neurologist
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10109613-DS-23 | 10,109,613 | 20,466,771 | DS | 23 | 2134-03-12 00:00:00 | 2134-03-13 04:48:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
gabapentin
Attending: ___.
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
ADMISSION LABS:
===============
___ 03:30PM BLOOD WBC-6.7 RBC-4.19 Hgb-13.3 Hct-40.1 MCV-96
MCH-31.7 MCHC-33.2 RDW-14.0 RDWSD-49.3* Plt ___
___ 03:30PM BLOOD Neuts-57.0 ___ Monos-6.8 Eos-0.1*
Baso-0.7 Im ___ AbsNeut-3.83 AbsLymp-2.36 AbsMono-0.46
AbsEos-0.01* AbsBaso-0.05
___ 03:30PM BLOOD ___ PTT-53.8* ___
___ 08:30PM BLOOD Glucose-116* UreaN-16 Creat-0.7 Na-141
K-4.7 Cl-106 HCO3-17* AnGap-18
___ 12:51AM BLOOD Calcium-8.6 Phos-3.6 Mg-2.1
___ 12:56AM BLOOD Lactate-0.7
___ 03:10PM URINE Color-Straw Appear-CLEAR Sp ___
___ 03:10PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NORMAL pH-7.0
Leuks-NEG
IMAGING:
=========
CT ABD & PELVIS WITH CO ___
1. No acute findings in the abdomen or pelvis.
2. Nonobstructing left renal calculi. No hydronephrosis
3. Moderate compound hiatal hernia.
4. Diverticulosis without evidence of diverticulitis.
5. Large stool burden.
CT HEAD W/O CONTRAST ___
1. No acute intracranial abnormality on noncontrast CT head.
Specifically, no evidence of acute large territory infarct or
intracranial hemorrhage.
2. Subtle volume loss of the right frontal and anterior right
temporal lobes (series 11 and 12 respectively), compatible with
encephalomalacia, potentially sequela of prior infarct.
DISCHARGE LABS:
================
___ 07:49AM BLOOD WBC-4.9 RBC-3.80* Hgb-12.0 Hct-36.1
MCV-95 MCH-31.6 MCHC-33.2 RDW-13.8 RDWSD-47.8* Plt ___
___ 06:55AM BLOOD Glucose-96 UreaN-19 Creat-0.7 Na-141
K-4.6 Cl-103 HCO3-25 AnGap-13
Brief Hospital Course:
PATIENT SUMMARY
=================
___ year old woman with a Factor V Leiden c/b prior cerebral
venous sinus thrombosis and DVT (on Coumadin), anxiety, and
migraines who presented with one episode of BRBPR and ongoing
weakness. BRBPR found to be most consistent with bleeding
internal hemorrhoids in the setting of chronic constipation. Her
bowel regimen was increased with improvement in constipation.
She had no additional episodes of BRBPR and hemoglobin remained
stable.
TRANSITIONAL ISSUES
====================
[] Patient can call ___ to make an appointment with Dr.
___ (hematologist) to discuss options other than warfarin
for anticoagulation
[] Check INR on ___ and adjust warfarin dosing accordingly.
[] Discontinued antihypertensives given patient was normotensive
and complaining of fatigue since starting these medications.
This can be reevaluated as needed on an outpatient basis.
ACUTE ISSUES
=============
# BRBPR:
Likely related to hemorrhoidal bleeding in the setting of
chronic constipation and straining for BMs. While H/H did
initially drop, suspect that initial CBC was hemoconcentrated.
Subsequent H/H stable and consistent with prior values.
Increased bowel regimen and trended H/H. Although patient
endorsed abdominal pain, exam was benign and CT imaging revealed
no acute findings.
# Constipation
Patient has chronic constipation. Had BMs after getting
senna/miralax and Bisacodyl PO and PR.
# Weakness:
Etiology not entirely clear, but appeared to be a subacute
complaint as she reported she felt weak and unfit for discharge
during last admission as well. Neuro exam non-focal which is
reassuring. Of note, she was seen by her outpatient neurologist
recently who commented that her weakness may be related to
polypharmacy, and he recommended stopping meclizine and baclofen
at that time. Also, while she was recently started on BP meds
during prior admission, her BP's were on the lower side, raising
concern that BP meds could be contributing. Consequently, her BP
meds were held and she remained normotensive. ___ was consulted
and recommends discharging to home with maximum services.
# Headaches:
Longstanding issue for this patient, for which she follows with
outpatient neurology. As above, neuro exam was non-focal, and CT
head without any concerning findings. Continued home regimen of
amitryptiline and diazepam.
# HTN:
Held home BP meds as above. Patient remains normotensive. Can be
reevaluated as an outpatient if necessary.
CHRONIC ISSUES
===============
# Factor V Leiden
# Prior DVT and venous sinus thrombosis (VST): Goal INR 2.0-3.0.
Checked INRs daily and dosed Warfarin accordingly.
# Depression/Anxiety:
Continued FLUoxetine 60 mg PO DAILY
Continued BusPIRone 15 mg PO BID
# Hyperlipidemia:
Continued Atorvastatin 20 mg PO QPM
# Urinary incontinence:
Held the patient's home mirabegron given non-formulary and that
patient had issues affording this as an outpatient, so she had
not been taking this.
# Recurrent UTI:
Continued Cephalexin 250 mg PO Q24H
# GERD:
Continued Pantoprazole 40 mg PO Q12H
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
further investigation.
1. Acetaminophen 1000 mg PO Q8H:PRN Headache
2. Atorvastatin 20 mg PO QPM
3. BusPIRone 15 mg PO BID
4. Calcium Carbonate 500 mg PO BID
5. Cephalexin 250 mg PO Q24H
6. Ferrous Sulfate 325 mg PO DAILY
7. FLUoxetine 60 mg PO DAILY
8. Magnesium Oxide 400 mg PO DAILY
9. Pantoprazole 40 mg PO Q12H
10. Tretinoin 0.025% Cream 1 Appl TP QHS
11. Triamcinolone Acetonide 0.025% Ointment 1 Appl TP DAILY
12. ___ MD to order daily dose PO DAILY16
13. Amitriptyline 10 mg PO QHS
14. amLODIPine 10 mg PO DAILY
15. Famotidine 40 mg PO Q12H
16. Baclofen 10 mg PO BID
17. ClonazePAM 1 mg PO BID
18. Meclizine 25 mg PO QID dizziness
19. Lisinopril 7.5 mg PO DAILY
Discharge Medications:
1. Bisacodyl 10 mg PO DAILY
RX *bisacodyl 5 mg 1 tablet(s) by mouth once a day Disp #*60
Tablet Refills:*3
2. Bisacodyl ___AILY:PRN Constipation - Second Line
RX *bisacodyl 10 mg 1 suppository(s) rectally once a day Disp
#*30 Suppository Refills:*3
3. Polyethylene Glycol 17 g PO TID
RX *polyethylene glycol 3350 [Miralax] 17 gram/dose 1 dose by
mouth three times a day Refills:*0
4. Senna 17.2 mg PO BID
RX *sennosides [senna] 8.6 mg 2 tablets by mouth twice a day
Disp #*60 Tablet Refills:*3
5. Warfarin 7.5 mg PO ONCE Duration: 1 Dose
6. Acetaminophen 1000 mg PO Q8H:PRN Headache
7. Amitriptyline 10 mg PO QHS
8. Atorvastatin 20 mg PO QPM
9. Baclofen 10 mg PO BID
10. BusPIRone 15 mg PO BID
11. Calcium Carbonate 500 mg PO BID
12. Cephalexin 250 mg PO Q24H
13. ClonazePAM 1 mg PO BID
14. Famotidine 40 mg PO Q12H
15. Ferrous Sulfate 325 mg PO DAILY
16. FLUoxetine 60 mg PO DAILY
17. Magnesium Oxide 400 mg PO DAILY
18. Meclizine 25 mg PO QID dizziness
19. Pantoprazole 40 mg PO Q12H
20. Tretinoin 0.025% Cream 1 Appl TP QHS
21. Triamcinolone Acetonide 0.025% Ointment 1 Appl TP DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Bleeding internal hemorrhoids
Constipation
Secondary diagnoses:
HIATAL HERNIA
FACTOR V LEIDEIN
DEEP VENOUS THROMBOPHLEBITIS
TBI
TRANSIENT ISCHEMIC ATTACK
MIGRAINE HEADACHES
DEPRESSION
ANXIETY
CEREBRAL VENOUS SINUS THROMBOSIS
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a privilege taking care of you at ___
___.
WHY WAS I IN THE HOSPITAL?
-You were admitted after you had blood in your bowel movement.
WHAT HAPPENED TO ME IN THE HOSPITAL?
You were closely monitored in the hospital and the work-up
suggests that the most likely cause of your bleeding was the
combination of your internal hemorrhoids and constipation. You
were given extra medications to make it easier for you to have
bowel movements to prevent hard stool from aggravating your
hemorrhoids and causing you to bleed again.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- Please have your INR checked within ___ days of hospital
discharge and discuss with your doctor regarding warfarin
dosing.
- Please call ___ to make an appointment with Dr. ___
___ (your hematologist) to discuss your anticoagulation and
options other than warfarin.
We wish you the best.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
Subsets and Splits