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19548230-DS-18
| 19,548,230 | 21,517,523 |
DS
| 18 |
2173-06-20 00:00:00
|
2173-06-22 05:58:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Daypro / silver metal / pollen / kiwi / Keflex / Bactrim /
Iodinated Contrast- Oral and IV Dye / clindamycin
Attending: ___
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HISTORY OF PRESENTING ILLNESS:
___ is a ___ year old woman with metastatic NSCLC c/b
recurrent right pleural effusion on pembrolizumab wwho is
admitted from the ED with worsening dyspnea, cough, chest, and
right back pain.
Patient's clinical course has been progressively declining over
the last several months with worsening bouts of shortness of
breath and cough. She is up to 3L home O2. She also has chronic
right sided chest pain from her known metastatic cancer.
However,
over the last week or so, she has had significant worsening of
her shortness of breath to the point she is short of breath even
at rest. She also notes her chronic cough has been progressing
during this time period and she has developed relatively new
substernal pleuritic chest discomfort up to ___ that is
associated with worsening cough and SOB. Her chronic right sided
chest and back pain has also worsened. Of note, she recently had
her right chest TPC removed a few weeks ago. She also notes b/l
___ edema over the last ___ weeks.
She denies known fevers, but has frequent chills. She notes
intermittent headaches and has blurry vision in her right eye
for
months. No dysphagia. She is losing weight and her appetite is
poor. No significant nausea. She has epigastric and RUQ
abdominal
pain. She reports alternating diarrhea and constipation. No
dysuria.
In the ED, initial VS were pain 0, T 98.2, HR 115, BP 111/64, RR
22, O2 95% 4LNC. Initial labs notable for Na 134, K 6.9
(hemolyzed), HCO3 22, Cr 0.9, Trop <0.01, Ca 9.3, Mg 1.8, P 3.8,
ALT 21, AST 58, ALP 172, TBili 1.0, Alb 3.3, BNP 566, WBC 7.6,
HCT 36.4, PLT 210, UA negative. Repeat K 4.5. CXR showed
unchanged complete opacification of right hemithorax, right
sided-sided loculated PTX, and similar small left pleural
effusion. Bilateral lower extremity Doppler US showed
nonocclussive thrombus in left femoral vein and occlusive
thrombus in right gastroc vein. Non-con CT chest showed interval
disease progression with near complete consolidation of right
lung, persistent moderate loculated effusion of right lung base
with larger foci of internal air, and new mall left effusion and
small pericardial effusion. Patient was given duonebs and
started
on IV heparin gtt. She was also given vancomycin and ordered
zosyn (did not receive it). VS prior to transfer were pain 5, T
98.2, HR 108, BP 114/86, RR 27, O2 96%4LNC.
REVIEW OF SYSTEMS:
A complete 10-point review of systems was performed and was
negative unless otherwise noted in the HPI.
Past Medical History:
PAST ONCOLOGIC AND TREATMENT HISTORY:
1. Status post right upper lobe lobectomy and lymph node
dissection on ___. Lobectomy specimen: invasive lung
adenocarcinoma measuring 5cm with metastatic carcinoma in 1 of 1
peribronchial lymph nodes, ___ level 4R nodes; Stage IIIA
(pT2apN2);
2. Status post adjuvant 5040 cGy radiotherapy to right chest and
mediastinum; completed on ___
3. Status post 4 cycles of platinum (cisplatin 75mg/m2 D1) and
pemetrexed (500 mg/m2) on ___ and
___
4. ___ study # ___: Randomized phase II study comparing
concise versus prolonged afatinib as adjuvant therapy for
patients with resected stage I-III NSCLC with EGFR
mutation(L858R
in her case). Participated in study from ___ thru ___
with dose-reduced afatinib 20mg daily.
5. On ___, she underwent right sided thoracentesis for
right-sided pleuritic chest pain and new evidence of pleural
effusion on chest x-ray. Thoracentesis was performed and
cytology
positive for malignancy consistent with metastasis from
known lung adenocarcinoma, indicating that her disease is now
Stage IV. Repeat tumor genomic profiling showed the same EGFR
L858R mutation.
6. Erlotinib 100mg daily started ___. Dose reduced to 100mg
every OTHER day ___ due to cutaneous toxicity.
7. R pleurx catheter placed on ___.
8. ___: Switched erlotinib to osimertinib 80mg daily in
setting of treatment-related toxicity (diarrhea, dermatitis) and
concern for possible intracranial progression.
PAST MEDICAL HISTORY:
Metastatic lung adenocarcinoma s/p RUL resection ___
Recurrent malignant pleural effusion ___
COPD
Arthritis
Depression
Social History:
___
Family History:
Father: bladder and stomach cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
===========================
VS: T 98.5 HR 114 BP 115/76 RR 18 SAT 100% O2 on 5LNC
GENERAL: Chronically ill and cachectic woman who appears anxious
and mildly uncomfortable due to pain and dyspnea
EYES: Anicteric sclerea, PERLL, EOMI;
ENT: Oropharynx clear without lesion, JVD not elevated
CARDIOVASCULAR: Tachycardic rate and regular rhythm, ___ SEM
RESPIRATORY: Appears tachypneic and speaks in short sentences.
Bronchial sounds over entire right side with dullness to
percussion. Left side is clear with fair air movement.
GASTROINTESTINAL: Normal bowel sounds; mildly distended; soft,
tender in epigastrum and RUQ
MUSKULOSKELATAL: Warm, well perfused extremities with 1+ lower
extremity edema; Decreased bulk
NEURO: Alert, oriented, anxious, motor and sensory function
grossly intact
SKIN: No significant rashes
LYMPHATIC: No cervical, supraclavicular, submandibular
lymphadenopathy. No significant ecchymoses
ACCESS: PIV
DISCHARGE PHYSICAL EXAM:
=============================
VS: ___ 0348 Temp: 97.9 PO BP: 100/66 L Lying HR: 92 RR: 20
O2 sat: 94% O2 delivery: 5LNC
GENERAL: Chronically ill and cachectic woman who appears
comfortable
EYES: Anicteric sclerea, PERLL, EOMI;
ENT: Oropharynx clear without lesion, JVD not elevated
CARDIOVASCULAR: Tachycardic rate and regular rhythm, ___ SEM at
apex
RESPIRATORY: Appears tachypneic. air movement is unappreciated
on
right, rhonchorous on left side. Left chest rises and falls with
respiration, left does not.
GASTROINTESTINAL: Normal bowel sounds; mildly distended; soft,
tender in epigastrum and RUQ
MUSKULOSKELATAL: Warm, well perfused extremities with 1+ lower
extremity edema on right leg > left
NEURO: Alert, oriented, anxious, motor and sensory function
grossly intact
SKIN: No significant rashes
ACCESS: PIV
Pertinent Results:
ADMISSIONS LABS:
================
___ 02:54PM BLOOD WBC-7.6 RBC-4.27 Hgb-11.4 Hct-36.4 MCV-85
MCH-26.7 MCHC-31.3* RDW-14.0 RDWSD-43.0 Plt ___
___ 02:54PM BLOOD Neuts-87* Bands-3 Lymphs-4* Monos-4*
Eos-1 Baso-1 ___ Myelos-0 AbsNeut-6.84*
AbsLymp-0.30* AbsMono-0.30 AbsEos-0.08 AbsBaso-0.08
___ 02:54PM BLOOD Glucose-134* UreaN-25* Creat-0.9 Na-134*
K-6.9* Cl-94* HCO3-22 AnGap-18
___ 02:54PM BLOOD Lipase-22
___ 02:54PM BLOOD cTropnT-<0.01 proBNP-566*
___ 02:54PM BLOOD Albumin-3.3* Calcium-9.3 Phos-3.8 Mg-1.8
___ 04:27PM BLOOD K-7.9*
___ 04:59PM BLOOD K-4.5
STUDIES:
=======
___ CHEST W/O CONTRAST
IMPRESSION:
1. Interval progression of disease on the right with now near
complete
consolidation of the right lung. Progression of malignancy is
possible though superimposed infection would also be possible
given rapid interval
development.
2. Persistent moderate loculated effusion at the right lung base
now with
larger foci of internal air to be correlated with interval
intervention.
3. New small left pleural effusion and small pericardial
effusion.
___ LOWER EXT VEINS
IMPRESSION:
1. Nonocclusive thrombus in the left distal femoral vein.
2. Occlusive thrombus in at least one right gastrocnemius vein.
___ (PA & LAT)
IMPRESSION:
Overall, no significant interval change from 1 day prior,
including complete opacification of the right hemithorax and
right-sided loculated pneumothorax. Similar small left pleural
effusion.
DISCHARGE LABS:
=================
___ 07:42AM BLOOD WBC-9.0 RBC-3.88* Hgb-10.0* Hct-33.1*
MCV-85 MCH-25.8* MCHC-30.2* RDW-14.3 RDWSD-44.2 Plt ___
___ 07:42AM BLOOD Glucose-90 UreaN-19 Creat-0.7 Na-140
K-4.3 Cl-99 HCO3-26 AnGap-15
___ 07:42AM BLOOD Calcium-9.1 Phos-3.4 Mg-1.5*
Brief Hospital Course:
___ year old woman with metastatic NSCLC previously on multiple
lines of therapy including XRT, most recently on Pembrolizumab
C1D1 ___, who initially presented with severe shortness of
breath, found to have complete white out of R lung likely from
malignant obstruction on ___, with initial plans for
bronchoscopy, however subsequently deferred given goals of care.
With malignant obstruction causing radiographic findings, was
also started on levofloxacin for postobstructive pneumonia. Also
found to have bilateral lower extremity DVTs, was initially
placed on a heparin drip, and subsequently transitioned to
Xarelto. After extensive goals of care conversations, was
transitioned to DNR/DNI, discharged home with hospice.
ACUTE ISSUES
===============
# Acute on chronic hypoxic respiratory failure
# Right lung consolidation - History of metastatic NSCLC on
multiple lines of therapy including XRT, most recently on
Pembrolizumab C1D1 ___, initially presenting with severe
dyspnea. Chest x-ray on admission showing complete opacification
of right hemithorax secondary to large pleural effusion and
atelectasis of right lung remnant. Also with loculated right mid
to lower chest pneumothorax. Radiographic findings in the
setting of malignant obstruction. Initially plan for
bronchoscopy, however this was subsequently deferred as it was
not within the patient's goals of care. Decision was made to
transition to DNR/DNI and discharged home with hospice.
Patient's symptoms were treated with duonebs, Morphine SR (MS
___ 15 mg PO DAILY, Morphine Sulfate (Concentrated Oral
Solution) 20 mg/mL 10 mg PO Q2H:PRN, and LORazepam 0.5 mg PO/NG
Q4H:PRN. Also provided scopolamine patch given copious
secretions.
# Post-obstructive PNA - Given radiographic findings, difficult
to exclude underlying pneumonia, patient was started on
levofloxacin ×7 days for postobstructive pneumonia.
# DVT - Bilateral LENIS obtained showed nonocclusive thrombus in
the left distal femoral vein and occlusive thrombus in right
gastrocnemius vein. Patient was initially started on heparin
drip, and subsequently transitioned to Xarelto with plan for 50
mg twice daily for 3 weeks, followed by 20 mg daily.
CHRONIC ISSUES
================
# Adenocarcinoma of the RUL, initially stage IIIA (pT2aN2, EGFR
exon 21 L85___, ___ now with recurrent/stage IV disease (___)
with metastasis to the right pleura and brain, s/p osimertinib,
on palliative Pembrolizumab since ___. As per goals of care
conversation above, plan to defer additional intervention,
discharge home with hospice.
# Acute on chronic cancer associated pain - Patient was
continued on
home MS contin ___ and Morphine Sulfate (Concentrated Oral
Solution) 20 mg/mL 10 mg PO Q2H:PRN.
TRANSTIONAL ISSUES
=====================
[ ] NEW/CHANGED MEDICATIONS
- Started rivaroxaban 15mg PO BID for PE x 3 weeks (continue
through ___ followed by 20mg QD
- Increased morpine sulfate 20mg/mL 5mg Q4H:PRN to 10mg PO
Q2H:PRN for dyspnea
- Increased lorazepam 0.5mg PO Q6H:PRN to Q4H:PRN for refractory
dyspnea
- Started fluticasone NASAL 2 SPRY NU DAILY for congestion
- Started levofloxacin 750mg PO Q48H for post-obstructive PNA to
continue through ___
- Started modafinil 200mg PO QAM
- Scopolamine Patch 1 PTCH TD ONCE Duration: 72 Hours for
secretions
[ ] Discharged home with hospice. Continue to assess comfort and
required hospice services
#Code Status: DNR/DNI
#Communication
Health care proxy chosen: Yes
Name of health care proxy: ___
Relationship: spouse
Phone number: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Citalopram 20 mg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. Milk of Magnesia 30 mL PO QHS:PRN constipation
4. Genteal Tears (PF) (dextran 70-hypromellose (PF)) 0.1-0.3 %
ophthalmic (eye) as needed for dry eyes
5. LORazepam 0.5 mg PO Q6H:PRN anxiety
6. Morphine Sulfate (Concentrated Oral Solution) 20 mg/mL 5 mg
PO Q4H:PRN Pain - Moderate
7. Morphine SR (MS ___ 15 mg PO DAILY
8. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Second
Line
9. levalbuterol tartrate 45 mcg/actuation inhalation Q6H:PRN
wheezing
10. Morphine SR (MS ___ 30 mg PO BID
11. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
12. Gabapentin 300 mg PO QHS
Discharge Medications:
1. Fluticasone Propionate NASAL 2 SPRY NU DAILY congestion
RX *fluticasone 50 mcg/actuation 1 2 spray in each nostril
daily:PRN Disp #*1 Spray Refills:*0
2. Levofloxacin 750 mg PO Q48H
RX *levofloxacin 750 mg 1 tablet(s) by mouth Q48H Disp #*3
Tablet Refills:*0
3. Modafinil 200 mg PO QAM
RX *modafinil 200 mg 1 tablet(s) by mouth QAM Disp #*30 Tablet
Refills:*0
4. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth Q8H:PRN Disp #*30
Tablet Refills:*0
5. Rivaroxaban 15 mg PO BID
RX *rivaroxaban [Xarelto] 15 mg 1 tablet(s) by mouth twice a day
Disp #*40 Tablet Refills:*0
6. Rivaroxaban 20 mg PO DAILY
RX *rivaroxaban [___] 20 mg 1 tablet(s) by mouth Daily Disp
#*30 Tablet Refills:*0
7. Scopolamine Patch 1 PTCH TD ONCE Duration: 72 Hours
RX *scopolamine base 1 mg/3 day Apply 1 patch over 3 days Disp
#*10 Patch Refills:*0
8. LORazepam 0.5 mg PO Q4H:PRN Refractory dyspnea/anxiety
RX *lorazepam 0.5 mg 1 by mouth Q4H:PRN Disp #*30 Tablet
Refills:*0
9. Morphine Sulfate (Concentrated Oral Solution) 20 mg/mL 10 mg
PO Q2H:PRN Dyspnea/pain
RX *morphine concentrate 100 mg/5 mL (20 mg/mL) 0.5mL by mouth
Q2H:PRN Refills:*0
10. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth Daily
Disp #*30 Packet Refills:*0
11. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
12. Citalopram 20 mg PO DAILY
13. Docusate Sodium 100 mg PO BID
14. Gabapentin 300 mg PO QHS
15. Genteal Tears (PF) (dextran 70-hypromellose (PF)) 0.1-0.3 %
ophthalmic (eye) as needed for dry eyes
16. levalbuterol tartrate 45 mcg/actuation inhalation Q6H:PRN
wheezing
17. Milk of Magnesia 30 mL PO QHS:PRN constipation
18. Morphine SR (MS ___ 15 mg PO DAILY
Administer 30mg QAM, 15mg during day, and 30QPM
19. Morphine SR (MS ___ 30 mg PO BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
# Acute on chronic hypoxic respiratory failure
# Right lung consolidation
# Bilateral lower extremity venous thrombosis
# Post obstructive PNA
SECONDARY DIAGONSIS
# Adenocarcinoma of the RUL, initially stage IIIA
# Acute on chronic cancer associated 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 taking care of you at ___
___.
Why did you come to the hospital?
- You initially came to the hospital because of severe worsening
shortness of breath
What happened during your hospitalization?
-Your chest x-ray showed that you had a right lung collapse from
your cancer
-You were found to have blood clots in your legs and you were
started on a blood thinner
-You were also treated for antibiotics for pneumonia
-After several conversations regarding your goals of care, the
decision was made to discharge you home with hospice
What should you do when you leave the hospital?
-Continue to take all your medications as prescribed
-You can keep any additional healthcare appointments you already
have scheduled
Sincerely,
Your ___ care team
Followup Instructions:
___
|
19548303-DS-13
| 19,548,303 | 28,513,764 |
DS
| 13 |
2175-12-13 00:00:00
|
2175-12-13 16:04:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
dyspnea, respiratory distress
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ h/o smoking, severe end-stage COPD on home
O2 of ___, presenting with increasing dyspnea, sputum
production and transferred to MICU for need for NIPPV.
.
Roughtly one week prior to admission reports gradual onset nasal
congestion, Patient called HCA triage on ___ with c/o that
congestion had progressed to his chest, and noted associated
thick secretions.
.
Wake this with morning with acute worsening of SOB. Progressive
symptoms prompted patient to call EMS. Sat 86% on RA per EMS, RR
___. On arrival to the ED, patient noted to be tri-poding.
Exam consistent with poor air entry and wheeze therefore
Treatment for COPD flare initiated with solumedrol 125mg,
azithro/CTX and patient placed on NIPPV; off CPAP desaturated
87% on 3L. CXR demonstrated hyperlucency of upper and mid zones
c/w severe emphysema, patchy opacities at bilateral bases,
left>right c/w crowding at emphysematic bases though cant rule
out super-imposed infiltrate. VS prior to transfer 100%02 on
CPAP ___ 100%, RR: 18, additional VS: 139/79 HR 98.
Past Medical History:
- COPD, on 4 L home oxgyen and 10 mg prednisone every other day,
followed by ___, no prior intubations
- Diabetes Mellitus, type 2
- Obstructive sleep apnea, followed by ___, in
process of starting therapy but not currently on non-invasive
- Likely CAD (coronary calcifications on CT)
- Depression/Anxiety
- Diverticulosis
- Scrotal hydrocele
- Dupuytren contractures
Social History:
___
Family History:
(per chart)
Multiple family members with DM
Brother with colon cancer
No family history of lung disease
Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: significantly redused air entry with distant breath
sounds, scattered wheezes. R less air entry than L.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
Pertinent Results:
Admission Labs:
___ 07:00AM BLOOD WBC-9.4 RBC-4.69 Hgb-13.7* Hct-40.1
MCV-85 MCH-29.2 MCHC-34.2 RDW-12.6 Plt ___
___ 07:00AM BLOOD ___ PTT-27.9 ___
___ 07:00AM BLOOD Glucose-155* UreaN-10 Creat-0.8 Na-142
K-3.8 Cl-97 HCO3-35* AnGap-14
___ 12:23PM BLOOD Type-ART Temp-37.2 pO2-154* pCO2-89*
pH-7.28* calTCO2-44* Base XS-11 Intubat-NOT INTUBA
___ 04:33PM BLOOD Type-ART FiO2-40 pO2-74* pCO2-78*
pH-7.34* calTCO2-44* Base XS-11 Intubat-NOT INTUBA
___ 10:15PM BLOOD Type-ART pO2-64* pCO2-68* pH-7.38
calTCO2-42* Base XS-11 Intubat-NOT INTUBA
___ 06:08AM BLOOD Type-ART pO2-84* pCO2-76* pH-7.36
calTCO2-45* Base XS-12 Intubat-NOT INTUBA
___ 10:15PM BLOOD O2 Sat-92
Discharge Labs:
___ 05:15AM BLOOD WBC-8.3# RBC-4.40* Hgb-12.7* Hct-37.8*
MCV-86 MCH-28.8 MCHC-33.6 RDW-12.6 Plt ___
___ 05:15AM BLOOD Glucose-98 UreaN-12 Creat-0.7 Na-142
K-3.7 Cl-99 HCO3-39* AnGap-8
ECGs:
Cardiovascular Report ECG Study Date of ___ 8:07:40 ___
Sinus rhythm. Poor R wave progression, probable normal variant.
Non-specific lateral ST-T wave changes. Compared to the previous
tracing of ___ the sinus rate is slower. The findings are
otherwise similar.
Cardiovascular Report ECG Study Date of ___ 7:09:08 AM
Baseline artfact. Probable sinus tachycardia. Poor R wave
progression.
Non-specific ST-T wave abnormalities, although artifact makes
interpretation difficult. Compared to the previous tracing of
___ sinus tachycardia and artifact are new.
Read by: ___.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
120 0 98 ___
IMAGING:
- Portable TTE (Complete) Done ___ at 1:56:18 ___ FINAL
-
IMPRESSION: Suboptimal image quality. Normal biventricular
cavity sizes with preserved global and regional biventricular
systolic function. No valvular pathology or pathologic flow
identified. Dilated ascending aorta.
CLINICAL IMPLICATIONS:
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.
Brief Hospital Course:
Mr. ___ is a ___ year old man with history of current tobacco
use, severe end-stage COPD on home O2 of ___ NC, admitted to
the MICU for COPD exacerbation, requiring NIPPV on presentation.
# COPD Exacerbation
Patient was admitted for COPD exacerbation, initially to MICU
for non-invasive ventilation, then transitioned back to nasal
canula over one day. Patient reports that last exacerbation was
about six months ago, for which he was not hospitalized, but he
created his own prednisone taper based on symptoms, which lasted
a couple of months. Patient was initially started on
ceftriaxone and azithromycin for treatment of potential LLL
pneumonia. Ceftriaxone was discontinued in MICU because
pneumonia was felt to be unlikely. He required albuterol
nebulizers every 2 hours in the MICU, transitioned to every 6
hours on the floor. He was also started on prednisone 60mg
daily on admission, transitioned to 40mg daily after 4 days.
Prednisone taper as follows: prednisone 40mg x 4 more days,
then decrease to prednisone 30mg x 6 days, then prednisone 20mg
x 6 days, then prednisone 10mg x 6 days, then back to home dose
of prednisone 10mg every other day. Patient may uptitrate for
symptoms if needed, but he should call primary care physician
___ doing so. He would like to join outpatient
pulmonary rehab at ___ once he meets requirements for smoking
cessation. Followup appointment with Dr. ___ was set up.
He was also started on alendronate in setting of chronic
prednisone use.
# Tobacco Use
Patient was counseled extensively on smoking cessation. He will
use nicotine patches at home, starting with 21mg/day patches,
which he states he already has. He was seen by social work for
extra support.
# DM2
Patient was well controlled on home metformin, but had a few
elevated blood sugars while on high dose steroids. He was
maintained on insulin sliding scale during hospitalization, but
transitioned back to metformin 500mg daily on discharge. Blood
sugars should be monitored while on prednisone taper.
# Hypertension
Patient with elevated blood pressures at primary care office on
multiple occasions, not on any medications yet. Had moderately
elevated blood pressures during hospitalization, ranging
120s-160s systolic. Will defer starting low dose agent to
primary care physician.
# Depression
Patient became anxious after discussion about severity of his
COPD. Spoke with social work for extra support. Continued on
home venlafaxine.
Transitional Issues:
- smoking cessation
- dilated aortic root seen on TTE (which was done in MICU to
look for ___ as potential etiology of shortness of breath) -->
needs followup echocardiogram in ___ year or in ___ years if
clinically stable
- monitor blood pressures
- consider starting bactrim for PCP prophylaxis
Medications on Admission:
FLUTICASONE [FLONASE] - 50 mcg Spray, Suspension - 2 sprays each
nostril once daily *** not currently taking
FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 250 mcg-50 mcg/Dose
Disk
with Device - 1 inhaled twice a day
LORATADINE - 10 mg Tablet - 1 Tablet(s) by mouth once a day as
needed for allergic symptoms *** not currently taking
METFORMIN [GLUCOPHAGE] - 500 mg Tablet - 1 Tablet(s) by mouth
once a day
PREDNISONE - 10 mg Tablet - 1 Tablet(s) by mouth ___ as
directed, but took 50mg today, and had been taking 60 earlier
this week
TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - 18 mcg Capsule,
w/Inhalation Device - one capsule inhaled once a day Empty
capsule into inhalation device
VENLAFAXINE - (Prescribed by Other Provider) - 225 mg Tablet
Extended Rel 24 hr - 1 (One) Tablet(s) by mouth
Discharge Medications:
1. prednisone 10 mg Tablet Sig: AS DIRECTED Tablet PO once a
day: - Prednisone 40mg x 4 days
- Prednisone 30mg x 6 days
- Prednisone 20mg x 6 days
- Prednisone 10mg x 6 days,
- then back to your previous dosing of prednisone 10mg every
other day
.
2. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) cap Inhalation once a day.
3. venlafaxine 75 mg Capsule, Ext Release 24 hr Sig: Three (3)
Capsule, Ext Release 24 hr PO DAILY (Daily).
4. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation BID (2 times a day).
5. metformin 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. temazepam 30 mg Capsule Sig: One (1) Capsule PO at bedtime as
needed for insomnia.
7. loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day as
needed for allergic symptoms.
8. Calcium 500 + D 500 mg(1,250mg) -400 unit Tablet, Chewable
Sig: One (1) Tablet, Chewable PO twice a day.
9. alendronate 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
10. nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily) for 5 weeks.
Disp:*30 Patch 24 hr(s)* Refills:*0*
11. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) capsule Inhalation every six (6) hours
as needed for shortness of breath.
12. ipratropium bromide 0.02 % Solution Sig: One (1) capsule
Inhalation every six (6) hours as needed for shortness of breath
or wheezing.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
COPD Exacerbation
Diabetes Mellitus
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ for ___ COPD
exacerbation. You were started on high dose prednisone and
given a 5 day course of azithromycin treatment. You will need
to continue prednisone for a few weeks, as listed below. As we
discussed, if you feel that the taper is too rapid, you can
increase your dose as needed, but please call Dr. ___ you
need to do this. Please also discuss smoking cessation with Dr.
___.
The following changes have been made to your medications:
* Prednisone taper as follows:
- Prednisone 40mg x 4 days
- Prednisone 30mg x 6 days
- Prednisone 20mg x 6 days
- Prednisone 10mg x 6 days, then back to your previous dosing
of prednisone 10mg every other day
* Please also start Alendronate 10mg daily and discuss this with
your primary care physician. You must be seated upright when
taking this medication and drink a full glass of water with it.
* Please continue taking calcium and vitamin D
* Please start using the Nicotine Patch as follows:
- nicotine patch 21 mg/day (highest dose) for 5 more weeks
- nicotine patch 14 mg/day for 2 weeks
- nicotine patch 7 mg/day for 2 weeks
(Your current prescription is only for 30 days of the 21mg/day
nicotine patch.)
While you were here you were seen by social work. She provided
you with information on smoking cessation and relaxation
techniques. It was alos recommended that you engage in out
atient therapy to help you cope with your chronic illness and
anxiety. You can contact one of the following to make an
appointment:
Dr. ___
___
___
___
___
___
If you need more referrals or any further assistance, please
contact the social worker you saw while you were here: ___
___ ___
Followup Instructions:
___
|
19548307-DS-14
| 19,548,307 | 28,542,533 |
DS
| 14 |
2163-09-17 00:00:00
|
2163-09-25 21:44:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old male with no significant medical history presents
following a fall down 25 stairs while intoxicated. He was
initially evaluated at OSH and found to have C5 laminar fracture
and right clavicular fracture and sent to ___ for further
evaluation.
Past Medical History:
None
Social History:
___
Family History:
n/c
Physical Exam:
General: sitting comfortably in bed in no acute distress
HEENT: EOMI, PERRLA, no septal hematoma, periorbital/retroaural
ecchymoses, good occlusion, neck in hard collar
CV: Regular rate and rhythm
Lungs: Breathing comfortably
Abdomen: Soft, non-tender, non-distended
Extremities: Right Arm in sling, TTP over R shoulder
Pertinent Results:
TRAUMA #3 (PORT CHEST ONLY) Study Date of ___ 12:34 AM
IMPRESSION:
1. Mildly displaced lateral right clavicular fracture.
2. Remote left fourth posterior rib fracture.
3. No cardiopulmonary injury is identified.
Please note that chest radiography is limited for evaluation of
blunt trauma.
CT CHEST W/CONTRAST Study Date of ___ 1:09 AM
IMPRESSION:
1. Acute right eighth through tenth nondisplaced rib fractures.
2. Remote left fifth and sixth rib fractures.
3. No evidence of solid organ injury in the chest, abdomen, or
pelvis.
4. Please note that the known right clavicle fracture is not
imaged.
CTA NECK W&W/OC & RECONS Study Date of ___ 1:20 AM
IMPRESSION
1. Acute nondisplaced fractures of the right C5 lamina and
right C5 inferior
facet extending into the right C5-6 facet joint, with preserved
normal
alignment.
2. No evidence of cervical arterial dissection or stenosis.
3. Multiple periapical lucencies are within the maxilla and
mandible. Please
correlate clinically whether active dental
infection/inflammation may be
present.
4. Symmetrically prominent palatine tonsils, unusual for age.
Please
correlate clinically whether there has been any recent upper
respiratory
infection or allergies to explain this finding. If clinically
warranted,
direct visualization could be considered.
5. Paraseptal emphysema in the imaged upper lungs.
CT Cervical Spine (OSH)
1. nondisplaced Right 5 Lamina and transverse process fractures
2. Incidental/non-acute findings are described above
CT Head w/o contrast (OSH)
1. No acute intracranial abnormality
Brief Hospital Course:
Given findings of Right ___ rib fracture, nondisplaced C5
fracture, Right clavicular fracture patient was admitted to the
Acute Care Surgery service for pain control, monitoring, and
further evaluation.
Neuro: A neurosurgery consult was placed and initial
recommendations for spinal fracture included no acute
neurosurgical intervention, hard cervical collar at all times
and f/u in clinic in ___ weeks with Dr. ___ with repeat
___ CT. The patient was alert and oriented throughout
hospitalization; His neuro exam remained stable. pain was
initially managed with IV narcotics and then transitioned to
oral pain regimen once tolerating a diet.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: The diet was advanced sequentially to a Regular diet,
which was well tolerated. Patient's intake and output were
closely monitored
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
Clavicular Fx: An orthopaedic consultation was obtained and
final recommendations included NWB RUE in sling at all times,
Follow-up with Dr. ___ in clinic this ___.
Clavicle films on non-urgent basis (can be obtained in clinic)
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
RX *acetaminophen 325 mg ___ tablet(s) by mouth every 4 hours
Disp #*30 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID constipation
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*0
3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp
#*60 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Mildly displaced lateral right clavicular fracture
Acute Right ___ Rib Fractures
Acute right eighth through tenth nondisplaced rib fractures
Remote left fourth posterior rib fracture.
Remote left fifth and sixth rib fractures
Acute nondisplaced fractures of the right C5 lamina and right C5
inferior facet extending into the right C5-6 facet joint
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were evaluated at ___ following a fall. You were found to
have a cervical spine fracture, a clavicular fracture, and
multiple rib fractures.
* Your injury caused 3 rib fractures which can cause severe pain
and subsequently cause you to take shallow breaths because of
the pain.
* You should take your pain medication as directed to stay ahead
of the pain otherwise you won't be able to take deep breaths. If
the pain medication is too sedating take half the dose and
notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to hold
against your chest and guard your rib cage while coughing and
deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non-steroidal ___ drugs
are very effective in controlling pain (ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
Regarding your Clavicular Fracture
Please do not bear or lift any weight with your Right Arm
Please follow these instructions carefully:
* Keep the injured part raised (higher than your heart) as
much as possible during the first two days. This is very
important if you
have a cast.
* Use frequently cold packs on the injury to lessen swelling
during the first two days. Place ice in a plastic bag and wrap
the bag in a towel. DO NOT PUT ICE DIRECTLY ON YOUR SKIN.
* Rest the injured part of your body. Please use RUE sling
provided during your hospitalization stay. Do not use your right
arm to bear any weight or lift any heavy objects until
follow-up.
*PLEASE WEAR YOUR HARD COLLAR AT ALL TIMES UNTIL FOLLOWUP WITH
YOUR NEUROSURGEON
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
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
* any acute shortness of breath, increased pain or
crackling sensation around your ribs (crepitus).
Followup Instructions:
___
|
19548728-DS-9
| 19,548,728 | 22,782,592 |
DS
| 9 |
2121-04-16 00:00:00
|
2121-04-16 10:46:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
Laparoscopic appendectomy
History of Present Illness:
___ who presented with RLQ pain that started ___ at 1000.
She has reported h/o RUQ/epigastric pain in past that she
correlates to gallstones in past and had similar episode of this
pain three days ago. The RLQ pain has persisted and
progressively worsened over this time frame. She has no current
RUQ/epigastric pain. She has had decreased episode and had 2
episodes of NBNB emesis. She denies any fevers, chills, chest
pain, SOB.
Past Medical History:
PMH:
GERD, hip dysplasia, migraines
PSH:
Rt hip fixation, labral tear right shoulder
Social History:
___
Family History:
non-contributory
Physical Exam:
T97.5 HR77 BP 140/88 RR18 Pox97%
GEN: NAD, AAOx3, breathing comfortably
HEART: RRR S1S2
PULM: CTAB
AB: soft, mild TTP in lower abdomen, nondistended, nonsaturated
dressings, normal bowel sounds
EXT: peripheral pulses intact bilaterally
Pertinent Results:
___ 06:25PM BLOOD WBC-7.0 RBC-4.87 Hgb-13.3 Hct-39.6
MCV-81* MCH-27.3 MCHC-33.6 RDW-13.3 Plt ___
___ 06:25PM BLOOD ___ PTT-35.8 ___
___ 06:25PM BLOOD Glucose-96 UreaN-7 Creat-0.7 Na-140 K-4.0
Cl-104 HCO3-27 AnGap-13
CT AB/PELVIS ___
IMPRESSION:
Acute appendicitis. No evidence of perforation or abscess.
Brief Hospital Course:
The patient was admitted to the Acute Care Surgery Service on
___ after undergoing laparoscopic appendectomy. Please see
the separately dictated operative note for details of procedure.
The patient was extubated and transferred to the hospital floor
for further post-operative care. The post-operative course was
uneventful and the patient was discharged to home.
Hospital Course by Systems:
Neuro: Pain was well controlled, initially with IV regimen which
was transitioned to oral regimen once tolerating oral intake.
Migraines treated with home imitrex and fioricet.
Cardiovascular: Remained hemodynamically stable.
Pulmonary: Oxygen was weaned and the patient was ambulating
independently without supplemental oxygen prior to discharge.
GI: Diet was advanced as tolerated. Bowel regimen was given prn.
GU: A foley catheter was used intra-operatively and removed on
POD0 with patient voiding independently afterwards.
Heme: Received heparin subcutaneously and pneumatic compression
boots for DVT prophylaxis.
ID: Received perioperative antibiotics.
The patient was discharged to home in stable condition,
ambulating, and voiding independently, and with adequate pain
control. The patient was given instructions to follow-up in the
___ clinic in ___ weeks. The patient was also given detailed
discharge instructions outlining wound care, activity, diet,
follow-up, and the appropriate medication scripts.
Medications on Admission:
OCP, Allegra, Imitrex
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Docusate Sodium 100 mg PO BID
3. Sumatriptan Succinate 25 mg PO PRN BID migrane Duration: 1
Dose
4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every ___ hours Disp
#*25 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
acute appendicitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the Acute Care Surgery service on ___
with acute appendicitis, and you underwent a laparoscopic
appendectomy. You are now ready to complete your recovery at
home. Please follow the instructions below:
-You are being given a prescription for a narcotic pain
medication. Please do not drink alcohol or drive while taking
this medication. If you experience constipation, please take
over-the-counter colace.
-You may remove your dressings in 48 hours after your surgery.
You may shower, allowing water to run over your incisions. Do
not rub or irritate your incisions. Pat dry with a towel. Do
not take a bath or go in a swimming pool for ___ weeks after
your surgery.
-You may resume your normal diet as tolerated.
-You may resume activity as tolerated. No strenuous activity or
heavy lifting for at least two weeks.
-Please follow up in the Acute Care Surgery clinic in ___ weeks.
Call ___ to schedule this appointment.
-Call the clinic, or go to the closest ER, if you develop a
fever >101, abdominal pain, drainage/redness from your incision
sites, or for anything else that concerns you.
Followup Instructions:
___
|
19548803-DS-21
| 19,548,803 | 26,074,572 |
DS
| 21 |
2186-12-08 00:00:00
|
2186-12-08 18:36:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Dilaudid / Percocet / percodan
/ Valium / codeine / amoxicillin / Symbicort / verapamil /
Darvocet-N
Attending: ___
Chief Complaint:
heartburn, abdominal pain, chest pain, watery diarrhea
Major Surgical or Invasive Procedure:
___ - Cardiac catheterization with DES to distal OM1
History of Present Illness:
___ POD ___ s/p laparoscopic hiatal hernia repair and
fundoplication returns with nausea/vomiting, watery diarrhea,
abdominal pain, and chest pain since 7pm yesterday (day of
discharge). Her diarrhea was watery, and non-bloody, non-bilious
vomiting occurred after a few sips of tea and one bite of bagel.
She also noted chest pain, which was initially mild but got
worse
this AM, prompting her to come to OSH ED. At OSH ED, her
troponins were elevated at 0.13 x2, and a chest CT was
performed,
which was negative for a PE. She was then transferred to ___
ED
for management of surgical pain.
Upon arrival here, she is hemodynamically stable. Her vomiting
and diarrhea have since resolved, but she still complains of
chest pain, abdominal pain and mild nausea. She states that she
has not been able to take in PO since her surgery.
Past Medical History:
PAST MEDICAL HISTORY:
Severe asthma
CAD
DMII
Gout
GERD
COPD
CKD II/III
PTSD
Anxiety
Social History:
___
Family History:
Mother - cardiac hx, deceased, aortic stenosis
Father - deceased
___ - sister - partial mastectomy/ brother - deceased -
colon cancer
Offspring - 2 daughters - asthma/allergies
Physical Exam:
ADMISSION PHYSICAL EXAM:
======================
T 98.5 HR 70 BP 127/63 RR 16 97% 2L
Gen: Awake and alert
CV: RRR
Resp: CTAB
Abd: Soft, diffusely mildly tender to palpation, mildly
distended, no rebounding/guarding
Incisions: Clean/dry/intact with some ___ bruising
Ext: Warm, well-perfused
DISCHARGE PHYSICAL EXAM:
======================
Vitals: 97.6 162/113 (121-162/60-140) 65 (56-71) 18 96%RA
I/O: 8:+280/-550 and BRP 24: +1240/-1200
Weight on admission 86.4kg
Today's weight: 87.7kg<-86kg<- 86.2kg
GENERAL: WDWN sitting in chair comfortably in NAD. Oriented x3.
Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with no visibly elevated JVP.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4. Mild chest wall tenderness
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB.
ABDOMEN: Soft, tender to palpation over laparoscopic surgical
sites. No rebound tenderness or guarding. No HSM. 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:
==============
___ 05:32AM BLOOD WBC-7.2 RBC-3.53* Hgb-8.6* Hct-29.2*
MCV-83 MCH-24.4* MCHC-29.5* RDW-17.1* RDWSD-51.0* Plt ___
___ 09:10PM BLOOD ___ PTT-28.6 ___
___ 05:32AM BLOOD Glucose-82 UreaN-12 Creat-0.8 Na-140
K-3.2* Cl-101 HCO3-29 AnGap-13
___ 09:10PM BLOOD ALT-37 AST-42* LD(___)-268* AlkPhos-66
TotBili-0.6
___ 09:10PM BLOOD Lipase-21
___ 09:10PM BLOOD CK-MB-6 cTropnT-0.21*
___ 05:32AM BLOOD Calcium-8.2* Phos-3.6 Mg-1.6
OTHER PERTINENT/DISCHARGE LABS:
============================
___ 06:05AM BLOOD WBC-6.9 RBC-3.14* Hgb-7.8* Hct-26.7*
MCV-85 MCH-24.8* MCHC-29.2* RDW-17.4* RDWSD-53.7* Plt ___
___ 06:05AM BLOOD ___ PTT-28.2 ___
___ 06:05AM BLOOD Glucose-79 UreaN-19 Creat-0.9 Na-140
K-4.1 Cl-103 HCO3-25 AnGap-16
___ 01:00PM BLOOD ALT-22 AST-21 LD(___)-250 AlkPhos-66
TotBili-0.2
___ 09:10PM BLOOD ALT-37 AST-42* LD(___)-268* AlkPhos-66
TotBili-0.6
___ 09:10PM BLOOD Lipase-21
___ 05:10AM BLOOD cTropnT-0.30*
___ 05:01AM BLOOD CK-MB-1 cTropnT-0.37* proBNP-___*
___ 04:56AM BLOOD cTropnT-0.42*
___ 03:30PM BLOOD CK-MB-6 cTropnT-0.31*
___ 09:10PM BLOOD CK-MB-6 cTropnT-0.21*
___ 06:05AM BLOOD Calcium-8.5 Phos-3.8 Mg-2.1
IMAGING/STUDIES:
==============
___ KUB:
Nonobstructive bowel gas pattern. Residual barium contrast
within the large bowel.
___ CT Torso outside hospital read :
1. No evidence of pulmonary embolism or aortic abnormality.
2. Pneumomediastinum, small locules of intra-abdominal free air
and fat
stranding about the GE junction is most likely postoperative.
3. Cholelithiasis.
CXR PA/LAT ___
Compared to prior chest radiographs ___.
Heart is mildly enlarged, predominantly the left atrium.
Mediastinal contours now normal. No pleural abnormality. Lungs
are essentially clear, and pulmonary vasculature is
unremarkable. This examination neither suggests nor excludes the
diagnosis of pulmonary embolism.
TTE ___
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is ___ mmHg. Normal left ventricular wall thickness, cavity
size, and regional/global systolic function (biplane LVEF = 58
%). There is no ventricular septal defect. Right ventricular
chamber size and free wall motion are normal. The diameters of
aorta at the sinus, ascending and arch levels are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.
Nuclear stress test ___
Non anginal type symptoms with uninterpretable EKG for ischemia.
1. Moderate reversible inferior wall defect.
2. Normal wall motion with estimated left ventricular ejection
fraction of 52%
Cardiac cath ___
Coronary Anatomy
Dominance: Co-dominant
* Left Main Coronary Artery
The LMCA is normal.
* Left Anterior Descending
The LAD has a widely patent stent in the ___ segment.
The ___ Diagonal is a moderate sized branch. Has widely patent
stent in the ___ segment, but there is a focal 50-60% stenosis
beyond the stent.
* Circumflex
The Circumflex has minimal luminal irregularity, and provides a
mixed dominant system.
The ___ Marginal is without significant disease.
Left posterolateral segment is sub-totally occluded (99%
stenosis) and has TIMI 2 distal flow. There are right to left
collaterals to this segment.
* Right Coronary Artery The RCA is normal.
2 vessel CAD. Successful PTCA/stent of left posterloateral
branch using a drug-eluting stent.
MICROBIOLOGY:
==============
none
Brief Hospital Course:
Ms. ___ was evaluated by the Thoracic Surgery service in the
Emergency Room and admitted to the hospital for further
management of her abdominal pain, heartburn and chest pain. Her
abdominal pain was directed at her port sites which were clean
and healing well. She was using Tramadol and Tylenol at home
for incisional pain as stronger narcotics gave her GI upset.
Her watery diarrhea resolved prior to her admission and her
heartburn improved with Pantoprozole and antacis which she took
at home. She denied any dysphagia but had nausea after drinking
certain liquids (green tea). Her chest pain was midsternal but
more pleuritic in nature and unrelieved with nitroglycerin.
Her nausea and vomiting resolved and she was able to tolerate a
regular diabetic diet. She occasionally complained of heartburn
but this resolved as long as she stayed away from bothersome
foods.
___ year old woman with a history of CAD s/p DES to D1 ___ and
DES to LAD ___ (cath ___ showed patent stents) presenting with
acute on chronic dyspnea and chest pain.
# CORONARIES: DES to D1 ___ and DES to LAD ___ DES to distal
___
# PUMP: EF 58%
# RHYTHM: normal sinus, intermittent LBBB
# Acute on chronic diastolic heart failure
- due to ischemia, underwent stress perfusion test showed
inferior wall defect and subsequent PCI to PLB in OM1 lesion. PO
diuresis with chlorthalidone. TTE with grade II diastolic
dysfunction. Continued Imdur 60mg
# CAD s/p DES ___, now with OM1 lesion treated with DES.
Maintained on ASA 81mg, added clopidogrel 75mg daily (minimum ___
year duration), continued metoprolol XL 100mg daily,
atorvastatin 80mg qHS, ramapril 10mg BID, Imdur 60mg daily as
per above, SL nitro PRN
# Asthma/COPD
- continued home prednisone 10mg daily, albuterol and
ipratropium PRN, fluticasone and montelukast.
# Htn - poorly controlled
- continued amlodipine 10mg daily. Started on chlorthalidone
25mg daily, will d/c with 20mEq potassium daily and BMP at
outpatient f/u in 4 days.
# GERD -severe, likely contributor to poorly controlled asthma
-s/p lap hiatal hernia repair and Nissen
-pantoprazole 40mg BID
-avoided exacerbating foods.
# DM2
- SSI, hold home metformin
TRANSITIONAL ISSUES:
- Please check BMP on ___ given addition of chlorthalidone
25mg daily and 20mEq potassium PO daily to hypertension regimen.
- Discharge weight: 87.7kg
- Full code
- No HCP per pt request, would address as outpatient
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 80 mg PO QPM
2. Fluticasone Propionate NASAL 2 SPRY NU DAILY
3. Hydrochlorothiazide 25 mg PO DAILY
4. Metoprolol Succinate XL 100 mg PO DAILY
5. Montelukast 10 mg PO QHS
6. PredniSONE 10 mg PO DAILY
7. Ramipril 10 mg PO BID
8. Sertraline 150 mg PO DAILY
9. Acetaminophen 650 mg PO Q6H
10. Amlodipine 10 mg PO DAILY
11. Aspirin 81 mg PO DAILY
12. Colchicine 0.6 mg PO BID:PRN gout flare
13. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 allergic reaction
14. Isosorbide Dinitrate 30 mg PO DAILY
15. MetFORMIN (Glucophage) 1000 mg PO QAM
16. MetFORMIN (Glucophage) 500 mg PO QPM
17. Methocarbamol 1500 mg PO BID:PRN pain
18. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN cp
19. Pantoprazole 40 mg PO Q12H
20. TraMADol 50-100 mg PO Q4H:PRN pain
21. Ipratropium Bromide Neb 1 NEB IH BID:PRN SOB
22. Levalbuterol Neb 1.25 mg NEB Q6H:PRN SOB
23. Docusate Sodium 100 mg PO BID
24. Milk of Magnesia 30 mL PO Q12H:PRN constipation
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Amlodipine 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Docusate Sodium 100 mg PO BID
6. Fluticasone Propionate NASAL 2 SPRY NU DAILY
7. Ipratropium Bromide Neb 1 NEB IH BID:PRN SOB
8. MetFORMIN (Glucophage) 1000 mg PO QAM
9. MetFORMIN (Glucophage) 500 mg PO QPM
10. Montelukast 10 mg PO QHS
11. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN cp
12. Pantoprazole 40 mg PO Q12H
13. PredniSONE 10 mg PO DAILY
14. Ramipril 10 mg PO BID
15. Sertraline 150 mg PO DAILY
16. TraMADol 50-100 mg PO Q4H:PRN pain
17. Colchicine 0.6 mg PO BID:PRN gout flare
18. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 allergic reaction
19. Hydrochlorothiazide 25 mg PO DAILY
20. Levalbuterol Neb 1.25 mg NEB Q6H:PRN SOB
21. Methocarbamol 1500 mg PO BID:PRN pain
22. Milk of Magnesia 30 mL PO Q12H:PRN constipation
23. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using HUM Insulin
24. Metoprolol Succinate XL 100 mg PO QHS
25. Isosorbide Mononitrate (Extended Release) 60 mg PO QAM
RX *isosorbide mononitrate 60 mg 1 tablet(s) by mouth once a day
Disp #*90 Tablet Refills:*3
26. Potassium Chloride 20 mEq PO DAILY
RX *potassium chloride [K-Tab] 20 mEq 1 tablet(s) by mouth daily
Disp #*30 Tablet Refills:*0
27. Chlorthalidone 25 mg PO DAILY
RX *chlorthalidone 25 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
28. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
29. Outpatient Lab Work
Basic metabolic panel on ___
ICD 10 Hypertension - I10
Results to Dr. ___: ___
Discharge Disposition:
Home
Discharge Diagnosis:
GERD
Acute on chronic diastolic heart failure
NSTEMI
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Call Dr. ___ ___ if you experience:
-Fevers > 101 or chills
-Difficult or painful swallowing
-Nausea, vomiting. Stay away from foods that don't agree with
you.
-Increased shortness of breath
Pain
-Acetaminophen 650 mg every 6 hours.
-Take stool softners to stay regular
-No driving while taking narcotics
Activity
-Shower daily. Wash incision with mild soap and water, rinse,
pat dry
-No tub bathing, swimming or hot tubs until incision healed
-No lotions or creams to incision
-Walk ___ times a day for ___ minutes increase to a Goal of
30 minutes daily
Diet:
Diabetic soft solids as tolerates
Eat small frequent meals. Sit in chair for all meals. Remain
sitting up for ___ minutes after all meals
NO CARBONATED DRINKS
* If you have any chest pain, shortness of breath or any
symptoms that concern you, call Dr. ___ at ___
or go to the nearest Emergency Room.
You were evaluated by the ___ Cardiology team because you
developed worse chest pain and shortness of breath during your
hospital team. You were evaluated with a stress test which
showed a reversible defect which was treated with a drug eluting
stent via cardiac catheterization. You should continue on
Plavix, also known as clopidogrel, until your cardiologist tells
you otherwise. You will need to continue on aspirin
indefinitely. You were also started on a new blood pressure
medication, chlorthalidone, and a potassium supplement.
Followup Instructions:
___
|
19549572-DS-10
| 19,549,572 | 26,728,667 |
DS
| 10 |
2171-05-20 00:00:00
|
2171-05-20 18:59:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
R sided weakness and facial
droop.
Major Surgical or Invasive Procedure:
thrombectomy
History of Present Illness:
Pt is an ___ yr F w/ PMH of HTN, Afib on Coumadin and bradycardia
s/p PPM who presented to OSH with R sided weakness and facial
droop. LKW at 9pm before going to bed. Reportedly, pt woke up
at
11:40pm not feeling well but went back to sleep. She woke up
later with R sided weakness and facial droop noted by her
husband
and was brought to OSH ED where her symptoms initially improved
and then worsened. There she had ___ of 10 and INR of 2.3. CTA
showed distal basilar artery occlusion. She was subsequently
transferred to ___ for further management with repeat CTA
showing basilar tip occlusion. As a result, she was taken
emergently for neurovascular intervention. Of note, pt's INR
here
was seen to be 1.9.
Husband reports that pt has not had strokes in the past and is
relatively compliant with AC therapy. Previous smoker in distant
past.
Unable to obtain ROS due to pt's clinical status and need for
urgent intervention
Past Medical History:
Atrial fibrillation
Hypertension
Osteoporosis
Anxiety
Frozen shoulder-? Arthritis
Tonsillectomy
Appendectomy
Cholecystectomy
S/P Tubaligation
S/p left elbow pain
Social History:
___
Family History:
N/C
Physical Exam:
Admission exam:
Vitals: HR: 61 BP: 149/75 RR: 23 SaO2: 100% NC
General: NAD
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: irregularly irregular rhythm, no M/R/G
Pulmonary: CTAB, no crackles or wheezes
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema
Neurologic Examination:
- Mental status: Appeared awake and alert. Oriented to person.
Expressive aphasia present w/ intact comprehension. Able to name
objects on ___ card. Dysprosody with slow, stuttering speech.
Attentive to examiner. Mild dysarthria. No apraxia. No evidence
of hemineglect. No left-right confusion. Able to follow both
midline and appendicular commands.
- Cranial Nerves: PERRL 2->1 brisk. VF full to confrontation.
EOMI, no nystagmus. Decreased activation of R facies. Unable to
assess other elements of CN exam.
- Motor: Normal bulk and tone. No drift seen when prompted to
lift arms and legs into air, able to maintain AG. No
adventitious
movements.
- Sensory: Withdrawal to noxious in all extremities.
- Coordination/Gait: Mild dysmetria on FNF R>L.
Discharge exam:
Heart rhythm: A Paced, V Paced
Gen: awake, alert, comfortable, in no acute distress
HEENT: normocephalic atraumatic, no oropharyngeal lesions
CV: warm, well perfused
Pulm: breathing non labored on room air
Extremities: no cyanosis/clubbing or edema
Neurologic:
-MS: Awake, alert, oriented to self, place, time and situation.
Easily maintains attention to examiner. Able to say months of
the year backwards. Speech fluent, no dysarthria. No evidence
of hemineglect.
-CN: Gaze conjugate, PERRL, mild left ptosis, EOMI no nystagmus,
face symmetric, palate elevates symmetrically, tongue midline
-Motor: normal bulk and tone. subtle R arm pronator drift. No
tremor or asterixis.
Delt Bic Tri ECR FEx FFl IO IP Quad Ham TA Gas
___
L 5 5 5 5 5 5 5 5 5 5 5 5 5
R 5 5 4 5 5 5 5 5 5 5 5 5 5
-Sensory: intact to LT and proprioception in bilateral UE and ___
-Coordination: finger nose finger intact, no dysmetria
-Gait: narrow based, no ataxia or sway
Pertinent Results:
___ 05:42AM GLUCOSE-131* UREA N-18 CREAT-0.9 SODIUM-136
POTASSIUM-4.3 CHLORIDE-103 TOTAL CO2-23 ANION GAP-14
___ 05:42AM ALT(SGPT)-26 AST(SGOT)-29 LD(LDH)-225
CK(CPK)-75 ALK PHOS-52 TOT BILI-0.3
___ 05:42AM GGT-31
___ 05:42AM CK-MB-2 cTropnT-<0.01
___ 05:42AM TOT PROT-6.0* ALBUMIN-3.7 GLOBULIN-2.3
CHOLEST-163
___ 05:42AM %HbA1c-4.6 eAG-85
___ 05:42AM TRIGLYCER-217* HDL CHOL-67 CHOL/HDL-2.4
LDL(CALC)-53
___ 05:42AM TSH-1.8
___ 05:42AM CRP-4.1
___ 05:42AM WBC-8.1 RBC-3.00* HGB-9.9* HCT-31.5* MCV-105*
MCH-33.0* MCHC-31.4* RDW-13.3 RDWSD-51.7*
___ 05:42AM NEUTS-86.3* LYMPHS-5.8* MONOS-6.9 EOS-0.1*
BASOS-0.4 IM ___ AbsNeut-6.98* AbsLymp-0.47* AbsMono-0.56
AbsEos-0.01* AbsBaso-0.03
___ 05:42AM PLT COUNT-197
___ 05:42AM ___ PTT-32.6 ___
___ 03:45AM URINE HOURS-RANDOM
___ 03:45AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG
___ 03:45AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 03:45AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 03:45AM URINE RBC-5* WBC-1 BACTERIA-NONE YEAST-NONE
EPI-<1
___ 03:43AM GLUCOSE-133* UREA N-19 CREAT-0.9 SODIUM-138
POTASSIUM-4.7 CHLORIDE-104 TOTAL CO2-24 ANION GAP-15
___ 03:43AM estGFR-Using this
___ 03:43AM estGFR-Using this
___ 03:43AM WBC-12.1*# RBC-3.40* HGB-11.2 HCT-35.2
MCV-104*# MCH-32.9*# MCHC-31.8* RDW-13.3 RDWSD-50.6*
___ 03:43AM NEUTS-88.3* LYMPHS-5.8* MONOS-4.9* EOS-0.2*
BASOS-0.4 IM ___ AbsNeut-10.70* AbsLymp-0.70* AbsMono-0.59
AbsEos-0.03* AbsBaso-0.05
___ 03:43AM PLT COUNT-240
___ 03:43AM ___ PTT-34.1 ___
CTA head and neck ___. Probable late subacute or chronic inferior left occipital
lobe infarction. Recommend correlation with outside hospital
imaging, if available. Gray-white matter differentiation is
relatively preserved elsewhere.
2. Focal hypoattenuation in the left and central aspect of the
pons is
probably artifactual given the amount of streak artifact at this
level.
3. The distal basilar artery is occluded to the level of the
basilar tip. The proximal P1 segments are reconstituted by small
posterior communicating arteries.
4. Moderate to severe proximal right V1 segment stenosis. This
will be better evaluated upon completion of curved reformats.
5. The remaining major vessels of the neck, circle of ___,
and their
principal intracranial branches appear normal without stenosis,
occlusion, or aneurysm formation.
6. Mediastinal lymphadenopathy. Recommend correlation with
oncologic history, not available at the time of preliminary
examination interpretation.
7. Multinodular thyroid gland with calcifications. No nodule
larger than 1.5 cm. Per ACR guidelines on incidentally
discovered thyroid nodules, no
specific follow-up is recommended.
8. Moderate paraseptal emphysema.
Final read pending 3D and curved reformats.
MRI ___
1. No evidence of acute infarction.
2. Mild age-appropriate involutional changes and nonspecific T2
and FLAIR
hyperintensities likely representing the sequela of chronic
microvascular
disease.
Brief Hospital Course:
___ female with PMH of HTN, Afib on Coumadin, 3rd degree
AV block s/p pacemaker who initially presented to an OSH with
right side weakness and right facial droop. CTA revealed basilar
artery occlusion. She was deemed not a candidate for tPA and was
transferred to ___ for clot retrieval. On arrival to ___,
___ was 5 for right facial droop, mild expressive aphasia,
mild R weakness, dysarthria. A repeat CTA here showed distal
basilar artery occlusion to the level of the basilar tip. Labs
were notable for INR 1.9 and patient emergently underwent
successful clot retrieval. She was intubated for the
thrombectomy and taken to PACU. Post procedure she was admitted
to ___ for further post-op monitoring. She was successfully
extubated on the morning of ___. Blood pressure goal was <180.
She was maintained on her home amiodarone and atenolol was
halved. Warfarin was initially held, then resumed with aspirin
bridge.
Of note, she has a pacemaker which was placed in ___ after she
underwent a PVI procedure and developed post-operative
bradycardia. Confirmed that pacemaker is MRI compatible. The
patient underwent an MRI on ___ which showed a punctate infarct
involving the splenium of the corpus callosum, but no
significant other injury. A TTE showed an atrial septal defect.
Subsequent lower extremity dopplers were negative for deep
venous thrombosis. A CTV did not show evidence of DVT. She was
discharged on therapeutic Coumadin, as well as atorvastatin.
Follow with Neurology after discharge.
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed â () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No
4. LDL documented? (x) Yes (LDL = 53) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) (x) Yes - () No [if
LDL 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: ()
Antiplatelet - (x) Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? (x) Yes - () No - () N/A
Transitional Issues
[ ] daily INR until stabilized
[ ] follow up with stroke neurology as above
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 25 mg PO DAILY
2. Amiodarone 200 mg PO EVERY OTHER DAY
3. Warfarin 4 mg PO DAILY16
4. Omeprazole 20 mg PO DAILY
5. Cyanocobalamin 1000 mcg PO DAILY
Discharge Medications:
1. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*5
2. Warfarin 3 mg PO DAILY16
RX *warfarin 3 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*3
3. Amiodarone 200 mg PO EVERY OTHER DAY
4. Atenolol 25 mg PO DAILY
5. Cyanocobalamin 1000 mcg PO DAILY
6. Omeprazole 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Basilar occlusion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ,
You were hospitalized due to symptoms of right sided weakness
resulting from an ACUTE ISCHEMIC STROKE, a condition where a
blood vessel providing oxygen and nutrients to the brain is
blocked by a clot. The brain is the part of your body that
controls and directs all the other parts of your body, so damage
to the brain from being deprived of its blood supply can result
in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
ATRIAL FIBRILLATION
HIGH BLOOD PRESSURE
We are changing your medications as follows:
START ATORVASTATIN 40MG DAILY
COUMADIN DOSE CHANGE TO 3.5MG
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:
___
|
19549821-DS-10
| 19,549,821 | 25,142,148 |
DS
| 10 |
2117-09-09 00:00:00
|
2117-09-11 07:35:00
|
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 and vomiting, fatigue in setting of recent infection
Major Surgical or Invasive Procedure:
None
History of Present Illness:
PCP:Name: ___
Location: HEALTHCARE ASSOCIATES
___
Address: ___, ___
Phone: ___
Fax: ___
_
________________________________________________________________
HPI:
___ y/o woman with PMH of breast cancer s/p radiation, lumpectomy
in ___, CAD s/p STEMI with PCI, type 1 diabetes c/b nephropathy,
neuropathy, retinopathy, osteoporosis, and femoral fracture in
___ recentl admitted from ___ - ___ with influenza ->
DKA now p/w/ recurrent nausea and vomiting since ___
night, shortly before admission. She initially felt well after
discharge and then 2 days prior to admission developed nausea
and vomiting and was not able to tolerate po. + fatigue,
reporting that she attempted to return to work for a full day on
the day prior to developing the symptoms. She returned from work
(___) and noted mild nausea, which gradually escalated. Her
vomitus was non bloodly, non-bilious and also dry heaves. She
also reported w/ left CVA pain. She denied fevers, chills, cough
or SOB. No interval or recent travel. She reports having had one
formed stool during this time, no diarrhea. No abdominal
surgeries.
In ER: (Triage Vitals:98 98 160/92 16 100% )
Meds Given:Morphine 5 mg Vial [class 2] 1 ___
___ 17:39 Ondansetron 2mg/mL-2mL 1 ___
___ 19:19 Ondansetron 2mg/mL-2mL 1 ___
___ 22:38 Lorazepam 2mg/mL Syringe [class 4] 1 ___
___ given: 2L NS
Radiology Studies:bedside US demonstrated complete IVC collapse
with inspiration concerning for dehydration
PAIN SCALE: ___
________________________________________________________________
REVIEW OF SYSTEMS: 10 or 2 with "all otherwise negative"
CONSTITUTIONAL: [] All Normal
[- ] Fever [ -] Chills [ ] Sweats [ ] Fatigue [ ] Malaise
[ ]Anorexia [ ]Night sweats
[ -] weight loss
Eyes
[X] All Normal
[ ] Blurred vision [ ] Loss of vision [] Diplopia [ ]
Photophobia
ENT
[ +] Dry mouth [ ] Oral ulcers [ ] Bleeding gums [- ] Sore
throat [] Sinus pain [ ] Epistaxis [ ] Tinnitus
[ ] Decreased hearing [ ] Other:
RESPIRATORY: [X] All Normal
[ ] Shortness of breath [ ] Dyspnea on exertion [ ] Can't
walk 2 flights [ ] Cough [ ] Wheeze [ ] Purulent sputum
[ ] Hemoptysis [ ]Pleuritic pain
[ ] Other:
CARDIAC: [X] All Normal
[ ] Palpitations [ ] Edema [ ] PND [ ] Orthopnea [ ]
Chest Pain [ ] Dyspnea on exertion [ ] Other:
GI: [] All Normal
[+] Nausea [+] Vomiting [-] Abd pain [] Abdominal swelling
[- ] Diarrhea [ +] Constipation [ ] Hematemesis
[ ] Blood in stool [ ] Melena [ ] Dysphagia: [ ] Solids
[ ] Liquids [ ] Odynophagia [ ] Anorexia [ ] Reflux
[ ] Other:
GU: [X] All Normal
[ ] Dysuria [ ] Incontinence or retention [ ] Frequency
[ ] Hematuria []Discharge []Menorrhagia
SKIN: [X] All Normal
[ ] Rash [ ] Pruritus
MS: [] All Normal
L CVA tenderness of admission to the ED but resolved now.
[ ] 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: [X] All Normal
[ -] Mood change [-]Suicidal Ideation [ ] Other:
ALLERGY:
[- ]Medication allergies - NKDA [ ] Seasonal allergies
[X]all other systems negative except as noted above
Past Medical History:
Type 1 IDDM (A1c was 7.8 % on ___ - followed at ___
- DM neuropathy
- DM retinopathy
- DM Nephropathy - Chronic kidney disease, Stage 3 (Cr 1.3-1.6)
CAD s/p STEMI (single vessel stent) ___
CHF
Osteoperosis
Fractures:
- Right ankle fracture ___
- Left Femur ___ in setting of low glucose and required major
surgery/rod etc.
Social History:
___
Family History:
Father-died of aneurysm, mother- had aneurysm, but lived and
died "of old age."
Physical Exam:
Admission PE
PHYSICAL EXAM: I3 - PE >8
VITAL SIGNS:
GLUCOSE:
PAIN SCORE
1. VS T = 97.7 P = 78 BP = 171/92 RR 16 O2Sat on _100 on RA
GENERAL: Very thin, pale female.
Nourishment: at risk
Grooming:OK
Mentation: She appears to be very sleepy.
2. Eyes: [] WNL
Pupils are pinpoint and do not react.
Conjunctivae: clear
3. ENT [] WNL
No lesions noted in OP
[] Moist [] Endentulous [] Ulcers [] Erythema [] JVD ____ cm
[X] Dry [] Poor dentition [] Thrush [] Swelling [] Exudate
4. Cardiovascular [] WNL
[X] Regular [] Tachy [x] S1 [X] S2 [-] Systolic Murmur /6,
Location:
[] Irregular []Brady []S3 [] S4 [] Diastolic Murmur /6,
Location:
[X] Edema RLE None
[X] Edema LLE None
[] Vascular access [X] Peripheral [] Central site:
5. Respiratory [ ]
[X] CTA bilaterally [ ] Rales [ ] Diminshed
[] Comfortable [ ] Rhonchi [ ] Dullness
[ ] Percussion WNL [ ] Wheeze [] Egophony
6. Gastrointestinal [ X] WNL
[X] Soft [] Rebound [] No hepatomegaly [x] Non-tender [] Tender
[] No splenomegaly
[] Non distended [] distended [] bowel sounds Yes/No []
guiac: positive/negative
7. Musculoskeletal-Extremities [] WNL
[ ] Tone WNL [ X]Upper extremity strength ___ and symmetrical
[ ]Other:
[ ] Bulk WNL [X] Lower extremity strength ___ and symmetrica
[ ] Other:
[] Normal gait []No cyanosis [ ] No clubbing [] No joint
swelling
8. Neurological [] WNL
[X ] Alert and Oriented x 3 Able to DOWB. Very slow to answer
questions with word finding difficulties as discribed in prior
d/c summaries.
[ ] Demented [ ] No pronator drift [] Fluent speech
9. Integument [] WNL
RUE ecchymosis that patient cannot explain
[] Warm [] Dry [] Cyanotic [] Rash:
none/diffuse/face/trunk/back/limbs
[ ] Cool [] Moist [] Mottled [] Ulcer:
None/decubitus/sacral/heel: Right/Left
10. Psychiatric [] WNL
[] Appropriate [X] Flat affect [] Anxious [] Manic []
Intoxicated [] Pleasant [] Depressed [] Agitated [] Psychotic
[] Combative
G/U
[- ] 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
Discharge PE Sigificant for:
Normotensive, remains pale but in no distress
Ambulating at the bedside independently.
Lungs without rales or rhonchi
Abdomen soft, non-tender without rebound or guarding
Alert and oriented, with fluent speech.
Pertinent Results:
___ 10:07PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 10:07PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-1000 KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 10:07PM URINE RBC-1 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-<1
___ 10:07PM URINE MUCOUS-RARE
___ 05:30PM ___ TEMP-36.8 PO2-79* PCO2-36 PH-7.45
TOTAL CO2-26 BASE XS-1 INTUBATED-NOT INTUBA COMMENTS-GREEN TOP
___ 05:30PM LACTATE-2.1*
___ 05:20PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 05:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-1000 KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 05:20PM URINE RBC-<1 WBC-1 BACTERIA-FEW YEAST-NONE
EPI-<1
___ 05:20PM URINE MUCOUS-RARE
___ 02:57PM ___ COMMENTS-GREEN TOP
___ 02:57PM LACTATE-1.8
___ 02:45PM GLUCOSE-280* UREA N-30* CREAT-1.2* SODIUM-140
POTASSIUM-4.1 CHLORIDE-99 TOTAL CO2-25 ANION GAP-20
___ 02:45PM estGFR-Using this
___ 02:45PM WBC-11.8*# RBC-3.77* HGB-12.1 HCT-37.1 MCV-98
MCH-32.0 MCHC-32.6 RDW-13.5
___ 02:45PM NEUTS-92.2* LYMPHS-5.0* MONOS-2.3 EOS-0.1
BASOS-0.4
___ 02:45PM NEUTS-92.2* LYMPHS-5.0* MONOS-2.3 EOS-0.1
BASOS-0.4
CXR ___
IMPRESSION: Small bilateral pleural effusions with minimal
adjacent basilar
lung opacities, which likely reflect atelectasis. No definite
pneumonia, but
followup radiographs may be helpful if symptoms persist in order
to exclude a
subtle basilar pneumonia.
Brief Hospital Course:
The patient is a ___ year old female with DM type I complicated
by nephropathy and neuropathy who presents with nausea,
vomiting, dehydration, hyperglycemia, lethargy. She was treated
empirically for pneumonia with community-acquired coverage for a
subtle infiltrate vs small bilateral effusions on serial chest
xrays, despite no cough or fever, given her recent admission.
The overall diagnosis leading to her admission was more likely
nausea and vomiting in the setting of a recent influenza
infection with fatigue and over-exertion in returning to work. A
viral gastroeneteritis is also quite possible, and would have
benefited from the supportive care, adjustment of her insulin
regimen as occurred with the assistance of ___, as well as IV
fluids for hydration.
# Nausea and vomiting, possible gastroenteritis vs recrudesence
of recent illness:
Initially thought to be due to a viral gastroenteritis vs.
gastroparesis vs. ACS. The patient has a signifcant cardiac
history with risk factors, as a result serial EKG's were checked
which were normal and Tn's were negative. The patient was
slowly re-hydrated and with antibiotics, her symptoms improved.
Her diet was advanced and she was symptom free, although she
noted her oral intake remained below her baseline, and her
insulin levels were therefore maintained below her usual
baseline.
# Hypotension, likely orthostatic related to dehydration:
Likely due to dehydration with untreated pneumonia. Once volume
resuscitated, BP's normalized. Random cortisol level was
normal.
# Infiltrate consistent with mild or early pneumonia:
The patient intially p/w a normal WBC but it then spiked a
temperature later during the hospitalziation accompanied with a
decreased blood pressure and a fever. The patient was started
on empiric CTX/azithro for empiric coverage for community
bacterial pathogens for pneumonia. The patient has a h/o
frequent UTI's but her UA's were normal. The patients repeat
CXR showed some streaky opacities which may have presented a
small pneumonia, and subsequent follow-up chest xrays revealed
the same borderline findings. On empiric antibiotics, the
patient was noted to have significant improvement after her
first day of treatment. She was continued on an empiric course
for mild pneumonia, felt less likely to be nosocomial in nature
despite her recent admission, given the overall clinical
picture. Her antibiotics where then changed to cefpodoxime on
discharge, to complete a 7 day total course. She completed
3-days of azithromycin.
# DM-1 with labile BG
The patient had a recent admission for DKA and has had injuries
at home because of hypoglycemia and hypoglycemic unawareness.
As a result, ___ was consult to help with safe titration of
the patients insulin. As the patients diet was advanced they
recommended maintaining her insulin regimen at the reduced
dosing used during her admission of glargine 2 units instead of
6 units. The patient felt that her oral intake remained reduced,
and was noted to have BGs in the 100s-200s at most during the
last 48 hours of her admission. She has close ___ follow-up
arranged for several days following admission, and is aware to
call sooner if she notes escalating trends in her blood sugars.
# Anemia
Recent baeline Hgb is ___. Initially, worsenign anemia was
thought to be due to hemodilution. The patient hemoccult was
then checked and it was positive. The patient had a recent
normal c-scope and EGD which showed evidence of gastritis. The
patient was palced on a PPI and her Hgb was watched. Her Hgb
was stable in discharge. We recommend that her blood counts be
monitored, and consider if additional work-up is needed based on
her clinical course.
# Diabetic neuropathy
According to the patient, as an outpatient the patient was
tapering her gabapentin and starting lyrica. Due to complain in
the setting of her acute illness, her lyrica was increased,
although in the setting of acute resolving nausea and vomiting,
we did not want to adjust this medication due to potential
inability to determine if she was having side effects or
resolving acute illness sequelae. We do recommend proceeding
with the planned adjustments to her pain regimen once she heals
further.
# Transitional Issues:
- Ongoing transition from gabapentin to lyrica.
- Oral hydration improved significantly during the admission.
The patient was provided with several compazine suppositories,
as she noted these can be helpful when she has nausea early in
her course at home, although she did not need these while here.
- Guaiac positive hemmocult on one occasion, although stable Hct
in setting of gastritis. Would benefit from follow-up Hct.
- Subtle infiltrate on CXR, treated empirically for
community-acquired pneumonia, noted to have small bilateral
effusions. It would be reasonable to recheck her CXR in ___
weeks to ensure that her effusions have resolved and no further
abnormalities are noted, based on her clinical course.
- ___ follow-up with her primary diabetologist to assist in
gradually increasing her insulin back to pre-morbid levels.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Pregabalin 50 mg PO TID
2. Sertraline 200 mg PO QHS
3. Gabapentin 300 mg PO BID
4. Vitamin D 50,000 UNIT PO 1X/WEEK (___)
once weekly
5. Glargine 6 Units Breakfast
Glargine 2 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Aspirin 325 mg PO DAILY - not taking
Rosuvastatin Calcium 10 mg PO DAILY - not taking
Vitamin D 50,000 UNIT PO 1X/WEEK (___) once weekly
Prochlorperazine 10 mg PO Q6H:PRN nausea
RX *prochlorperazine maleate 10 mg 1 tablet(s) by mouth three
times a day Disp #*6 Tablet Refills:*0 - not taking
8. Alendronate Sodium 70 mg PO QSUN - not taking
once weekly
Discharge Medications:
1. Gabapentin 300 mg PO BID
2. Sertraline 200 mg PO QHS
3. Vitamin D 50,000 UNIT PO 1X/WEEK (___)
once weekly
4. Cefpodoxime Proxetil 200 mg PO Q12H
Please complete 4 more days, through ___.
RX *cefpodoxime 200 mg 1 tablet(s) by mouth twice daily Disp #*8
Tablet Refills:*0
5. Pregabalin 50 mg PO TID
6. Glargine 2 Units Breakfast
Glargine 2 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
7. Aspirin 325 mg PO DAILY
Continue your home regimen.
8. Prochlorperazine 25 mg PR Q12H prn nausea and vomiting
RX *prochlorperazine 25 mg 1 Suppository(s) rectally every 12
hours Disp #*14 Suppository Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Intractable nausea and vomiting
Pneumonia, likely bacterial
Anemia
Hypoglycemia, in setting of decreased oral intake
Diabetes Mellitus I, long-standing
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
It was a pleasure to care for you during your admission. As you
know, you were admitted to ___ with nausea, vomiting and
inability to tolerate things by mouth. Initially, your were
hydrated and your heart enzymes check checked and normal. You
blood pressure was then found to be low in addition to an
elevated white count. You were started on antibiotics for a
early pneumonia. Your symptoms improved and your diet was
advanced. Your antibiotics were changed to by mouth
(cefpodoxime) to complete a 7 day course total.
Medications changes-see below:
#Add cefpodoxime antibiotic for 4 more days (through ___
#We decreased your insulin to 2 units glargine while you are
still taking less by mouth (with blood sugars from 140-200
here).
#We provided you with compazine suppositories for use at home,
for when you are unable to take medications orally and have
nausea.
Weigh yourself every morning, call MD if weight goes up or down
more than 3 lbs in ___ days.
Followup Instructions:
___
|
19549821-DS-12
| 19,549,821 | 23,648,734 |
DS
| 12 |
2118-06-18 00:00:00
|
2118-06-24 07:28:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
clindamycin
Attending: ___
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ yo F with DM1 c/b nephropathy, neuropathy,
and retinopathy, CAD s/p STEMI w single vessel stent in ___,
and osteoporosis w hx of multiple fractures, who presents for
evaluation of syncope. Patient states that early this AM, she
got up to go to the bathroom, felt lightheaded, and fell,
hitting her right shoulder on the ground. States that she
remembers everything that happened, but per ED notes, daughter
reported a ___ sec LOC. Patient denies head strike. She also
denies any diaphoresis, CP, SOB, palpitations, vision changes,
HA or confusion prior to or after the fall. Event was witnessed
by her husband, who feels that she may have hit her head.
Patient took a FSBS after the fall and notes that it was 130.
Patient reports several episodes of syncope in the setting of
poor PO intake. Each time, she feels a little lightheaded and
falls. States that her PCP ___ 8 bottles of water per day
and increasing salt in her diet.
Of note, patient had been taking clindamycin for the past week
for leg cellulitis, and endorses poor po intake ___ the
antibiotic causing n/v. She has since stopped taking the
clindamycin (took only for 1 day) and notes that she was eating
and drinking all of ___ but feels that she is still
pretty dehydrated.
In the ED, initial VS were 97.7 90 150/98 18 99%. Labs were
notable for Cr 1.5, glucose 304, anion gap 20, urine dipstick
with 1000 glucose and 10 ketones. CXR showed emphysema but was
otherwise unremarkable. CT head was unremarkable. Patient
received 1L bolus of fluids.
On arrival to the floor, patient reports right sided shoulder
pain that is worse with movement. No numbness or tingling. No
skin changes. Denies any lightheaded/dizziness, headache, vision
changes, CP, n/v, palpitations, or SOB. ROS is otherwise
negative.
Past Medical History:
Type 1 IDDM (A1c was 9.3 % on ___ - followed at ___
- DM neuropathy
- DM retinopathy
- DM Nephropathy - Chronic kidney disease, Stage 3 (Cr 1.3-1.6)
CAD s/p STEMI (single vessel stent) ___
Osteoperosis
Fractures:
- Right ankle fracture ___
- Left Femur ___ in setting of low glucose and required major
surgery/rod etc.
- L shoulder fx
BREAST CANCER ___- R breast; radiation, lumpectomy, no
chemotherapy
Social History:
___
Family History:
___ siblings with DM1 all dx in teens and late ___.
Brother with IBD and throat cancer
Father-died of aneurysm, mother- had aneurysm, but lived and
died "of old age."
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T:98.1 HR:88 BP:141/85 RR:20 O2sat:99RA
General: AOx3, NAD, lying in bed comfortably
HEENT: MMM, OP clear, pupils equal and reactive to light
Neck: supple, full ROM
CV: RRR, no m/r/g
Lungs: CTAB, no wheezes or crackles
Abdomen: soft, NT, ND, +bowel sounds
GU: no foley
Ext: TTP of R shoulder over the top of the R trapezius muscle,
full ROM. Small 1-2cm area of ulceration with overlying
granulation tissue and surrounding erythema over the right shin
Neuro: no focal neurologic deficits
Skin: intact, wwp, 2+ distal pulses
DISCHARGE PHYSICAL EXAM:
VS: T:97.3 HR:66 BP: 140/78 (90-157/50-99) RR:18 O2:100 RA
AM I/O: ___ FSG: 442(5L,14H) - 350(7H) - 250(6H) - 350(8L, 2H)
General: AOx3, NAD, lying in bed comfortably
HEENT: MMM, OP clear, pupils equal and reactive to light
Neck: supple
CV: RRR, no m/r/g
Lungs: CTAB, no wheezes or crackles
Abdomen: soft, NT, ND, +bowel sounds
GU: no foley
Ext: Full ROM of all extremities. Small 1-2cm area of ulceration
with dry well-formed scab over right shin. No erythema. No
tenderness
Neuro: no focal neurologic deficits
Skin: intact, wwp, 2+ distal pulses
Pertinent Results:
Admission Labs
___ 08:25AM BLOOD WBC-6.7 RBC-4.01* Hgb-12.7 Hct-38.4
MCV-96 MCH-31.6 MCHC-33.0 RDW-13.1 Plt ___
___ 12:30PM BLOOD Glucose-304* UreaN-20 Creat-1.5* Na-139
K-3.3 Cl-92* HCO3-27 AnGap-23*
___ 12:30PM BLOOD CK(CPK)-93
___ 12:30PM BLOOD CK-MB-4 cTropnT-0.10*
___ 08:25AM BLOOD Calcium-8.5 Phos-3.2 Mg-1.4*
___ 12:34PM BLOOD ___ pO2-30* pCO2-49* pH-7.44
calTCO2-34* Base XS-6
Discharge Labs
___ 07:35AM BLOOD WBC-5.5 RBC-3.67* Hgb-11.4* Hct-36.0
MCV-98 MCH-31.0 MCHC-31.6 RDW-13.1 Plt ___
___ 07:35AM BLOOD Glucose-267* UreaN-53* Creat-1.9* Na-139
K-4.4 Cl-99 HCO3-28 AnGap-16
___ 07:35AM BLOOD Calcium-9.0 Phos-4.0 Mg-2.2
Other labs
___ 12:30PM BLOOD CK-MB-4 cTropnT-0.10*
___ 11:30PM BLOOD CK-MB-3 cTropnT-0.10*
___ 08:25AM BLOOD CK-MB-3 cTropnT-0.10*
___ 07:30AM BLOOD cTropnT-0.09*
___ 07:50AM BLOOD cTropnT-0.04*
Micro: None
Imaging:
___ EKG: Normal sinus rhythm. Left atrial abnormality. Poor
R wave progression, may be consistent with prior anteroseptal
myocardial infarction. Non-specific ST-T wave changes. Compared
to the previous tracing of ___ there is no significant
change.
___ CT HEAD W/O CONTRAST: No acute intracranial process.
___ CHEST (PA & LAT): No acute cardiopulmonary process.
Emphysema.
___ EKG: Normal sinus rhythm. Q waves in leads V1-V2
consistent with prior anteroseptal myocardial infarction. Left
axis deviation. Non-specific ST-T wave changes. Compared to
tracing #1 no significant change.
___ EKG: Normal sinus rhythm. Left atrial abnormality.
Intraventricular conduction delay. Poor R wave progression.
Compared to the previous tracing of ___ no significant
change. These findings are consistent with prior anteroseptal
myocardial infarction.
Brief Hospital Course:
___ with uncontrolled DM1 ___ HgA1C 9.3) c/b nephropathy,
neuropathy, and retinopathy, CAD s/p STEMI w single vessel stent
in ___, and osteoporosis w chronic fractures, here for
evaluation of syncope, found to be orthostatic.
ACUTE ISSUES:
# Syncope: Likely secondary to orthostasis from volume depletion
as pt had been not taking in good POs in the setting of nausea
from clindamycin, which was prescribed to treat RLE cellulitis
(see below). CT head was negative, and she had some consequent
shoulder pain in the posterior right trapezius that was treated
with lidocaine with good effect. Her orthostasis continued to be
an issue throughout her hospitalization (see below). She had no
more episodes of syncope during her hospitalization.
# Orthostasis: Was remarkably orthostatic from sitting to
standing with SBP drops of ___. Most likely due to some
combination of dehydration from osmotic diuresis coupled with
autonomic instability ___ long history of DM1. AM cortisol was
normal. Patient started on 5mg midodrine TID on ___ and was
increased to 10mg TID on ___. She was also started on
fludrocortisone 0.1mg daily. She could increase fludrocortisone
on ___ (after 1wk), would go up to 0.2mg, and if still
needs more, then to 0.3mg, though beyond that there's often not
much benefit. Once patient's blood sugars were under control
(see below) and was no longer having osmotic diuresis, she was
still mildly orthostatic, but less symptomatic. Upon discharge,
patient was able to walk without dizziness.
# DM1: Long standing, c/b neuropathy, nephropathy, and
retinopathy with last HgbA1C of 9.3. Was hyperglycemic with
daily blood sugars ranging from 300-500. Patient evaluated by
___ who increased pm lantus dose from 3U to 9U and adjusted
her HISS to incorportate her carb correction dosing to
ultimately simplify her insulin regimen. Patient is now on a
carb consitent diet. Patient did not experience any episodes of
DKA during this admission, and upon discharge, her insulin
regimen was sufficient to maintain a glucose range of around the
low 200s.
# ___: Has diabetic nephropathy. Baseline Cr appeared to be
around 1.1, but more recently in the mid 1s. She was 1.5 upon
admission though fluctuated and was 1.9 upon discharge.
Initially thought to be pre-renal in the setting of osmotic
diuresis from hyperglycemia, but potentially from progression of
diabetic nephropathy as there seemed to have been progression of
her kidney disease throughout the year. Would recommend repeat
labs as outpt follow-up to assess any interval change.
# Cellulitis: Patient hit her R shin and developed some
surrounding celluitis about one and a half weeks ago. Was
treated with clindamycin but was unable to tolerate the oral
antibiotic. She was switched to oral bactrim and completed a 5
day course of antibiotics. Upon discharge, the wound was
superficially ulcerated, but without tenderness or erythema.
# Right shoulder pain: Had fell on her right shoulder after her
syncopal fall and reported pain with movement that improved
during this admission. Patient had full ROM and strength, so
imaging was not warranted.
# Troponinemia: Pt with troponin of 0.10 on admission with flat
CK-MB. She had no concerning signs/symptoms for a cardiac
etiology to her syncope or any evidence of syncope. Troponin
downtrending now s/p IVF. Was likely secondary to acute kidney
injury and decreased clearance.
# Hx of CAD s/p STEMI in ___: Aspirin was on med list but on
medication reconciliation patient reports that Asprin was dc'd
by her optholmalogist ___ to her diabetic retinopathy. Patient
reports that her cardiologist is aware of this, so aspirin was
taken off of her medication list.
Transitional Issues:
- started on midodrine and titrated up to 10mg TID. ___ consider
addition of fludrocortisone if clinically indicate.
- insulin regimen changed significantly. Will need to f/u as
outpatient with ___ to ensure glucose is controlled.
- should have repeat chem 7 to assess progression/improvement in
kidney disease
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Pregabalin 50 mg PO TID
2. Diphenoxylate-Atropine 1 TAB PO BID:PRN diarrhea
3. Rosuvastatin Calcium 20 mg PO DAILY
4. Glargine 5 Units Breakfast
Glargine 3 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
5. OxycoDONE (Immediate Release) 2.5-5 mg PO Q12H:PRN pain
6. Sertraline 200 mg PO QHS
7. Calcium Carbonate 500 mg PO BID
8. Vitamin D 200 UNIT PO BID
Discharge Medications:
1. Calcium Carbonate 500 mg PO BID
2. OxycoDONE (Immediate Release) 2.5-5 mg PO Q12H:PRN pain
3. Pregabalin 50 mg PO TID
4. Rosuvastatin Calcium 20 mg PO DAILY
5. Sertraline 200 mg PO QHS
6. Vitamin D 200 UNIT PO BID
7. Midodrine 10 mg PO TID
RX *midodrine 10 mg 1 tablet(s) by mouth three times a day Disp
#*90 Tablet Refills:*0
8. Diphenoxylate-Atropine 1 TAB PO BID:PRN diarrhea
9. Fludrocortisone Acetate 0.1 mg PO DAILY
RX *fludrocortisone 0.1 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
10. Lidocaine 5% Patch 1 PTCH TD DAILY
12 hours on, 12 hours off
RX *lidocaine 5 % (700 mg/patch) 1 patch daily Disp #*1 Box
Refills:*0
11. Glargine 5 Units Breakfast
Glargine 9 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Orthostatic Hypotension
Secondary: Type 1 Diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent, though sometimes with
___
Discharge Instructions:
Dear Ms. ___,
It was a pleasure to care for you here at ___
___. As you know, you were hospitalized after having
a fainting episode causing you to fall. This likely happened
because when you stand, your blood pressure drops significantly,
causing decreased blood flow to the brain, which makes you
lightheaded. This is called orthostatic hypotension. Orthostatic
hypotension can happen for several reasons, but in your case it
is likely happening because of a combination of dehydration and
dysfunction of the nerves of your blood vessels due to your
diabetes.
In order to treat this, we started you on a drug called
midodrine, which helps your blood vessels respond appropriately
in order to increase your blood pressure upon standing, and we
also started a medication called fludrocortisone, which helps
you retain salt. Certain things that you can do to prevent
yourself from becoming lightheaded upon standing include
drinking plenty of water, increasing your salt intake, moving
from sitting to standing very slowly and carefully, and being
very cautious when walking and moving around.
In terms of your diabetes, your evening lantus was increased to
9 Units at bedtime. We placed you on a carb consistent diet and
adjusted your insulin sliding scale such that it already
includes your carb corrections. With this new regimen, your
blood sugars seem to be under better control. Please follow up
with ___ at the appointment listed below for further
management and adjustment of your insulin doses.
In addition, you completed an antibiotic course for the
cellulitis (skin infection) that was affecting your right lower
shin, and the area appears significantly improved.
In summary, we started you on new medications called Midodrine
and Fludrocortisone. Your insulin regimen was adjusted so that
now you will take 5 Unit of lantus in the morning, 9 units of
lantus at night, and you will use the insulin sliding scale to
cover yourself throughout the day. Please contact your doctor
immediately or return to the hospital if you are persistently
dizzy when standing and feeling unsteady on your feet, if you
have persistently elevated blood sugars >300, if you are feeling
confused, nauseous, or vomitting, or with any other symptoms
that concern you.
Followup Instructions:
___
|
19549821-DS-9
| 19,549,821 | 26,531,740 |
DS
| 9 |
2117-08-23 00:00:00
|
2117-08-23 22:29:00
|
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, vomiting, diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ y/o F with PMH of breast cancer s/p radiation,
lumpectomy in ___, CAD s/p STEMI with PCI, type 1 diabetes c/b
nephropathy, neuropathy, retinopathy, osteoporosis, and femoral
fracture in ___ who presents with 1 day of cough/malaise and
persistent n/v/diarrhea. ___ is a poor historian given
altered mental status/word finding difficulty. On presentation.
She was last in her usual state of health on the day prior to
presentation when she developed the ___ symptoms.
She also felt general malaise in this time as well. Her husband
is recently recovering from an illness from 6 days prior to her
presentation in which he experienced cough and fever to 102.4.
___ initially presented to ___ where her
blood sugar was found to be in the in 400s. There, she had
red/brown vomitis, ? ___ Tear. NG tube was placed.
___ relates that shortly before that episode she had drank
cranberry juice. An insulin drip started @5U/hr. blood sugar 93
on leaving ___. At ___, WBC 5.0 hct: 33.5 95%
NEUTS Na: 136 K 3.2 Cl 95 C02: 18 BUN/Cr: ___ 410. Gap
23 ast: 22/ ALT: 13 Alk phos: 167 Bili 0.05 Urine: 0 wbc, no
bacteria 3= glucose, 2+ ketones neg nitrite, leuks, bili.
In the ED, initial vs were 98.6 90 102/50 16 98%. ___ glucose was
35, so insulin gtt was discontinued and given 1 amp dextrose,
1mg ativan and 2mg ondansetron for vomiting, and started d5w
20meq kcl @100cc/hr. Repeat ___ 190. Chem 7 showed anion gap of
13. Trop K<0.01. Cr. 2.1, WBC 7.0 with N 82.1. NT lavage was
negative so NGT discontinued. CXR without acute cardiopulmonary
process, and UA with 1000 glu, no ketones, neg leuks, 1 WBC.
Prior to transfer, ___ received 4units insulin glargine.
Repeat chem 7 in the ED showed: ___ AG:14.
Last recorded vital signs prior to transfer were 99.1 85 132/88
21 98%.
On arrival to the floor, VS: T98.1, BP154/83, HR:76, RR:16,
O2sat99%RA, FSBS 223. She received an additional 2 units of
glargine and SS humalog. ___ reports no pain, ongoing nausea
and malaise, and general mental fugue with ___
difficulty. CT head was ordered to rule out acute intracranial
pathology.
Past Medical History:
Type 1 IDDM (A1c was 8.7% on ___ - followed at ___
- DM neuropathy
- DM retinopathy
- DM Nephropathy - Chronic kidney disease, Stage 3 (Cr ___
CAD s/p STEMI (single vessel stent) ___
CHF
Osteoperosis
Fractures:
- Right ankle fracture ___
- Left Femur ___ in setting of low glucose and required major
surgery/rod etc.
Social History:
___
Family History:
___ of aneurysm, mother- had aneurysm, but lived and
died "of old age."
Physical Exam:
ADMISSION:
VS: T98.1, BP154/83, HR:76, RR:16, O2sat99%RA
GEN: ___ difficulty, in mild distress but no
respiratory distress, A+Ox3
HEENT: NCAT, dry mucous membranes, EOMI, sclera anicteric, OP
clear
NECK supple, no JVD, no LAD
PULM: Good aeration, CTAB, no wheezes, rales, rhonchi
CV: RRR normal S1/S2, no mrg
ABD: soft, mild TTP in the epigastric region, ND, normoactive
bowel sounds, no reboud or guarding
EXT: WWP, 2+ pulses palpable bilaterally, no c/c/e
NEURO: ___ intact, strength ___ proximally and distally
throughout, no sensory deficits in 1 dermatome in each
extremity, cerebellar testing normal with ___
pointing
SKIN: no ulcers or lesions
.
DISCHARGE:
VS: 98.0/98.6, 151/71 (___), 75 (___), 98% RA
GEN: Looks significantly better, answers all questions quickly,
very thankful, fully oriented
I/O: 1.1/750, no BMs x 2 days
FSBG: 101,99 ___ yest)
HEENT: NCAT, moist mucous membranes, EOMI, sclera anicteric, OP
clear otherwise
SKIN: Left shoulder and right shoulder with circular scab
overlying erosion/abrasion. Resolving
NECK: supple, no JVD, no LAD
PULM: Comfortable, Good aeration, CTAB, no wheezes, rales,
rhonchi
CV: RRR normal S1/S2, no mrg
ABD: Less guarding this morning, no TTP in the epigastric
region, ND, normoactive bowel sounds, guarding without rebound
EXT: WWP, 2+ pulses palpable bilaterally, no c/c/e
NEURO: ___ intact, strength ___ proximally and distally
throughout
Pertinent Results:
ADMISSION:
Cr 1.2
___ 04:40PM BLOOD ___
___ Plt ___
___ 04:40PM BLOOD ___ ___
___ 04:40PM BLOOD ___
___
___ 04:40PM BLOOD ___
___ 04:40PM BLOOD ___
___ 07:40PM BLOOD ___
___ 08:10AM BLOOD ___
MICRO:
- Influenza A POS
- UCx - negative
.
EKG:
(___): Extensive baseline artifact. Underlying rhythm is
probably sinus with sinus arrhythmia. Left axis deviation with
left anterior fascicular block. Cannot exclude prior inferior
and anterior wall myocardial infarction of indeterminate age.
Compared to the previous tracing of ___ the rate is faster.
R wave progression in the precordial leads has somewhat improved
but remains sluggish.
.
(___): Sinus rhythm. The findings are similar to those
reported in prior ECG
.
IMAGING:
(___) CXR: Cardiomegaly without acute cardiopulmonary
process. Incompletely visualized changes of the proximal left
humerus. Please correlate clinically.
.
(___) CT Head w/o contrast: No acute intracranial process.
If clinical concern for stroke or intracranial lesion is high,
MRI is more sensitive.
.
(___) CT Abdomen with contrast:
1. No evidence of obstruction.
2. Mesenteric edema with trace amount of free fluid in the
pelvis without evidence of vascular etiology, finding is likely
secondary to third spacing or possibly hypoproteinemia.
3. Diverticulosis
.
DISCHARGE:
Cr 1.3
___ 10:25AM BLOOD ___
___ Plt ___
___ 10:25AM BLOOD ___
___
___ 10:25AM BLOOD ___
Brief Hospital Course:
Ms. ___ is a ___ y/o F with h/o type 1 diabetes c/b
nephropathy (Cr ___, neuropathy, retinopathy, CAD s/p PCI
___, breast cancer, osteoporosis, who presented with
nausea/vomiting, found to be in DKA. This occured concurrently
with cough and general malaise, was exposed to her husband who
is recovering from ___ illness.
.
# DKA in Type 1 Diabetic: ___ with ___ year h/o type 1
diabetes. Followed at ___, last HbA1c was 7.8 in ___. On
presentation to OSH ___ was found to be in DKA with Glc >400
and gap of 23, at ___ was started on insulin drip but
transferred here due lack of ICU beds at OSH. Etiology of DKA
unclear but likely precipitated by ___ illness (given h/o
nausea/emesis/myalgia/cough). CXR, U/A do not suggest infection.
___ was afebrile on admissino and during her stay. Also
without elevated WBC on admission and during stay. EKG does not
suggest ischemic cause and trop <0.01. Anion gap closed when
arrived in our ED but FSBG was 35 so was taken off of insulin
gtt and started on sliding scale with Lantus BID. She was
severely nauseous for the first 48 hours and did not tolerate PO
fluids or solids. Her blood sugars were checked q4H and were
well controlled during her stay. She was followed by ___
during her stay and her sliding scale was titrated back to her
home regimen on day before discharge with Lantus 6U in AM and 2U
in ___. In the last two days of her admission the ___
nausea fully resolved and she tolerated a regular diet and PO
meds.
.
# Cough, malaise: ___ was confirmed with Influenza A.
___ presented with cough and malaise for several days before
admission. Her husband had ___ at home. She did receive the flu
shot this year. Influenza likely precipitated DKA and
precipitated GI upset associated with it. ___ was on
droplet precautions and received 75mg PO Tamiflu BID, which
should finish on ___.
.
# N/V: The ___ presented with significant nausea and did not
tolerate PO intake for the first 36 hours of her admission. DDX
included mechanical obstruction vs intoxication vs enterovirus
or ___ virus vs. other GI virus vs. DKA symptoms. No
diarrhea or BMs during her stay. Given her history of abdominal
surgery a CT was checked and ruled out obstruction. UDS negative
for substances. Ultimately, the ___ was confirmed with
Influenza A, and this was likely the cause of her severe nausea.
___ was initially started on Zofran, Phenergan 4mg q6h, and
Ativan PRN. On day 3 the ___ nausea substantially improved
and on day 4 the ___ did not require anti nausea medication.
She tolerated a regular diet on the last two days of her
admission and felt at her baseline.
.
# AMS: Initially the ___ was very lethargic, and slow to
answer questions although fully oriented. She had a non focal
neruo exam, and negative UDS. Likely this was in the setting of
severe sickness with DKA and Influenza. After nausea subsided,
the ___ was significantly better, fully alert, answered
questions quickly, was smiling and thankful. A CT head was
checked on arrival to ED that was normal.
.
# CKD Stage 3: h/o diabetic nephropathy with baseline Cr.
___, her range on this admission was 1.1 - 1.3 Her discharge
Cr was 1.3.
.
# CAD: no current ischemic symptoms. we continue her home ASA,
statin. She did stop her Aspirin on ___ due to planned botox
injections in the subsequent week. Please
.
# Neuropathy: we continued the patients zoloft, and lyrica. She
did require extra morphine but we weaned this prior to
discharge.
.
# Osteoporosis with Fracture history: we continued the ___
Ca/VitD, no issues on this admission.
.
## TRANSITIONAL ##
- Full Code
- Follow up with ___, PCP
- ___ noted that she uses Gabapentin but this was Inactive
in OMR, please reconcile as an outpatient
- Followed by PACT
- Restart Aspirin after cosmetic procedure
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Glargine Unknown Dose
Insulin SC Sliding Scale using HUM Insulin
2. ___ 1 TAB PO TID:PRN diarrhea
3. Pregabalin 50 mg PO TID
4. Sertraline 200 mg PO QHS
5. Aspirin 325 mg PO DAILY
6. Vitamin D 50,000 UNIT PO Frequency is Unknown
once weekly
7. Calcium 500 + D *NF* (calcium ___ D3) 500
mg(1,250mg) -200 unit Oral BID
8. Alendronate Sodium 70 mg PO Frequency is Unknown
once weekly
9. Rosuvastatin Calcium 10 mg PO DAILY
10. Gabapentin 300 mg PO BID
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Pregabalin 50 mg PO TID
3. Rosuvastatin Calcium 10 mg PO DAILY
4. Sertraline 200 mg PO QHS
5. Vitamin D 50,000 UNIT PO 1X/WEEK (___)
once weekly
6. Oseltamivir 75 mg PO Q12H
RX *oseltamivir [Tamiflu] 75 mg 1 capsule(s) by mouth twice a
day Disp #*3 Capsule Refills:*0
7. Prochlorperazine 10 mg PO Q6H:PRN nausea
RX *prochlorperazine maleate 10 mg 1 tablet(s) by mouth three
times a day Disp #*6 Tablet Refills:*0
8. Alendronate Sodium 70 mg PO QSUN
once weekly
9. Calcium 500 + D *NF* (calcium ___ D3) 500
mg(1,250mg) -200 unit Oral BID
10. Glargine 6 Units Breakfast
Glargine 2 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
11. Gabapentin 300 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
- Influenza A
- Diabetic Ketoacidosis
SECONDARY:
- CKD Stage 3
- Peripheral Neuropathy
- CAD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
It was a pleasure taking care of you at ___. You were admitted
from ___ with severe nausea, vomitting, and
complications of your Diabetes (Diabetic Ketoacidosis). You also
had a cough and some malaise. It was found that you had
Influenza A and we started treatment with Tamiflu for that (you
will need a total of 5 days). Your diabetes was well controlled
with recommendations from your ___ doctors. ___ nausea
improved significantly with ___ medication and as your
influenza was treated.
You noted that Botox will be done on ___ and that
you will need to hold your Aspirin starting ___. Please make
sure to restart on ___ or based on the recommendations of
your PCP and ___ Doctor.
___ follow up with your providers below, specifically your
PCP and ___ doctors.
___ wear a protective mask when in public places for the next
five days.
START
- Tamiflu 75mg by mouth twice daily until ___
Continue all other medications as before
- You tolerated all other oral medications very well including
Crestor
Followup Instructions:
___
|
19549941-DS-3
| 19,549,941 | 21,272,740 |
DS
| 3 |
2155-01-15 00:00:00
|
2155-01-15 20:47:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
allopurinol
Attending: ___.
Chief Complaint:
Rash
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ w/ obesity, HTN, asthma, gout, CKD referred by
PCP with rash, concerning for DRESS syndrome.
Of note, patient was started on allopurinol and Lipitor within
the past few weeks. He developed symptoms on ___ night
with itching, then noticed red spots next morning. The rash
started to coalesce in the last 3 days. Spreading to face.
Sensation feels like pins and needles, painful and itchy. Took
Benadryl, didn't help. Also took Allegra. Patient also reports
"hot flashes, shaking" ___, has not happened recently. His
reported Temp at home was 100.4 but normal within clinic. He
stopped all medications on ___. Reports he took
allopurinol ___ daily for 1 month in ___ and restarted in
___ with 200mg daily, then increased to 300mg daily.
He was started on Lipitor on ___. He has CKD, last Cr is
1.74 stable since ___. He has taken prednisone 90mg daily for 3
days (recommended for 10 days with slow taper) and derm biopsy
of rash is pending per atrius records.
At his PCP's office, he was noted to have elevated LFTs and
creatinine. He was sent in for further work-up to the emergency
room.
In the ED, initial vital signs were:97 89 170/98 16 98% RA
- Exam was notable for: rash
- Labs were notable for: WCC of 12.8, with diff of 7.3 eos, ALT
315/AST 182, ALP 156, creatinine of 2.3 (Baseline 1.8) and
potassium of 5.2.
- Imaging: none
- The patient was given: no medications or fluids
Upon arrival to the floor, patient reports breathing
comfortably and feeling well apart from his rash. He denies any
new sexual contacts apart from his fiancé. He denies any travel
or sick contacts. He denies any malaise or weight loss.
Past Medical History:
VARICOSE VEINS
OBESITY - MORBID
HYPERTENSION - ESSENTIAL, BENIGN
Sleep apnea
ASTHMA
Nasal polyposis
Lumbar disc disease
Gout
CKD - baseline creatinine 1.7
Social History:
___
Family History:
Brother and mother deceased
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: T97.2 BP 138/86 HR 74 RR 19 Sats 99 RA
GENERAL: Pleasant, obese, 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: Extensive coalescing mobilliform rash over arms, torso and
legs.
NEUROLOGIC: A&Ox3, CN II-XII grossly normal, normal sensation,
with strength ___ throughout.
DISCHARGE PHYSICAL EXAM:
VITALS: T98 BP 109/46 HR 82 SPO2 100% on RA
GENERAL: Pleasant, obese, 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: Extensive coalescing mobilliform rash over arms, torso and
legs.
NEUROLOGIC: A&Ox3, CN II-XII grossly normal, normal sensation,
with strength ___ throughout.
Pertinent Results:
ADMISSION LABS:
___ 10:20PM BLOOD WBC-12.8* RBC-4.33* Hgb-13.1* Hct-40.6
MCV-94 MCH-30.3 MCHC-32.3 RDW-14.3 RDWSD-49.2* Plt ___
___ 10:20PM BLOOD Neuts-70.9 Lymphs-15.7* Monos-4.2*
Eos-7.3* Baso-0.3 Im ___ AbsNeut-9.07* AbsLymp-2.01
AbsMono-0.54 AbsEos-0.94* AbsBaso-0.04
___ 07:00AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-1+
Macrocy-NORMAL Microcy-NORMAL Polychr-OCCASIONAL Ovalocy-1+
Burr-1+
___ 07:00AM BLOOD ___ PTT-23.0* ___
___ 10:20PM BLOOD Glucose-120* UreaN-60* Creat-2.3* Na-140
K-5.3* Cl-112* HCO3-17* AnGap-16
___ 10:20PM BLOOD ALT-315* AST-182* AlkPhos-156*
TotBili-0.4
___ 10:20PM BLOOD Albumin-3.9 Calcium-8.8 Phos-4.2 Mg-2.6
___ 07:00AM BLOOD Cortsol-4.2
___ 07:00AM BLOOD ANCA-NEGATIVE B
___ 07:00AM BLOOD HIV Ab-Negative
___ 10:31PM BLOOD Lactate-1.8 K-5.2*
___ 07:00AM BLOOD STRONGYLOIDES ANTIBODY,IGG-Negative
___ 03:42AM URINE Color-Yellow Appear-Clear Sp ___
___ 03:42AM URINE Blood-TR Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 03:42AM URINE RBC-2 WBC-1 Bacteri-NONE Yeast-NONE
Epi-<1
___ 03:42AM URINE CastHy-1* CastWax-1*
___ 01:50PM URINE Hours-RANDOM UreaN-752 Creat-43 Na-103
K-27 Cl-100
DISCHARGE LABS:
___ 07:10AM BLOOD WBC-22.7* RBC-3.72* Hgb-11.2* Hct-34.8*
MCV-94 MCH-30.1 MCHC-32.2 RDW-14.4 RDWSD-48.0* Plt ___
___ 07:10AM BLOOD Neuts-78* Bands-2 Lymphs-9* Monos-6 Eos-0
Baso-1 Atyps-1* Metas-2* Myelos-1* AbsNeut-18.16* AbsLymp-2.27
AbsMono-1.36* AbsEos-0.00* AbsBaso-0.23*
___ 07:10AM BLOOD Plt Smr-NORMAL Plt ___
___ 07:10AM BLOOD Glucose-143* UreaN-63* Creat-1.9* Na-136
K-5.4* Cl-104 HCO3-21* AnGap-16
___ 07:10AM BLOOD ALT-140* AST-22 CK(CPK)-60 AlkPhos-100
TotBili-0.6
___ 07:10AM BLOOD Calcium-9.1 Phos-5.1* Mg-2.1
___ 03:36PM BLOOD ___ pO2-53* pCO2-41 pH-7.27*
calTCO2-20* Base XS--7
MICROBIOLOGY
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
**FINAL REPORT ___
RPR w/check for Prozone (Final ___:
NONREACTIVE.
Reference Range: Non-Reactive.
**FINAL REPORT ___
HIV-1 Viral Load/Ultrasensitive (Final ___:
HIV-1 RNA is not detected.
IMAGING:
RENAL ULTRASOUND ___
FINDINGS:
The right kidney measures 11.1 cm. The left kidney measures 10.0
cm. There is
no hydronephrosis, stones, or suspicious masses bilaterally.
There is an 8 mm
cyst in the right lower pole. Normal cortical echogenicity and
corticomedullary differentiation are seen bilaterally. Renal
contours are
slightly lobulated, but there is no cortical thinning.
The bladder is not very well distended, but grossly normal in
appearance.
IMPRESSION:
No hydronephrosis.
CXR PA/Lat ___
IMPRESSION:
Heart size is normal. Mediastinum is normal. Lungs overall
clear. No
pleural effusion or pneumothorax is seen.
Hyperinflation is suspected. If clinically warranted there,
correlation with
chest CT for pre size characterization of the airways an lung
parenchyma is to
be considered.
EKG ___
ECGStudy Date of ___ 11:11:10 AM
Clinical indication for EKG: E87.5 - Hyperkalemia
Sinus rhythm. Unchanged compared to the EKG from ___.
Intervals Axes
RatePRQRSQTQTc (___) ___
___
Brief Hospital Course:
This is a ___ w/ obesity, HTN, asthma, gout, CKD referred by
PCP with rash, concerning for DRESS syndrome.
#DRESS SYNDROME: Rash, eosinophilia, and transaminitis + ___ all
fit the constellation of DRESS, and skin biopsy from ___ was
confirmatory. Thought to be due to allopurinol hypersensitivity
reaction. His allopurinol was held and added to allergy list.
His atorvastatin was also stopped, though much less likely to be
the culprit drug. Dermatology was consulted and he was treated
with 2 days of IV methylprednisolone 1mg/kg and started on
prednisone taper. His eosinophilia trended down to normal by
hospital day 3, and LFTs and Cr were also downtrending. His
strongyloides antibody was negative. He was started on calcium,
vitamin D, a PPI, and atovaquone for PJP prophylaxis (no bactrim
given hyperkalemia).
___ on CKD: Patient has CKD with baseline creatinine of
1.7-1.8, which was increased to 2.3 on admission. Improved to
1.8 after fluid challenge, so likely pre-renal. His lisinopril
was held due to hyperkalemia.
#HYPERKALEMIA: Overall picture is consistent with type IV RTA.
AM cortisol was normal, so no adrenal insufficiency. Urine lytes
showing decreased K excretion, so hypoaldosteronism was
consistent with his clinical picture. His lisinopril was held.
Nephrology was consulted and recommended stopping lisinopril and
getting a renal US to rule out obstructive uropathy causing type
4 renal tubular acidosis. The US did not show hydronephrosis.
TRANSITIONAL ISSUES:
- Prednisone taper as detailed in discharge medication list.
Adjust as needed at dermatology followup.
- Allopurinol should be added to allergy list
- Consider restarting atorvastatin once DRESS has completely
resolved, as it is unlikely to be the culprit drug.
- Please screen for diabetes during and after his steroid taper.
- Lisinopril was held due to hyperkalemia
- Please arrange outpatient nephrology followup for his CKD and
hyperkalemia within 2 weeks
- Please check Chem7 at PCP followup appointment
___ on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Furosemide 20 mg PO DAILY
2. Fluticasone Propionate 110mcg 2 PUFF IH BID
3. Fluticasone Propionate NASAL 2 SPRY NU DAILY
4. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain
5. Lisinopril 20 mg PO DAILY
Discharge Medications:
1. Fluticasone Propionate 110mcg 2 PUFF IH BID
2. Fluticasone Propionate NASAL 2 SPRY NU DAILY
3. Furosemide 20 mg PO DAILY
4. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain
5. Calcium Carbonate 500 mg PO BID
RX *calcium carbonate 500 mg calcium (1,250 mg) 1 tablet(s) by
mouth twice a day Disp #*60 Tablet Refills:*1
6. Cetirizine 10 mg PO DAILY
RX *cetirizine 10 mg 1 tablet(s) by mouth daily Disp #*14 Tablet
Refills:*0
7. Clobetasol Propionate 0.05% Cream 1 Appl TP BID
RX *clobetasol 0.05 % Apply to rash twice a day Refills:*1
8. DiphenhydrAMINE 12.5 mg PO Q8H:PRN itching
RX *diphenhydramine HCl 25 mg 0.5 (One half) tablet(s) by mouth
every eight (8) hours Disp #*21 Tablet Refills:*0
9. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*1
10. Sarna Lotion 1 Appl TP TID:PRN itching
RX *camphor-menthol [Anti-Itch (menthol/camphor)] 0.5 %-0.5 %
Apply to itchy areas three times a day Refills:*1
11. PredniSONE 70 mg PO BID Duration: 5 Days
Take from ___ to ___
RX *prednisone 20 mg 3.5 tablet(s) by mouth twice a day Disp
#*80 Tablet Refills:*0
12. PredniSONE 60 mg PO BID Duration: 5 Days
Take from ___ to ___
Tapered dose - DOWN
13. PredniSONE 50 mg PO BID Duration: 5 Days
Take from ___ to ___
Tapered dose - DOWN
14. PredniSONE 80 mg PO DAILY Duration: 5 Days
Take from ___ to ___
Tapered dose - DOWN
RX *prednisone 20 mg 4 tablet(s) by mouth daily Disp #*45 Tablet
Refills:*0
15. PredniSONE 60 mg PO DAILY Duration: 5 Days
Take from ___ to ___
Tapered dose - DOWN
16. PredniSONE 40 mg PO DAILY Duration: 5 Days
Take from ___ to ___
Tapered dose - DOWN
17. PredniSONE 20 mg PO DAILY Duration: 5 Days
Take from ___ to ___
Tapered dose - DOWN
RX *prednisone 20 mg 1 tablet(s) by mouth daily Disp #*9 Tablet
Refills:*0
18. PredniSONE 10 mg PO DAILY Duration: 7 Days
Take from ___ to ___
Tapered dose - DOWN
19. Vitamin D 1000 UNIT PO DAILY
RX *cholecalciferol (vitamin D3) 1,000 unit 1 capsule(s) by
mouth daily Disp #*30 Capsule Refills:*1
20. Atovaquone Suspension 1500 mg PO DAILY
With meals
RX *atovaquone 750 mg/5 mL 10 mL by mouth daily Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
DRESS syndrome
Allopurinol hypersensitivity
Type 4 renal tubular acidosis
Hyperkalemia
Secondary Diagnoses:
Acute kidney injury
Chronic kidney disease
Acute liver injury
Eosinophilia
Gout
Obstructive sleep apnea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ for a drug hypersensitivity rash in
reaction to allopurinol. We monitored you for worsening of the
rash and gave you IV steroids. Your liver function and kidney
function improved, and your blood eosinophil count, which is a
sign of drug hypersensitivity/allergy, decreased.
Please continue taking oral prednisone until you follow up with
your dermatologist. While you are on the prednisone, you will
need calcium and vitamin D to prevent bone density loss. You
will also need Bactrim, an antibiotic to prevent infection.
Please discuss the taper of prednisone with your dermatologist.
You should never take allopurinol again. There is a very small
possibility that the rash could be in response to atorvastatin,
but this is much less likely than the allopurinol, which has
been added to your allergy list. Please discuss other gout
treatment and whether to restart atorvastatin, with your primary
care doctor. Your rash should continue to improve, but it will
likely take weeks to months to resolve completely.
Your potassium was also high, which we think is due to your
kidney function being slightly worse. Please do not take your
lisinopril as this can make potassium higher. Your blood
pressure was not significantly elevated during this admission.
You had a normal kidney ultrasound while you were here.
When you go home you will need to have your primary care doctor
make you an urgent appointment with a kidney doctor in the next
___ weeks to check your lab work
Best wishes,
Your ___ Team
Followup Instructions:
___
|
19550197-DS-2
| 19,550,197 | 20,308,418 |
DS
| 2 |
2171-12-13 00:00:00
|
2171-12-14 10:38:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is ___ man with history of hepatitis C and
polysubstance abuse who presented to ED with one day of crushing
left-sided chest pain. Patient reports he woke up with the pain,
which he describes as sharp, localized to ___ his chest
and worse with sitting up/walking. He felt as if someone was
"pushing on the ___ my chest with two thumbs" Pt also
experienced nausea, SOB. He was seen at ___ where
a troponin was elevated and he was given IV morphine, which
partially relieved pain. He had a CTA at ___ that was
reportedly negative for PE. Patient reports history of IVDU and
current marijuana and cocaine use. He last used cocaine
approximately one week ago.
Patient was sent from ___ to ___ and he was seen by
cardiology fellow, but left AMA because he felt his pain was not
being addressed. He reports walking around the area and found
that his chest pain was worse with activity, so he returned to
___.
In the ED initial vitals were: pain ___, temp 98.0 F, BP
160/97, HR 65, RR 18, 100% RA. EKG: NSR, rate ___, Q wave III,
non-specific ST/T wave changes in inferior and anterior leads.
Labs/studies notable for: trop: 0.47-> 0.97 CK: 478 MB: 37->54
MBI: 7.7->8.6 proBNP 287. CTA here showed no PE.
Patient was given: SL nitroglycerin, IV morphine and started on
heparin gtt. Patient was seen in ED by cardiology fellow who
recommended treating patient for NSTEMI, with likely TTE in AM.
Bedside echo normal, per cardiology fellow. No need for cath lab
emergently.
On arrival to floor patient feeling well, is currently CP free.
Reports feeling very hungry, but no additional complaints.
Past Medical History:
1. CARDIAC RISK FACTORS
-No diabetes, HTN or HLD
2. CARDIAC HISTORY
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY
Hepatitis C-never treated
?Cirrhosis-had ultrasound at ___ reportedly
consistent w/cirrhosis. Never biopsied.
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
Physical Exam:
ADMISSION EXAM:
VS: T97.9 BP145/94 HR76 RR16 O2 SAT 97% RA
GENERAL: Well appearing man, sitting up in bed, NAD
HEENT: Sclera anicteric. MMM, O/P clear.
NECK: No JVD.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RRR, normal S1, S2. No murmurs/rubs/gallops. No thrills,
lifts.
LUNGS: CTAB.
ABDOMEN: Soft, NTND
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric
DISCHARGE EXAM:
Vitals: 98/97.9 ___ 97-98/RA ___
GENERAL: Well appearing man, sitting up in bed, NAD
HEENT: Sclera anicteric. MMM, clear oropharynx.
NECK: No JVD.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RRR, normal S1, S2. No murmurs/rubs/gallops. No thrills,
lifts.
LUNGS: CTAB.
ABDOMEN: Soft, NTND
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric
Pertinent Results:
======================
ADMISSION LABS
======================
___ 02:00PM ___ PTT-29.8 ___
___ 02:00PM BLOOD WBC-7.9 RBC-4.74 Hgb-15.2 Hct-44.3 MCV-94
MCH-32.1* MCHC-34.3 RDW-12.3 RDWSD-42.3 Plt ___
___ 02:00PM BLOOD ___ PTT-29.8 ___
___ 02:00PM BLOOD Plt ___
___ 02:00PM BLOOD Glucose-98 UreaN-12 Creat-0.9 Na-137
K-4.2 Cl-101 HCO3-25 AnGap-15
___ 02:00PM BLOOD CK(CPK)-478*
___ 02:00PM BLOOD CK-MB-37* MB Indx-7.7* proBNP-285*
___ 02:00PM BLOOD cTropnT-0.47*
___ 02:00PM BLOOD Calcium-8.6 Phos-3.4 Mg-2.0
___ 02:17PM BLOOD Lactate-1.1
=============================
DISCHARGE LABS
==============================
___ 05:35AM BLOOD Albumin-3.9 Calcium-8.6 Phos-3.1 Mg-2.2
___ 05:35AM BLOOD ALT-107* AST-87* AlkPhos-68 TotBili-0.8
___ 05:35AM BLOOD Glucose-103* UreaN-12 Creat-1.0 Na-140
K-3.2* Cl-100 HCO3-27 AnGap-16
___ 05:35AM BLOOD WBC-6.7 RBC-4.53* Hgb-15.1 Hct-42.9
MCV-95 MCH-33.3* MCHC-35.2 RDW-12.6 RDWSD-43.7 Plt ___
___ 05:35AM BLOOD WBC-6.7 RBC-4.53* Hgb-15.1 Hct-42.9
MCV-95 MCH-33.3* MCHC-35.2 RDW-12.6 RDWSD-43.7 Plt ___
___ 01:19AM URINE bnzodzp-NEG barbitr-NEG opiates-POS*
cocaine-POS* amphetm-NEG oxycodn-NEG mthdone-NEG
==================
IMAGING & STUDIES
==================
Echo ___: Left ventricular wall thickness, cavity size
and regional/global systolic function are normal (LVEF >55%).
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is no pericardial effusion.
IMPRESSION: Normal global and regional biventricular systolic
function.
CTA Chest ___: 1. No evidence of pulmonary embolism or
acute aortic abnormality.
2. Diffuse mild bronchial wall thickening may reflect small
airways disease.
No consolidation to suggest pneumonia.
3. Incompletely imaged moderate splenomegaly.
RUQ Ultrasound ___: Technically limited study though
normal abdominal ultrasound, specifically no
focal liver lesions.
Brief Hospital Course:
SUMMARY: ___ with history of EtOH abuse, former IVDU, untreated
hepatitis C, ?cirrhosis who presents with acute chest pain. His
chest pain was thought to be in the setting of cocaine-induced
vasospasm. An echocardiogram was performed with no focal wall
motion abnormalities and LVEF of >55%. His pain was managed with
morphine and SL nitroglycerin and resolved. His troponins were
trended and he was discharged home in stable condition.
ACUTE ISSUES:
#Chest pain: Patient presented with chest pain and elevated
troponin concerning for NSTEMI in setting of cocaine vasospasm.
Patient reports last using cocaine one week ago but utox
positive for cocaine on admission. Troponins were trended to
peak and pain managed with morphine and SL nitro. Heparin gtt
was initially started then discontinued due to low suspicion for
type I NSTEMI. Patient planned for outpatient stress test to r/o
cardiac ischemia.
#Hepatitis C: Patient has hepatitis C, reports history of IVDU.
Never been treated. Viral load sent this admission and pending
at time of discharge. Patient self-reported evidence of
cirrhosis on OSH ultrasound; RUQ U/S repeated this admission
with no evidence of cirrhosis. Will require outpatient follow up
with hepatology as outpatient for consideration of hepatitis C
treatment.
# Polysubstance abuse: Patient reports history of IVDU, but none
currently. Occasional cocaine use, daily marijuana. Previously
drank heavily, but now reports only few beers per week. Social
work was consulted.
TRANSITIONAL ISSUES:
- Troponin on discharge: 0.70, downtrending
- Outpatient stress echo scheduled at ___ on ___ to rule
out coronary artery disease
- Will require hepatology f/u for consideration of hepatitis C
treatment and further workup for cirrhosis. HCV VL still
pending.
- Substance abuse, including of cocaine, should be explored and
patient may benefit from specific counseling for this
# CODE: full, confirmed
# CONTACT: HCP: Brother ___ ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
None
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
===================
- NSTEMI, cocaine-induced vasospasm
SECONDARY DIAGNOSIS
====================
- Hepatitis C
- Cocaine use, alcohol use
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 ___ because of chest pain, which was
thought to be related to your cocaine use.
WHAT HAPPENED WHEN YOU WERE IN THE HOSPITAL?
============================================
- We closely monitored troponins, which is a blood test that
measures damage to your heart
- We temporarily started you on a blood thinner medication which
was then discontinued
- We performed an ultrasound of your heart, which did not show
any permanent damage to your heart at this time
- We performed an ultrasound of the liver, which did not show
cirrhosis. However, you will still need further testing to know
if you have cirrhosis or not
WHAT WILL HAPPEN WHEN YOU LEAVE THE HOSPITAL?
==============================================
- You can continue taking nitroglycerin to help your chest pain
- Please come back here to ___ to have a stress test performed
on ___ at 3:00 ___ (see below), to see if there are
any underlying problems with your heart
** DO NOT EAT, DRINK, OR SMOKE FOR 3 HOURS BEFORE YOUR
APPOINTMENT **
- Please avoid using cocaine
- Please follow up with your primary care doctor and discuss
treating your hepatitis C
It was a pleasure taking care of you!
- Your ___ care team
Followup Instructions:
___
|
19550378-DS-30
| 19,550,378 | 27,191,438 |
DS
| 30 |
2147-07-08 00:00:00
|
2147-07-08 13:12:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Tetracycline / Grapefruit / Amoxicillin / Tegaderm
/ diazepam
Attending: ___.
Chief Complaint:
Nausea, vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ w/ h/o DM2, idiopathic axonal sensorimotor
polyneuropathy, SBO, coronary vasospasm who presents with one
day of N/V. She began vomiting evening prior to presentation
(she says too many to count), accompanied by chills, body aches,
lower abdominal pain, and substernal left chest pain immediately
after her vomiting episodes without associated symptoms. She
took nitro. The pain resolved within 5 minutes. None since. No
URI symptoms. Lives in assisted living, several other residents
with similar symptoms.
She does note ongoing issues with constipation, though has had
several loose BMs in the last couple of days.
In the ED, initial vitals: 96.7 67 180/72 18 95% RA
Labs and CT abd/pelvis reassuring. EKG wnl, trops neg x2.
Pt received:
___ 01:50 IV Ondansetron 4 mg
___ 01:50 IVF 1000 mL NS 1000 mL
___ 02:15 IV Metoclopramide 10 mg
___ 03:00 PO Aspirin
___ 03:00 IH Albuterol 0.083% Neb Soln
___ 03:00 IH Ipratropium Bromide Neb
___ 03:41 IV Lorazepam 1 mg
___ 09:01 IV Diazepam 10 mg
___ 12:06 IV Prochlorperazine 10 mg
___ 12:06 IV DiphenhydrAMINE 25 mg
Briefly apneic after receiving 10 mg valium but quickly
recovered. She was unable to tolerate POs.
Vitals prior to transfer: 99.0 72 143/98 22 96% RA
Currently, the patient notes mild lower back pain that started
during the present episode without other associated symptoms.
Past Medical History:
- Severe idiopathic axonal sensorimotor polyneuropathy
* initial sx in ___ (weakness and sensory loss in legs -->
abdomen --> arms)
* responsive to plasmapheresis ~yearly, last ___
- Vitamin B12 deficiency
- Partial SBO, managed conservatively, ___
- DM2 (not on medication)
- HTN
- GERD
- Depression
- Diverticulosis
- Coronary vasospam on amlodipine
PAST SURGICAL HISTORY:
- c-section x 2
- hysterectomy for leiomyomata
- left breast lumpectomy
- bilateral knee replacements
- portacath (since removed)
- surgery related to recent abdominal hematoma related to sc
heparin
Social History:
___
Family History:
from OMR
- negative for neurological conditions
- positive for DM (mother, brother), malignancy (mother - liver,
cervical, colon; father - lung), CAD (mother)
Physical Exam:
ON ADMISSION:
=============
Vitals- 98.8 150/77 68 18 96% RA
General- Alert, oriented, no acute distress
HEENT- Sclerae anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated
Lungs- CTAB no wheezes, rales, rhonchi
CV- RRR, Nl S1, S2, systolic murmur at the ___
Abdomen- Obese, soft, mild ttp in the bilateral lower quadrants,
bowel sounds present, no rebound tenderness or guarding, no
organomegaly
GU- no foley
Ext- warm, well perfused, no clubbing, cyanosis or edema
Neuro- CNs2-12 grossly intact, moving all extremities
ON DISCHARGE:
=============
VS: 98.2 134/76 70 20 97RA
GENERAL: Well appearing, alert, oriented, no acute distress.
HEENT: MMM, oropharynx clear.
NECK: Supple, JVD not elevated
CV: RRR, normal S1, S2. Systolic murmur at ___.
RESP: Clear to auscultation bilaterally.
ABD: +BS, soft, nondistended, nontender to palpation.
GU: No foley
EXT: Warm and well perfused. No edema.
SKIN: No rashes.
Pertinent Results:
ON ADMISSION:
======================================
___ 01:20AM PLT COUNT-178
___ 01:20AM NEUTS-77.7* LYMPHS-12.4* MONOS-6.5 EOS-3.3
BASOS-0.1
___ 01:20AM WBC-5.8 RBC-4.76 HGB-14.9 HCT-43.2 MCV-91
MCH-31.3 MCHC-34.5 RDW-13.9
___ 01:20AM ALBUMIN-3.9
___ 01:20AM cTropnT-<0.01
___ 01:20AM LIPASE-21
___ 01:20AM ALT(SGPT)-18 AST(SGOT)-24 ALK PHOS-89 TOT
BILI-0.5
___ 01:20AM estGFR-Using this
___ 01:23AM LACTATE-1.6
___ 02:40AM URINE MUCOUS-RARE
___ 02:40AM URINE RBC-<1 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 02:40AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-NEG
___ 02:40AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 02:40AM URINE UHOLD-HOLD
___ 02:40AM URINE HOURS-RANDOM
___ 07:45AM cTropnT-<0.01
ON DISCHARGE:
============================
___ 05:26AM BLOOD WBC-4.4 RBC-4.73 Hgb-14.6 Hct-42.2 MCV-89
MCH-30.8 MCHC-34.5 RDW-14.1 Plt ___
___ 05:26AM BLOOD Glucose-113* UreaN-20 Creat-1.0 Na-139
K-3.7 Cl-101 HCO3-26 AnGap-16
___ 05:26AM BLOOD Calcium-9.0 Phos-3.6 Mg-2.1
MICRO:
========================
Urine Culture: No growth
Blood Culture: Pending, no growth to date
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay
STUDIES:
CT ABD/PELVIS (___)
1. Diverticulosis throughout the colon without signs of
diverticulitis.
2. No convincing evidence of small bowel obstruction. Tortuous
colon with cecum positioned in the midline, and mild prominence
of distal small bowel, but no focal zone of transition.
3. Stable right adrenal nodule dating back to ___.
4. Slight thickening of the distal sigmoid colon may be due to
collapsed segment. Suggest followup nonemergent endoscopy.
CXR ___:
No acute cardiopulmonary process.
Brief Hospital Course:
___ with PMH significant for DM2, idiopathic axonal
sensorimotor polyneuropathy, SBO, coronary vasospasm who
presents with one day of nausea, vomiting, and loose stools.
# VIRAL GASTROENTERITIS:
Given sick contacts, chills, body aches, the patient's symptoms
were felt to be secondary to viral gastroenteritis. She did not
have any URI symptoms or myalgias to suspect influenza. CT
ABD/PELVIS showed diverticulosis and slight thickening of the
distal sigmoid colon, which may be due to a collapsed segment.
Blood cultures with no growth to date. C difficile was negative.
The patient was treated with IVF and anti-emetics. Her diet was
advanced slowly. Her symptoms improved by day 2 of
hospitalization.
# ACUTE KIDNEY INJURY:
Cr was elevated at 1.8 on day 2 of hospitalization, from
baseline of 0.8. FENa was 0.08%, which was consistent with a
pre-renal etiology. She did not have any episodes of
hypotension. She was not on nephrotoxic medications. She was
treated with IVF.
# CHEST PAIN:
Suspect this may be esophageal irritation in the setting of
vomiting given temporality. Troponins were negative x 2. EKG was
also reassuring. The patient was given omeprazole. She was
continued on medications for CAD/coronary vasospasm. Simvastatin
was switched to atorvastatin given drug interaction with
amlodipine.
# DM2:
HbA1c was 5.4% in ___ without therapy. Her glucose with daily
chemistries were normal.
# CHRONIC PAIN:
She was continued on tramadol and gabapentin.
# SENSIROMOTOR NEUROPATHY:
She will have outpatient follow up with plasmapheresis as
planned.
# DEPRESSION:
She was continued on sertraline.
# HOME MEDICATIONS:
- Continued eye drops.
- Held psyllium.
TRANSITIONAL ISSUES:
* CT Abd/Pelvis showed slight thickening of the distal sigmoid
colon, which may be due to collapsed segment. Radiology
suggested followup with nonemergent endoscopy.
* Simvastatin switched to atorvastatin due to drug interaction
with amlodipine.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO DAILY
2. Artificial Tears 2 DROP BOTH EYES Q6H:PRN dry eyes
3. Aspirin 81 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Bisacodyl 5 mg PO DAILY:PRN constipation
6. Lactulose 15 mL PO TID
7. Lorazepam 0.5 mg PO Q6H:PRN anxiety
8. Polyethylene Glycol 17 g PO Q12H
9. Multivitamins 1 TAB PO DAILY
10. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
11. Reguloid (psyllium husk;<br>psyllium seed (sugar)) 0.52 gram
oral BID
12. Cyanocobalamin 1000 mcg PO DAILY
13. Vitamin D 1000 UNIT PO DAILY
14. BuPROPion 100 mg PO BID
15. Sertraline 100 mg PO DAILY
16. Amlodipine 2.5 mg PO DAILY
17. Gabapentin 100 mg PO BID
18. Ondansetron 4 mg PO Q6H:PRN nausea
19. Simvastatin 20 mg PO DAILY
20. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
Discharge Medications:
1. Acetaminophen 1000 mg PO DAILY
2. Amlodipine 2.5 mg PO DAILY
3. Artificial Tears 2 DROP BOTH EYES Q6H:PRN dry eyes
4. Aspirin 81 mg PO DAILY
5. BuPROPion 100 mg PO BID
6. Cyanocobalamin 1000 mcg PO DAILY
7. Docusate Sodium 100 mg PO BID
8. Gabapentin 100 mg PO BID
9. Lactulose 15 mL PO TID
10. Lorazepam 0.5 mg PO Q6H:PRN anxiety
11. Multivitamins 1 TAB PO DAILY
12. Polyethylene Glycol 17 g PO Q12H
13. Sertraline 100 mg PO DAILY
14. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
15. Vitamin D 1000 UNIT PO DAILY
16. Bisacodyl 5 mg PO DAILY:PRN constipation
17. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
18. Ondansetron 4 mg PO Q6H:PRN nausea
19. Reguloid (psyllium husk;<br>psyllium seed (sugar)) 0.52 gram
oral BID
20. Atorvastatin 10 mg PO QPM
RX *atorvastatin 10 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnoses:
Viral gastroenteritis
Acute kidney injury
Constipation
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 caring for you at ___. You were admitted
with a gastrointestinal infection. You were treated with IV
fluids and nausea medications. Your kidney function was
decreased on admission, but improved with IV fluids. We are glad
you are feeling better.
Best wishes,
Your ___ Team
Followup Instructions:
___
|
19550378-DS-31
| 19,550,378 | 21,917,882 |
DS
| 31 |
2147-07-23 00:00:00
|
2147-07-23 16:25:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Tetracycline / Grapefruit / Amoxicillin / Tegaderm
/ diazepam
Attending: ___
Chief Complaint:
cc: nausea/vomiting
Major Surgical or Invasive Procedure:
NGT decompression
History of Present Illness:
___ y/o female with history of idopathic axional polyneuropathy
treated with plasmapheresis, HTN, recurrent pertial SBO with
recent admission for abdominal pain, nausea and vomiting,
presents with recurrent symptoms.
She reports she never felt totally better after her recent
discharge. Then one day prior to presentation developed
nausea/vomiting abdominal pain and diarrhea. She reports lower
abdominal pain which radiates to her epigastrum. Pain is ___ in
sererity. Pain medication helps a little. She has vomited a
number of times. Denies blood in vomitus. Last BM was this
morning, thinks she continues to pass gas. She has no fever but
has had chills. Also complains of SOB which she associates with
her pain. She does report some chest pain which she says is not
like her cardiac pain and seems to radiate from her epigastrum.
She also endorses a headache.
Remainder of 12 point ROS asked and negative.
Past Medical History:
- Severe idiopathic axonal sensorimotor polyneuropathy
* initial sx in ___ (weakness and sensory loss in legs -->
abdomen --> arms)
* responsive to plasmapheresis ~yearly, last ___
* now wheelchair-bound
- Vitamin B12 deficiency
- Partial SBO, managed conservatively, ___
- DM2 (not on medication)
- HTN
- GERD
- Depression
- Diverticulosis
- Coronary vasospam on amlodipine
PAST SURGICAL HISTORY:
- c-section x 2
- hysterectomy for leiomyomata
- left breast lumpectomy
- bilateral knee replacements
- portacath (since removed)
- surgery related to abdominal hematoma secondary to
subcutaneous heparin
Social History:
___
Family History:
from ___, confirmed with patient
- negative for neurological conditions
- positive for DM (mother, brother), malignancy (mother - liver,
cervical, colon; father - lung), CAD (mother)
Physical Exam:
VS: 98.3 BP: 151/75 HR: 77 R: 20 O2: 100% 2L
Obese female laying in bed in some distress due to pain and
nausea
Pain ___
HEENT: NGT in place, MMM, no oral lesions
Lungs: Clear b/l on anterior auscultation
___: RRR, S1, S2 present
ABD: Soft, tender on palpation of lower quadrants, left>right,
epigastrum, no rebound or guarding
EXT: No edema
NEURO: AAOx3, difficult to asses stregnth due to patient
cooperation
Psych: ___ and cooperative
Pertinent Results:
___ 09:45AM ___ PTT-29.3 ___
___ 07:59AM ___ PTT-UNABLE TO ___
___ 07:46AM COMMENTS-GREEN TGOP
___ 07:46AM LACTATE-1.3
___ 07:39AM GLUCOSE-149* UREA N-16 CREAT-0.9 SODIUM-140
POTASSIUM-5.1 CHLORIDE-102 TOTAL CO2-24 ANION GAP-19
___ 07:39AM estGFR-Using this
___ 07:39AM ALT(SGPT)-23 AST(SGOT)-29 ALK PHOS-91 TOT
BILI-0.5
___ 07:39AM LIPASE-36
___ 07:39AM ALBUMIN-4.4
___ 07:39AM WBC-8.0# RBC-5.15 HGB-15.6 HCT-46.8 MCV-91
MCH-30.3 MCHC-33.4 RDW-14.1
___ 07:39AM NEUTS-79.7* LYMPHS-14.7* MONOS-3.5 EOS-1.9
BASOS-0.2
___ 07:39AM PLT COUNT-___
IMPRESSION:
1. Distended gas and fluid-filled small bowel loops, with 2
transition points
the left upper quadrant, raising concern for closed loop small
bowel
obstruction. No evidence of abdominopelvic free fluid or free
air.
2. Severe colonic diverticulosis, with no evidence of
diverticulitis.
3. Stable right adrenal nodule.
CT Chest: ___
IMPRESSION:
1. Orogastric tube terminates in the stomach.
2. Low lung volumes. Left costophrenic angle is not clearly
visualized, could be secondary to atelectasis, pleural effusion
or also secondary to patient's positioning and overlying soft
tissues
Brief Hospital Course:
Ms ___ is a ___ w/ h/o DM2 (diet-controlled), idiopathic axonal
sensorimotor polyneuropathy rx with plasmapheresis, recurrent
partial SBO, coronary vasospasm, with recent admission for
nausea/vomiting with negative CT thought to be viral gastritis.
Re-presented with similar symptoms, CT with evidence of partial
SBO. Surgery following. Improved quickly with conservativ mgmt.
NGT clamped and then removed ___. Tolerating po's. Diet
advanced slowly. Deconditioned and working with ___, who
recommended ___ rehab. Pt declined and strongly prefers
to go home, feels she is very close to her baseline level of
activity.
#partial small bowel obstruction: possibly secondary to
polyneuropathy. Gen surgery consulted, agreed with conservative
mgmt including bowel rest, NGT, IVF. Diet gradually advanced,
tolerated well. Nutrition consulted re low residue diet, pt
expressed understanding. F/u with GI Dr. ___ as outpatient
#Coronary vasospasm
Amlodipine, ASA, statin held on admit
--Statin resumed ___
--Resumed ASA, amlodipine ___
# Chronic pain
- resumed gabapentin ___
- resumed prn ultram ___
# SENSORIMOTOR NEUROPATHY:
Neurology Dr. ___ of admission, no acute issues.
# DEPRESSION:
-- resumed sertraline, bupropion ___
#Chronic constipation
-- resumed miralax ___, rest of bowel regimen on discharge
# disp: ___ consulted, recs as noted above. Nursing obrtained
orthotics for feet for transfers.
#Code: Full- confirmed with patient
#NOK: Niece ___- ___
#communication with PCP ___, NP via email
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen 1000 mg PO DAILY
2. Amlodipine 2.5 mg PO DAILY
3. Artificial Tears 2 DROP BOTH EYES Q6H:PRN dry eyes
4. Aspirin 81 mg PO DAILY
5. BuPROPion 100 mg PO BID
6. Cyanocobalamin 1000 mcg PO DAILY
7. Docusate Sodium 100 mg PO BID
8. Gabapentin 100 mg PO BID
9. Lactulose 15 mL PO TID
10. Lorazepam 0.5 mg PO Q6H:PRN anxiety
11. Multivitamins 1 TAB PO DAILY
12. Polyethylene Glycol 17 g PO Q12H
13. Sertraline 100 mg PO DAILY
14. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
15. Vitamin D 1000 UNIT PO DAILY
16. Bisacodyl 5 mg PO DAILY:PRN constipation
17. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
18. Ondansetron 4 mg PO Q6H:PRN nausea
19. Reguloid (psyllium husk;<br>psyllium seed (sugar)) 0.52 gram
oral BID
20. Atorvastatin 10 mg PO QPM
Discharge Medications:
1. Amlodipine 2.5 mg PO DAILY
2. Artificial Tears 2 DROP BOTH EYES Q6H:PRN dry eyes
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 10 mg PO QPM
5. BuPROPion 150 mg PO BID
6. Gabapentin 100 mg PO BID
7. Polyethylene Glycol 17 g PO Q12H
8. Sertraline 75 mg PO DAILY
9. Acetaminophen 650 mg PO QHS:PRN pain
10. Cyanocobalamin 1000 mcg IM/SC QMONTH
11. Docusate Sodium 100 mg PO BID
12. Multivitamins 1 TAB PO DAILY
13. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
14. Ondansetron 4 mg PO Q6H:PRN nausea
15. Vitamin D 1000 UNIT PO BID
16. Lorazepam 0.5 mg PO QDAY PRN anxiety
17. Bisacodyl 5 mg PO DAILY:PRN constipation
18. Lactulose 30 mL PO TID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
recurrent partial small bowel obstruction, possibly secondary to
polyneuropathy
SECONDARY:
# axonal sensorineural polyneuropathy
# DM type II (diet-controlled)
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:
It was a pleasure taking care of you during your recent
admission to ___. You were admitted with nausea, vomiting and
abdominal pain and found to have a bowel obstruction. You were
managed conservatively with the help of the surgical team and
you improved. Please follow a low-fiber diet as discussed with
the nutritionist.
Followup Instructions:
___
|
19550378-DS-34
| 19,550,378 | 27,631,454 |
DS
| 34 |
2148-11-21 00:00:00
|
2148-11-23 10:50:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Penicillins / Tetracycline / Grapefruit / Amoxicillin / Tegaderm
/ diazepam
Attending: ___.
Chief Complaint:
Abdominal pain, nausea, vomiting
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ w/ morbid obesity, polyneuropathy requiring serial
plasmepheresis, s/p C sectionx2 and hysterectomy, multiple SBO
managed conservatively who presents with abdominal pain, nausea
and vomiting. Patient was discharged yesterday after receiving
plasmapheresis for several days due to demyelinating disease.
She was doing well at the time of discharge. At around ___
yesterday she developed acute onset abdominal pain associated
with nausea and 7 episodes of non bilious vomiting. This is
similar, yet more severe,than her prior episode of partial small
bowel obstruction. She has been passing flatus and has several
bowel movements. She otherwise denies fever/chills. In ED she
continues to be afebrile, non toxic looking with stable vital
sings.
Past Medical History:
Severe idiopathic axonal sensorimotor polyneuropathy with
symptoms beginning in the late ___ or early ___. Symptoms began
with weakness and sensory loss in the legs proximally. Symptoms
have been responsive to plasmapheresis approximately yearly. As
noted above, she is wheelchair bound.
TREATMENT HISTORY:
___ Weakness and sensory loss in legs, torso and arms
___ Visit with Dr. ___
___ Sural nerve biopsy
Pathology: marked loss of large and small myelinated axons
___ - ___ IVIG
___ Worse symptoms with dysarthria, hypophonia, and dsypahgia
___ Plasmapheresis, had coronary vasospasm, bradycardia and
one episode of bilateral shoulder pain
___ line infection
___ Plasmapheresis, nausea, vomiting
___ Plasmapheresis, transient nausea and emesis
___ Plasmaexchange
___ Had abdominal pain, procedure postponed
___ - ___ Plasma exchange x4
___ Plasma exchange #1
Vitamin B12 deficiency
History of partial small-bowel obstruction
Diabetes, not on any medications at present
Hypertension
GERD
Depression
Diverticulosis
Coronary vasospasm
Status post C-section x 2
Status post hysterectomy for leiomyomata
Left breast lumpectomy
Status post bilateral knee replacements
History of abdominal hematoma due to subcutaneous heparin
Social History:
___
Family History:
Mother, brother with diabetes. Mother with liver, cervix, and
colon cancer, as well as CAD; father with lung cancer.
Physical Exam:
Admission Physical Exam:
Vitals: T 96.7, HR 82, BP 135/73, RR 16, sat 99%/RA
GEN: A&Ox3, appears comfortable, non toxic looking
HEENT: No scleral icterus, mucus membranes moist
CV: RRR,
PULM: Clear to auscultation b/l, no labored breathing
ABD: obese, Soft, moderately distended, TTP at R lower abdomen,
no rebound or guarding, non peritoneal
Ext: No ___ edema, ___ warm and well perfused
Discharge Physical exam:
VS: 98.8, 64, 120/43, 18, 99 RA
Gen: Awake alert, sitting up in bed. Pleasant and interactive.
HEENT: No deformity. PERRL, EOMI. Neck supple, trachea midline.
CV: RRR
Resp: Clear to auscultation bilaterally.
Abd: Obese, soft, non-tender. Active bowel sounds.
Extremities: Obese, warms and dry. 2+ ___ pulses.
Neuro: A&Ox3. Follows commands and moves all extremities equal
and strong. Speech is clear and fluent.
Pertinent Results:
___ 06:10AM BLOOD WBC-7.6 RBC-4.36 Hgb-13.6 Hct-41.4 MCV-95
MCH-31.2 MCHC-32.9 RDW-16.3* RDWSD-57.1* Plt ___
___ 06:27AM BLOOD WBC-8.8 RBC-4.47 Hgb-14.2 Hct-41.7 MCV-93
MCH-31.8 MCHC-34.1 RDW-16.3* RDWSD-54.5* Plt ___
___ 08:40AM BLOOD WBC-6.5 RBC-4.29 Hgb-13.2 Hct-39.7 MCV-93
MCH-30.8 MCHC-33.2 RDW-16.2* RDWSD-54.7* Plt ___
___ 06:10AM BLOOD ___ PTT-23.9* ___
___ 02:45AM BLOOD ___ PTT-27.6 ___
___ 06:10AM BLOOD Glucose-101* UreaN-11 Creat-0.8 Na-143
K-4.0 Cl-106 HCO3-27 AnGap-14
___ 02:45AM BLOOD Glucose-158* UreaN-15 Creat-1.0 Na-138
K-8.0* Cl-103 HCO3-25 AnGap-18
___ 08:40AM BLOOD Glucose-90 UreaN-15 Creat-0.8 Na-139
K-4.2 Cl-106 HCO3-23 AnGap-14
___ 06:10AM BLOOD Calcium-9.4 Phos-3.4 Mg-1.9
___ 08:40AM BLOOD Calcium-9.2 Phos-3.5 Mg-1.8
___ 03:02AM BLOOD Lactate-1.3 K-4.4
___ CT Ab/Pelvis
1. Partial or early small bowel obstruction, with a transition
point in the
left abdomen. No evidence of ischemia or perforation.
2. 2.7 x 2.4 cm right adrenal nodule, stable from ___.
Brief Hospital Course:
Ms. ___ is a ___ yo F admitted to the Acute Care Surgery service
with abdominal pain, nausea and vomiting. She has a past medical
history significant for idiopathic axonal sensorimotor
polyneuropathy requiring plasmapheresis, diverticulitis,
hysterectomy, and diabetes. She had a CT scan that showed a
small bowel obstruction with transition point in the left upper
quadrant. She was made NPO, given IV fluids and admitted the
floor hemodynamically stable for further management.
On HD1 she had flatus and a bowel movement. Her diet was
advanced sequentially to regular with good tolerability. The
patient voided without problem. During this hospitalization, the
patient ambulated early and frequently, was adherent with
respiratory toilet and incentive spirometry, and actively
participated in the plan of care. The patient received
subcutaneous heparin and venodyne boots were used during this
stay.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, having bowel movements, ambulating, voiding without
assistance, and pain was well controlled. The patient was
discharged home without services. The patient received discharge
teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 2.5 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 10 mg PO QPM
4. Bisacodyl 10 mg PO DAILY:PRN constipation
5. BuPROPion 150 mg PO BID
6. Docusate Sodium 100 mg PO BID
7. Gabapentin 100 mg PO BID
8. Lactulose 15 mL PO Q8H:PRN constipation
9. LORazepam 0.5 mg PO QHS:PRN insomani
10. Ondansetron 4 mg PO Q8H:PRN nausea
11. Polyethylene Glycol 17 g PO BID
12. Sertraline 75 mg PO DAILY
13. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
14. Miconazole Powder 2% 1 Appl TP TID:PRN skin irritation
Discharge Medications:
1. amLODIPine 2.5 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 10 mg PO QPM
4. Bisacodyl 10 mg PO DAILY:PRN constipation
5. BuPROPion 150 mg PO BID
6. Docusate Sodium 100 mg PO BID
7. Gabapentin 100 mg PO BID
8. Lactulose 15 mL PO Q8H:PRN constipation
9. LORazepam 0.5 mg PO QHS:PRN insomani
10. Miconazole Powder 2% 1 Appl TP TID:PRN skin irritation
11. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
12. Polyethylene Glycol 17 g PO BID
13. Sertraline 75 mg PO DAILY
14. Ondansetron 4 mg PO Q8H:PRN nausea
Discharge Disposition:
Home
Discharge Diagnosis:
Partial small bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the Acute Care surgery service with
abdominal pain, nausea, and vomiting. You had a CT scan that
showed a small bowel obstruction. You were given IVF and managed
non-operatively. You are now tolerating a regular diet and
having bowel function. You are now ready to be discharged home
to continue your recovery.
Please note the following discharge instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Followup Instructions:
___
|
19550378-DS-35
| 19,550,378 | 21,825,106 |
DS
| 35 |
2149-02-20 00:00:00
|
2149-02-20 18:40:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Penicillins / Tetracycline / Grapefruit / Amoxicillin / Tegaderm
/ diazepam
Attending: ___.
Chief Complaint:
Abdominal Pain, Nausea, Vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ female with a history of C-section
x 2, hysterectomy, morbid obesity and a history of recurrent
SBOs
managed conservatively who presents with abdominal pain, nausea
and vomiting.
The patient's most recent admission was to the ACS service on
___ for a recurrent SBO, which presented in a similar
fashion to her presenting complaints today. She was made NPO,
and
had return of bowel function within the first hospital day
without requiring NG tube decompression. She was discharged
thereafter in good condition.
On evaluation today, she reports having experiencing colicky
epigastric pain since mid-day yesterday which has worsened
overnight, and associated nausea with 3 bouts of bilious emesis
since time of onset. She initially had a large episode of
diarrhea, but since that time had not been having bowel
movements
or passing flatus. She does report having had passed flatus
approximately 1 hour prior to our consultation, however, and
feels an improvement in her nausea and pain since that time (now
reportedly minimal). Otherwise no fevers/chills, no
lethargy/malaise, no weight loss, no BRBPR.
Past Medical History:
Severe idiopathic axonal sensorimotor polyneuropathy with
symptoms beginning in the late ___ or early ___. Symptoms began
with weakness and sensory loss in the legs proximally. Symptoms
have been responsive to plasmapheresis approximately yearly. As
noted above, she is wheelchair bound.
TREATMENT HISTORY:
___ Weakness and sensory loss in legs, torso and arms
___ Visit with Dr. ___
___ Sural nerve biopsy
Pathology: marked loss of large and small myelinated axons
___ - ___ IVIG
___ Worse symptoms with dysarthria, hypophonia, and dsypahgia
___ Plasmapheresis, had coronary vasospasm, bradycardia and
one episode of bilateral shoulder pain
___ line infection
___ Plasmapheresis, nausea, vomiting
___ Plasmapheresis, transient nausea and emesis
___ Plasmaexchange
___ Had abdominal pain, procedure postponed
___ - ___ Plasma exchange x4
___ Plasma exchange #1
Vitamin B12 deficiency
History of partial small-bowel obstruction
Diabetes, not on any medications at present
Hypertension
GERD
Depression
Diverticulosis
Coronary vasospasm
Status post C-section x 2
Status post hysterectomy for leiomyomata
Left breast lumpectomy
Status post bilateral knee replacements
History of abdominal hematoma due to subcutaneous heparin
Social History:
___
Family History:
Mother, brother with diabetes. Mother with liver, cervix, and
colon cancer, as well as CAD; father with lung cancer.
Physical Exam:
GEN: NAD, well appearing
HEENT: NCAT, trachea midline
CV: RRR, 2+ radial pulses b/l
RESP: breathing comfortably on room air
GI: obese, soft, non-TTP, no distension, rebound or guarding, no
masses or hernias on palpation
EXT: well perfused
Pertinent Results:
___ 07:00AM BLOOD WBC-6.5 RBC-4.61 Hgb-13.6 Hct-43.1 MCV-94
MCH-29.5 MCHC-31.6* RDW-13.5 RDWSD-46.6* Plt ___
___ 08:42AM BLOOD Neuts-67.1 ___ Monos-6.2 Eos-2.9
Baso-0.3 Im ___ AbsNeut-4.47 AbsLymp-1.52 AbsMono-0.41
AbsEos-0.19 AbsBaso-0.02
___ 07:00AM BLOOD Plt ___
___ 07:00AM BLOOD Glucose-104* UreaN-11 Creat-0.8 Na-140
K-4.2 Cl-102 HCO3-31 AnGap-11
___ 08:42AM BLOOD ALT-15 AST-28 AlkPhos-119* TotBili-0.5
___ 07:00AM BLOOD Calcium-9.0 Phos-3.7 Mg-2.2
___ 01:06PM BLOOD Lactate-1.8
Brief Hospital Course:
Ms. ___ was admitted to the hospital for management of her
small bowel obstruction. She has an extensive history of
multiple small bowel obstructions that have all previously
resolved with medical management. Upon admission to the ___
team, she received a nasogastric tube for bowel decompression
and was made NPO. Over the course of her stay, she slowly
experienced a return of her bowel function and she was passing
gas appropriately. Her diet was advanced in a stepwise fashion
until she was tolerating a regular diet with no issues. At the
time of discharge, she denied abdominal discomfort, nausea,
vomiting and was passing gas and tolerating a regular diet. She
was OOB to chair as she is wheelchair dependent. She was
discharged to her long term care facility with no additional
medications. She was instructed to follow up with Dr. ___ in
clinic at her designated appointment time.
CT Scan:
1. Small bowel obstruction with likely transition point in the
distal ileum.
No evidence of bowel ischemia or perforation.
2. Stable 2.7 x 2.3 cm right adrenal nodule, unchanged since
___.
Medications on Admission:
1. AmLODIPine 2.5 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 10 mg PO QPM
4. BuPROPion 150 mg PO BID
5. Gabapentin 100 mg PO BID
6. Omeprazole 20 mg PO DAILY
7. Polyethylene Glycol 17 g PO DAILY:PRN constipation
Discharge Medications:
1. AmLODIPine 2.5 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 10 mg PO QPM
4. BuPROPion 150 mg PO BID
5. Gabapentin 100 mg PO BID
6. Omeprazole 20 mg PO DAILY
7. Polyethylene Glycol 17 g PO DAILY:PRN constipation
Discharge Disposition:
Home
Discharge Diagnosis:
Small Bowel Obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Unable to ambulate, wheelchair dependent
Discharge Instructions:
Ms. ___,
You were admitted to the hospital for a small bowel obstruction.
You were given bowel rest and intravenous fluids and a
nasogastric tube was placed in your stomach to decompress your
bowels. Your obstruction has subsequently resolved after
conservative management. You have tolerated a regular diet, are
passing gas and your pain is controlled with pain medications by
mouth. You may return home to finish your recovery.
If you have any of the following symptoms please call the office
for advice or go to the emergency room if severe: increasing
abdominal distension, increasing abdominal pain, nausea,
vomiting, inability to tolerate food or liquids, prolonged loose
stool, or extended constipation.
Thank you for allowing us to participate in your care! Our hope
is that you will have a quick return to your life and usual
activities.
Good luck!
Followup Instructions:
___
|
19550378-DS-38
| 19,550,378 | 20,326,880 |
DS
| 38 |
2151-02-14 00:00:00
|
2151-02-14 09:30:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Tetracycline / Grapefruit / Amoxicillin / Tegaderm
/ diazepam
Attending: ___.
Chief Complaint:
HA, abd pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ presented with HA and abd pain.
Her abd pain began after dinner on ___ dull, ___, without
radiation. + nausea/diarrhea. Developed fever to 101 -> to ED
for eval. In the ED, WBC 17.3 and CT with small amount of
transverse colon thickening. Pt treated with
cipro/metronidazole
and admitted for further care.
On admission to the medical service, she reports marked
improvement, with abd pain ___, headache ___ and resolution of
her nausea. Her last diarrhea/vomiting were in the ED.
Past Medical History:
Severe idiopathic axonal sensorimotor polyneuropathy with
symptoms beginning in the late ___ or early ___. Symptoms began
with weakness and sensory loss in the legs proximally. Symptoms
have been responsive to plasmapheresis approximately yearly. As
noted above, she is wheelchair bound.
Vitamin B12 deficiency
History of repeated partial small-bowel obstruction; requires
low residue diet
Diabetes
Hypertension
GERD
Depression
Diverticulosis
Coronary vasospasm
Status post C-section x 2
Status post hysterectomy for leiomyomata
Left breast lumpectomy
Status post bilateral knee replacements
History of abdominal hematoma due to subcutaneous heparin
Social History:
___
Family History:
No family history of neurologic disease other than a brother who
is ___ with recent symptoms of dementia. Mother and brother had
diabetes. Mother had liver, cervical and colon cancer. Father
had lung cancer. Mother had coronary artery disease as well.
Physical Exam:
Discharge exam:
===============
VS: T 98.2 PO BP 115 / 74 HR 57 RR 18 pOx 95% RA
GENERAL: NAD
Head: NC/AT
Eyes: anicteric sclera
Ears/Nose/Mouth/Throat: MMM, no OP lesions appreciated, no
frontal or maxillary sinus tenderness to palpation, grossly
normal hearing
Neck: normal aROM
Resp: decreased breath sounds in b/l lung bases (shallow depth
of inspiration), otherwise breath sounds are clear and she has
normal WOB at rest and with conversation
CV: RR, normal S1S2, +systolic murmur (___) heard best over
RUSB
GI: obese, soft, NT/ND, bowel sounds present
Skin: No rashes or lesions noted
Extremities: No pitting edema
Neuro: awake, alert, conversant with clear speech, moving all
4s with no difficulty and with normal coordination and no
tremor/asterixis
Psych: calm, cooperative, pleasant
Pertinent Results:
ADMISSION LABS:
================
___ 11:35AM BLOOD WBC-17.3* RBC-4.92 Hgb-15.3 Hct-46.3*
MCV-94 MCH-31.1 MCHC-33.0 RDW-14.6 RDWSD-48.7* Plt ___
___ 11:35AM BLOOD Neuts-92.0* Lymphs-3.6* Monos-3.6*
Eos-0.1* Baso-0.2 Im ___ AbsNeut-15.91* AbsLymp-0.62*
AbsMono-0.62 AbsEos-0.02* AbsBaso-0.03
___ 11:35AM BLOOD ___ PTT-21.5* ___
___ 07:20AM BLOOD Glucose-70 UreaN-18 Creat-1.0 Na-144
K-4.0 Cl-102 HCO3-28 AnGap-14
___ 07:20AM BLOOD Calcium-9.0 Phos-4.1 Mg-1.9
___ 01:14PM BLOOD Lactate-1.5
.
.
MICRO:
========
-Bld cx ___ growing Group B strep
___ 11:14 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
BETA STREPTOCOCCUS GROUP B. FINAL SENSITIVITIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
BETA STREPTOCOCCUS GROUP B
|
CEFTRIAXONE-----------<=0.12 S
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.12 S
PENICILLIN G---------- 0.12 S
VANCOMYCIN------------ 0.5 S
Aerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___. ___ ON ___ AT
0130.
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
-Repeat cx on ___ and ___ NGTD
-U/A was not suggestive of inflammation or infection;
corresponding UCx grew E. coli with resistance to Ampicillin,
Amp+Sulbactam, Cipro, and TMP/SMX
.
.
IMAGING:
=========
___ CXR:
"1. Mild pulmonary vascular congestion.
2. No focal consolidations or pleural abnormality."
___ CT abd/pelvis:
"1. Diverticulosis without evidence of diverticulitis. No
evidence for colitis.
2. No gastrointestinal obstruction."
.
.
DISCHARGE LABS: (last labs prior to discharge)
===============
___ 10:55AM BLOOD WBC-6.5 RBC-4.37 Hgb-13.3 Hct-41.1 MCV-94
MCH-30.4 MCHC-32.4 RDW-13.6 RDWSD-47.7* Plt ___
___ 10:55AM BLOOD UreaN-13 Creat-1.0 Na-141 K-4.1 Cl-101
HCO3-29 AnGap-11
Brief Hospital Course:
# Fever, abdominal pain, nausea and diarrhea x1 day
Pt with abdominal pain, nausea, and diarrhea prior to admission.
She had a leukocytosis but CT abd/pelvis showed no acute
pathology. She had no evidence for abscess or obstruction. She
received antibiotics in the ED for possible transverse colitis
(on the preliminary radiology read), with marked improvement by
the time she reached the medical floor. She was treated with
ciprofloxacin/metronidazole through ___. Her abd pain resolved
fully and she was able to transition to her PO diet without an
issue.
Unclear etiology. Possibly she had a food-borne illness or SBO
that then resolved. No stool studies could be sent because after
arrival on floor she had no BM.
.
.
# Group B strep bacteremia w/ sepsis - Her blood culture x 1
from admission showed Group B strep. Initially was given dose of
vancomycin on ___, but transitioned to CTX once GBS speciated.
ID was consulted and they felt that given her age/comorbidities
that she should be treated with IV antibiotics x 2 weeks. First
dose of CTX given via midline on ___. A TTE was obtained and
showed no evidence of endocarditis. ID team recommended against
___. There was no clear source for her Group B strep bacteremia,
and we suspect that her initial GI symptoms may in fact have
been result of sepsis from a primary Group B strep bacteremia,
rather than the bacteremia having been the result of a GI
process.
[] Complete 14-day total course of Ceftriaxone via midline; last
day will be ___.
.
.
# Possible HFpEF (new diagnosis)
She did have an o2 requirement initially (___) which resolved
with time and getting up to chair. CXR showed mild pulmonary
vascular congestion. TTE showed elevated PCWP and elevated E/e'
without reduced LVEF, overall suggestive of HFpEF. She has
multiple risk factors for HFpEF. The mild hypoxia resolved and
aside from generalized non-pitting edema (of unclear chronicity)
she did not have signs/symptoms concerning for decompensated CHF
at the time of discharge.
[]Please check daily weights, consider initiation of loop
diuretic if weight increasing or if patient develops other signs
to suggest worsening CHF (worsening pitting edema in dependent
areas, orthopnea, dry cough, SOB/DOE, etc.)
[]She has cardiology follow-up scheduled on ___
.
.
# Recurrent headaches - she reported that she has had recurrent
headaches for months which she believes are worsening. During
hospital stay, easily treated with tylenol. We recommended she
discuss with her neurologist.
.
.
# Idiopathyic axonal sensorimotor polyneuropathy - Continued
gabapentin. Outpatient f/u per Neuro.
.
.
.
.
.
Time in care: greater than 30 minutes in discharge-related
activities today.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 10 mg PO QPM
4. Bacitracin Ointment 1 Appl TP BID
5. Bisacodyl ___ID:PRN constipation
6. Docusate Sodium 100 mg PO BID
7. Gabapentin 100 mg PO BID
8. Multivitamins 1 TAB PO DAILY
9. Ondansetron 4 mg PO Q6H:PRN nausea
10. Polyethylene Glycol 17 g PO BID
11. Sertraline 100 mg PO DAILY
12. TraZODone 25 mg PO QHS:PRN insomnia
13. LORazepam 0.5 mg PO DAILY:PRN anxiety
14. melatonin 1 mg oral QHS:PRN
15. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
16. nystatin 100,000 unit/gram topical BID
17. Zinc Oxide Diaper Cream (dimethicone-ZnOx-vit A-D-aloe) ___
% topical DAILY:PRN
18. Cyanocobalamin 1000 mcg PO DAILY
Discharge Medications:
1. CefTRIAXone 2 gm IV Q 24H
RX *ceftriaxone in dextrose,iso-os 2 gram/50 mL 2 gm IV once a
day Disp #*13 Intravenous Bag Refills:*0
2. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 10 mg PO QPM
5. Bacitracin Ointment 1 Appl TP BID
6. Bisacodyl ___ID:PRN constipation
7. Cyanocobalamin 1000 mcg PO DAILY
8. Docusate Sodium 100 mg PO BID
9. Gabapentin 100 mg PO BID
10. Lactulose 30 mL PO DAILY:PRN constipation
11. LORazepam 0.5 mg PO DAILY:PRN anxiety
12. melatonin 1 mg oral QHS:PRN
13. Multivitamins 1 TAB PO DAILY
14. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
15. nystatin 100,000 unit/gram topical BID
16. Ondansetron 4 mg PO Q6H:PRN nausea
17. Polyethylene Glycol 17 g PO BID
18. Sertraline 100 mg PO DAILY
19. TraZODone 25 mg PO QHS:PRN insomnia
20. Zinc Oxide Diaper Cream (dimethicone-ZnOx-vit A-D-aloe)
___ % topical DAILY:PRN
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
# Fever/abdominal pain/nausea/diarrhea
# Group B strep bacteremia w/ sepsis
# Pulmonary edema w/ mild hypoxia on ___ - possible HFpEF
exacerbation
# Constipation (chronic)
# Headache (chronic)
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 with belly pain, nausea, vomiting. Luckily
these symptoms improved quickly and you were able to begin
eating.
Unfortunately a blood culture grew a bacteria for which we need
to treat you with antibiotics for 2 weeks.
During your hospital stay your headaches which you are having at
home continued. We recommend you discuss more with your primary
care doctor and neurologist.
Best of luck!
Your ___ team
Followup Instructions:
___
|
19550442-DS-14
| 19,550,442 | 22,855,385 |
DS
| 14 |
2149-01-30 00:00:00
|
2149-01-30 13:16:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
Iodine / Penicillins / shelffish / Bee Pollen
Attending: ___.
Chief Complaint:
traumatic brain injury
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ yo RHWM s/p fall last ___ while visiting family in
___. Was admitted to VCU for TBI and discharged yesterday
without operative intervention. Was very confused and lethargic
on drive home.
Past Medical History:
-Systolic heart failure with markedly reduced ejection
fraction and ischemic cardiomyopathy with ___ ICD
single-chamber of ___ placed at ___, ___
-DMII
-Hyperlipidemia
-Hypertension
-Bipolar DO
-Nephrolithiasis
-Prostatitis (last tx ___ years ago)
-CKD (baseline Cr. 1.3) lithium-induced acute renal failure
+Tobacco History
-CARDIAC HISTORY:
-CAD (hx. ___ MIs, ___
-s/p CABG: ___ LIMA unusable; SVG to LAD and SVG to diag
-PERCUTANEOUS CORONARY INTERVENTIONS:
-___ DES to L circumflex
-s/p PCI ___ 2 stents to SVG to LAD, 1 stent to SVG to diag
-s/p PCI ___: DES of SVG to LAD
-s/p Ballon angioplasty of SVG to LAD ___
Social History:
___
Family History:
Sister passed away at ___ from a suspected MI.
Family history of CAD and hyperlipidemia.
Physical Exam:
at admission:
PHYSICAL EXAM: AFVSS
Gen: WD/WN, NAD.
HEENT: Pupils: PERRLA.
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Arousals, cooperative with exam.
Orientation: Oriented to person.
Language: Dysarthric/slurred speech with good comprehension and
repetition.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields unable to assess.
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.
At discharge:
A&Ox3, needed cues for month. Unable to recall state. Some WFD.
RUE tremor baseline per wife. ___. ___. ___ strength throughout
Pertinent Results:
CT HEAD W/O CONTRAST Study Date of ___ 5:17 AM
IMPRESSION:
1. Compared with the most recent CT, no change in the size or
appearance of the hyperdense left subdural hematoma, as well as
the right greater than left frontal subarachnoid hemorrhage.
2. Persistent 2 mm leftward shift of normally midline
structures.
3. Areas of hypodensity involving the left MCA territory and
bilateral frontal lobes are unchanged compared to ___nd may reflect sequelae of recent acute to
subacute infarction.
4. Please note MRI of the brain is more sensitive for the
detection of acute infarct.
CT ABD & PELVIS W/O CONTRAST Study Date of ___ 5:18 AM
IMPRESSION:
1. No acute intra-abdominal or intrapelvic process to correlate
with fever.
2. Non-obstructive 5 mm left renal stone; no hydronephrosis.
PORTABLE ABDOMEN Study Date of ___ 11:10 ___
IMPRESSION:
Prominent loops of small and large bowel without abnormal
dilation. There is gas seen to the level of the rectum
suggestive of ileus rather than
obstruction.
___ EEG:
IMPRESSION: This is an abnormal continuous ICU EEG monitoring
study because of a slower than average and poorly organized
background consistent with a moderate encephalopathy of toxic,
metabolic, and/or anoxic etiology. No epileptiform findings were
seen. Interval results were conveyed to the treating team
intermittently during this recording period to assist with real-
time medical decision-making.
___ EEG:
IMPRESSION: This is an abnormal continuous ICU EEG monitoring
study because of a slower than average and poorly organized
background consistent with a moderate encephalopathy of toxic,
metabolic, and/or anoxic etiology. No epileptiform findings were
seen. Interval results were conveyed to the treating team
intermittently during this recording period to assist with
___ medical decision-making.
___ ECHO:
Conclusions
The left atrium is normal in size. The estimated right atrial
pressure is at least 15 mmHg. Left ventricular wall thicknesses
are normal. Overall left ventricular systolic function is
severely depressed (LVEF = 20 %) secondary to hypokinesis of the
inferior wall, akinesis of the posterior wall, and extensive
apical hypokinesis with focal apical akinesis. No masses or
thrombi are seen in the left ventricle. Tissue Doppler imaging
suggests an increased left ventricular filling pressure
(PCWP>18mmHg). Doppler parameters are most consistent with Grade
III/IV (severe) left ventricular diastolic dysfunction. The
right ventricular cavity is dilated with depressed free wall
contractility. The ascending aorta is mildly dilated. There are
focal calcifications in the aortic arch. The aortic valve is not
well seen. There is no aortic valve stenosis. The mitral valve
leaflets are structurally normal. Mild to moderate (___) mitral
regurgitation is seen. The left ventricular inflow pattern
suggests a restrictive filling abnormality, with elevated left
atrial pressure. Tricuspid regurgitation is present but cannot
be quantified. There is severe pulmonary artery systolic
hypertension. There is no pericardial effusion. Compared with
the prior study (images reviewed) of ___ the pulmonary
artery pressure is further increased.
___ EEG:
IMPRESSION: This is an abnormal continuous ICU EEG monitoring
study because of a slower than average and poorly organized
background consistent with a moderate encephalopathy of toxic,
metabolic, and/or anoxic etiology. No epileptiform findings were
seen. Interval results were conveyed to the treating team
intermittently during this recording period to assist with real-
time medical decision-making.
___ CT Head without contrast
IMPRESSION:
1. Unchanged left frontoparietal subdural hematoma and bifrontal
subarachnoid hemorrhages.
2. Unchanged areas of hypodensity within the left MCA and
bilateral ACA
territories consistent with subacute to chronic infarctions.
___ Portable Chest xray:
IMPRESSION:
Cardiomegaly is moderate, unchanged. Mediastinal silhouette is
stable. There is interval progression of bilateral pleural
effusions currently large as well as interval development of
bilateral hilar enlargement and perihilar interstitial opacities
consistent with interstitial pulmonary edema.
There is no pneumothorax.
Post sternotomy wires are unremarkable. Pacemaker defibrillator
lead
terminates in the expected location of the right ventricle.
Brief Hospital Course:
Mr. ___ was admitted to the SICU on ___ for management
of ___. Head CT was stable compared to ___ at ___.
Exam was EO to voice, ___, Ox2 (not location), SAR ___, slight
right down drift. He was started on a regular diet which was
well tolerated. He was started on an insulin gtt for
hyperglycemia. SBP was maintained <140. He was continued on
Keppra 500 mg big for seizure prophylaxis.
On ___ he was A&Ox3, SAR ___, no drift. Cardiology was
consulted for preop evaluation. They did not recommend a cardiac
cath since he is unable to be anticoagulated in setting of
intracranial bleed. He was continued on Amiodarone, lisinopril,
and metoprolol. He was started on EEG.
On ___ patient remained neurologically and hemodynamically
stable. EEG was negative but remained on overnight to evaluate
for seizure. He was made NPO after midnight and prepped for
possible OR for evacuation of hematoma ___.
On ___ his was closely monitored and he continued to have a
non-focal neurologic exam. Neurosurgeon decided to hold off on
operating given his stable exam. Plan to repeat head CT
tomorrow.
On ___ the patient remained neurologically and hemodynamically
stable. A repeat NCHCT was stable and it was decided that
surgery would be postponed at this time. The patient was
transferred to the floor and planned to work with ___ for
dispo planning.
On ___, the patient remained neurologically stable. In the
early morning he had urinary frequency and retention. He was
straight cathed x 1 and UA UC was sent. The UA was negative.
Again he had rrinary retention during day. He was straight
cathed x1 for bladder scan >500cc and he continues on Flomax. He
experienced dyspnea on exertion with ambulation and some mild
shortness of breath at rest in bed. His O2 sats are WNL on RA.
His WBC are trending up and we will continue to monitor daily.
He is afebrile. A CXR showed bilateral pleural effusions with
pulmonary edema. 20mg IV Lasix and 40mEq K were given and a
foley was inserted given his retention and to measure his urine
output. He is receiving PRN bowel meds for constipation. We
restarted his home dose of Aspirin 325mg and started SQ Heparin
per Dr. ___. ___ and OT evaluated him and both are
recommending rehab. He is pending bed availability at ___
___.
On ___ the patient was ding neurologically well and was stable.
He was offered a bed at ___ which was accepted. He
was given instructions for followup and all questions were
answered prior to discharge.
Medications on Admission:
Amiodarone, Fioricet, Aripiprazole, Furosemide, Insulin,
Lamotrigine, Keppra 500 BID, Lisinopril, Metoprolol, Zofran,
Crestor, Tamsulosin.
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Amiodarone 400 mg PO BID Duration: 1 Dose
1 dose at ___ on ___ and then switch to daily dosing
3. Amiodarone 400 mg PO DAILY
START ___. ARIPiprazole 20 mg PO DAILY
5. Aspirin 325 mg PO DAILY
6. Bisacodyl 10 mg PO/PR DAILY constipation
7. Docusate Sodium 100 mg PO BID
8. Ezetimibe 10 mg PO DAILY
9. Famotidine 20 mg PO Q12H
10. Furosemide 10 mg PO DAILY
11. Heparin 5000 UNIT SC BID
12. NPH 15 Units Breakfast
NPH 15 Units Bedtime
Insulin SC Sliding Scale using REG Insulin
13. Lactulose 30 mL PO DAILY PRN constipation
14. LamoTRIgine 100 mg PO DAILY
15. LamoTRIgine 200 mg PO QHS
16. LevETIRAcetam 500 mg PO BID
17. Lisinopril 5 mg PO DAILY
18. Metoprolol Tartrate 12.5 mg PO BID
19. Milk of Magnesia 30 mL PO Q12H:PRN constipation
20. Ondansetron 4 mg IV Q8H:PRN nausea
21. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
22. Phenelzine Sulfate 15 mg PO TID
23. Polyethylene Glycol 17 g PO DAILY
24. Rosuvastatin Calcium 40 mg PO DAILY
25. Senna 17.2 mg PO QHS
26. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
subdural hematoma
cerebral contusion
subarachnoid hemorrhage
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
Brain Hemorrhage
Activity
· We recommend that you avoid heavy lifting, running,
climbing, or other strenuous exercise until your follow-up
appointment.
· You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
· No driving while taking any narcotic or sedating
medication.
· If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
· No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
· Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
· You have been discharged on Keppra (Levetiracetam). This
medication helps to prevent seizures. Please continue this
medication as indicated on your discharge instruction. It is
important that you take this medication consistently and on
time.
· You may use Acetaminophen (Tylenol) for minor discomfort
if you are not otherwise restricted from taking this medication.
What You ___ Experience:
· You may have difficulty paying attention, concentrating,
and remembering new information.
· Emotional and/or behavioral difficulties are common.
· Feeling more tired, restlessness, irritability, and mood
swings are also common.
· Constipation is common. Be sure to drink plenty of fluids
and eat a high-fiber diet. If you are taking narcotics
(prescription pain medications), try an over-the-counter stool
softener.
Headaches:
· Headache is one of the most common symptoms 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:
· 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:
___
|
19550522-DS-3
| 19,550,522 | 24,975,588 |
DS
| 3 |
2164-07-29 00:00:00
|
2164-08-01 14:26:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa(Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
right-sided abdominal pain x 3 months
Major Surgical or Invasive Procedure:
ERCP
History of Present Illness:
___ with hx of ___'s disease, polykystic kidney disease s/p
transplant in ___, recurrent cholangitis and chronic abdominal
pain presenting with severe abdominal pain. The pain started 3
month ago and has been progressively worsening. The pain is
located on the mid and right epigastrum and irradiates to the
back. He takes oxycodone 5mg ___ for the pain, which
provides relief. Associated with vomiting (non-bloody) and
decreased appetite (taking fluids and ensure). Has also had
increased leg swelling over last week, and a tremor in his feet.
No jaundice, diarrhea, constipation, cp, sob, no
dysuria/frequency/change in color.
PCP supportive of admission for pain control and nutrition in a
monitored setting. He has seen patient numerous times in the
last 4 months for pain control. Currently undergoing GI workup,
most recently with MRCP. Needs to have ERCP and EGD. Physician
also questions whether there are emerging behavioral/dependence
issues with his pain control, as he went through a prescription
for oxycodone in less time than he should have last month. PCP
also notes ___ bipolar, and acute depressive episode.
In ED initial VS were 98.4 64 124/61 14 98% RA
Labs were remarkable for WBC 5.7, HCT 27 (baseline 29 per PCP),
BUN/Cr > 20, Cr 1.4 (baseline around 1.2) per PCP, ___ 5.3
Ros as documented above, and in admission note, otherwise
negative in 8 other systems.
Past Medical History:
History of renal transplant
BCC (basal cell carcinoma), face
Dupuytren's Contracture
PAIN SYNDROME - CHRONIC
BILIARY TRACT DISEASE, UNSPEC
ABDOMINAL PAIN - EPIGASTRIC / PROBABLE ___ DZ with
CHOLEDOCHAL CYST
HISTORY NEPHRECTOMY, Bilateral
ESOPHAGEAL REFLUX
KIDNEY TRANSPLANT
POLYCYSTIC KIDNEY DISEASE, AUTOSOM DOMINANT
HYPERTENSION - ESSENTIAL
Social History:
___
___ History:
pt's parents died when he was young of unknown causes, no known
family history
Physical Exam:
INITIAL
VS: T 99.3 BP 135/66 HR 68 RR 18 SaO2 98% on RA
GENERAL: AOx3, NAD
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, tender in RUQ, most tender under right costal
margin, nondistended, normoactive bowel sounds, nondistended. no
guarding or rebound
EXT: trace edema. DPs, PTs 2+.
LYMPH: no cervical, axillary, or inguinal LAD
SKIN: dry, no rash
NEURO/PSYCH: AxOx3, CNs II-XII intact. Strength and sensation in
U/L extremities grossly intact. gait not assessed. Tremor in
feet. ___ strength throughout. Sensation intact throughout.
DISCHARGE
Vitals:Tm 100.5 BP110/62 HR 55 RR 18 O2sat 98 RA
GENERAL: AOx3, NAD
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, tender in RUQ, most tender under right costal
margin, nondistended, normoactive bowel sounds, nondistended. no
guarding or rebound
EXT: no pitting edema. DPs, PTs 2+.
LYMPH: no cervical, axillary, or inguinal LAD
SKIN: dry, no rash
NEURO/PSYCH: AxOx3, CNs II-XII intact. Strength and sensation in
U/L extremities grossly intact. gait not assessed. Tremor in
feet. ___ strength throughout. Sensation intact throughout.
Pertinent Results:
LABS ON ADMISSION
___ 11:45AM BLOOD Neuts-85.3* Lymphs-8.8* Monos-4.3 Eos-1.4
Baso-0.2
___ 11:45AM BLOOD Glucose-93 UreaN-28* Creat-1.4* Na-138
K-5.3* Cl-106 HCO3-26 AnGap-11
___ 11:45AM BLOOD ALT-38 AST-47* AlkPhos-492* TotBili-0.4
___ 05:57PM BLOOD K-5.2*
LIVER OR GALLBLADDER US (SINGLE ___:
1. Extensive intrahepatic bile duct dilatation, compatible with
known
Caroli's disease and similar to prior. Dilatation of the CBD to
13 mm,
similar to prior, without an obstructive lesion seen.
2. Normal gallbladder without evidence of cholecystitis.
3. Echogenic liver consistent with fatty infiltration. Other
forms of liver disease and more advanced liver disease including
significant hepatic fibrosis/cirrhosis cannot be excluded on
this study.
4. Splenomegaly and trace perihepatic ascites, similar to
prior.
ERCP ___:
The z-line was at 40 cm. 2 small tongues of salmon colored
mucosa suspicious for short segment ___ esophagus were
seen (C0M1). The tongues were biopsied at the proximal margins
and sumbitted to pathology.
A small hiatal hernia was present.
Evidence of a previous sphincterotomy was noted in the major
papilla.
The intrahepatics were dilated, consistent with the patient's
known Caroli's disease. The CBD was dilated to 20 mm. No filling
defects were seen.
A 9-12 mm stone extraction balloon was used to sweep the CBD
three times and this did not yield any stones or sludge. A 2.5
cm trapazoid basket was used to sweep the duct and this did not
yield any sludge, stones, or debris.
No biliary findings explaining the patient's abdominal pain.
LABS AT DISCHARGE:
___ 05:35AM BLOOD WBC-5.1 RBC-2.41* Hgb-8.3* Hct-25.8*
MCV-107* MCH-34.4* MCHC-32.2 RDW-17.2* Plt ___
___ 05:35AM BLOOD ___ PTT-27.9 ___
___ 05:35AM BLOOD Glucose-88 UreaN-26* Creat-1.3* Na-136
K-4.9 Cl-106 HCO3-22 AnGap-13
___ 05:35AM BLOOD Calcium-8.0* Phos-3.3 Mg-1.6
___ 05:35AM BLOOD ALT-30 AST-35 AlkPhos-397* TotBili-0.3
Brief Hospital Course:
Mr. ___ is a ___ year-old male with a history of Caroli's
disease, polycystic kidney disease status-post transplant in
___, recurrent cholangitis and chronic abdominal pain
presenting with severe abdominal pain for the past several
months, evaluated with ERCP without acute findings.
.
ACUTE ISSUES
# ABDOMINAL PAIN: Etiologies included acute cholangitis or
cholecystitis however LFTs on ___ were within normal limits.
Other possibilites included gastritis or peptic ulcer disease,
pancreatitis, and hepatic related disease due to liver pathology
secondary to his caroli's. Labs and imaging were reassuring for
no acute infectious or inflammatory process. Therefore, for
further workup of his chronic abdominal pain an ERCP was done on
___, with results as documented in the results above, with no
stones, and Z line consistent with possible ___
Given that his abdominal pain was stable, and labs at baseline,
with stable Cr, stable elevated alk phos, he was discharged home
to follow up with his PCP this next week.
Biopsies, concerning for ___ esophagus, were pending at
discharge, so he will likely need to be initiated on a PPI when
those results return.
CHRONIC ISSUES.
# S/p Renal xplant: Pt's creatinine was slightly elevated at Cr
1.4 on admission (baseline around 1.2) per PCP. He was conintued
on his home immunosuppressants his creatinine was monitored with
serial daily chemistry tests.
.
# Hyperkalemia: pt's potassium was 5.3 on ___ but down
trended to ___ is 4.9. His creatinine came down to 1.3 down
from 1.4 during this same time.
#Code: Full Code (confirmed)
TRANSITIONAL ISSUES:
Biopsies pending from ERCP at discharge.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. OxycoDONE (Immediate Release) 5 mg PO Q4-6H:PRN pain
hold for RR<12 or sedation
2. Lorazepam 1 mg PO BID:PRN anxiety
hold for RR<12 or sedation
3. Tacrolimus 1 mg PO Q12H
4. Azathioprine 50 mg PO BID
Discharge Medications:
1. Azathioprine 50 mg PO BID
2. OxycoDONE (Immediate Release) 5 mg PO Q4-6H:PRN pain
hold for RR<12 or sedation
3. Tacrolimus 1 mg PO Q12H
4. Lorazepam 1 mg PO BID:PRN anxiety
hold for RR<12 or sedation
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:
Mr. ___,
It was a pleasure taking care of you here at ___. You were
admitted because of your abdominal pain that you have been
experiencing. You received an EGD and ERCP. You will need close
followup care with your primary care physician ___.
___. You have an appointment with ___. ___ on
___ at 4:30pm (see below for details). Also you
will need close followup with Dr. ___, your
gastroenterologist, at ___ in ___ to discuss
the results of the studies. Please call Dr. ___ office at
___ to make an appointment for next week. Please
followup as well with Dr. ___ at ___
regarding the need for an endoscopic ultrasound that is
currently scheduled for ___ at 2:00 ___.
Followup Instructions:
___
|
19550692-DS-7
| 19,550,692 | 25,163,326 |
DS
| 7 |
2144-10-27 00:00:00
|
2144-10-27 19:09:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___
Chief Complaint:
lower extremity edema and dyspnea on exertion
Major Surgical or Invasive Procedure:
Stress echocardiogram ___
History of Present Illness:
HISTORY OF PRESENTING ILLNESS: ___ year old male with past
history of CAD s/p stent at ___ E's ___, NIDDM, hypertension,
hyperlipidemia who presents with several weeks of intermittent
chest pain and a week of exertional dyspnea. He initially
attributed this to his asthma. The patient has also noted recent
lower extremity swelling over the past ___ days and PND. He has
a stable ___ pillow orthopnea. His chest pain is intermittent
and not necessarily exertional, but is typically relieved by
nitroglycerin. He does use an exercise bike at his house for 1
hour each day with no issue.
In the ED, initial vitals were
97.8 77 154/85 18 99% RA
On arrival to the floor, the patient denies any current
symptoms.
He says that he sometimes has SOB usually after walking 2
blocks. He denies CP, SOB, N/V/D/C, f/c. He endorses PND
sometimes. He reports that he had a cath done ___ years ago at ___
___ and TTE at the ___ a couple months ago. He says
they told him his results were completely normal.
Past Medical History:
Asthma
Retinal detachment
HTN
OSA
Obesity
HLD
CAD s/p stent to mid-LAD in ___
Social History:
___
Family History:
no pulmonary disease
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: AF, BP 183/91, HR 74, RR 20, O2Sat 99% on RA
General: NAD, comfortable, pleasant
HEENT: NCAT, PERRL, EOMI
Neck: supple, JVD to mid neck at 30 degrees
CV: regular rhythm, no m/r/g. distant heart sounds
Lungs: CTAB, no w/r/r.
Abdomen: soft, NT/ND, BS+. obese abdomen.
Ext: WWP, 1+ edema b/l, 2+ distal pulses bilaterally
Neuro: moving all extremities grossly
DISCHARGE PHYSICAL EXAM
VS: 98.6, BP 137-180/72-102, HR 66-73, RR 18, O2Sat 96% on RA
General: NAD, comfortable, pleasant
HEENT: NCAT, PERRL, EOMI
Neck: supple, no JVD
CV: regular rhythm, no m/r/g. distant heart sounds
Lungs: CTAB, no w/r/r.
Abdomen: soft, NT/ND, BS+. obese abdomen.
Ext: WWP, 1+ edema b/l, 2+ distal pulses bilaterally
Neuro: moving all extremities grossly
Pertinent Results:
ADMISSION LABS:
___ 10:27AM BLOOD WBC-5.2 RBC-3.85* Hgb-12.2* Hct-35.3*
MCV-92 MCH-31.7 MCHC-34.6 RDW-12.5 RDWSD-41.0 Plt ___
___ 10:27AM BLOOD Neuts-50.8 ___ Monos-9.3 Eos-6.4
Baso-1.0 Im ___ AbsNeut-2.64 AbsLymp-1.65 AbsMono-0.48
AbsEos-0.33 AbsBaso-0.05
___ 10:27AM BLOOD Glucose-108* UreaN-9 Creat-0.6 Na-142
K-4.0 Cl-103 HCO3-27 AnGap-16
___ 10:27AM BLOOD ALT-41* AST-40 AlkPhos-64 TotBili-0.3
___ 10:27AM BLOOD cTropnT-<0.01
___ 10:27AM BLOOD proBNP-128
___ 10:27AM BLOOD Albumin-4.6
DISCHARGE LABS:
___ 07:40AM BLOOD WBC-4.8 RBC-4.32* Hgb-13.5* Hct-39.7*
MCV-92 MCH-31.3 MCHC-34.0 RDW-12.1 RDWSD-40.3 Plt ___
___ 07:55AM BLOOD Glucose-123* UreaN-18 Creat-0.6 Na-139
K-3.9 Cl-102 HCO3-27 AnGap-14
___ 07:55AM BLOOD Calcium-9.5 Phos-3.2 Mg-2.0
IMAGING:
___ Exercise stress
INTERPRETATION: This is a ___ year old man here for the
evaluation of
chest pain. The patient exercised on a Modified ___ treadmill
protocol and stopped for fatigue after the completion of 6
minutes. The
peak estimated metabolic capacity was ___ METs, a low/poor
functional
capacity for age. There were no chest, arm, neck or back
discomforts
reported throughout the study. There were no ischemic ECG
changes. The
rhythm was sinus with rare PACs, PVCS, and ventricular couplets.
The
blood pressure and heart rate responses were appropriate.
IMPRESSION: No anginal type symptoms with no ischemic ECG
changes to
the low/poor workload achieved. Normal hgemodynamic response to
exercise. Echo report sent separately.
___ STRESS Echo
IMPRESSION: Poor functional exercise capacity. No 2D
echocardiographic evidence of inducible ischemia to achieved
workload. Normal hemodynamic response to exercise.
Left Ventricle - Ejection Fraction: 55% to 60%
___ CXR PA&L
FINDINGS:
The cardiomediastinal and hilar contours are within normal
limits. Lungs are clear. There is no focal consolidation,
pleural effusion or pneumothorax.
IMPRESSION:
No acute cardiopulmonary process.
___ ECG
Baseline artifact. Sinus rhythm. Borderline A-V conduction
delay.
Non-diagnostic inferior Q waves. Diffuse T wave flattening with
non-specific ST segment changes and T wave inversion in leads
V4-V6. Cannot exclude possible myocardial ischemia. Compared to
the previous tracing of ___ the sinus rate has decreased by
about 60 beats per minute and the described ST-T wave changes
are new. Clinical correlation is suggested.
MICROBIOLOGY: None
Brief Hospital Course:
___ year old male with past history of CAD s/p stent at ___ E's
___, NIDDM, hypertension, hyperlipidemia who presents with
several weeks of intermittent chest pain and a week of
exertional dyspnea concerning for fluid overload and heart
failure.
# Coronaries: 100% chronic total occlusion of proximal total R
PDA, s/p PCI to midLAD and Lcx, stent in midLAD, unknown type.
(per ___ records)
# Pump: normal EF
# Rhythm: sinus
#HFpEF exacerbation: Patient had progressive swelling of lower
extremities with DOE and PND concerning for heart failure
exacerbation. Trop neg x1. EKG had T wave flattening but no
specific ST changes concerning for acute MI. Patient was
started on IV Lasix for diuresis and transitioned to PO regimen
of 40 mg Lasix. He was started on lisinopril 10 mg and
carvedilol 12.5 mg PO BID. Echo records from outside hospital
showed normal EF in ___. He also had records from ___ which
showed chronic total occlusion of RCA and stent placed to
mid-LAD. Stress echocardiogram was done which showed no
inducible ischemia and stress ECG was without ischemic changes.
He was discharged on atorvastatin 40mg, carvedilol 12.5mg BID,
furosemide 40mg BID and lisinopril 20mg. He will follow up with
an outpatient cardiologist, Dr. ___, for further
management. Discharge weight: 130.8kg
#Hypertensive urgency: Patient non-compliant with HTN meds at
home (takes HCTZ intermittently) and found to have elevated SBP
180s on floor, asymptomatic. Home amlodipine, HCTZ, and
verapamil were d/c'ed and patient was transitioned to lisinopril
20mg and carvedilol 12.5mg for both HTN and CAD/HF management.
BP should be monitored and medications titrated as needed.
#Low back pain - patient uses gabapentin, tramadol, and naproxen
at home. Naproxen was discontinued given concern for ___ and
cardiovascular risk.
#Diabetes: Insulin sliding scale while inpatient. Restarted
metformin on discharge.
#Asthma: Controlled with Albuterol inhaler prn
#OSA: non-compliant with CPAP. Encourage use as outpatient.
TRANSITIONAL ISSUES:
- patient to establish care with cardiologist for further
outpatient f/u. Appointment schedule with Dr. ___.
- continued titration of diuretic dose based on volume status
and creatinine
- monitor BP and titrate anti-hypertensives as needed
- patient reports poor compliance with CPAP for OSA- please
continue to encourage use
Discharge weight: 130.8kg
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Hydrochlorothiazide 25 mg PO DAILY
4. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB, wheeze
5. Naproxen 500 mg PO Q8H:PRN pain
6. Zolpidem Tartrate 5 mg PO QHS
7. TraMADOL (Ultram) 50 mg PO Q8H:PRN pain
8. Simvastatin 20 mg PO QPM
9. Verapamil SR 180 mg PO Q24H
10. MetFORMIN (Glucophage) 1000 mg PO BID
11. Gabapentin 300 mg PO TID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Gabapentin 300 mg PO TID
3. TraMADOL (Ultram) 50 mg PO Q8H:PRN pain
4. Zolpidem Tartrate 5 mg PO QHS
5. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB, wheeze
6. MetFORMIN (Glucophage) 1000 mg PO BID
7. Lisinopril 20 mg PO DAILY
RX *lisinopril 20 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
8. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
9. Carvedilol 12.5 mg PO BID
RX *carvedilol 12.5 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
10. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
- Diastolic Heart Failure
- Coronary Artery Disease
- Hypertensive Urgency
Secondary Diagnosis
- Hyperlipidemia
- Diabetes
- Asthma
- Obstructive Sleep Apnea
- Low back pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ due to lower extremity swelling and
some new shortness of breath with walking. You were found to
have signs of fluid overload and heart failure on exam and were
treated with a medication called Lasix. You will need to
continue this medication at home. You were also found to have
very high blood pressure. You were started on carvedilol, a
medication that helps treat your heart disease and high blood
pressure. You were also started on Lisinopril for blood pressure
control. You were also started on Lipitor for your heart
disease. A stress echocardiogram was done to evaluate your
heart for worsening heart disease and for heart pumping
function. This showed no major abnormalities. We have set up an
appointment for you with ___ cardiology (see below).
You need to take these medications every day. Please weigh
yourself daily and call your doctor if your weight goes up by
more than 3 lbs in one day.
It was a pleasure taking care of you.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19550773-DS-17
| 19,550,773 | 29,593,282 |
DS
| 17 |
2183-03-20 00:00:00
|
2183-03-21 22:06:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right sided chest pain
Major Surgical or Invasive Procedure:
Right Chest Tube Placement
History of Present Illness:
___ M with hx of HTN, CAD presenting with R sided chest pain that
began a 4 days ago. He describes it as an intermittent R sided
pain that comes and goes. It is positional and pleuritic. He
denies any fevers or chills but complains of SOB and productive
cough. Episodes last for a few minutes. He also complains of RUQ
pain and a decreased appetite. No nausea, no vomiting. No
dysuria or hematuria. No diarrhea or constipation. He recently
came back from a trip to ___, drove back yesterday. No
new leg swelling.
In the ED, initial vitals were:
98.9 105 154/82 18 98% RA
Labs notable for: WBC 12.3, otherwise normal chem-7, U/A, CBC,
trop X1
Imaging notable for:
RUQUS:
1. Status post cholecystectomy.
2. Normal sonographic appearance of the liver.
3. Large right pleural effusion.
CXR:
Large right pleural effusion with associated compressive
atelectasis. Clear left lung.
Patient was given: 325 mg aspirin.
Vitals prior to transfer: 97.8 90 118/77 28 98% RA
On the floor, patient reports that the chest pain has been
sudden and getting worse over the last 4 days, is localized over
anterior and posterior right chest and right upper abdomen.
Patient reports a minor cough (without hemoptysis). He reports
no sick contacts save for his daughter with a mild URI. He
reports 1 kg recent weight loss which was unintentded. He
reports never being tested for TB but reports not being in
contact with anyone with TB. He is visiting from ___, as his
sone lives in ___ and his Daughter in ___. He arrived in
the ___ in late ___. He denies any cancer history.
ROS:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain.
Denies headache, sinus tenderness, rhinorrhea or congestion.
Denies cough, shortness of breath. Reports chest pain or
tightness, denies 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:
1. Hypertension
2. Coronary Artery Disease
3. Cerebrovascular Accident
Social History:
___
Family History:
Father died of liver failure. Mother had a history of stroke.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
Vital Signs: 97.0 PO 146 / 81L Lying 84 20 98 RA
General: Alert, oriented, no acute distress. Cluthese right side
when breathing deeply intermittently.
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Decreased breath sounds on right, noticeable on posterior
chest. Rhonchorous sounds1 on right > L noted midlevel.
Abdomen: Soft, tender in RUQ, normoactive bnowel sounds.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, gait deferred.
DISCHARGE PHYSICAL EXAM
=======================
Vital Signs: 98.1 138/81 103 20 95%RA
CT output: 2 in place, clamp trial underway.
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, neck supple,
JVP not elevated, no LAD
Chest: Chest tube dressing c/d/I, site overall non-inflamed.
Bibasilar crackles with extension to mid back on right. No
wheeze. Breath sounds bilaterally but decreased on right side.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Without rashes or lesions
Neuro: CNII-CNXII intact, strength/sensation intact bilaterally
Pertinent Results:
ADMISSION LABS
==============
___ 09:36PM BLOOD WBC-12.3* RBC-5.81 Hgb-15.3 Hct-47.6
MCV-82 MCH-26.3 MCHC-32.1 RDW-14.0 RDWSD-40.8 Plt ___
___ 09:36PM BLOOD Neuts-68.9 ___ Monos-6.5 Eos-0.9*
Baso-0.3 Im ___ AbsNeut-8.49* AbsLymp-2.82 AbsMono-0.80
AbsEos-0.11 AbsBaso-0.04
___ 09:36PM BLOOD ___ PTT-48.4* ___
___ 09:36PM BLOOD Glucose-116* UreaN-11 Creat-1.1 Na-133
K-4.3 Cl-96 HCO3-23 AnGap-18
___ 09:36PM BLOOD ALT-37 AST-35 AlkPhos-103 TotBili-0.6
___ 09:36PM BLOOD proBNP-243*
___ 09:36PM BLOOD Albumin-3.8
___ 08:13AM BLOOD TotProt-7.3 Albumin-3.5 Globuln-3.8
Calcium-8.7 Phos-3.8 Mg-2.2
IMAGING:
=======
___ CT CHEST w/ Contrast:
1. Right upper lobe ill-defined mass measuring up to 3.4 x 2.8 x
2.2 cm with associated right upper lobe atelectasis and right
hilar, right paratracheal, and right subcarinal lymphadenopathy
are concerning for primary lung malignancy.
2. Bilateral ground-glass opacities measuring up to 1 cm could
also be malignant.
3. No significant pleural effusion after placement of a right
pigtail
catheter. Associated small right pneumothorax without evidence
of tension.
4. Long segment circumferential esophageal wall thickening
probably chronic inflammation, less likely infiltrative process.
Recommend direct visualization with endoscopy as clinically
indicated.
5. Likely intraosseous T2 vertebral body hemangioma.
___ CT Abd/pelvis w/ and w/o contrast:
1. No CT evidence of malignancy in the abdomen or pelvis.
2. Moderate calcified and noncalcified atherosclerotic disease
with focal areas of severe, near-complete narrowing of the right
common iliac artery.
3. Nonspecific sclerotic lesions in the left sacrum and iliac,
likely bone islands.
4. Mild prostatomegaly.
BRAIN MRI ___
IMPRESSION:
1. Study is moderately degraded by motion.
2. Within limits of study, no evidence of intracranial
metastatic disease.
3. Chronic right posterior parietal infarct.
4. No acute intracranial abnormality.
CHEST X-RAY ___
IMPRESSION:
Previously seen right pigtail catheter no longer visualized.
New moderately large right pneumothorax identified. Probable
small right effusion.
Prominence of superior mediastinum and right hilum is similar to
prior. (Note is made that the patient underwent a chest CT on
___.
Aside from minimal upper zone redistribution, left lung and
pleural sulcus are grossly clear. No overt CHF.
PATHOLOGY/CYTOLOGY
==================
Pleural fluid cytology ___: Pleural fluid, right:
POSITIVE FOR MALIGNANT CELLS. - Metastatic lung adenocarcinoma.
Note: Two cell blocks were prepared (block 1A and 1B), both with
high tumor cellularity.
Immunohistochemical stains show the following profile in tumor
cells:
Positive: TTF-1, CK7, ___, AE1/AE3, Napsin-A (focal)
Negative: WT-1, Calretinin
___ 06:25AM BLOOD WBC-15.7* RBC-4.63 Hgb-12.1* Hct-37.8*
MCV-82 MCH-26.1 MCHC-32.0 RDW-14.7 RDWSD-42.6 Plt ___
___ 09:36PM BLOOD Neuts-68.9 ___ Monos-6.5 Eos-0.9*
Baso-0.3 Im ___ AbsNeut-8.49* AbsLymp-2.82 AbsMono-0.80
AbsEos-0.11 AbsBaso-0.04
___ 06:25AM BLOOD Plt ___
___ 10:10AM BLOOD Glucose-138* UreaN-11 Creat-0.9 Na-124*
K-4.8 Cl-90* HCO3-15* AnGap-24*
___ 12:19AM BLOOD cTropnT-<0.01
___ 08:13AM BLOOD cTropnT-<0.01
___ 10:10AM BLOOD Calcium-7.5* Phos-2.8 Mg-2.4
___ 10:10AM BLOOD Osmolal-271*
___ 06:54AM BLOOD TSH-2.1
___ 06:54AM BLOOD Cortsol-16.5
___ 06:23AM URINE Color-YELLOW Appear-Clear Sp ___
___ 06:23AM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-4* pH-6.0 Leuks-NEG
___ 06:23AM URINE RBC-2 WBC-2 Bacteri-FEW Yeast-NONE Epi-<1
___ 06:23AM URINE Hours-RANDOM Creat-73 Na-37 Cl-33
___ 06:23AM URINE Osmolal-___
___ 04:12AM URINE Osmolal-___
___ 04:44PM PLEURAL WBC-___* ___-___* Polys-55* Lymphs-6*
Monos-3* Meso-2* Macro-34*
___ 08:06PM PLEURAL WBC-___* ___-___* Polys-1* Lymphs-10*
Monos-3* Other-86*
Brief Hospital Course:
Mr. ___ is a ___ M with a hx of HTN and CAD presenting with R
sided chest pain and dyspnea of several days who was found to
have a large right pleural effusion. He is in the ___ from ___
to visit his children. He has a smoking history of 2.5 ppd for
___ years, quitting ___ years ago. Patient was ruled out
initially for Tuberculosis, and during this time patient
underwent a right chest tube placement which was then sent for
further testing and cytology was concerning for adenocarcinoma.
Patient underwent staging CT Torso scan and was found to have a
large right upper lobe mass with involvement of paratracheal and
hilar lymph nodes. Oncology was consulted and recommended
outpatient further testing , as well as MRI brain to complete
staging workup given Stage IV with malignant effusion. Patient
underwent an MRI brain which was did not reveal metastatic
disease. Given that he lives in ___ and is without health
insurance, financial services was contacted to help arrange for
follow-up. During the course of his hospitalization he was
treated for the following:
# Primary Lung Malignancy
# Unilateral Pleural Effusion s/p right chest tube: Pleural
effusion with malignant cells on cytology. Small pleural
effusion remained after chest tube removal but dramatically
improved compared with presentation. Lung adenocarcinoma on
cytology. No abd/pelvic or brain involvement on imaging (see
pertinent results). Pt to see Dr. ___ oncology on
___. Final read of pleural fluid cytology/immunostaining and
molecular testing results pending at discharge.
# Right Pneumothorax: Patient found to have pneumothorax after
chest tube was removed on ___. IP placed a new chest tube on
___ with near resolution with 20cm suction by ___. Suction
reduced to 10cm on ___ but increased back to -20 due to
concern for reaccumulation. IP performed talc pleurodesis on
___. Bedside US ___ was concerning for loculation, and
therefore underwent second chest tube placement. Patient was
eventually weaned from the CT prior to discharge.
#Hyponatremia: Serum Na as low as 121 during admission, with
initial levels in 130s. Urine Na 37 w/ Osm 436 --> 399. SIADH
likely ___ malignancy. TSH 2.1, cortisol 16.5. Nephrology was
consulted and recommended 1L fluid restriction plus ensure
shakes TID for solute. His Na stabilized around 124 prior to
discharge. He would likely benefit with a liberalized diet with
reduced water intake and close follow-up of his Na.
#Acute Renal Failure: Resolved. Likely to be pre-renal as Cr
responded well to NS boluses. Patient also received contrast.
Unclear baseline Cr. Cr on admission was 1.2 and 0.9 on
discharge.
#Leukocytosis: WBC stuttering from ___ over last few days.
Thought to be largely ___ to pleurodesis and antibiotics were
not given, though there was a low threshold for infection given
CT placement x2. Discharge WBC count was relative stable for 3
days at 15.1.
# Hx of CAD/CVA: He was continued on home clopidogrel,
atorvastatin 80, ranolazine.
# HTN: his home losartan was held given late abnormalities but
was continued on home metoprolol.
====================
>> TRANSITIONAL ISSUES:
# Pathology: Patient will have follow up with oncology ___
regarding pending results, further work-up and treatment.
# Follow-up: Thoracic oncology follow up given, however
possibility patient may follow up in ___. Discussed to pick up
reports, and pathology in the next 2 weeks if so.
# Malignant Effusion: Evacuation of > 2L of fluid, no dyspnea or
oxygen requirement.
# Pending Results: Pending final pleural results, some molecular
testing, and AFB final results.
# CODE: FULL
# CONTACT: SON ___ ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Ranolazine ER 500 mg PO BID
2. Nitroglycerin SL 0.3 mg SL BID:PRN chest pain
3. Atorvastatin 10 mg PO QPM
4. Clopidogrel 75 mg PO DAILY
5. Losartan Potassium 25 mg PO QHS
6. Metoprolol Tartrate 25 mg PO BID
Discharge Medications:
1. Atorvastatin 10 mg PO QPM
2. Metoprolol Tartrate 25 mg PO BID
3. Nitroglycerin SL 0.3 mg SL BID:PRN chest pain
4. Ranolazine ER 500 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
1. Malignant Pleural Effusion
2. Metastatic Lung Adenocarcinoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___
___. You were admitted to the hospital because you
felt very short of breath, and we found that you had a fluid
build up in the right part of your lung. To relieve this, we
placed a chest tube and drained all of this fluid. To help
identify what was causing this fluid, we did a CT scan of your
chest and your abdomen, and an MRI of your brain. Unfortunately,
the fluid appeared to be caused by a cancer.
We have a variety of testing that will still be pending upon
leaving the hospital, including the specific pathology of this
cancer. Please make a follow-up appointment below so that you
can follow up with our cancer specialists to determine what type
of treatment can be used in your case in the future.
We wish you the best,
Your care team at ___
Followup Instructions:
___
|
19551213-DS-13
| 19,551,213 | 24,704,510 |
DS
| 13 |
2144-05-27 00:00:00
|
2144-05-28 10:06:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Acute acetaminophen toxicity
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with recently diagnosed bipolar disorder admitted ___ to
SICU under transplant surgery after intentional acetaminophen
overdose now with downtrending LFTs with SICU course c/b
S.viridans bacteremia now being transferred to Medicine for
further management.
Per report, patient did not show up for work on the day of
admission, and his supervisor at work was concerned and called
patient's father to check on him. Patient last seen normal a few
days prior. Patient found in the basement of his home,
unconscious with unknown amount of acetaminophen ingested. EMS
arrived and noted patient to be minimally responsive,
hypothermic to 90dF with ___ 50. Given glucagon and naloxone
prior to transport to ___. He was given a loading dose
of NAC 150mg/kg at 15:40, along with 4LNS and D50 25gm x2.
Patient was lethargic and intubated for airway protection at
15:52 with etomidate and succinylcholine. Initial pH at OSH
measured at 6.9, lactate 20, INR 1.6, AST 280, ALT 369, TBili
1.8, APAP level 389. Lithium level at OSH reportedly normal.
NCHCT and CXR unremarkable. Patient transferred to this facility
for further evaluation of his acute liver failure on ___.
On arrival here patient was noted to have ALT in 6000s and AST
in 8000s with T.bili 1.8 and acetaminophen level of 248 with INR
2.5. Utox negative for other ingestion. He was placed on NAC gtt
and initially considered for transplant. ALT/AST subsequently
peaked in 7000s/5000s and have since been coming down. At this
time T.bili remains high at 16.8. Extensive workup for other
etiologies of liver disease (other hepatidities, CMV, EBV, HIV,
ceruloplasmin, ___, Toxo, Rubella, VZV) are negative.
AFP, CA ___, CEA, PSA were all checked. RUQ showed patent
portal vein w/o splenomegaly.
Through the SICU course he has required 2u FFPs and 1mg IV VitK
to reverse coagulopathy but no blood. On ___ he was found have
GPCs in BCx, initially on vancomycin but switched to CTX on ___
when GPC speciated out as S.viridans. Planned course for 2
weeks. Surveillance cx subsequently have been negative.
Currently, VSS, AAOx3 without complaints, abdominal exam benign.
He continues on ceftriaxone for strep viridans bacteremia for
planned ___onsulting teams are transplant, liver,
ID, toxicology and psych. Per psych, he currently has 1:1 sitter
and will require inpatient psych admission when medically
stable.
Electrolyte repletions today prior to transfer: 80meq K, 2g Mg,
2g Ca gluconate, 8PM got PO Phos.
Past Medical History:
Bipolar disorder
Social History:
___
Family History:
Non-contributory
Physical Exam:
Admission Physical Exam
Vitals: 97.9-98.2 ___ ___ 16 95-100%
GEN: Sleeping on exam, jaundiced, NAD, bilateral subconjunctival
hemorrhages
HEENT: PERRL, EOMI
NECK: Supple, no lymphadenopathy, no JVD elevation
CV: RRR, normal S1/S2, no mumurs/rubs/gallops
RESP: CTAB
ABD: +BS, soft, NT, ND
Discharge Physical Exam
Vitals: 98.3 124/64 66 20 98%
GEN: Jaundiced, NAD, bilateral subconjunctival hemorrhages
HEENT: PERRL, EOMI
NECK: Supple, no lymphadenopathy, no JVD elevation
CV: RRR, normal S1/S2, no mumurs/rubs/gallops
RESP: CTAB
ABD: +BS, soft, NT, ND
EXT: Mild edema throughout
Pertinent Results:
Pertinent labs
___ 11:07PM ___ 11:07PM IRON-194*
___ 11:07PM calTIBC-204* FERRITIN-1277* TRF-157*
___ 11:07PM HBsAg-NEGATIVE HBs Ab-POSITIVE HBc
Ab-NEGATIVE HAV Ab-NEGATIVE
___ 11:07PM AMA-NEGATIVE Smooth-NEGATIVE
___ 11:07PM ___
___ 11:07PM CEA-2.9 PSA-0.7 AFP-<1.0
___ 11:07PM IgG-758 IgA-232 IgM-120
___ 11:07PM HIV Ab-NEGATIVE
___ 11:07PM ACETMNPHN-208*
___ 08:55PM ASA-NEG ETHANOL-NEG ACETMNPHN-256*
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 08:55PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 05:45PM BLOOD Osmolal-302
___ 10:17AM BLOOD AFP-1.1
___ 11:07PM BLOOD Lithium-LESS THAN
___ 02:09AM BLOOD Type-ART pO2-90 pCO2-32* pH-7.48*
calTCO2-25 Base XS-0
___ 02:09AM BLOOD Lactate-1.8
___ RUBELLA ANTIBODY IGM <0.90
___ COPPER (SERUM) 56 L
___ HERPES SIMPLEX VIRUS 1 AND 2 ANTIBODY IGM NEG
___ HERPES SIMPLEX VIRUS 1 >5.0 HERPES SIMPLEX VIRUS 2
(IGG) <0.90
___ 23:07 CERULOPLASMIN 15 L
___ 23:07 ANTI-LIVER-KIDNEY-MICROSOME ANTIBODY <20
___ 23:07 ALPHA-1-ANTITRYPSIN 107
Admission Labs
___ 11:07PM ___ PTT-36.5 ___
___ 11:07PM ___
___ 08:55PM GLUCOSE-284* UREA N-9 CREAT-1.2 SODIUM-136
POTASSIUM-4.6 CHLORIDE-114* TOTAL CO2-13* ANION GAP-14
___ 08:55PM ALT(SGPT)-1258* ___ ALK PHOS-65
TOT BILI-1.9*
___ 08:55PM LIPASE-45
___ 08:55PM ALBUMIN-3.5 CALCIUM-7.1* PHOSPHATE-1.1*
MAGNESIUM-1.8
___ 08:55PM WBC-15.8* RBC-4.32* HGB-12.8* HCT-40.5 MCV-94
MCH-29.7 MCHC-31.7 RDW-12.1
Discharge Labs
___ 06:15AM BLOOD WBC-5.6# RBC-3.55* Hgb-10.6* Hct-32.4*
MCV-91 MCH-30.0 MCHC-32.8 RDW-13.4 Plt Ct-66*
___ 06:15AM BLOOD ___ PTT-37.9* ___
___ 06:15AM BLOOD Plt Ct-66*
___ 11:42AM BLOOD ___
___ 06:15AM BLOOD Glucose-81 UreaN-5* Creat-0.8 Na-140
K-3.5 Cl-105 HCO3-26 AnGap-13
___ 06:15AM BLOOD ALT-1487* AST-76* AlkPhos-106
TotBili-16.8*
___ 05:45PM BLOOD cTropnT-0.02*
___ 08:55PM BLOOD cTropnT-<0.01
___ 06:15AM BLOOD Calcium-7.9* Phos-1.9* Mg-1.8
___ 06:40AM BLOOD ___ Folate-8.9
MICRO
___
VARICELLA-ZOSTER IgG SEROLOGY (Final ___:
POSITIVE BY EIA.
RADIOLOGY
CXR ___
No acute intrathoracic process. Note distal left edge of the
endotracheal tube abutting left tracheal wall.
ECHO ___
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thicknesses
and cavity size are normal. Regional left ventricular wall
motion is normal. Left ventricular systolic function is
hyperdynamic (EF>75%). The estimated cardiac index is high
(>4.0L/min/m2). Doppler parameters are most consistent with
normal left ventricular diastolic function. Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve leaflets are structurally normal. There is no
mitral valve prolapse. No mitral regurgitation is seen. There is
mild pulmonary artery systolic hypertension. There is no
pericardial effusion.
RUQ US ___
1. Top normal spleen, measuring 13 cm.
2. Patent main portal vein. No ascites.
3. Limited evaluation.
Brief Hospital Course:
Mr ___ is a ___ male who was found down after being found
down ___ tylenol ingestion as part of suicide attempt.
# ACETAMINOPHEN INGESTION / LIVER FAILURE: The patient was
transferred from an outside hospital for management and
transplant evaluation and admitted on ___ after being found
unresponsive in his home and intubated. He was managed in the
ICU for 5 days with evaluation by toxicology, transplant surgery
and hepatology. He received 6 days of NAC with initial
worsening of his LFTs associated with an elevated acetaminophen
level. In preparation for possible transplant, he received 2U
FFP and 1mg IV vit K. However, ultimately this was followed by a
steady downtrending of his LFTs, normalization of his INR and
improvement in his mental status. He was extubated ___.
Thorough workup for other causes of liver failure was found to
be negative. He was transferred to the floor on ___ for further
monitoring and continued to improve. NAC was stopped on ___
and pt was deemed to be medically stable on ___ for transfer to
psychiatry.
# S. VIRIDANS BACTERMIA: The patient was found to be bacteremic
on initial (___) blood cultures. The patient was started on
vancomycin on ___ and this was switched to ceftriaxone on ___
with a plan for a two week course (tentative end date ___.
His bacteremia cleared quickly and all subsequent blood cultures
were negative. ID was consulted and theorized that recent dental
procedure instrumentation (which the patient endorsed) or oral
trauma while unconscious/intubated were possible etiologies. The
patient did deny current mouth or tooth pain and on exam did not
have obvious tooth decay. He had a TTE without evidence of
vegetation or valvular abnormality. Blood cultures will be
repeated on an outpatient basis following completion of a two
week antibiotic course in order to determine the utility of TEE,
and the patient will have a Panorex to evaluate for oral
infection.
# PANCYTOPENIA: On initial presentation, the patient had a
relatively normal CBC, but progressively developed pancytopenia
through the first few days of his hospitalization. This was
presumed to be secondary to inflammation from liver failure with
component of marrow suppression from sepsis. An HIV was checked
and was negative. The patient's CBC fluctuated through his stay
but he required no blood products. His CBC should be rechecked
as an outpatient.
# BIPOLAR D/O: The patient was followed by psychiatry and social
work during his hospitalization. His home medications were held
per psychiatry recommendations. He was monitored by a sitter
throughout his stay. He was discharged to an inpatient
psychiatric facility following medical stability.
# Transitional
- PICC placed, will continue ceftriaxone to complete a two week
coursece (day 1 = ___ through ___
- ID recommends repeat blood cultures ___ days after completing
antibiotics; if positive, the patient will require a TEE to
evaluate for endocarditis
- The patient will also require a Panorex to evaluate for dental
infection
- Repeat CBC one week after discharge given pancytopenia during
hospitalization; continue to trend appropriately until full
recovery achieved.
- Repeat LFTs one week after discharge to ensure continuing
resolution of liver injury
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Zolpidem Tartrate 5 mg PO HS:PRN insomnia
2. ClonazePAM 0.5 mg PO BID
3. Lithium Carbonate 900 mg PO DAILY
Discharge Medications:
1. CeftriaXONE 2 gm IV Q24H
2. Ondansetron 8 mg IV Q8H:PRN n/v
3. Pantoprazole 40 mg IV Q24H
4. Polyethylene Glycol 17 g PO DAILY:PRN Constipation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: Acute acetaminophen toxicity, acute hepatic failure, S.
viridans bacteremia
Secondary: Bipolar disorder
Discharge Condition:
Mental Status: Generally clear and coherent
Level of Consciousness: Sometimes lethargic but arousable, often
alter and agitated.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It has been our pleasure to care for you during your stay at
___. You were admitted to the ICU following an overdose of
tylenol, and you were treated supportively and with medications
to reduce the injury to your liver. You were also treated with
antibiotics for a blood infection that we found when you were
admitted. You were evaluated by a number of teams, including the
liver transplant team. Ultimately, you improved enough to be
moved to a normal floor, where we continued to monitor your
clinical progress and improvement. You were ultimately deemed
medically well enough to be discharged to a facility to receive
further psychiatric care. You will continue antibiotics there
and will be evaluated again to ensure that your blood infection
has cleared and your liver has recovered. If you have any new or
concerning symptoms after your discharge, including abdominal
pain, chest pain, fever, chills, or anything else that concerns
you, please contact your doctor immediately or return to the
emergency department. We wish you the best in your recovery,
Your ___ Care Team
Followup Instructions:
___
|
19551392-DS-8
| 19,551,392 | 20,839,781 |
DS
| 8 |
2173-01-26 00:00:00
|
2173-02-11 14:58:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ F p/w abdominal pain since EGD and colonoscopy two days ago.
Pain is dull, ache, continuous, and mainly periumbilical,
yesterday became more periumbilical. Mild nausea, no emesis, is
tolerating clears. passing minimal flatus. Last bowel movement
night before colonoscopy. No prior episodes, no history of
abdominal
surgery.
Past Medical History:
ESOPHAGEAL RING
IRITIS - ACUTE / SUBACUTE
ASTHMA
LATERAL HUMERAL ___
HYPERCHOLESTEROLEMIA
Family History:
Noncontributory
Physical Exam:
Upon presentation to ___:
Vital signs: 99.4 90 115/92 18 100%
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, minimally distended, TTP over umbilicus, no rebound
or
guarding, normoactive bowel sounds, no palpable masses
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
___ 12:20PM GLUCOSE-86 UREA N-6 CREAT-0.8 SODIUM-135
POTASSIUM-4.3 CHLORIDE-95* TOTAL CO2-27 ANION GAP-17
___ 12:20PM ALT(SGPT)-14 AST(SGOT)-20 ALK PHOS-72 TOT
BILI-0.9
___ 12:20PM LIPASE-30
___ 12:20PM WBC-8.9 RBC-5.01 HGB-14.8 HCT-45.5 MCV-91
MCH-29.6 MCHC-32.6 RDW-13.2
___ 12:20PM NEUTS-79.9* LYMPHS-14.6* MONOS-3.9 EOS-1.2
BASOS-0.4
___ 12:20PM PLT COUNT-382
CT abd/pelvis:
IMPRESSION:
1. Small-bowel obstruction (likely partial) secondary to a long
segment of edematous small bowel in the distal/terminal ileum.
The cause of small bowel wall thickening could be inflammatory
versus infectious etiology, less likely ischemic. Small volume
associated ascites. No signs of bowel perforation.
2. Mass-like lesion along the ascending colon -- correlate with
findings from colonoscopy performed 2 days ago.
Brief Hospital Course:
She was admitted to the Acute Care Surgery team and underwent CT
imaging of her abdomen showing small-bowel obstruction (likely
partial) secondary to a long segment of edematous small bowel in
the distal/terminal ileum. She was made NPO, given IV fluids and
serial exams were followed. IV Cipro and Flagyl were started as
well. Over the course of her short stay her exam improved
quickly. She was given clear liquids and then advanced to solid
foods without any problems. Her Cipro and Flagyl were changed to
oral antibiotics and she will continue these for another 10 days
after discharge.
She is being discharged to home and will follow up with her
primary care providers -appointments have been made for her to
see her PCP and ___.
Medications on Admission:
Denies
Discharge Medications:
1. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
2. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 10 days.
Disp:*qs Tablet(s)* Refills:*0*
3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
Discharge Disposition:
Home
Discharge Diagnosis:
Partial small bowel obstruction
Secondary diagnosis: 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 to the hospital with a partial obstruction in
your intestines that has now resolved. You were seen by the
Gastroenterology team and they have recommended that you
continue with 10 days of Ciprofloxacin and Flagyl.
You will also need to follow up with your priamry GI doctor -
Dr. ___ you are discharged from the hospital.
You may resaume your home medications as prescribed.
Followup Instructions:
___
|
19551627-DS-15
| 19,551,627 | 23,029,390 |
DS
| 15 |
2145-11-18 00:00:00
|
2145-11-18 17:11:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Left Subdural Hematoma.
Major Surgical or Invasive Procedure:
Left Craniotomy and evacuation of Subdural Hematoma on
___.
History of Present Illness:
This is a ___ yo female history ESRD, on comadin for Afib who was
at dialysis
yesterday ___ when she developed worsening HA. She was sent to
ED where initially she was treated for HA management. When HA
worsened CT head was performed that showed acute left SDH with
MLS. She was given 1 unit of FFP, intubated for unclear reasons
and transferred to ___ for further care.
Past Medical History:
ESRD on dialysis, HTN, Anemia, Sick Sinus Syndrome with
Pacemaker, GERD, Paroxysmal Afib, IDDM, hyperlipidemia.
Social History:
___
Family History:
NC.
Physical Exam:
PHYSICAL EXAMINATION ON ADMISSION:
O: T: 95 BP: 130/62 HR:95 R: 161 O2Sats:100%
Gen: WD/WN, comfortable, NAD.
HEENT: normocephalic, atraumatic.
Pupils:
Right 4mm brisk
Left 4mm sluggish
Mental status:
Intubated, sedated with propofol which was held for exam:
Attempts to open eyes for examiner
Motor:
Pt follows commands in right arm and bilateral legs which are at
least antigravity.
Right grip ___,
Left UE is less brisk than the right and Left grip ___
Toes downgoing bilaterally
PHYSICAL EXAMINATION ON DISCHARGE:
Patient is awake and alert. Oriented to person, place and time.
Face symmetrical, speech fluent.
No pronator drift
Moves all extremities ___.
Follows commands.
Pertinent Results:
Head CT: ___
1. Significant decrease in left frontal subdural hematoma with
decreased mass effect. Small residual hyperdense subdural blood
products.
2. New small left frontal subarachnoid hemorrhage deep to the
preexisting
subdural collection.
___ CXR:
In comparison with the earlier study of this date, the
monitoring
and support devices remain in good position. Increased
opacification at the right base with hazy opacification of the
hemithorax are consistent with pleural effusion and atelectasis.
Indistinctness of pulmonary vessels suggests some elevated
pulmonary venous pressure.
___ CXR:
As compared to the previous radiograph, the lung volumes have
increased,
potentially reflecting increased ventilatory pressure. No
pneumothorax. No larger pleural effusions. No overt pulmonary
edema. Moderate cardiomegaly persists. The monitoring and
support devices are constant.
___ CT Head:
No significant interval change in appearance of small left
frontal subdural hematoma and adjacent left frontal subarachnoid
hemorrhage since the prior study from 5 hr ago.
___ CT Head:
Stable left frontal subdural hematoma, unchanged from the
previous
examination.
___ CXR:
In comparison with the earlier study of this date, the
endotracheal tube has been removed. Nasogastric tube and pacer
leads appear unchanged. No change in the appearance of the
heart and lungs.
___ EEG
This is an abnormal continuous ICU EEG monitoring study because
of occasional bursts of high amplitude rhythmic delta seen over
the left
hemisphere. These findings with be consistent with more a more
focal region
of cerebral dysfunction. The background activity demonstrates a
slow
posterior dominant rhythm and intermittent bursts of irregular
diffuse delta
activity indicative of moderate diffuse cerebral dysfunction.
There were no
clear electrographic seizures seen. The telemetry is improved
from the prior
day.
___ CT Head:
1. No significant interval change in size of small residual
left frontal
extra-axial hematoma. There is resolution of previously seen
pneumocephalus. Left frontal subarachnoid hemorrhages are
slightly improved from prior exam.
No new intra cranial hemorrhage.
2. There is suggestion of hypodensity within the left medial
temporal cortex and left cerebral peduncle, which may be
artifactual secondary to adjacent beam hardening although this
may also represent ischemic injury secondary to mass effect from
uncal herniation seen on initial CT of ___. Clinical
correlation is recommended. If clinically indicated and there
are no contraindications, MRI may yield additional information.
Brief Hospital Course:
The patient received 1 unit of FFP for an INR of 1.7 at the
outside hospital. She received an additional 2 units of FFP
prior to going to the operating room emergently for evacuation
of the hematoma. She underwent a left craniotomy and evacuation
of subdural hematoma. Post-operatively, the patient's INR was
1.7 and she received an additional 2 units of FFP and 10mg of
Vitamin K. Her repeat INR was 1.4. She tolerated the procedure
well and post-operatively she was admitted to the ICU for close
monitoring. A repeat INR was 1.4. Renal was consulted and she
underwent Hemodialysis today. She underwent a non-contrast head
CT post-operatively which showed expected post-operative
changes.
On ___ she had a seizure with nystagmus and gaze deviation. She
revcieved Ativan and was given a fosphenytoin load. She
underwent a CT head which showed stable ICH.
On ___, she was placed on EEG, had a stable Head CT after
another questionable seziure, and had dialysis
On ___, she was extubated in the morning, continued on EEG, and
underwent dialysis per the renal team.
On ___ Patient was moving all 4 extremities well, language
barrier limits exam. EEG was discontinued after found to be
negative for seizurs.
On ___, Patient pulled out NGT. She went for Dialysis. She was
given an extra 500mg keppra post dialysis.
On ___, She was evaluated by speech and swallow and was passed
for a diet of thin liquids, pureed solids and crushed pills.
Patient underwent a Routine CT head which was stable.
On ___, the patient remained neurologically stable on
examination. She is pending discharge to rehabilitation.
___ the patient remained stable. Her diet was advanced to soft
solids, thin liquids.
On ___, The patient was neurologically stable and awaiting
placement at rehab.
On ___, The patient was has hemodyalysis. The patient had half
of her staples removed but became aggitated and the rest of the
staples were left in place. The patient was reevaluated by
physical therapy that recommended rehabiliation disposistion.
The family however would like to take the patient home with 24
hours supervision. The patient neurological exam was stable.
On ___, her staples were removed. She remained neurologically
stable and a disposition planning meeting with family was
planned. Physically therapy evaluated her and felt safe to
discharge the patient home with 24 hour supervision.
Medications on Admission:
Coumadin, RenVela TID, Metoprolol 50mg Daily, Insulin, Advair
250/50, Hydroxyzine 25mg QID, Albuterol-Ipratropium PRN.
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
3. Diltiazem 60 mg PO QID
4. Docusate Sodium 100 mg PO BID
5. LeVETiracetam 1000 mg PO BID
RX *levetiracetam [Keppra] 1,000 mg 1 tablet(s) by mouth twice a
day Disp #*60 Tablet Refills:*0
6. Sarna Lotion 1 Appl TP QID:PRN pruritis
7. Nephrocaps 1 CAP PO DAILY
8. Metoprolol Tartrate 50 mg PO TID
9. Senna 8.6 mg PO BID:PRN constipation
10. sevelamer CARBONATE 2400 mg PO TID W/MEALS
11. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN Wheezing
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Left Subdural Hematoma
End stage renal disease
dysphagia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Craniotomy for Hemorrhage
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 staples. You may wash your hair now
that the staples have been removed. They were taken out ___.
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.
If you were on a medication such as Coumadin (Warfarin), or
Plavix (clopidogrel), or Aspirin, prior to your injury, you may
safely resume taking this on only after your follow up in one
month.
You have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring. Please take an extra 500mg of
Keppra following your dialysis.
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.
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:
___
|
19552525-DS-17
| 19,552,525 | 20,465,783 |
DS
| 17 |
2131-07-04 00:00:00
|
2131-07-07 16:33:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
doxycycline
Attending: ___.
Chief Complaint:
Fevers and night sweats.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year-old male who presents with fevers to
103, night sweats and malaise. One week prior to admission he
began to have fevers controlled intermittently with
Tylenol/ibuprofen, headaches, chills, night sweats and malaise.
He also noted abnormal "warmth" when urinating and mild
constipation. He denies congestion, sore throat, cough, SOB,
chest pain, confusion, myalgias/arthralgias, weight loss.
.
No recent travel, spends time outdoors but denies known tick
exposure, however he was golfing 2 weeks prior to admission in a
tick-infested area. He was seen by his PCP (Dr. ___
on ___ for fevers, tested negative for Lyme and mononucleosis
in his PCP's office.
In the ED, his initial vitals were 103.2, 86, 106/51, 18, >95%
RA. He was given Quinine Sulfate 324 mg, Doxycycline Hyclate 100
mg and Acetaminophen 500mg. Labs significant for WBC 4, Hgb
12.9, Hct 37.8, Plt 103, Neuts 86.6, Glucose 122, Na 126, Cl 92,
ALT 326, AST 458, LDH 1183, AlkPhos 219, TotBili 2.5, Hatp <5.
PA & lateral chest x-ray significant for small bilateral pleural
effusions with no radiographic evidence of a pneumonia.
.
Upon admission to the floor, he reports feeling flushed and
"bad."
.
ROS: 10 point ROS negative except as noted above in HPI
Past Medical History:
Hypercholesterolemia
Hypertension
BPH
Lentigines
___ damaged skin, chronic
Social History:
___
Family History:
- Father (deceased): cancer
- Mother (deceased): dementia
- Sister: healthy
- Children: healthy
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.4, 128/54, 85, 18, 98RA
GENERAL: NAD, well-appearing man who appears stated age, AOx3
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink 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: slightly distended, firm, +fluid shift test, +BS,
nontender in all quadrants, no rebound/guarding, no
hepatosplenomegaly
EXTREMITIES: moving all extremities well, no cyanosis, clubbing,
+1 lower pitting edema
PULSES: 2+ DP & radial pulses bilaterally
NEURO: CN II-XII grossly intact, sensorty and motor grossly ___.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
VS: 98.8, 97.8, 64-75, 110/61-119/68, ___, 97-98% RA
I/O 24h: 480 PO/BRP+ BMx1
8h: 1000/BRP
GENERAL: NAD, well-appearing man who appears stated age, AOx3
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, facial flushing markedly improved
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: slightly distended, firm, +fluid shift test, +BS,
nontender in all quadrants, no rebound/guarding, no
hepatosplenomegaly
EXTREMITIES: moving all extremities well, no cyanosis, clubbing,
+1 lower pitting edema
PULSES: 2+ DP & radial pulses bilaterally
NEURO: CN II-XII grossly intact, sensory and motor grossly ___.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LAB RESULTS:
___ 11:55AM BLOOD WBC-4.0 RBC-3.98* Hgb-12.9* Hct-37.8*
MCV-95 MCH-32.3* MCHC-34.0 RDW-13.9 Plt ___
___ 11:55AM BLOOD Neuts-86.6* Lymphs-9.9* Monos-2.6 Eos-0.1
Baso-0.8
___ 11:55AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-1+ Microcy-NORMAL Polychr-NORMAL
___ 12:19PM BLOOD ___ PTT-42.1* ___
___ 07:21PM BLOOD ___ 11:55AM BLOOD Parst S-NEGATIVE
___ 11:55AM BLOOD Ret Aut-0.8*
___ 11:55AM BLOOD Glucose-122* UreaN-17 Creat-1.2 Na-126*
K-3.7 Cl-92* HCO3-24 AnGap-14
___ 11:55AM BLOOD ALT-326* AST-458* LD(LDH)-1183*
AlkPhos-219* TotBili-2.5*
___ 11:55AM BLOOD Lipase-55
___ 11:55AM BLOOD Albumin-3.6
___ 07:21PM BLOOD Calcium-7.5* Phos-3.1 Mg-1.9 UricAcd-4.1
___ 11:55AM BLOOD Hapto-<5*
___ 01:32PM URINE Color-Orange Appear-Hazy Sp ___
___ 01:32PM URINE Blood-MOD Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-MOD Urobiln-4* pH-6.0 Leuks-NEG
___ 01:32PM URINE RBC-5* WBC-1 Bacteri-NONE Yeast-NONE
Epi-0
DISCHARGE LAB RESULTS:
___ 07:05AM BLOOD WBC-7.2 RBC-4.03* Hgb-13.1* Hct-39.0*
MCV-97 MCH-32.5* MCHC-33.6 RDW-14.6 Plt ___
___ 07:05AM BLOOD Plt ___
___ 07:05AM BLOOD ___ PTT-35.4 ___
___ 07:05AM BLOOD Glucose-90 UreaN-21* Creat-0.9 Na-130*
K-4.0 Cl-94* HCO3-27 AnGap-13
___ 07:05AM BLOOD ALT-331* AST-358* AlkPhos-372*
TotBili-3.2* DirBili-2.6* IndBili-0.6
___ 07:05AM BLOOD Calcium-8.1* Phos-3.6 Mg-2.3
___ 06:40AM BLOOD calTIBC-222 VitB12-1014* ___
TRF-171*
___ 06:40AM BLOOD Osmolal-263*
___ 06:34AM BLOOD ANCA-NEGATIVE B
___ 06:35AM BLOOD HIV Ab-NEGATIVE
MICROBIOLOGY:
___ SEROLOGY/BLOOD LYME SEROLOGY
NO ANTIBODY TO B. BURG___ DETECTED BY EIA.
Negative results do not rule out B. burg___ infection.
Patients in early stages of infection or on antibiotic therapy
may not produce detectable levels of antibody. Patients with
clinical history and/or symptoms suggestive of lyme disease
should be retested in ___ weeks.
___ URINE CULTURE
NEGATIVE <10,000 organisms/ml.
___ Blood (EBV)
___ VIRUS VCA-IgG AB (Final ___: POSITIVE BY
EIA.
___ VIRUS EBNA IgG AB (Final ___: POSITIVE BY
EIA.
___ VIRUS VCA-IgM AB (Final ___: NEGATIVE
<1:10 BY IFA.
INTERPRETATION: RESULTS INDICATIVE OF PAST EBV INFECTION.
In most populations, 90% of adults have been infected at
sometime
with EBV and will have measurable VCA IgG and EBNA
antibodies.
Antibodies to EBNA develop ___ weeks after primary
infection and
remain present for life. Presence of VCA IgM antibodies
indicates
recent primary infection
___ URINE CULTURE {ESCHERICHIA COLI, KLEBSIELLA OXYTOCA}
ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML..
KLEBSIELLA OXYTOCA. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
________________________________________________________
ESCHERICHIA COLI
| KLEBSIELLA OXYTOCA
| |
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S 8 S
CEFAZOLIN------------- <=4 S 8 R
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- <=16 S <=16 S
PIPERACILLIN/TAZO----- <=4 S <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
___ SEROLOGY/BLOOD MONOSPOT
NEGATIVE by Latex Agglutination
IMAGING:
___ LIVER OR GALLBLADDER US
LIVER: The hepatic parenchyma appears within normal limits. The
contour of the liver is smooth. There is no focal liver mass.
Main portal vein is patent with hepatopetal flow. There is no
ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD
measures 4 mm.
GALLBLADDER: The gallbladder wall is edematous, likely
secondary to
underlying liver function abnormality. There is no evidence of
stones.
PANCREAS: Evaluation of the pancreas is limited by overlying
bowel gas.
SPLEEN: Normal echogenicity, measuring 11.5 cm.
KIDNEYS: The right kidney measures 10.6 cm. The left kidney
measures 12.0 cm. Representative images of the right and left
kidney are normal.
RETROPERITONEUM: Visualized portions of aorta and IVC are within
normal
limits.
IMPRESSION: Normal hepatic parenchyma. No intra or extrahepatic
biliary duct dilatation.
___ CHEST X-ray (PA & LAT)
Small bilateral pleural effusions. No radiographic evidence of
pneumonia.
Brief Hospital Course:
Mr. ___ is a ___ year-old male with a history of
hypertension and hyperlipidemia presenting with fevers to 103,
night sweats and malaise of one week duration.
#Fever, likely tick-borne illness: The patient initially
presented with fevers to 103, malaise, and night sweats for one
week duration. Prior to admission, he had a negative Lyme
serology, Babesia smear, and Monospot from his PCP's office.
Initial labs were notable for normal WBC at 4, hemolytic anemia,
thrombocytopenia, and elevated LFTs (see below) concerning for
possible tick borne infection. The patient was initially started
on broad spectrum for tick borne infections with azitromycin,
atovaquone, and doxycline. Babesia smears were negative x3 and
azitromycin and atovaquone were discontinued. A repeat Lyme
antibody was also negative. Infectious Disease was consulted and
recommended further lab tests (Babesia PCR, serologies and viral
loads for EBV, CMV, Parvovirus B19, Anaplasma smear) which were
pending at the time of discharge. The patient's fevers were
treated with PRN tylenol and the patient was continued with oral
doxycline. On the third day of admission, the patient
defervesced. At the time of discharge, the patient was afebrile
and continued oral doxycline for a total of ten days.
Infectious Disease felt that given the response to doxycycline,
Lyme or anaplasma remained a possibility. He did have a urine
culture that grew 2 GNR's in ___ CFU's, however, ID felt
that this was more likely to represent contaminant or
asymptomatic bacteruria as he did not have any urinary symptoms.
#Hemolytic Anemia/Thrombocytopenia: The patient was found to
have lab values concerning for hemolytic anemia (Hct 37.8,
baseline low ___, haptoglobin <5, LDH 1183, Tbili 2.5) and
thrombocytopenia (platelets 114, baseline 343 on ___. A
direct Coombs test was negative. INR was 1.1 and fibrinogen was
251. During the hospitalization, the patient did not develop any
petechiae, ecchymoses, or signs of bleeding. The patient was
seen by Hematology consult, and his hemolytic anemia and
thromboyctopenia was attributed to an underlying infection as
above. At the time of discharge, the patient's hemoglobin and
hematocrit were stable at 39.8, LDH was trending downwards and
his platelets normalized to 304.
#Transaminitis: The patient was also found to have elevated
LFTs: ALT 233, AST 139, AlkPhos 152. This was attributed to an
underlying viral or tick borne infection as above. Right upper
quadrant ultrasound was reassuring, and viral hepatitis
serologies were pending at discharge. At the time of discharge,
the patient's LFTs were stable with ALT 259, AST 139, and
AlkPhos 339.
#Hyponatremia: On admission, the patient was found to have Na
126 with normal volume status. His euvolemic hyponatremia was
likely due to SIADH in the setting of an underlying infection
versus hypovolemic hyponatremia. The patient's sodium was stable
at 129 at the time of discharge.
#Ferritinemia: The patient's ferritin was 13,277 with low serum
iron and transferrin. Initially, there was a concern for
hemophagocytic lymphohistiocytosis (HLH) versus adult onset
Still's disease given markedly elevated ferritin with fever as a
chief complaint, however, the patient did not meet criteria for
either condition. A bone marrow biopsy was not felt to be
indicated by Hematology during this admission. The patient's
ferritin will be repeated after by his PCP during ___ followup
visit.
CHRONIC ISSUES:
#Hypertension: The patient's hypertension was stable throughout
the hospitalization. He was continued on his home metoprolol,
terazosin, and olmesartan.
#Hypercholesterolemia: The patient's hypercholesterolemia was
stable during the hospitalization. His home rosuvastatin was
held in the setting of the transaminitis.
#Benign prostatic hypertrophy: The patient's BPH was stable
throughout the hospitalization as he did not experience any
urinary retention. His home alfuzosin was not given because it
was not on formulary. Instead, he was administred prosazosin.
TRANSITIONAL ISSUES:
* Patient will continue 10-day course of doxycline 100 mg PO BID
(Day 10= ___.
* Empiric folic acid was started at the suggestion of
hematology.
* Pending infectious disease and rheumatologic serologies as
detailed in the discharge worksheet.
* Repeat CBC, Chem7, liver function tests, and ferritin are
advised at primary care follow-up.
* Statin was held at discharge in the setting of liver function
test abnormalities and may be resumed at primary care physician
discretion in the event of improved liver function tests.
* Infectious disease and hematology follow-ups may be considered
in the event of recurrent fever or recurrent/unimproving
cytopenias.
* Hepatology follow-up may be considered in the event of
unresolved liver function test abnormalities.
*Code status: FULL CODE
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. olmesartan 20 mg oral daily
2. Rosuvastatin Calcium 10 mg PO DAILY
3. Metoprolol Succinate XL 25 mg PO DAILY
4. alfuzosin 10 mg oral daily
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth once a day Disp #*7
Tablet Refills:*0
2. alfuzosin 10 mg oral daily
3. Metoprolol Succinate XL 25 mg PO DAILY
4. olmesartan 20 mg oral daily
5. Doxycycline Hyclate 100 mg PO Q12H
Please take through ___.
RX *doxycycline hyclate 100 mg 1 capsule(s) by mouth twice a day
Disp #*7 Capsule Refills:*0
RX *doxycycline hyclate 100 mg 1 capsule(s) by mouth twice a day
Disp #*13 Capsule Refills:*0
6. Acetaminophen 325 mg PO Q6H:PRN fever, pain
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Fever, likely due to viral or tick-borne illness
Hemolytic Anemia
Thrombocytopenia
Transaminitis
Ferritinemia
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 part in your care during your admission
to ___. As you know, you were
admitted for fevers, low red blood cell count, and elevated
liver function tests. You were evaluated by the hematology and
infectious disease services, and it was felt that your fevers
and low blood counts and elevated liver function tests were
likely due to a tick-borne infection versus a viral infection,
though the cause of your infection was not immediately
identifiable; multiple blood tests for various viral and
tick-borne infections remain pending at discharge. You were
treated empirically with an antibiotic called doxycycline, which
covers Lyme disease and Anaplasma, another tick-borne infection,
and your fevers resolved and your blood counts improved. You are
advised to complete a 10-day course of doxycycline (through
___.
Please take your medications as prescribed and follow up with
your primary care doctor as detailed below, including for repeat
blood work.
Followup Instructions:
___
|
19552525-DS-18
| 19,552,525 | 22,376,031 |
DS
| 18 |
2131-07-18 00:00:00
|
2131-07-19 06:55:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
doxycycline
Attending: ___
___ Complaint:
EBV viremia, abdominal pain, weakness, ataxia
Major Surgical or Invasive Procedure:
Bone marrow biopsy ___
Lumbar puncture ___
History of Present Illness:
Patient seen and examined agree with house officer admit note by
Dr. ___ with additions below:
___ year old Male, discharged 3 days prior, who presented with a
febrile illness with no etiology from the prior admission, who
presents with recurrent fever, weakness, lethargy and myalgias.
His EBV PCR which was pending on discharge from prior admission,
has now returned at ___ copies. He was previously IGG+/IGM-
implying former clearance, making this a recurrence.
On the prior admission he presented with additionally
transaminitis, hemolytic anemia, thrombocytopenia, hyponatremia
and hypocalcemia. Lyme was negative and mononucleosis at ___'s
office on ___.
The patient has been feeling progressively unwell in the few
days since discharge, with marked lethargy, arthralgias,
anorexia, along with brown urine and a trunk rash. He has also
been markedly ataxic
In the ED, initial vital signs were: T 98.7 HR 71 BP 127/66 RR
18 O2 sat 98% on RA. He underwent CT abdomen and pelvis with
contrast and was noted to have numerous small hypodensities
throughout the liver and spleen, which were felt to be new from
6 days ago, concerning for a hematologic malignancy.
Past Medical History:
Hypercholesterolemia ___
Hypertension ___
Prostatism ___
Lentigines
___ damaged skin, chronic
Social History:
___
Family History:
- Father (deceased): Acute Leukemia
- Mother (deceased): dementia
- Sister: healthy
- Children: healthy
Physical Exam:
On Admission:
VSS: 98.1, 163/72, 71, 18, 98%
GEN: NAD
Pain: ___
HEENT: EOMI, MMM, - OP Lesions
PUL: CTA B/L
COR: RRR, S1/S2, - MRG
ABD: NT/ND, +BS, - CVAT
EXT: - CCE
NEURO: CAOx3, Severely ataxic gait (essentially unable to
stand), normal FNF, fundus exam wnl, motor ___
DERM: Morbilliform rash across torso and thighs
On Discharge:
98.0 158/88 53 18 98%RA
General: Caucasian male, seated in chair no acute distress
HEENT: EOMI, PERRL, MMM, no oral lesions
Neck: JVD not elevated
CV: RRR, no MRG
Lungs: CTAB
Abdomen: +BS, soft, mildly distended, non-tender
Ext: no edema
Neuro: end-gaze nystagmus to left, CNII-XII intact, decreased
grip strength on right, ___ finger strengths with extension,
flexion, and abduction on right, sensation preserved throughout
all extremities, gait was not tested given history of
instability
Skin: no rash over arms, legs, and abdomen
Pertinent Results:
On Admission:
___ 11:20AM BLOOD WBC-6.8 RBC-4.11* Hgb-13.0* Hct-39.8*
MCV-97 MCH-31.7 MCHC-32.7 RDW-15.2 Plt ___
___ 11:30AM BLOOD WBC-7.5 RBC-4.07* Hgb-13.1* Hct-39.8*
MCV-98 MCH-32.1* MCHC-32.9 RDW-15.5 Plt ___
___ 11:20AM BLOOD Neuts-61 Bands-2 ___ Monos-11 Eos-1
Baso-0 ___ Metas-1* Myelos-0
___ 11:20AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-NORMAL
Macrocy-1+ Microcy-NORMAL Polychr-OCCASIONAL
___ 11:20AM BLOOD ___ PTT-28.9 ___
___ 11:30AM BLOOD ESR-3
___ 11:20AM BLOOD Glucose-134* UreaN-12 Creat-0.7 Na-129*
K-4.4 Cl-93* HCO3-27 AnGap-13
___ 11:30AM BLOOD Na-131* K-4.1 Cl-91*
___ 11:20AM BLOOD ALT-259* AST-139* AlkPhos-339*
TotBili-1.2
___ 11:30AM BLOOD ALT-302* AST-200* AlkPhos-371*
TotBili-1.3
___ 11:20AM BLOOD Albumin-3.6
___ 11:30AM BLOOD Calcium-8.4 Phos-3.3 Mg-2.3
___ 11:30AM BLOOD PSA-14.2*
___ 02:01PM BLOOD Lactate-1.3
___ 12:40PM URINE Color-Yellow Appear-Clear Sp ___
___ 11:30AM URINE Color-Yellow Appear-Clear Sp ___
___ 12:40PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 11:30AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 12:40PM URINE RBC-<1 WBC-2 Bacteri-FEW Yeast-NONE
Epi-<1
___ 11:30AM URINE RBC-0 WBC-1 Bacteri-NONE Yeast-NONE Epi-0
IMAGING:
CT ABD & PELVIS WITH CONTRAST Study Date of ___
IMPRESSION:
1. Numerous, small hypodensities throughout the liver and
spleen, likely new from 6 days prior accounting for differences
in technique. The most likely diagnosis is an infectious
etiology ___, fungal or pyogenic). Lymphoma/leukemia and
metastases are less likely. Further evaluation should be
performed with MRI. Spleen is normal size but increased from
___.
2. Small, bilateral pleural effusions, unchanged from ___,
and minimal mesenteric edema.
3. 1.5 cm left adrenal nodule, minimally increased from ___, suspicious for either an adenoma or malignant process.
This should be evaluated by MRI as well.
4. Patent portal vein and no ascites
CT ABD & PELVIS WITH CONTRAST ___:
IMPRESSION:
1. Small hypodensities throughout the liver, and two in the
spleen, new since the remote prior study and not detectable on
recent ultrasound. This may indicate that these are also new
since that prior study but potentially these are not visible
sonographically. Differential considerations include
infectious etiologies (such as microabscesses with atypical
organisms) versus malignant nodules. Further evaluation with
MRI may be helpful. Spleen is normal size but increased
somewhat from ___.
2.Small, bilateral pleural effusions, unchanged from ___.
3.1.5 cm left adrenal nodule, minimally increased from ___, so probably an adenoma given minimal change. However, this
should be evaluated by MRI as well.
4.Patent portal vein andno ascites identified.
MR HEAD W & W/O CONTRAST ___
IMPRESSION:
Numerous foci of slightly ill-defined enhancement scattered
throughout the
brain in the cortex, subcortical white matter, and deep gray
nuclei. The
appearance is nonspecific with a broad differential diagnosis
including
infectious (septic embolic), inflammatory, and neoplastic
disease. None of the lesions demonstrate ischemic or
hemorrhagic properties.
Correlate clinically and with labs and consider close followup
to assess
interval change and better characterization.
CT CHEST W/ CONTRAST ___:
No evidence of active intrathoracic infection or malignancy.
Small bilateral pleural effusions
ABDOMINAL US ___:
No lesion identified within the liver. Ultrasound guided
targeted biopsy is not feasible.
MRI TOTAL SPINE W & W/O CONT ___:
IMPRESSION:
1. No evidence of metastatic disease to the cervical, thoracic
or lumbar
spine.
2. Multilevel degenerative changes most prominent in the
cervical and lumbar spine. In the lumbar spine, the changes are
most severe at L4-5 and L5-S1.
BONE MARROW BX ___:
CD45-bright, low side-scatter gated lymphocytes comprise 29% of
total analyzed events.
B cells comprise 5% of lymphoid-gated events, are polyclonal,
and do not express aberrant antigens.
T cells comprise ~80% of lymphoid gated events and express
mature lineage antigens CD3, CD5, CD7 that are all CXB ???
restricted. Approximately 14% of T-cells show loss of CD7.
T-cells co-express ___, represent ~32% of lymphoid gated
events. T-cells have a helper-cytotoxic ratio of 4.87 (usual
range in blood 0.7-3.0).
Natural killer cells are quantitatively normal.
INTERPRETATION
Immunophenotypic findings consistent with involvement by an
expanded population of CD4(+) alpha-beta subtype T-cells without
aberrant express or significant loss of other markers. The
differential diagnosis includes an infection related reactive
process or a lymphoma. Please correlate with corresponding bone
marrow biopsy report and TCR-PCR (pending).
ECHO ___:
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. No
masses or vegetations are seen on the aortic valve. The mitral
valve appears structurally normal with trivial mitral
regurgitation. No mass or vegetation is seen on the mitral
valve. The pulmonary artery systolic pressure could not be
determined. No vegetation/mass is seen on the pulmonic valve.
There is no pericardial effusion.
CXR LINE PLACEMENT ___:
Right PICC line terminates at the cavoatrial junction.
MRI ABD W/ AND W/O CONTRAST ___:
1. Numerous hepatic and splenic cystic lesions largest measuring
9 mm. Given decrease in size and conspicuity of many of these
lesions compared to recent CT as well as presence of left
paraspinal fluid collection, resolving micro abscesses are
favored. Cystic metastases may have a similar appearance, but
are considered less likely.
2. Peripherally enhancing fluid collection in the left
paraspinal musculature measuring 11 x 14 mm (1102:116)
concerning for additional microabscess.
On Discharge:
___ 12:00AM BLOOD WBC-6.4 RBC-3.65* Hgb-11.9* Hct-34.1*
MCV-93 MCH-32.5* MCHC-34.9 RDW-14.1 Plt ___
___ 12:00AM BLOOD Neuts-34* Bands-0 Lymphs-47* Monos-15*
Eos-3 Baso-0 Atyps-1* ___ Myelos-0
___ 12:00AM BLOOD Hypochr-NORMAL Anisocy-OCCASIONAL
Poiklo-OCCASIONAL Macrocy-OCCASIONAL Microcy-NORMAL
Polychr-NORMAL Tear Dr-OCCASIONAL
___ 08:45AM BLOOD ___ PTT-29.7 ___
___ 12:00AM BLOOD Glucose-101* UreaN-17 Creat-0.8 Na-135
K-4.1 Cl-101 HCO3-26 AnGap-12
___ 12:00AM BLOOD ALT-46* AST-24 LD(LDH)-270* AlkPhos-111
TotBili-0.6
TotBili-1.1
___ 12:00AM BLOOD Albumin-3.7 Calcium-8.7 Phos-4.2 Mg-2.1
___ 01:25PM BLOOD Ferritn-1822*
Microbiology:
EBV PCR ___: ___ copies
EBV PCR ___: ___ copies
___ 19:25 ___'s disease by pcr (negative)
___ 19:25 Q-FEVER (___) ANTIBODY
(negative)
___ 19:25 MYCOPLASMA PNEUMONIAE ANTIBODIES (IGG pos,
IGM neg)
___ 08:33 Bartonella ___ IgG/IgM
Antibody Panel (negative)
___ 21:35 ASPERGILLUS GALACTOMANNAN ANTIGEN (negative)
___ 21:35 B-GLUCAN (negative)
___ CSF;SPINAL FLUID GRAM STAIN-NEG; FLUID
CULTURE-NEG
___ IMMUNOLOGY HIV-1 Viral
Load/Ultrasensitive-NEG
___ BLOOD CULTURE Blood Culture, Routine-NEG
___ BLOOD CULTURE Blood Culture, Routine-NEG
___ BLOOD CULTURE Blood Culture, Routine-NEG
___ BLOOD CULTURE Blood Culture, Routine-NEG
___ BLOOD CULTURE Blood Culture, Routine-NEG
___ URINE URINE CULTURE-NEG
Brief Hospital Course:
Mr. ___ is a ___ relatively healthy man who
presented for a recent prior hospitalization with fever, chills,
and malaise and was readmitted with new ataxia and abdominal
distension with new findings of numerous lesions in his brain,
liver, and spleen, likely due to a post viral syndrome after a
critical EBV reactivation infection.
# Ataxia
Neurology evaluation suggested that the cause of his ataxia is
likely due to his numerous brain lesions seen on MRI of the
brain. MRI of the spine showed no significant abnormalities. CSF
studies showed 200 WBC with 60% atypicals with mostly an
abnormal T cell population that is also present in the
peripheral blood. In combination with the liver and spleen
lesions, there was a lot of concern for T cell lymphoma. A bone
marrow biopsy was performed, and there was evidence of clonal
rearrangement of the T cell receptor gamma gene, suggestive of
lymphoma. However, the rearrangement can occasionally be seen in
autoimmune diseases, congenital and acquired immune deficiency
syndromes, and reactive T-cell expansions in blood. Over the
course of the patient's stay, his ataxia had mild improvement,
and his laboratory abnormalities all trended toward normal,
including his Na, fibrinogen, ALT, AST, LDH, AlkPhos, TBili, and
ferritin. Furthermore, his highly elevated EBV viral PCR came
down from over 6,000,000 copies/mL to 3,600,000 copies/mL. Given
that he did not worsening symptoms with no treatment, T cell
lymphoma with CNS involvement seemed unlikely, and intrathecal
methotrexate was held. During his stay, he did receive empiric
ceftriaxone and acyclovir with CNS dosing. All other infectious
work up were negative as well.
# Liver, Spleen, and Paraspinal Lesions / Transaminitis /
Abdominal Distension
On admission, he was found on CT to have multiple new hypodense
lesions in his liver and spleen. The lesions were found to have
interval decrease in size on an abdominal MRI. A new paraspinal
lesion was found on abdominal MRI, which was seen in retrospect
on the previous spine MRI as well. During his course, his
transaminitis and abdominal distension also improved. Initial
infectious work up of fungal, tick-born, and viral illnesses
were all negative except for highly elevated EBV titers. Given
the constellation of findings, it was likely that his abdominal
symptoms were related to the EBV infection mentioned above.
# Hemolytic Anemia
On prior admission, the patient's labs were consistent with an
intravascular hemolytic process with increased bilirubin to 2.5,
elevated LDH to 1183, and decreased haptoglobins to <5. His
anemia stablized during his stay, and all his related laboratory
abnormalities trended toward normal. See above for a discussion
of the likely cause.
# Hyponatremia
The patient had a persistent hyponatremia since the previous
admission. Urine studies from before suggested SIADH, which in
the setting of brain lesions was likely a central process. With
improvement of his other symptoms, his hyponatremia normalized
as well.
TRANSITIONAL ISSUES:
- He was discharged on acyclovir for treatment of elevated EBV
viral load. This may need to be reassessed after discharge based
on his clinical response.
- On CT abdomen, a 1.5 cm nodule was noted in the L adrenal
gland. This may require further evaluation in the outpatient
setting if clinically indicated.
The most likely problem is that the patient has an underlying
immune deficiency and a T cell lymphoproliferative DO the exact
virulence is not known. As there is currently spontaneous
regression it is prudent to fully characterize the D/O prior to
engaging in a treatment plan for the lymphoproliferative DO he
will see Dr. ___ at ___ to assist and consult. The
final plan of care is dependent on that consultation.
Medications on Admission:
Metoprolol Succinate XL 25 mg PO DAILY
Olmesartan 20 mg oral daily
Aspirin 81 mg PO daily
Alfuzosin 10 mg oral daily
Folic acid 1 mg PO DAILY
Acetaminophen 325 mg PO Q6H:PRN fever, pain
Doxycycline Hyclate 100 mg PO Q12H Please take through ___.
Nitrofurantoin 100 mg PO BID for 7 days.
Discharge Medications:
1. alfuzosin 10 mg oral daily
2. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth Every day Disp #*30
Tablet Refills:*0
3. Lidocaine 5% Patch 1 PTCH TD QPM back pain
RX *lidocaine 5 % (700 mg/patch) Place patch to affected area
Once each evening Disp #*15 Patch Refills:*0
4. Metoprolol Succinate XL 25 mg PO DAILY
5. Acetaminophen 325 mg PO Q6H:PRN fever, pain
6. olmesartan 20 mg oral daily
7. Acyclovir 400 mg PO Q8H
RX *acyclovir 400 mg 1 tablet(s) by mouth three times a day Disp
#*90 Tablet Refills:*0
8. Outpatient Occupational Therapy
9. Outpatient Physical Therapy
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
EBV infection
Meningitis possible malignant
T cell lymphoproliferative d/o
Ataxia
Weakness
PRIMARY DIAGNOSIS:
Abdominal and intracranial lesions
Ataxia
PRIMARY DIAGNOSIS:
Abdominal and intracranial lesions
Ataxia
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 being part of your care at ___. You were
admitted to the hospital with weakness, difficulty keeping your
balance and abdominal distention. Scans of your head and abdomen
revealed multiple collections in your head and abdomen. Lumbar
puncture revealed abnormal T cells in the spinal fluid, which
were also noted in the blood. This was concerning for an
infectious, inflammatory or malignant illness. However your
laboratory tests subsequently normalized, and repeat scanning of
your abdomen showed decrease in size of your abdominal
collections. Given your stabilizing clinical status, you were
subsequently discharged with plans for further outpatient workup
of your condition.
After discharge, please be sure to keep your follow-up
appointments (details below).
Followup Instructions:
___
|
19553572-DS-18
| 19,553,572 | 26,471,455 |
DS
| 18 |
2141-12-10 00:00:00
|
2141-12-10 14:19:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Left tibia/fibula fracture
Major Surgical or Invasive Procedure:
Left Tib IM Nail
History of Present Illness:
HPI: ___ who presents s/p fall while mountain biking today. She
went over a log and fell from her bike, and her bike fell on top
of her, twisted her leg and she heard a snap. She presents with
left leg pain and inability to ambulate. No other injuries, no
headstrike, no LOC. She was wearing a helmet.
PMH/PSH: Hypertension, Breast cancer
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have left tibia/fibula fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for left tibia IM nail, which the
patient tolerated well. For full details of the procedure please
see the separately dictated operative report. The patient was
taken from the OR to the PACU in stable condition and after
satisfactory recovery from anesthesia was transferred to the
floor. The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given ___
antibiotics and anticoagulation per routine. The patient's home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to home was
appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
NVI distally in the left lower extremity, and will be discharged
on lovenox for DVT prophylaxis. The patient will follow up with
Dr. ___ routine. A thorough discussion was had with the
patient regarding the diagnosis and expected post-discharge
course including reasons to call the office or return to the
hospital, and all questions were answered. The patient was also
given written instructions concerning precautionary instructions
and the appropriate follow-up care. The patient expressed
readiness for discharge.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Metoprolol Succinate XL 25 mg PO DAILY
2. Furosemide 20 mg PO DAILY
3. Tamoxifen Citrate Dose is Unknown PO BID
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Docusate Sodium 100 mg PO BID
3. Enoxaparin Sodium 40 mg SC QPM
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 40 mg/0.4 mL 40 MG SC QPM Disp #*28 Syringe
Refills:*0
4. Senna 8.6 mg PO BID:PRN constipation
5. Furosemide 20 mg PO DAILY
6. Metoprolol Succinate XL 25 mg PO DAILY
7. Tamoxifen Citrate Dose is Unknown PO BID
8. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth Q4H: PRN Disp #*60
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Left tibia/fibula fracture
Discharge Condition:
Mental Status: AOX3, ambulating with crutches, Overall improved
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 LLE
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take Lovenox 40mg daily for 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.
- No dressing is needed if wound continues to be non-draining.
Followup Instructions:
___
|
19553622-DS-20
| 19,553,622 | 29,690,771 |
DS
| 20 |
2162-06-23 00:00:00
|
2162-06-23 14:33:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
shrimp
Attending: ___.
Chief Complaint:
Polytrauma
Major Surgical or Invasive Procedure:
___ I&D R femur, R tibia; retrograde IM nail R femur, IM nail
R tibia, closed reduction R hip and skeletal traction
___ ORIF L radius, front R acetabulum
___ ORIF R posterior acetabulum
___ IVC filter
___ I&D, partial closure tibial wound. Start WTD
History of Present Illness:
The patient is a ___ y/o M s/p MVC, moped vs car. He was
transferred from OSH to the ___ ED. Imaging revealed multiple
pelvic fractures, closed left diaphyseal radius fracture, and
right midshaft tib/fib fracture. He was taken to the OR, where
he became acidotic and had elevated lactate. He recieved 8L
crystalloids, 2U albumin and 2U PRBC intraoperatively. Total EBL
was 600ml and urine output was about 3L intraop.He was brought
to the ICU for further management
Past Medical History:
HTN/HLD
PSH: oral surgery
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM
Temp: 97.5 HR: 103 BP: 98/53 Resp: 22 O(2)Sat: 100 Normal
Constitutional: Pain with movement
HEENT: Normocephalic, atraumatic, Pupils equal, round and
reactive to light, Extraocular muscles intact, Pupils 2mm
bilaterally, Midface stable, No TTP or stepoffs of mandible,
MMM, Oropharynx within normal limits, No blood in nares
Chest: Clear to auscultation, airways intact, Equal breath
sounds bilaterally, TM's clear
Cardiovascular: Regular Rate and Rhythm, Normal first and second
heart sounds, Palpable radial pulse bilaterally
Abdominal: Soft, Nontender, Nondistended
GU/Flank: No costovertebral angle tenderness
Extr/Back: No tenderness or stepoffs of the spine, No cyanosis,
clubbing or edema
Skin: Abrasion over left thumb, Good capillary refill
bilaterally, Abrasions over left thigh, Deep lacerations on
right knee and thigh with foreign body(glass), Laceration of
left shin with bleeding, No rash, Warm and dry
Neuro: Awake, alert and oriented, CMS intact, Speech fluent
Psych: Normal mentation
DISCHARGE PHYSICAL EXAM
V: 98.4F 96 141/81 18 100% RA
GEN: NAD, AAOx3
LUE: Splint in place; SILT R/M/U +thumbs up +OK sign
LLE: ___ brace in place; SILT DP/SP/S/S; ___ 2+
___, WWP
RLE: Wet-to-dry dsg in wounds; SILT DP/SP/S/S; ___
2+ ___, WWP
Pertinent Results:
Labs on Admission
___ 06:56PM BLOOD WBC-27.6* RBC-4.25* Hgb-13.2* Hct-38.9*
MCV-91 MCH-31.0 MCHC-33.9 RDW-13.1 Plt ___
___ 01:29AM BLOOD WBC-8.9# RBC-3.77* Hgb-11.5* Hct-33.6*
MCV-89 MCH-30.4 MCHC-34.1 RDW-14.4 Plt ___
___ 01:29AM BLOOD Glucose-214* UreaN-12 Creat-0.9 Na-142
K-5.1 Cl-109* HCO3-21* AnGap-17
___ 05:52AM BLOOD Glucose-182* UreaN-13 Creat-0.9 Na-143
K-4.8 Cl-109* HCO3-24 AnGap-15
___ 01:29AM BLOOD ___
___ 08:16AM BLOOD ___
Labs on Discharge:
___ 05:10AM BLOOD WBC-7.6 RBC-3.18* Hgb-9.3* Hct-28.4*
MCV-89 MCH-29.4 MCHC-32.9 RDW-14.1 Plt ___
___ 05:10AM BLOOD Glucose-128* UreaN-6 Creat-0.5 Na-137
K-3.6 Cl-101 HCO3-29 AnGap-11
Imaging:
Please see imaging on separate disk
Brief Hospital Course:
Mr. ___ initially arrived to the ED from an OSH; imaging
revealed multiple pelvic fractures, closed left diaphyseal
radius fracture, and right midshaft tib/fib fracture. He was
taken to the operating room with orthopedics for IM nail R tibia
+ femur and closed reduction of the right hip; for full details
please see the dictated operative note. Post-operatively he was
taken to the trauma ICU for continued monitoring.
On ___, he was extubated in the ICU and his c-spine was cleared
clinically and radiographically. He was off all pressors. He
took small amounts of PO and pain was well controlled. A
tertiary survey was performed and revealed no new injuries. He
was transferred to the ortho trauma team on ___ for continued
management of his numerous fractures. On ___ he was taken to
the OR for ORIF of his L radius, and anterior R acetabulum
fractures. On ___ his RLE wounds were I&D'd in the OR and he
underwent ORIF for his R post acetabular fracture. On ___ he
had an IVC filter placed, and underwent further I&Ds for his RLE
on ___ and ___.
The patient tolerated these procedure without complications and
was transferred to the PACU in stable condition each time.
Please see the individual operative reports for details. Post
operatively pain was controlled with a PCA with a transition to
PO pain meds once tolerating POs. The patient tolerated diet
advancement without difficulty and made steady progress with ___.
The patient was transfused 1 unit of blood on ___ for acute
blood loss anemia.
Weight bearing status:
- NWB LUE in splint
- TDWB RLE
- WBAT LLE with ___ brace in locked position.
The patient received ___ antibiotics as well as
lovenox for DVT prophylaxis. The incision was clean, dry, and
intact without evidence of erythema or drainage; and the
extremity was NVI distally throughout. The patient was
discharged in stable condition with written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient will be continued on chemical DVT
prophylaxis for 2 weeks post-operatively. All questions were
answered prior to discharge and the patient expressed readiness
for discharge.
Medications on Admission:
anti-hypertensives, specifics unknown
remained of medication history undocumented
Discharge Medications:
1. Enoxaparin Sodium 40 mg SC Q24H Duration: 2 Weeks
2. Acetaminophen 650 mg PO Q6H:PRN temp, pain
3. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
RX *tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp
#*90 Tablet Refills:*0
4. Docusate Sodium (Liquid) 100 mg PO BID
5. Senna 1 TAB PO BID constipation
6. Lorazepam 0.5 mg PO Q4H:PRN Anxiety
RX *lorazepam 0.5 mg 1 tablet by mouth every four (4) hours Disp
#*60 Tablet Refills:*0
7. moxifloxacin *NF* 400 mg Oral Q24H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
polytrauma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
******WOUND CARE******
- Do not remove splint before the follow-up appointment, and do
not get it wet.
- Keep left leg ___ brace locked in extension when
standing/weight-bearing. It may be unlocked when laying down.
- Right leg: continue wet-to-dry dressings twice a day.
- You can get wounds wet/take a shower starting from 3 days
post-op. No baths or swimming for at least 4 weeks.
******WEIGHT-BEARING******
- weight-bearing as tolerated right upper extremity
- non-weight-bearing left upper extremity
- touch-down weight-bearing right lower extremity
- weight-bearing as tolerated left lower extremity with ___
brace in locked position
******MEDICATIONS******
- Resume your pre-hospital medications.
- You have been given medication for your pain control. Please
do not operate heavy machinery or drink alcohol when taking this
medication. As your pain improves please decrease the amount of
pain medication. This medication can cause constipation, so you
should drink eight 8-oz glasses of water daily and take a stool
softener (colace) to prevent this side effect.
- Medication refills cannot be written after 12 noon on ___.
******ANTICOAGULATION******
- Take Lovenox for DVT prophylaxis for 2 weeks post-operatively.
Physical Therapy:
******WEIGHT-BEARING******
- weight-bearing as tolerated right upper extremity
- non-weight-bearing left upper extremity
- touch-down weight-bearing right lower extremity
- weight-bearing as tolerated left lower extremity with ___
brace in locked position
___ treatment daily
Treatments Frequency:
Continue wet-to-dry dressings right lower extremity twice daily
Followup Instructions:
___
|
19554206-DS-12
| 19,554,206 | 22,447,214 |
DS
| 12 |
2165-11-17 00:00:00
|
2165-11-18 07:34:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Dilantin / valproic acid
Attending: ___.
Chief Complaint:
abnormal behavior
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year-old RH man with a history of
refractory temporal lobe epilepsy ___ TBI, s/p VNS (___) and
right anterior temporal lobectomy ___ who presents to the ___
with abnormal behavior. Neurology is consulted in the ___ for
further management. History is obtained from the patient, his
sister, and ___.
The patient himself tells me that he has been feeling well since
hospital discharge. He completed his dexamethasone taper 2
weeks
ago. He has been using the Ativan prn prescription, but instead
of taking Ativan for seizure or aura, he was "taking it for
fun."
He has not yet run out and denies taking more than 3 per day (as
per the script). (Importantly, his sister notes that he has had
trouble with benzo abuse in the past. The details were not
discussed in the ___.
Today, the patient was visited by his sister who found him
confused and naked in his bathroom. The patient notes that he
had constipation and was trying to have a bowel movement. His
sister also felt the appartment was messy and describes empty
water bottles in the kitchen and an unusual old kid's toy out.
But in asking the patient, he had found this toy in his closet
and was taking a picture for a friend.
Yesterday, the sister tells me she received a few "non sensical"
texts from the patient. The patient tells me he was trying to
send a text and accidentally pressed translat a few times when
sending this. He remembers doing this, but unclear why he didnt
tell his sister about the error.
Two days ago, in conversation with his cousin, he was talking in
"non-sequetors" and was somewhat tangential. His sister also
noted his conversation was much more tangential.
Apart from taking more ativan that needed, he has been taking
his
medication as instructed (clobazam ___, and Zonegran 300/400).
No recent illnesses, fever, pain or draining at incision site or
alcohol use. Last reported seizure was during his most recent
hospitalization 3 weeks ago for right temporal lobectomy on
___. He has been having trouble regulating his bowels
recently, with more constipation than diarrhea.
At ___, initial vitals 98.1 100 126/74 18 100%. He was
comfortable in bed and relayed the history above.
Regarding his seizure history, seizures started shortly after a
TIB with ___ in ___. He is followed at ___ by Dr. ___ and
is noted to have 3 seizure types:
" 1. Possible simple partial: Lightheadedness, "little head
rush", lasting several seconds. Uses his VNS magnet and
usually
resolves. Started ___.
2. Complex partial: Nocturnal wandering with unresponsiveness,
drooling and facial twitching. Most at night, one daytime
episode with pain in his head on the wall, laughing, looking
confused, and unresponsive. Unclear frequency, as often unaware
of these. Frequency ___ every 3 months.
3. Secondarily generalized tonic-clonic: Nocturnal episodes of
generalized shaking, witnessed by his wife in past; unexplained
tongue biting and urinary incontinence. Daytime, may have brief
lightheadedness, then generalized shaking. At least one every
few
months." After multiple ineffective medication trials and VNS
placement in ___, he ultimately underwent right anterior
lobectomy on ___. Last seizure was 3 weeks ago while
hospitalized for his lobectomy.
ROS: Positive as above and also for constipation and alternating
diarrhea recently. Negative for headache or lightheadedness.
Denies difficulty with producing or comprehending speech. Denies
loss of vision, blurred vision, diplopia, vertigo, tinnitus,
hearing difficulty, dysarthria, or dysphagia. Denies focal
muscle
weakness, numbness, parasthesia. Denies loss of sensation.
Denies
bowel or bladder incontinence or retention. Denies difficulty
with gait. No fevers, rigors, night sweats, or noticeable
weight
loss. Denies chest pain, palpitations, dyspnea, or cough. Denies
nausea, vomiting or abdominal pain. No recent change in bowel
or
bladder habits. Denies dysuria or hematuria. Denies myalgias,
arthralgias, or rash.
Past Medical History:
- Traumatic SDH & coma x12 days s/p craniotomy & evacuation in
___.
- Complex partial and GTC seizures s/p vagus nerve stimulator
VNS: Generator: Model 103, SN ___, implanted ___
- s/p Right anterior temporal lobectomy ___
- Hyperlipidemia
Social History:
___
Family History:
No family history of seizures or neurological disorders.
Physical Exam:
Admission Exam:
Vitals: 98.1 100 126/74 18 100%
General: NAD
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: RRR, no M/R/G
Pulmonary: CTAB, no crackles or wheezes
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema
Neurologic Examination:
Awake, alert, oriented x 3. Able to relate history without
difficulty, but at times there are non sequetors. Attentive,
able
to name ___ backward with one error only. Speech is fluent with
full sentences, intact repetition, and intact verbal
comprehension. Naming intact. No paraphasias. No dysarthria.
Normal prosody. No apraxia. No evidence of hemineglect. No
left-right confusion. Able to follow both midline and
appendicular commands.
- Cranial Nerves - PERRL 2->1.5 brisk. VF full to finger wiggle.
EOMI, no nystagmus. V1-V3 without deficits to light touch
bilaterally. No facial movement asymmetry. Hearing intact to
finger rub bilaterally. Palate elevation symmetric.
SCM/Trapezius strength ___ bilaterally. Tongue midline.
- Motor - Normal bulk and tone. No drift. No tremor or
asterixis.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA Gastroc
L 5 ___ ___ 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5
- Sensory - No deficits to light touch bilaterally.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 tr
R 2 2 2 2 tr
Plantar response flexor bilaterally.
- Coordination - No dysmetria with finger to nose testing and
toe to target bilaterally. Good speed and intact cadence with
rapid alternating movements.
- Gait - Normal initiation. Narrow base. Normal stride length
and
arm swing. Stable without sway. Negative Romberg.
Discharge Exam:
Unchanged except patient no longer says non-sequitors during
exam.
Pertinent Results:
___ CT Head
1. Small (5 mm) residual extra-axial hypodense fluid collection
along the
right frontoparietal convexity, likely a small amount of
residual blood
products.
2. No acute hemorrhage or infarction.
3. Expected postoperative sequela from prior right temporal
craniotomy and lobectomy.
4. No abnormal enhancement following contrast administration.
___ EEG: final reads pending
___ 06:44AM BLOOD WBC-4.9 RBC-3.97* Hgb-11.8* Hct-36.7*
MCV-92 MCH-29.7 MCHC-32.2 RDW-13.3 RDWSD-45.6 Plt ___
___ 04:41PM BLOOD ___ PTT-26.4 ___
___ 06:44AM BLOOD Glucose-91 UreaN-6 Creat-0.9 Na-143 K-3.9
Cl-111* HCO3-18* AnGap-18
___ 06:44AM BLOOD Calcium-9.3 Phos-4.2# Mg-1.9
Brief Hospital Course:
Mr. ___ is a ___ year-old ___ man with a history of refractory
temporal lobe epilepsy secondary to TBI, s/p VNS (___) and
right anterior temporal lobectomy ___ who presented with
abnormal behavior likely due to an ativan overdose (took 10 mg).
He was seizure-free during hospitalization. His mental status
and behaviors returned to baseline. He was evaluated by
psychiatry and was determined not to have any acute psychiatric
needs. Since he has a history of prior benzodiazepine abuse, he
was discharged with instructions only to have a few ativan pills
with him at any time, with the rest of his supply given to his
sister (HCP) for safe-keeping. No changes were made to his AEDs.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 20 mg PO QPM
2. Clobazam 10 mg PO QAM
3. Clobazam 20 mg PO QPM
4. Zonisamide 300 mg PO QAM
5. Zonisamide 400 mg PO QPM
6. Acetaminophen 325-650 mg PO Q4H:PRN fever or pain
7. Lorazepam 1 mg PO Q8H:PRN cluster of seizures
8. Calcium Carbonate 500 mg PO BID
9. Vitamin D 400 UNIT PO BID
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q4H:PRN fever or pain
2. Atorvastatin 20 mg PO QPM
3. Calcium Carbonate 500 mg PO BID
4. Clobazam 10 mg PO QAM
5. Clobazam 20 mg PO QPM
6. Vitamin D 400 UNIT PO BID
7. Zonisamide 300 mg PO QAM
8. Zonisamide 400 mg PO QPM
9. Lorazepam 1 mg PO Q8H:PRN cluster of seizures
Discharge Disposition:
Home
Discharge Diagnosis:
Post-surgical hypomania
Lorazepam toxicity
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted after your family noticed abnormal behaviors.
This is most likely due to your experiencing hypomania related
to your recent epilepsy surgery. You were taking an excess of
Ativan to treat some of the symptoms. You were monitored in the
hospital and have not had any seizures. You are back to your
baseline.
You should not take ativan unless you are having seizures. If
taken in excess, this medication can actually cause seizures.
You should keep only a few pills of ativan with you in case of
seizures, and your sister should keep the rest of the pills, to
minimize any medication mistakes or potential to overdose on
ativan.
Followup Instructions:
___
|
19554213-DS-4
| 19,554,213 | 24,363,578 |
DS
| 4 |
2190-07-16 00:00:00
|
2190-07-16 21:28:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Bee sting
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
___: laparoscopic appendectomy
History of Present Illness:
Mr. ___ is a ___ yo male who presents w/ 1-day history of
abdominal pain severe enough to prevent sleeping. It began as a
periumbilical pain around ___ p.m. Pt denies migration of the
pain overnight. Claims it felt like stomach cramps different
from
the pain he associated w/ his previous cholecystitis and GERD.
Endorses intermittent vomiting throughout the night, along w/
loose stools. Pt denies recent fevers or chills, though
developed
sweats during the night. The pain is mild ___ ___ut
movement causes moderate pain and palpation severe pain. Pt has
only had scattered sips since ___ p.m.
Past Medical History:
hepatitis - ? HAV
Social History:
___
Family History:
Father with h/o gallstones and some sort of subsequent CA from
which he died in his ___. Half-brother who is healthy. ___
descent. No IBD. No autoimmune ds.
Physical Exam:
EXAM: upon admission: ___:
VS - T97.5 HR87 BP130/79 RR19 O2 sat 100% RA
GEN - NAD, lying in bed
HEENT - NCAT, EOMI, no scleral icterus, MMM
___ - RRR
PULM - no increased WOB, CTAB, no w/r/r
ABD - well-healed laparoscopic incisions c/w prior
cholecystecomy. soft, nondistended, moderate to severe TTP in
the
RLQ extending up to the periumbilical area without rebound or
guarding. Equivocal Rovsing's/Obturator signs.
EXTREM - warm, well-perfused; no peripheral edema
Discharge physical exam: ___
VS: 98.2 62 120/68 18 99RA
Gen: NAD, lying in bed
HEENT: nonicteric, EMOI, MMM
Card: S1/S2, RRR
Pulm: no respiratory distress
Abd: soft, mildly distended, nontender, no rebound/guarding,
port incision dressing clean
Ext: warm, well perfused, no cyanosis, no edema
Pertinent Results:
___ 02:30AM BLOOD WBC-17.0*# RBC-4.96 Hgb-15.4 Hct-40.6
MCV-82 MCH-31.1 MCHC-38.0* RDW-13.0 Plt ___
___ 02:30AM BLOOD Neuts-74.2* ___ Monos-4.4 Eos-1.2
Baso-0.2
___ 02:30AM BLOOD Glucose-128* UreaN-17 Creat-0.9 Na-140
K-3.8 Cl-101 HCO3-24 AnGap-19
___ 02:30AM BLOOD ALT-40 AST-26 AlkPhos-61 TotBili-0.3'
___: cat scan of abdomen and pelvis:
Acute appendicitis, with the tip of the appendix dilated to
1.4-cm and
Preliminary Reportperiappendiceal stranding. No evidence of an
adjacent abscess or rupture.
Brief Hospital Course:
The patient was admitted to the hospital with right lower
quadrant abdominal pain and an elevated white blood cell count.
He was made NPO, given intravenous fluids, and underwent
imaging. A cat scan of the abdomen showed acute appendicitis.
Based on these findings, the patient was taken to the operating
room on HD #1 where he underwent a laparoscopic appendectomy.
The operative course was stable with minimal blood loss. The
patient was extubated after the procedure and monitored in the
recovery room. His post-operative course was stable. He was
started on a regular diet. His incisional pain was controlled
with oral analgesia. He was voiding without difficulty. On the
operative day, the patient was discharged home in stable
condition. An appointment for follow-up was made with the acute
care service.
Medications on Admission:
flovent Flovent HFA 110 mcg/actuation aerosol
inhaler. 1 puffs(s) twice a day, albuterol inhaler, prevacid
ProAir HFA 90 mcg/actuation aerosol inhaler. 2 puffs(s) po four
times a day as needed for sob/wheezing - OMEPRAZOLE - omeprazole
20 mg capsule,delayed release. 1 capsule(s) by mouth once a day
for acid reflux
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet(s) by
mouth every 8 hours Disp #*30 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*50 Tablet Refills:*0
3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
may cause dizziness, do no drive while on this medicaiton
RX *oxycodone 5 mg 1 tablet(s) by mouth every 4 hours Disp #*20
Tablet Refills:*0
4. Senna 8.6 mg PO BID:PRN constipation
5. Omeprazole 20 mg PO DAILY
6. Fluticasone Propionate 110mcg 1 PUFF IH BID
7. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
qid
Discharge Disposition:
Home
Discharge Diagnosis:
laparoscopic appendectomy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with abdominal pain. You
underwent cat scan imaging which was suggestive of appendicitis.
You were started on antibiotics and taken to the operating room
to have your appendix removed. You are recovering from your
surgery and you are preparing for discharge home with the
following instructions:
You were admitted to the hospital with acute appendicitis. You
were taken to the operating room and had your appendix removed
laparoscopically. You tolerated the procedure well and are now
being discharged home with the following instructions:
Please follow up at the appointment in clinic listed below. We
also generally recommend that patients follow up with their
primary care provider after having surgery. We have scheduled an
appointment for you listed below.
ACTIVITY:
Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
You may climb stairs.
You may go outside, but avoid traveling long distances until you
see your surgeon at your next visit.
Don't lift more than ___ lbs for ___ weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
You may feel weak or "washed out" a couple weeks. You might want
to nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You could have a poor appetite for a couple days. Food may seem
unappealing.
All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressings you have small plastic bandages
called steristrips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay.
Your incisions may be slightly red around the stitches. This is
normal.
You may gently wash away dried material around your incision.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing or clothes. If the staining is severe, please call
your surgeon.
You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
Constipation is a common side effect of narcotic pain
medicaitons. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
If you go 48 hours without a bowel movement, or have pain moving
the bowels, call your surgeon.
PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your surgeon.
You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. Do not
take it more frequently than prescribed. Do not take more
medicine at one time than prescribed. Do not drink alcohol or
drive while taking narcotic pain medication.
Your pain medicine will work better if you take it before your
pain gets too severe.
Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
Remember to use your "cough pillow" for splinting when you cough
or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
DANGER SIGNS:
Please call your surgeon if you develop:
- worsening abdominal pain
- sharp or severe pain that lasts several hours
- temperature of 101 degrees or higher
- severe diarrhea
- vomiting
- redness around the incision that is spreading
- increased swelling around the incision
- excessive bruising around the incision
- cloudy fluid coming from the wound
- bright red blood or foul smelling discharge coming from the
wound
- an increase in drainage from the wound
Followup Instructions:
___
|
19554256-DS-4
| 19,554,256 | 26,726,367 |
DS
| 4 |
2183-04-24 00:00:00
|
2183-04-25 18:22:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left forearm laceration, suicide attempt
Major Surgical or Invasive Procedure:
___: Left forearm laceration irrigation closure
History of Present Illness:
The patient is a ___ year old gentleman with a history of
depression, EtOH abuse who presents w/ self-inflicted laceration
to LUE volar forearm, now s/p exploration/washout of LUE
laceration.
The patient endorsed not wanting to live any longer and cut his
left wrist at 230 AM ___ after drinking one and a half 750 ml
bottles of liquor. He was given cefazolin and his LUE was washed
out and closed. He was placed on CIWA protocol and given
oxycodone and dilaudid for pain control.
This was his first admission for suicide attempt. He has been
drinking about 12 beers a night for the past ___ years. For the
past month he has been drinking a 750 ml bottle daily. He has
been admitted to ___ rehab in ___ of this year at ___ for etoh withdrawal with hallucinations, vomiting, shakes,
night terrors. He was also admitted to ___ rehab at ___ in ___ for depression.
He currently endorses passive SI, but not active SI. He feels
anxious and diaphoretic. He denies fevers, chills, cough, SOB,
CP, nausea, vomiting, abdominal pain, constipation, diarrhea,
blood in stool, dysuria.
Past Medical History:
Hypertension
Major Depressive Disorder
Anxiety
Social History:
___
Family History:
CAD in father's side, no sudden cardiac death
Hypertension in mother and father's sides
Depression and anxiety on father's side
Physical ___:
ADMISSION:
Vitals: 99.1 PO 133 / 82 R Lying ___ Ra
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: CTAB, no wheezes, rales, or rhonchi
CV: RRR, S1/S2, no m/r/g
Abdomen: soft, NT/ND, BS+, no rebound tenderness or guarding, no
organomegaly
Ext: warm, well perfused, no clubbing, cyanosis or edema, not
tremulous, L forearm bandaged, c/d/I, 2+ pulse, able to move all
muscles in hand, decreased grip strength, sensation intact
Neuro: CN2-12 intact, no focal deficits, 3 beats horizontal
nystagmus
Skin: No rash or lesion, mildly diaphoretic
DISCHARGE:
Vitals: 98.4 138/87 87 18 94 Ra
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: CTAB, no wheezes, rales, or rhonchi
CV: RRR, S1/S2, no m/r/g
Abdomen: soft, NT/ND, BS+, no rebound tenderness or guarding, no
organomegaly
Ext: warm, well perfused, no clubbing, cyanosis or edema, not
tremulous, L forearm bandaged, c/d/I, 2+ pulse, able to move all
muscles in hand, sensation intact
Pertinent Results:
ADMISSION:
___ 06:10AM BLOOD WBC-5.0 RBC-4.43* Hgb-13.3* Hct-40.0
MCV-90 MCH-30.0 MCHC-33.3 RDW-13.2 RDWSD-43.2 Plt ___
___ 06:10AM BLOOD Neuts-51.2 ___ Monos-9.9 Eos-2.4
Baso-1.6* Im ___ AbsNeut-2.54 AbsLymp-1.71 AbsMono-0.49
AbsEos-0.12 AbsBaso-0.08
___ 06:10AM BLOOD ___ PTT-16.6* ___
___ 06:10AM BLOOD ___
___ 12:45PM BLOOD Ret Aut-4.2* Abs Ret-0.14*
___ 06:10AM BLOOD Glucose-155* UreaN-16 Creat-1.0 Na-142
K-4.2 Cl-102 HCO3-21* AnGap-19*
___ 06:58AM BLOOD ALT-30 AST-25 LD(LDH)-130 AlkPhos-38*
TotBili-0.9
___ 06:58AM BLOOD Albumin-3.7 Calcium-8.7 Phos-3.6 Mg-1.9
Iron-147
___ 06:58AM BLOOD calTIBC-272 Ferritn-347 TRF-209
___ 06:10AM BLOOD ASA-NEG ___ Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 06:31AM BLOOD pO2-26* pCO2-47* pH-7.31* calTCO2-25 Base
XS--3
___ 06:31AM BLOOD Glucose-145* Lactate-4.0* Na-140 K-3.8
Cl-105 calHCO3-25
___ 06:31AM BLOOD freeCa-1.06*
IMAGING:
___ Imaging CHEST (PORTABLE AP)
FINDINGS:
The lungs appear clear without focal consolidation. There is no
pulmonary
edema, pneumothorax, or pleural effusion. Incidental note is
made of an
azygos lobe. The cardiomediastinal silhouette and hilar
contours appear
unremarkable.
IMPRESSION:
No acute cardiopulmonary process
DISCHARGE:
___ 01:15PM BLOOD WBC-3.6* RBC-3.03* Hgb-9.1* Hct-27.8*
MCV-92 MCH-30.0 MCHC-32.7 RDW-13.3 RDWSD-44.2 Plt ___
Brief Hospital Course:
Patient summary:
___ year old gentleman with a history of depression, EtOH abuse
who presents w/ self-inflicted laceration to LUE volar forearm,
now s/p exploration/washout of LUE laceration.
Active issues:
#Left upper extremity laceration: Self inflicted stab wound as
part of a suicide attempt. On ___ was irrigated and closed
with staples in the OR. He received 2 days of prophylactic and
biotics with cefazolin. Per report from the surgery team in the
OR there were no signs of active infection, and no deep
structure damage. Staples should be removed at follow-up in 2
weeks postop, around ___.
#Major depressive disorder complicated by suicide attempt:
Was placed under ___, with a one-to-one sitter.
Psychiatry consult recommended inpatient psychiatric treatment
and after medically stable he was transferred to the inpatient
psych unit. He was continued on home venlafaxine
#Alcohol use disorder:
He has been drinking about 12 beers a night for the past ___
years. For the
past month he has been drinking a 750 ml bottle daily. On
admission he had a positive alcohol level, and he did report
withdrawal symptoms in the past. He was placed on a CIWA scale
however he was not scoring in order to receive diazepam. When
it was felt that he was out of the withdrawal window he was
cleared for transfer to the psych unit. He was also placed on
thiamine folate and a multi-vitamin.
Transition issues:
[] Needs forearm staples removed around ___. If still
inpatient, consult ACS for staple removal. If discharged before
then, schedule appointment with ACS around ___ for
staple removal.
[] Is high risk for alcohol relapse, will need support and
follow-up on discharge
[] Please recheck CBC on ___ for stabilization of Hgb/Hct
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Venlafaxine XR 150 mg PO DAILY
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
2. Multivitamins 1 TAB PO DAILY
3. Nicotine Patch 14 mg TD DAILY
4. Thiamine 250 mg PO DAILY
5. Venlafaxine XR 150 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Left upper extremity laceration
Major depressive disorder complicated by suicide attempt
Alcohol used disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted after sustaining a stab wound. The surgeons
wash the wound and closed it in the operating room with staples.
He should have the staples removed in 2 weeks after the
procedure, around ___.
You will go from here to the psychiatric inpatient unit, to help
improve your depression.
It was a pleasure taking care of you,
Your ___ medical team
Followup Instructions:
___
|
19554360-DS-6
| 19,554,360 | 20,903,475 |
DS
| 6 |
2148-02-14 00:00:00
|
2148-02-14 19:06:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest pain and cough
Major Surgical or Invasive Procedure:
Diagnostic and therapeutic thoracentesis ___
History of Present Illness:
Mr. ___ is a ___ y.o lifelong non-smoker who was recently
diagnosed with poorly differentiated Stage IV NSCLC (T3N3M1a)
s/p bronchoscopy/EBUS/TBNA ___ s/p core needle biopsy of
RLL mass ___ who subsequently developed pleuritic
right-sided chest pain, cough, and shortness of breath, and
found to have a new right pleural effusion.
He had a core needle biopsy 9 days prior to admission, and
reports onset of right-sided chest pain, non-productive cough,
shortness of breath, and pleuritic chest pain approximately ___
days afterward. He called into the clinic on ___, and was
referred to the emergency room for further evaluation.
His oncology history is included below. He is being evaluated
for a chemotherapy clinical trial ___ ___
(carboplatin/pemetrexed +/- pembrolizumab), set to begin in a
few weeks. He has been treated for a chronic cough with codeine
and tessalon pearls.
In the ED, initial vital signs were: T 96.3, HR 80, BP 118/74,
RR 18, O2 99% RA
- Exam notable for diminished breath sounds bilaterally (R>L)
- Labs were notable for Hgb 12.5, WBC 6.3, Trop < 0.01, D-dimer
876, Cr 0.6, Na 132, Lactate 1.2, UA negative (Few bact, <1 WBC)
- Patient was given vanc/cefepime/azithromycin and tessalon
pearls, along with mIVF. He was evaluated by oncology.
- Vitals on transfer: T 98.2, HR 75, BP 108/65, RR 19, O2 94%
on NC
Upon arrival to the floor, the patient reported improved chest
pain, but continued shortness of breath. He had a significant
dry cough exacerbated by positional changes and deep breaths.
Review of Systems:
(+) per HPI , (-) otherwise
Past Medical History:
- Hypertension
- Diabetes Mellitus
- Stage IV ___ (see below)
Social History:
___
Family History:
From outpatient oncology note: "Father died from lung cancer in
his ___. He was a heavy tobacco user. Mother died from gastric
cancer in her ___
Physical Exam:
Admission exam:
Vitals- 98.0, 114/68, 75, 20, 95% 4L O2 by NC
GENERAL: AOx3, diaphoretic thin male
HEENT: Normocephalic, atraumatic. PERRL, EOMI, MMM
NECK: Thyroid is normal in size and texture, no nodules. No
cervical lymphadenopathy.
CARDIAC: Regular rhythm, normal rate, no murmurs/rubs/gallops.
No JVD.
LUNGS: Diminished lung sounds at right base, otherwise clear to
auscultation, no wheezes
BACK: Skin. no spinous process tenderness. no CVA tenderness.
ABDOMEN: Normal bowels sounds, non distended, non-tender to
deep palpation in all four quadrants
EXTREMITIES: No clubbing, cyanosis, or edema, 2+ radial pulses
SKIN: No evidence of ulcers, rash or lesions
NEUROLOGIC: CN2-12 intact. ___ strength througout. Normal
sensation
Discharge exam:
Vitals- 98.5, BP 100-113/57-67, HR 84-86, RR 16, O2 94-96% RA
GENERAL: AOx3, diaphoretic thin male
HEENT: Normocephalic, atraumatic. PERRL, EOMI, MMM
NECK: Thyroid is normal in size and texture, no nodules. No
cervical lymphadenopathy.
CARDIAC: Regular rhythm, normal rate, no murmurs/rubs/gallops.
No JVD.
LUNGS: Clear to auscultation, slightly diminished breath sounds
on right base, no wheezes
BACK: Skin. no spinous process tenderness. no CVA tenderness.
ABDOMEN: Normal bowels sounds, non distended, non-tender to
deep palpation in all four quadrants
EXTREMITIES: No clubbing, cyanosis, or edema, 2+ radial pulses
SKIN: No evidence of ulcers, rash or lesions
NEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal
sensation
Pertinent Results:
Admission labs:
___ 09:30PM BLOOD WBC-6.3 RBC-4.24* Hgb-12.5* Hct-38.1*
MCV-90 MCH-29.5 MCHC-32.8 RDW-12.3 RDWSD-39.9 Plt ___
___ 09:30PM BLOOD Neuts-71.5* Lymphs-17.8* Monos-9.1
Eos-0.5* Baso-0.8 Im ___ AbsNeut-4.53 AbsLymp-1.13*
AbsMono-0.58 AbsEos-0.03* AbsBaso-0.05
___ 01:20PM BLOOD ___ PTT-33.0 ___
___ 09:30PM BLOOD Glucose-143* UreaN-23* Creat-0.6 Na-132*
K-4.4 Cl-98 HCO3-24 AnGap-14
___ 06:54AM BLOOD LD(LDH)-143
___ 01:20PM BLOOD Calcium-8.3* Phos-3.3 Mg-2.0
Discharge labs:
___ 07:50AM BLOOD WBC-6.7 RBC-4.57* Hgb-13.5* Hct-41.2
MCV-90 MCH-29.5 MCHC-32.8 RDW-12.3 RDWSD-40.3 Plt ___
___ 08:05AM BLOOD ___ PTT-32.2 ___
___ 07:50AM BLOOD Glucose-137* UreaN-10 Creat-0.6 Na-137
K-4.2 Cl-99 HCO3-26 AnGap-16
___ 08:05AM BLOOD Calcium-8.4 Phos-3.7 Mg-2.1
Fluid studies:
___ 03:04PM PLEURAL WBC-___* ___ Polys-4*
Lymphs-40* ___ Meso-25* Macro-28* Other-3*
___ 03:04PM PLEURAL TotProt-2.9 Glucose-152 LD(LDH)-173
Albumin-1.7 Cholest-46 ___ Misc-BODY FLUID
___ 3:04 pm 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..
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
Imaging:
CXR ___:
Interval development of a right pleural effusion, moderate in
size. Small left pleural effusion with left basal ground-glass
opacity concerning for atelectasis versus pneumonia.
CTA Chest ___:
1. No evidence of pulmonary embolus.
2. Interlobular septal thickening, bilateral pleural effusions,
and
peribronchial opacity consistent with a component of edema.
Cannot exclude lymphangitic spread of disease.
3. Bilateral, peripheral, peribronchovascular opacities, while
could
partially be explained by edema, likely represent a component of
infection.
CXR ___:
1. Status post removal of right pigtail catheter improved small
bilateral
pleural effusions, with possible loculation on the right.
Persistent small
right apical pneumothorax.
2. Persistent bilateral lower lobe opacities suggest
atelectasis, less likely
pneumonia.
3. Mild central vascular congestion with increased interstitial
markings could
reflect mild interstitial pulmonary edema.
Cytology:
___ Pleural fluid:
Pleural fluid, right:
POSITIVE FOR MALIGNANT CELLS.
- Malignant epithelioid neoplasm with angiogenic di
fferentiation, see Note.
- Immunohistochemical stains show the following pro
file in tumor cells:
Positive: CD31, WT-1 (focal, cytoplasmic), Cyto
keratin cocktail (AE1/AE3 & Cam5.2, weak/patchy)
Negative: TTF-1
Note:
In total, the findings are consistent with a malig
nant neoplasm of angiogenic lineage, the
differential diagnosis includes an EPITHELIOID HEMA
NGIOENDOTHELIOMA or EPITHELIOID
ANGIOSARCOMA. The tumor cells in this specimen are
morphologically similar to those present in
the prior lung core biopsy ___ refer to t
hat report for further characterization including a
more comprehensive immunohistochemical staining pro
file. The prepared cell block for this
specimen has high tumor cellularity.
Brief Hospital Course:
Mr. ___ is a ___ y/o male lifelong non-smoker who was recently
diagnosed with poorly differentiated Stage IV NSCLC (T3N3M1a)
s/p bronchoscopy/EBUS/TBNA ___ s/p core needle biopsy of
RLL mass ___ who subsequently developed pleuritic
right-sided chest pain, cough, and shortness of breath, and
found to have a new malignant right pleural effusion, s/p right
___ (1.8L drained) w/chest tube placement now removed w/o
significant reaccumulation.
# Right malignant pleural effusion:
Symptoms included pleuritic chest pain, cough, and dyspnea on
exertion. On exam, diminished breath sounds more notable on
right side, and CXR demonstrating a right sided pleural
effusion, with cytology confirming the presence of malignant
cells. Briefly started on antibiotics, which were discontinued
as paitent was afebrile with no leukocytosis. IP was consulted
and performed a thoracentesis (drained 1.8L), subsequently
placed a chest tube which has since been removed. Pleural fluid
studies reveal exudative effusion by two-test rule and
three-test rule (cholesterol > 45). Discharged off supplemental
O2 at rest and with ambulation. Continued home tessalon pearls,
codeine prn for cough.
- If he develops fevers or other signs of infection, would
maintain a low threshold to treat for post-obstructive pneumonia
given CT findings
# ___: First noticed symptoms in ___. Now s/p core
needle biopsy. Poorly differentiated and stage IV. Fortunately,
MRI brain and bone scan negative. Follows with outpatient
oncology (Dr. ___. Recently consented for ___ trial of
carboplatin/pemetrexed plus or minus pembro. Received B12
injection in anticipation of pemetrexed ___.
# Hypertension: Stable
# Diabetes: Metformin held while inpatient, restarted on
discharge.
#Code Status: FULL confirmed
#Emergency Contact/HCP: (C), ___ (DAUGHTER, ___
___ issues:
- F/up with Interventional Pulmonary as scheduled on ___
- F/up with Dr. ___ as scheduled on ___
- Please change the dressing every day for ___ days or until
incision is clean and dry
- New medications: Zofran prn nausea
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Benzonatate 100 mg PO BID:PRN cough
2. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough
3. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
4. FoLIC Acid 1 mg PO DAILY
Discharge Medications:
1. Ondansetron 8 mg PO Q8H:PRN nausea
RX *ondansetron 8 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*21 Tablet Refills:*0
2. Benzonatate 100 mg PO BID:PRN cough
3. FoLIC Acid 1 mg PO DAILY
4. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough
5. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Right exudative (probable malignant) pleural effusion
Secondary diagnosis:
Stage IV Non-small cell lung cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted for a pleural effusion (fluid collection in
your chest) that was likely caused by your lung cancer. Our
Interventional Pulmonary team removed the fluid. You briefly had
a chest tube to drain excess fluid, and the chest tube was
subsequently removed. Once you leave, please continue taking all
of your home medications. If you develop any worsening chest
pain or shortness of breath, please see a doctor urgently.
It was a pleasure to take care of you. We wish you all the best.
Sincerely,
Your ___ team
Followup Instructions:
___
|
19554830-DS-6
| 19,554,830 | 25,865,129 |
DS
| 6 |
2208-08-18 00:00:00
|
2208-08-20 17:38:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Percodan
Attending: ___
Chief Complaint:
left facial droop
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a ___ year old woman with past medical hx of HTN, DM,
neuropathy, anxiety, depression, migraine and vertigo who
presents with right facial numbness and left facial droop.
Briefly, pt was in her usual state of health until 8 am
yesterday morning when she noticed right facial numbness while
walking to her mothers house. She said it came on pretty
acutely. She attributed it to the cold and did not think much of
it. Then at 3 pm while back at her house she looked in the
mirror and noticed that her lower face was drooped. She tried to
drink something but it came out of the left side of her mouth.
She then went to bed and when the following morning she still
had these symptom she called her PCP who recommended going to
the ED. She denies any other foal weakness, parasthesia,
difficulty talking or walking.
Of note, pt also endorses a 3 week hx of dull headache. This is
nothing new for her as she gets mild headaches and migraines all
the time. She did not think much of it. However, last night she
said she woke up with a severe posterior headache R>L. Headache
is not associated with photo and phonophobia, no nausea or
emesis, no visual symptoms. She said it feels pretty much like
her usual headache just more severe. Currently her headache is
___. She on HA pxx with propranolol and takes aleve for acute
HA.
No recent fever, illness, travel.
Past Medical History:
Hypertension
Diabetes
Neuropathy
Hyperlipidemia
Migraines
Vertigo
Social History:
___
Family History:
2 brothers with aneurysms. 1 of them passed away due to the
aneurysm
Physical Exam:
PHYSICAL EXAM ON DISCHARGE
MS - Alert, oriented to place, situation, able to provide a
detailed history. Attentive to exam.
CN - Left facial droop - decreased activation on the smile. Weak
eye closure and delayed blink. Decreased activation of left
frontalis. Hyperaccusis on the left. Corneals were checked
bilaterally and were present but with decreased/slowed eye
closure on the left secondary to facial weakness. PERRL - but
with cataract and sluggish - 2.5 to 2mm bilaterally. No RAPD.
Facial sensation intact to light touch and PP in V1-V3. Slightly
dysarthric from the facial droop - no lingual dysarthria. Strong
shoulder shrug and head turn.
Motor - No pronator drift. ___ in b/l deltoid, bicep, tricep,
IP, Hamstring, Quad, TA.
Sensory - facial sensation as above. No other sensation deficits
to light touch and pinprick in her extremities.
Reflexes - 2+ b/l patella, biceps. Plantar flexion responses.
Coordination: No intention tremor. No dysmetria on FNF
bilaterally.
Pertinent Results:
Labs on admission
___ 09:50AM BLOOD WBC-9.5 RBC-4.26 Hgb-13.1 Hct-39.4 MCV-93
MCH-30.8 MCHC-33.2 RDW-12.0 RDWSD-40.8 Plt ___
___ 09:50AM BLOOD Neuts-56.6 ___ Monos-8.4 Eos-1.7
Baso-0.9 Im ___ AbsNeut-5.36 AbsLymp-3.05 AbsMono-0.80
AbsEos-0.16 AbsBaso-0.09*
___ 11:09AM BLOOD ___ PTT-32.8 ___
___ 09:50AM BLOOD Plt ___
___ 09:50AM BLOOD Glucose-229* UreaN-7 Creat-0.5 Na-133*
K-4.1 Cl-96 HCO3-25 AnGap-12
___ 09:50AM BLOOD ALT-7 AST-12 AlkPhos-64 TotBili-0.4
___ 09:50AM BLOOD cTropnT-0.05*
___ 09:50AM BLOOD Albumin-4.4 Calcium-9.3 Phos-3.5 Mg-1.7
Cholest-239*
___ 12:38PM BLOOD %HbA1c-8.8* eAG-206*
___ 09:50AM BLOOD Triglyc-115 HDL-68 CHOL/HD-3.5
LDLcalc-148*
___ 09:50AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 01:30PM URINE Hours-RANDOM
___ 01:30PM URINE Uhold-HOLD
___ 01:30PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
Brief Hospital Course:
___ with multiple vascular risk factors presents with sudden
left facial weakness. Neurologic exam significant for left upper
and lower facial weakness - involving the forehead, eye closure,
smile. Hyperaccusis on the left was present. Corneals were
checked bilaterally and were present but with decreased/slowed
eye closure on the left secondary to facial weakness. Sensation
was symmetric to light touch and pinprick on her face. Pupils
equal and reactive though sluggish and with cataracts
bilaterally. Otherwise, neurologic exam was normal.
While her exam was most consistent with a peripheral ___ nerve
palsy, she had a right basal ganglia hypodensity on her CT scan
with multiple vascular risk factors. In addition there were
symmetric posterior periventricular hypo densities which were
somewhat worse compared to the only other hCT in the system from
___. Thus, there seems to be progressive white matter disease
(most likely related to poor control of vascular risk factors).
We recommended brain MRI to evaluate for this but she left
against medical advice before this could be performed. Therefore
she was not started on treatment for Bell's Palsy. She also did
not receive standard workup for Bells Palsy including Lyme
testing.
There was originally some concern that she might have right
facial sensory deficit but on our evaluation, she had symmetric
light touch and pinprick - instead feeling that the sensation on
the left was altered/with slight tingling but ultimately intact.
Therefore, she felt is was possible that she just had somewhat
asymmetric sensation and misinterpreted the sensation on the
right as being off.
Patient was counseled on the possibility that her left facial
weakness could represent a stroke and the increased risk of
recurrent stroke in the acute period during which she would
usually be monitored. She understood that we recommended further
workup for the hypodensities on her head CT. She also was
counseled on the risk of worsening weakness from Bell's Palsy
without treatment. Understanding the risks of leaving the
hospital, she decided to leave against medical advice. Follow up
with Neurology was recommended.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Lisinopril 40 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. ___ is Unknown PO DAILY
4. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using UNK Insulin
5. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using REG Insulin
2. Propranolol ___ unknown PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Lisinopril 40 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Left facial weakness
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with left facial weakness and possible right
facial sensory change. On your exam, you only had left facial
weakness. We wanted to get a Brain MRI to rule out a stroke
given a finding on your head CT. However, you decided to leave
AMA. Therefore, because we were unable to rule out a central
process, we did not start the treatment for Bell's Palsy. The
potential risks of recurrent stroke, worsening left facial
weakness without treatment for Bell's Palsy were discussed with
the patient and she acknowledged the risks before leaving
against medical advice.
Followup Instructions:
___
|
19554899-DS-21
| 19,554,899 | 21,895,367 |
DS
| 21 |
2195-09-29 00:00:00
|
2195-09-30 14:48:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Aspirin / Bactrim DS / Diovan / Lisinopril
Attending: ___.
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ yo ___ speaking female with history of
hypertension, COPD/asthma who presents with several days of
shortness of breath, worsening today in setting of sudden
accidental death of son.
Pt reports that she has been out of her proair, flovent, ?
spiriva for many days, possibly as long as 1 month. Over the
past few days, she has been increasingly short of breath with
wheezing, mild non productive cough. She denies any fevers or
chest pain. Her son died tragically today in a motor vehicle
accident which caused acute worsening of her symptoms.
In the ED, initial VS were: 126 164/76 22 97%. She received
methylpred 125 mg IV x 1, albuterol and ipratropium nebs x4 with
some improvement in her symptoms. No peak flow was measured. Her
chest xray was negative for any acute processes. Vitals on
transfer: 98.9 104 159/72 18 95%,
On arrival to the floor, pt reports some shortness of breath but
improved from presentation. She is not able to provide much
history because she is very upset.
Past Medical History:
- Hypertension
- Asthma/COPD: FEV1 37%
- Osteopenia
- GERD
- Uterine tumor removed ___ years ago at ___
- Hysterectomy
- Neurocysticercosis
- laparoscopic cholecystectomy with drain.
- Brain surgery for ?tumor
Social History:
___
Family History:
Positive for asthma and hypertension.
Physical Exam:
ADMISSION:
VS - Temp 98.3 F, 180/80 BP , 106 HR , 18 R , O2-sat 96% RA
GENERAL - elderly woman resting comfortably, tearful,
appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric but with injected
conjunctiva, MMM, OP clear
NECK - supple, no thyromegaly
LUNGS - Diffuse expiratory wheezing, decent air movement, resp
unlabored, no accessory muscle use
HEART - tachy to 90-100s, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout
DISCHARGE:
Vitals: afebrile 98.7 140-160/70-80 HR ___ sat 94-97% on RA
Gen: NAD
Neck: supple
HEENT: oropharynx clear, moist mucosa
Pulm: minimal exp wheezes, improved air movement
CV: NR, RR, no murmurs
Abd: mild abd distention but not firm, nontender
Ext: 1+ pitting edema
Neuro: A&O, no gross deficits
Pertinent Results:
___ 03:00PM BLOOD WBC-12.7* RBC-5.20 Hgb-13.6 Hct-42.6
MCV-82 MCH-26.1* MCHC-31.8 RDW-14.4 Plt ___
___ 07:20AM BLOOD WBC-12.7* RBC-5.31 Hgb-13.8 Hct-43.9
MCV-83 MCH-25.9* MCHC-31.3 RDW-14.9 Plt ___
___ 03:00PM BLOOD Glucose-120* UreaN-10 Creat-0.6 Na-138
K-3.5 Cl-96 HCO3-30 AnGap-16
___ 07:20AM BLOOD Glucose-86 UreaN-17 Creat-0.6 Na-143
K-3.5 Cl-100 HCO3-35* AnGap-12
___ 07:20AM BLOOD Calcium-8.9 Phos-2.7 Mg-2.1
___ CXR PA/Lat: The cardiac silhouette size is top normal,
unchanged. Prominent epicardial fat pad is again noted.
Mediastinal and hilar contours are stable, with minimal
tortuosity of the thoracic aorta again noted. Pulmonary
vascularity is normal. Lungs remain hyperinflated, with
unchanged mild thickening of the minor fissure. No focal
consolidation, pleural effusion or pneumothorax is detected.
There are mild degenerative changes in the thoracic spine.
IMPRESSION: No acute cardiopulmonary abnormality.
EKG #1: ___: Baseline artifact. Probable sinus tachycardia.
Non-diagnostic Q waves in the inferior leds. ST-T wave
abnormalities can be considered. Since the previous tracing of
___ the rate is faster.
EKG #2: ___: Sinus tachycardia. Since the previous tracing
the rate is slower. ST-T waves are probably improved.
Brief Hospital Course:
Ms. ___ is a ___ yo ___-speaking female with COPD, HTN, and
recent traumatic loss of son who presented with new productive
cough and shortness of breath most likely due to COPD
exacerbation.
# COPD Exacerbation: Most likely COPD exacerbation givne
patient's new sputum, leukocytosis, dyspnea, and hyperinflation
on CXR. Patient denied COPD hx, however is on multiple COPD meds
at home. Patient does have impaired LV relaxation on ___
echo, and CXR appears may have some vascular prominince.
Pulmonary embolism considered but less likely.
-given 1 dose IV lasix 10mg IV on day 1
-prednisone 60mg po daily x5 followed by 6 day taper
(40,40,20,20,10,10)ending ___
-received ___zithromycin (day 1 = ___
-continue albuterol standing for 3 days after d/c then will be
PRN
-continue home Tiotropium
-continue home Advair
# HTN
-continued home clonidine
-continued home hydralazine
-continued home HCTZ
# Psychosocial: Son was killed walking to work on night of
admission after she filed a missing person's report.
-social work consulted
# CONTACT: ___ (son) ___, ___ (son) ___
## TRANSITIONAL ISSUES:
-follow up with PCP ___
-will finish prednisone 6 day taper (40,40,20,20,10,10) ending
___ for 11 day total course
-3 days of standing albuterol nebs at home
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ProAir HFA *NF* (albuterol sulfate) 90 mcg/actuation
Inhalation q 4 hr prn shortness of breath
2. CloniDINE 0.2 mg PO BID
3. Fluticasone Propionate 110mcg 2 PUFF IH BID
4. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
5. Tiotropium Bromide 1 CAP IH DAILY
6. HydrALAzine 10 mg PO Q8H
7. Omeprazole 20 mg PO DAILY
8. Hydrochlorothiazide 12.5 mg PO DAILY
Discharge Medications:
1. CloniDINE 0.2 mg PO BID
2. Omeprazole 20 mg PO DAILY
3. HydrALAzine 10 mg PO Q8H
4. Hydrochlorothiazide 12.5 mg PO DAILY
5. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
RX *fluticasone-salmeterol [Advair Diskus] 500 mcg-50 mcg/Dose 1
puff inh twice per day Disp #*1 Inhaler Refills:*0
6. ProAir HFA *NF* (albuterol sulfate) 90 mcg/actuation
Inhalation q 4 hr prn shortness of breath
RX *albuterol sulfate 90 mcg 1 puff(s) every four hours as
needed Disp #*1 Inhaler Refills:*0
7. Tiotropium Bromide 1 CAP IH DAILY
RX *tiotropium bromide [Spiriva with HandiHaler] 18 mcg 1 puff
once daily Disp #*1 Capsule Refills:*0
8. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheezing/SOB
RX *albuterol sulfate 2.5 mg/3 mL (0.083 %) 1 neb inh every four
hours as needed Disp #*3 Cartridge Refills:*0
9. PredniSONE Taper(6 days) 40mg,40mg,20mg,20mg,10mg,10mg ending
___
10. Lorazepam 0.25 mg PO HS
RX *lorazepam 0.5 mg one half tablet by mouth at night as needed
Disp #*2 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
COPD exacerbation
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 while you were hospitalized
at ___. You were admitted because you were having shortness
of breath, and there was concern that this was an exacerbation
of your COPD. You were started on steroids and antibiotics.
Please follow up with your outpatient providers, as outlined
below.
Followup Instructions:
___
|
19554899-DS-23
| 19,554,899 | 25,580,002 |
DS
| 23 |
2196-05-04 00:00:00
|
2196-05-04 17:07:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Aspirin / Bactrim DS / Diovan / Lisinopril
Attending: ___.
Chief Complaint:
SOB
Reason for MICU transfer: frequent nebulizer treatments
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ ___ speaking female with history of hypertension,
severe COPD with recent admissions ___ and ___, presents with
"not feeling well" for the last 2 days. She has had a cough
that's been productive of yellow sputum. Afebrile. Positive
chills. Patient states once she started not feeling well she's
been having increasing shortness of breath and wheezing. Patient
complained of pain when she coughs but otherwise no chest pain,
which is also reproducible to palpation over the anterior chest
wall. Patient denies lower extremity edema. The patient states
this feels similar to her prior COPD exacerbations. Patient
tried using her nebulizer machine at home without improvement
and came in this evening because she could not sleep because she
was short of breath. No sick contacts at home.
ED Course (labs, imaging, interventions, consults):
Patient given 4 rounds of nebulizer treatments as well as
steroids and azithromycin. Chest x-ray was felt to show right
lower lobe pneumonia so was covered with IV ceftriaxone. She
originally with peak flow of 50. After 3 rounds of meds patient
peak flow to 200. Per report, the patient required nebulizers
greater than q2 hours for tachypnea and so would necessitate
MICU transfer.
On arrival to the MICU, she has no complaints.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
# HTN
# Asthma/COPD for ___ years: multiple hospitalizations
- PFT (___): FEV1 0.66 (41%), FVC 1.44 (70%), FEV/FVC 75%
- revesible effect with bronchodilators >12% increase on
___
# mild dCHF
- Echo (___): EF 70%, no LVMA, no LAE, E/A 0.9, E
deceleration (267 ms), TR 30
# Osteopenia
# GERD
# neurocysticercosis
# brain surgery for ? tumor
# Uterine tumor s/p Hysterectomy ___ years ago at ___
# laparoscopic cholecystectomy
Social History:
___
Family History:
Positive for asthma and hypertension.
Physical Exam:
Admission Physical Exam:
Vitals: afebrile, 117, 167/84, 20, 95%2LNC
General: Well appearing female in no acute distress
HEENT: Mucous membs moist,
Neck: JVP non elevated
CV: S1/S2 Regular tachycardia, no murmurs/gallops appreciated
Lungs: Diffuse expiratory wheeze throughout, reduced air
movement bilaterally
Abdomen: Soft, nontender, normoactive bowel sounds
Ext: Warm no peripheral edema peripheral pulses 2+ ___
Neuro: grossly intact
Pertinent Results:
# CXR (___): Chest, portable AP upright. The lungs are
hyperinflated. However, there is no airspace consolidation.
There is no pneumothorax or pleural effusion. Several
eventrations of the diaphragm are unchanged. The hilar and
mediastinal contours are normal. The pulmonary vascularity is
normal.
Brief Hospital Course:
___ hx severe COPD and HTN who presents with 2d of cough and
shortness of breath consistent with a COPD exacerbation.
#COPD exacerbation: Patient initially required frequent
nebulizer treatments in the ED and was admitted to the ICU. By
the time she was in the ICU, she was not in distress. She was
started on treatment of COPD with prednisone 60mg and
azithromycin 500mg x1 then 250mg daily along with frequent
nebulized treatments. CXR showed no focal infiltrate. She was
transfered to the floor the following day.
She had complaints of sore throat on admission with
cough/secretions - possibly consistent with viral URI. Other
potential exacerbating factors are possibly allergies (during
this time of the season), postnasal gtt, and GERD symptoms. She
has a baseline severe COPD/Chronic asthma with PFT FEV1 0.66
(41%) and reversal airway component (>12% increase in FEV1, FVC
with bronchodilators), so I felt that along with the usual COPD
treatments, the reactive airway component (and any exacerbating
factors) should also be treated aggressively.
She was treated with duonebs ATC and then PRN, advair,
azithro, singulair, and prednisone. Afrin was given PRN for
postnasal gtt, prilosec increased to 40 mg BID for likely GERD
component. She had an allergic reaction to cetirizine and thus
an allergy medication was not initiated during this stay.
Zyrtec may be considered as an outpt.
She was also given codeine for cough suppression as this
might be precipitating bronchospasm. He was then transitioned
to her home spiriva and weaned of oxygen.
She was able to ambulate (with walker) and keep O2 sats above
90%. She was cleared by ___ to go home (with home ___. She was
recommended to follow with her PCP in the following ___ weeks.
# HTN: mildly hypertensive during this hospitalization (SBP
160). She was continued on clonidine, hydralazine. HCTZ was
increased to 25 mg daily.
# FEN: diet, replete electrolytes
# Prophylaxis:
- DVT: pneumoboots, heparin BID
- GI: omeprazole
# Access: PIVs
# Communication: son ___ ___, son ___ ___,
or ___ ___
# Code: DNR/DNI
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheezing/SOB
2. CloniDINE 0.2 mg PO BID
3. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
4. HydrALAzine 10 mg PO Q8H
5. Hydrochlorothiazide 12.5 mg PO DAILY
6. Lorazepam 0.25 mg PO HS
7. Omeprazole 20 mg PO DAILY
8. ProAir HFA *NF* (albuterol sulfate) 90 mcg/actuation
Inhalation q 4 hr prn shortness of breath
9. Tiotropium Bromide 1 CAP IH DAILY
10. Nystatin Oral Suspension 5 mL PO QID
for thrush
11. Fluticasone Propionate 110mcg 2 PUFF IH BID
12. Montelukast Sodium 10 mg PO DAILY
13. Cetirizine *NF* 10 mg Oral qd
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheezing/SOB
RX *albuterol sulfate 2.5 mg/3 mL (0.083 %) 3 mL NEB Q4hours
Disp #*30 Vial Refills:*0
2. CloniDINE 0.2 mg PO BID
3. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
4. HydrALAzine 10 mg PO Q8H
5. Hydrochlorothiazide 25 mg PO DAILY
RX *hydrochlorothiazide 25 mg 1 tablet(s) by mouth Daily Disp
#*30 Tablet Refills:*0
6. Lorazepam 0.25 mg PO HS
7. Montelukast Sodium 10 mg PO DAILY
8. Nystatin Oral Suspension 5 mL PO QID
9. Omeprazole 40 mg PO BID
RX *omeprazole 40 mg 1 capsule,delayed ___ by
mouth twice a day Disp #*60 Capsule Refills:*0
10. Tiotropium Bromide 1 CAP IH DAILY
11. Azithromycin 250 mg PO Q24H
RX *azithromycin [Zithromax] 250 mg 1 tablet(s) by mouth Daily
Disp #*2 Tablet Refills:*0
12. Benzonatate 100 mg PO TID:PRN cough
13. Guaifenesin-CODEINE Phosphate 10 mL PO Q6H:PRN cough
RX *codeine-guaifenesin 100 mg-10 mg/5 mL 10 mL by mouth Q6
hours Disp #*1 Bottle Refills:*0
14. Oxymetazoline 1 SPRY NU BID:PRN nasal congestion Duration: 3
Days
15. PredniSONE 40 mg PO DAILY Duration: 14 Days
RX *prednisone 20 mg 2 tablet(s) by mouth Daily Disp #*14 Tablet
Refills:*0
16. ProAir HFA *NF* (albuterol sulfate) 90 mcg/actuation
Inhalation q 4 hr prn shortness of breath
17. Respiratory
Nebulizer for severe COPD/asthma
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
- Asthma/COPD exacerbation
- Viral URI
- GERD
- postnasal drip
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
It was a pleasure looking after you Ms. ___. As you know, you
were admitted for shortness of breath consistent with worsening
asthma. You were given multiple treatments in the intensive
care unit and this was continued on the regular medicine floors.
A chest x-ray here showed no evidence of pneumonia.
We believe that the asthma exacerbation was likely due to a
number of factors: possible a cold (viral infection), allergy,
and acid reflux. You are given medications to assist with
improving your breathing. Please be sure that your house does
not have any mold (during this summer months) that can possibly
worsen your breathing. Also avoiding places with a lot of
smoking would also help.
Please continue to take your medications except for the
following changes:
- STOP the fluticasone (Flovent)
- INCREASE the hydrochlorthiazide to 25 mg Daily (from 12.5 mg
daily)
- INCREASE the omeprazole to 40 mg twice a day (from 20 mg
daily)
- START albuterol nebulizer treatments as needed for shortness
of breath
These medications are to be used for the short-term, temporarily
after this hospitalization
- Azithromycin for 2 additional days
- Prednisone for 7 additional days
- Guaifenesin/Codeine as needed for cough
- Benzonatate as needed for cough
Followup Instructions:
___
|
19554899-DS-26
| 19,554,899 | 27,728,267 |
DS
| 26 |
2198-09-25 00:00:00
|
2198-09-25 19:25:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Aspirin / Bactrim DS / Diovan / Lisinopril / sulfur dioxide
Attending: ___.
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ F with PMH HTN, COPD, asthma (no prior hx
intubation) who presents with c/o dyspnea and palpitations.
Following history is obtained from ___ translator at
bedside. Patient notes that she has had intermittent
palpitations and left sided neck pain for the last 3 days. Early
this morning, she suddenly felt associated palpitations with
dyspnea at which time she felt she was going to "pass out and
die." She notes she also felt weak and dizzy. Symptoms are
consistent with prior asthma exacerbations. She also states she
has had associated cough productive of white thick phlegm. She
has been using her albuterol inhaler only once a day.
In the ED, initial vitals were:
21:40 0 98.4 110 169/71 16 97% RA
- Labs were significant for D-dimer 700*, trop<0.01, proBNP 123,
wbc 10.8, negative u/a, and negative flu swab.
- Imaging revealed CTA with no PE but with mild centrilobular
emphysema
- EKG showed sinus tachy qrs 90 and qtc 430
- The patient was given 500ccc NS, 500mg azithro, Alb/ipra neb X
2, 2gm mag sulfate, 125mg IV methylprednisolone (___)
with minimal improvement.
Vitals prior to transfer were:
Today 04:46 0 98.1 101 162/64 22 93% RA
Upon arrival to the floor, patient notes her breathing has
remarkably improved. She does become tearful during the
interview stating that today is death anniversary of one of her
son's. She does not know her baseline peak flow.
Past Medical History:
# HTN
# Asthma/COPD for ___ years: multiple hospitalizations
- PFT (___): FEV1 0.66 (41%), FVC 1.44 (70%), FEV/FVC 75%
- revesible effect with bronchodilators >12% increase on
___
# mild dCHF
- Echo (___): EF 70%, no LVMA, no LAE, E/A 0.9, E
deceleration (267 ms), TR 30
# Osteopenia
# GERD
# neurocysticercosis
# brain surgery for ? tumor
# Uterine tumor s/p Hysterectomy ___ years ago at ___
# laparoscopic cholecystectomy
Social History:
___
Family History:
Positive for asthma and hypertension.
Physical Exam:
On admission:
Vitals: T98.3 159/72 104 20 93%RA 92kg
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry MM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: regular, tachycardic, no m/r/g
Lungs: expiratory wheezing throughout
Abdomen: obese, soft, nondistended, nontender
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, gait deferred.
On discharge:
Vitals: T 98.2 144/82 70 16 95%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: rrr, no m/r/g
Lungs: CTAB without wheezing, no accessory muscle use
Abdomen: obese, soft, nondistended, nontender
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, gait deferred.
Pertinent Results:
On admission:
___ 12:42AM BLOOD WBC-10.8* RBC-4.87 Hgb-12.8 Hct-40.2
MCV-83 MCH-26.3 MCHC-31.8* RDW-15.2 RDWSD-45.5 Plt ___
___ 12:42AM BLOOD Neuts-68.4 ___ Monos-9.0 Eos-0.3*
Baso-0.5 Im ___ AbsNeut-7.41* AbsLymp-2.33 AbsMono-0.97*
AbsEos-0.03* AbsBaso-0.05
___ 12:42AM BLOOD ___ PTT-28.0 ___
___ 12:42AM BLOOD Glucose-120* UreaN-11 Creat-0.8 Na-142
K-3.2* Cl-102 HCO3-29 AnGap-14
___ 09:55AM BLOOD CK(CPK)-98
___ 12:42AM BLOOD proBNP-123
___ 12:42AM BLOOD cTropnT-<0.01
___ 09:55AM BLOOD CK-MB-3 cTropnT-<0.01
___ 12:42AM BLOOD Calcium-8.9 Phos-2.4* Mg-1.8
___ 12:42AM BLOOD D-Dimer-700*
___ 09:55AM BLOOD %HbA1c-6.3* eAG-134*
___ 11:15PM URINE Color-Straw Appear-Clear Sp ___
___ 11:15PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
On discharge:
___ 10:09AM BLOOD WBC-17.4*# RBC-5.03 Hgb-12.9 Hct-42.0
MCV-84 MCH-25.6* MCHC-30.7* RDW-15.8* RDWSD-47.5* Plt ___
___ 10:09AM BLOOD Neuts-76.7* Lymphs-18.3* Monos-4.3*
Eos-0.1* Baso-0.2 Im ___ AbsNeut-13.40*# AbsLymp-3.20
AbsMono-0.76 AbsEos-0.01* AbsBaso-0.04
___ 10:09AM BLOOD Glucose-135* UreaN-16 Creat-0.6 Na-142
K-3.5 Cl-103 HCO3-28 AnGap-15
Microbiology:
___ 11:15 pm URINE
URINE CULTURE (Pending):
Imaging:
ECGStudy Date of ___ 9:49:20 ___
Sinus tachycardia with minor non-specific ST segment
abnormalities. Compared
to the previous tracing of ___ sinus tachycardia persists
and there are no
significant changes.
CHEST (PA & LAT)Study Date of ___ 11:12 ___
IMPRESSION:
Emphysematous changes without evidence of pneumonia.
CTA CHEST W&W/O C&RECONS, NON-CORONARYStudy Date of ___
3:01 AM
IMPRESSION:
1. No evidence of pulmonary embolism. Respiratory motion
limits evaluation
for subsegmental atelectasis within the lower lobes bilaterally.
2. Centrilobular emphysema is mild and upper lobe predominant.
3. Enhancing and indistinct foci within the liver domes appear
stable dating
back through ___, nonspecific for which MRI can be performed if
clinically
warranted.
Brief Hospital Course:
___ F with PMH HTN, COPD, asthma (no prior hx intubation) who
presents with c/o sudden cough and palpitations consistent with
prior COPD/asthma exacerbations.
# COPD exacerbation: The patient reported initially vague
symptoms, which included palpitations and "feeling like she was
going to die". She was noted to have a clear CXR, with an
elevated WBC and diffuse wheezing on exam. Additionally, she had
a CTA which was negative for PE. Based on her history of
worsening dyspnea, cough, and wheezing on exam, the patient was
started on empiric treatment for a COPD exacerbation with a 5d
course of azithromycin and 40mg prednisone burst. Additionally,
the patient was continued on her home controller medications,
and given levalbuterol and ipratropium standing nebulizers q4
hours. The patient improved greatly over the first night in
house (including peak flow at 250- baseline 240), and was deemed
ready for discharge on her second hospital day given resolution
in her difficulty breathing. She will complete a five day
course of azithromycin and prednisone (40 mg) to treat this
current exacerbation.
# Palpitations: Pt initially reported palpitations which were
likely in the setting of dyspnea given COPD exacerbation.
Reassuring that BNP wnl and troponins negative with EKG in NSR.
The patient's tachycardia resolved with treatment of her
underlying pulmonary disease.
# Hypertension: pt noted to have elevated systolic blood
pressures while in house (170-190's) until her home
antihypertensive regimen was resumed (amlodipine, clonidine,
hydralazine, and HCTZ). SBP's stabilized to 140-160's following
resumption of her medications.
#Hyperglycemia: Pt without h/o DM, though with elevated BG in
the setting of steroid burst. Likely with elevated BG at home,
an A1c was sent which was 6.3, indicating pre-diabetes. Given
her age and other comorbid conditions, she likely would benefit
from lifestyle modification in the future.
CHRONIC ISSUES:
# Chronic diastolic CHF: No evidence acute exacerbation during
this admission. BNP wnl's, and patient remained euvolemic and
clinically stable throughout.
# GERD: continued home omeprazole
Transitional issues:
#The patient's WBC elevated on her last day of admission, and a
differential showed neutrophilia c/w steroid use. She should
have a repeat CBC to document resolution of her leukocytosis in
the future.
#The patient should continue prednisone and azithromycin until
___
#Pt's blood glucose was elevated, likely in the setting of
steroid use, an A1c indicated that she is likely pre-diabetic.
She would likely benefit from lifestyle modification in the
future
Medications on Admission:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheezing
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheeze
3. Amlodipine 5 mg PO DAILY
4. CloniDINE 0.2 mg PO BID
5. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
6. HydrALAzine 10 mg PO Q8H
7. Montelukast 10 mg PO DAILY
8. Omeprazole 20 mg PO DAILY
9. Tiotropium Bromide 1 CAP IH DAILY
10. Acetaminophen 500 mg PO Q6H:PRN pain
11. Cetirizine 10 mg PO QHS
12. Vitamin D 1000 UNIT PO DAILY
13. Hydrochlorothiazide 12.5 mg PO DAILY
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H:PRN pain
2. Amlodipine 5 mg PO DAILY
3. Cetirizine 10 mg PO QHS
4. CloniDINE 0.2 mg PO BID
5. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
6. HydrALAzine 10 mg PO Q8H
7. Hydrochlorothiazide 12.5 mg PO DAILY
8. Montelukast 10 mg PO DAILY
9. Omeprazole 20 mg PO DAILY
10. Tiotropium Bromide 1 CAP IH DAILY
11. Vitamin D 1000 UNIT PO DAILY
12. Azithromycin 250 mg PO Q24H Duration: 4 Days
RX *azithromycin 250 mg 1 tablet(s) by mouth every day Disp #*3
Tablet Refills:*0
13. PredniSONE 40 mg PO DAILY
RX *prednisone 20 mg 2 tablet(s) by mouth every day Disp #*6
Tablet Refills:*0
14. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheezing
15. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheeze
Discharge Disposition:
Home
Discharge Diagnosis:
COPD exacerbation
palpitations related to underlying pulmonary disease
hypertension
Chronic issues
Chronic diastolic heart failure
Discharge Condition:
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Discharge Instructions:
Ms ___-
You were admitted for difficulty breathing and your heart
racing. Based on how much your examination as your symptoms of
worsening breathing and worse cough, it was determined that you
were suffering from an exacerbation of your underlying COPD. You
were treated with an antibiotic and a steroid, both of which you
should continue to take for the next three days. You should
attend all appointments as described and take all of your
medications as listed below. We wish you the best in the future-
-Your ___ Care Team
Followup Instructions:
___
|
19554899-DS-28
| 19,554,899 | 28,923,518 |
DS
| 28 |
2202-03-12 00:00:00
|
2202-03-12 20:27:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Aspirin / Bactrim DS / Diovan / Lisinopril / sulfur dioxide
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Bronchoscopy, Bronchoscopy under intubation
History of Present Illness:
Ms. ___ is a ___ ___ speaking female with a
PMH of COPD/asthma, DMII, hypertension, who presents with
shortness of breath.
History is taken with assistance of ___ phone
interpreter. Patient is a poor historian and remembers very few
details prior to her presentation. She states "Yesterday I
became
sick and they brought me here." When asked to describe how she
was sick she states, "they said I have pneumonia. After I came
here the pneumonia went away." When asked about specific
symptoms
such as cough, fever, or shortness of breath, patient states,
"Now I feel good," and is not able to describe whether these
were
symptoms she was having previously.
On review of records, patient was hospitalized at ___ from
___ through ___ with shortness of breath. During this
hospital course, she was initially on IV steroids and treated
with vanc, cefepime, azithromycin. A MRSA swab was negative and
vanc was stopped. She completed 5 days of azithromycin and 11
days of cefepime. She also had a CTA on ___ given her
tachycardia, showing no PE, but with mucus plugging. Despite
these antibiotics, patient continued to be short of breath with
an O2 requirement on the days leading up to discharge, though
she
was able to be discharged off of oxygen. Hospitalization was
also
notable for tachycardia, which was persistent throughout. She
was
also followed by cardiology for a bilateral lower extremity
edema. She had an echo with an EF of 70%. She was discharged on
daily Lasix and spironolactone. She was started on insulin for
new onset diabetes, felt to be in part from steroid use.
Of note, patient was also admitted at ___ on ___
and ___, also with respiratory symptoms.
Per review of records from ___, patient started to have
congestion and shortness of breath on ___. She was started on a
prednisone taper. However, by the next day her symptoms at
worsened, and she was found to have an O2 sat of 83%. Decision
was therefore made to transfer to ___.
Re diabetes, patient is on lantus with a Humalog sliding scale.
Re GERD, patient is on omeprazole
Re insomnia, patient takes melatonin at home.
Past Medical History:
Past Medical History:
- Asthma/COPD
- Hypertension
- Osteopenia
- GERD
- Neurocysticercosis
Past Surgical History:
- Resected left temporal meningioma
- Hysterectomy
Social History:
___
Family History:
Positive for asthma and hypertension.
Physical Exam:
Admission Physical Exam:
==========================
VITALS: T 97.6, HR 116, BP 101/64, RR 20, 94% 4L
GENERAL: Alert and in no apparent distress, chronically ill
appearing
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate. MMM
CV: Heart tachycardic, ___ SEM best heard at LUSB, no S3, no S4.
Unable to appreciate JVP given body habitus
RESP: Lungs with poor air movement, diffuse expiratory wheezes,
no rhonchi or crackles.
GI: Small ventral hernia. Abd distended but soft, nontender to
palpation. Normal bowel sounds
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
EXT: wwp, minimal peripheral edema
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented to place and date, though takes
significant amount of time to think of answers. Not able to
recall details of recent hospitalization or symptoms. Globally
weak, requiring help to turn.
PSYCH: pleasant, appropriate affect
Discharge Physical Exam:
==========================
Vitals:97.8 BP:130 / 70 HR:106 R:22 O2:91 Ra
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
CV: Heart regular, tachycardic, no murmur, no S3, no S4. ___
pitting edema to shin.
RESP: Today has poor air movement, perhaps some expiratory
wheezes but difficult to appreciate. Prolonged expiatory phase.
Breathing is non-labored, though pursed-lip.
GI: Abdomen distended, obese, non-tender 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, speech fluent, moves all
limbs
PSYCH: pleasant, appropriate affect
Pertinent Results:
Admission Labs:
___ 11:50AM WBC-18.4* RBC-4.87 HGB-12.7 HCT-39.8 MCV-82
MCH-26.1 MCHC-31.9* RDW-16.3* RDWSD-47.3*
___ 11:50AM NEUTS-87.6* LYMPHS-5.9* MONOS-5.7 EOS-0.0*
BASOS-0.1 IM ___ AbsNeut-16.11* AbsLymp-1.08*
AbsMono-1.04* AbsEos-0.00* AbsBaso-0.02
___ 11:50AM proBNP-3521*
___ 11:50AM cTropnT-<0.01
___ 11:50AM GLUCOSE-275* UREA N-23* CREAT-0.6 SODIUM-136
POTASSIUM-3.7 CHLORIDE-89* TOTAL CO2-34* ANION GAP-13
___ 11:55AM LACTATE-1.9
___ 11:55AM ___ PO2-92 PCO2-50* PH-7.48* TOTAL
CO2-38* BASE XS-11 COMMENTS-GREEN TOP
Allergic Asthma/Mimics Labs:
================
___ 05:20AM BLOOD ANCA-NEGATIVE B
___ 05:20AM BLOOD ASPERGILLUS ANTIBODY-Negative
___ 05:20AM BLOOD IGE-784 H <OR=114 ___
___ 12:58PM BLOOD STRONGYLOIDES ANTIBODY,IGG-PND
Microbiology Labs:
=====================
Blood Cx x2 ___: NG
Urine Cx ___: NG
Bronchial Sample: ___ 9:06 am BRONCHIAL WASHINGS
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.
RESPIRATORY CULTURE (Final ___:
10,000-100,000 CFU/mL Commensal Respiratory Flora.
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
Immunofluorescent test for Pneumocystis jirovecii (carinii)
(Final
___: NEGATIVE for Pneumocystis jirovecii
(carinii).
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
NOCARDIA CULTURE (Preliminary): NO NOCARDIA ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
Respiratory Viral Antigen Screen (Final ___:
TEST CANCELLED, PATIENT CREDITED .
UNABLE TO PERFORM RVA ON BAL SAMPLE THAT WAS FROZEN AT -20
OVERNIGHT.
FOR RESULTS REFER TO CULTURE.
Reported to and read back by ___ AT 13:37 ON
___.
Respiratory Viral Culture (Preliminary): Flu positive.
___ 6:42 pm BRONCHOALVEOLAR LAVAGE
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final ___:
___ CFU/mL Commensal Respiratory Flora.
BACILLUS SPECIES; NOT ANTHRACIS. ~1000 CFU/mL.
Immunofluorescent test for Pneumocystis jirovecii (carinii)
(Final
___: NEGATIVE for Pneumocystis jirovecii
(carinii).
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
Imaging:
CT Chest:
Left lung volumes slightly lower than the right. Minimal
retrocardiac
opacities and ill-defined borders of the left medial diaphragm
irregular. No areas of focal consolidation seen elsewhere.
Cardiomediastinal silhouette is unchanged. No pneumothorax. No
right pleural effusion.
Ill-defined borders of the left medial diaphragm could be either
subpulmonic pleural effusion or atelectasis. Lateral chest
radiograph and left lateral decubitus are recommended if patient
tolerates.
CXR:
=========
___: IMPRESSION: Ill-defined borders of the left medial
diaphragm could be either subpulmonic pleural effusion or
atelectasis. Lateral chest radiograph and left lateral
decubitus are recommended if patient tolerates.
___: IMPRESSION: Compared to chest radiographs since ___ most recently ___. Left lower lobe collapse is
new accompanied by increased small to moderate left pleural
effusion. Right lung shows a stable degree of mild basal
atelectasis. Upper lung is clear. Cardiac silhouette partially
obscured by new pleural and parenchymal abnormalities in the
left lung is probably unchanged in size. There is no pulmonary
edema or pneumothorax.
___: IMPRESSION: Ill-defined borders of the left medial
diaphragm could be either subpulmonic pleural effusion or
atelectasis. Lateral chest radiograph and left lateral
decubitus are recommended if patient tolerates.
___: Compared to most recent prior chest radiographs ___.
Both lobes of the left lung are now collapsed. There is
probably some
accompanying pleural effusion. Right lung is well expanded.
Small opacities it developed in the lower lung, perhaps
aspiration.
Left heart border is obscured, so heart size cannot be assessed
but there are no findings of cardiac decompensation.
___: 1. Improved aeration of the left upper lung. Persistent,
complete collapse of the left lower lobe and moderate pleural
effusion. 2. Increased patchy opacities at the right lung base
are concerning for aspiration or pneumonia.
___: IMPRESSION: Compared to chest radiographs since ___ most recently ___. Nodular
consolidation, right lower lobe has improved slightly are
probably pneumonia. Large scale atelectasis left lung has
worsened. Is impossible to say whether there is new
paramediastinal pleural fluid or atelectasis responsible for
this
change. Mediastinal widening is possible, but less likely
because I would
attribute that to acute aortic dilatation or bleeding from the
aorta and that should displace the trachea to the right.
Instead the trachea is displaced slightly leftward. As before,
the lumen the left main bronchus is obliterated, and airway
obstruction is presumed. Chest CT with contrast if tolerated, is
recommended for assessment of the ambiguous findings in the left
hemithorax, as well as nodules in the right lung
___: IMPRESSION: Left pleural effusion is moderate. Heart size
and mediastinum are stable. Right basal opacity is noted,
progressing with no central lucency and its concerning for
cavitary (necrotizing) pneumonia. There is no pneumothorax.
___: IMPRESSION: Comparison to ___. The parenchymal
opacities at the right lung bases have minimally decreased.
Also decreased is the left pleural effusion and the left basilar
atelectasis. Moderate cardiomegaly persists. No pulmonary
edema.
Discharge Labs:
===================
___ 07:20AM BLOOD WBC-7.8 RBC-4.46 Hgb-11.7 Hct-36.6 MCV-82
MCH-26.2 MCHC-32.0 RDW-16.1* RDWSD-46.8* Plt ___
___ 07:08AM BLOOD Glucose-106* UreaN-20 Creat-0.4 Na-134*
K-4.5 Cl-90* HCO3-36* AnGap-8*
Brief Hospital Course:
Ms. ___ is a ___ ___ speaking female with a
PMH of COPD/asthma, dystolic heart failure, DMII, hypertension,
who presents with shortness of breath and recurrent
hospitalization for pulmonary symptoms since ___ in which
she has not recovered back to baseline with reactive airway
disease and significant mucous plugging, now significantly
improved after bronchoscopy.
ACUTE/ACTIVE PROBLEMS:
# Shortness of breath
# COPD
# Acute on chronic hypoxemic respiratory failure
# Hypercarbic respiratory failure
# Left lung mucous plugging, complete white out
# Influenza, Flu A positive
# Hospital Acquired Pneumonia
Patient presenting with shortness of breath and hypoxia to
mid-80s. She has a history of COPD, and has had three recent
hospitalization at ___ within the past 2 months for
similar symptoms, including a recent prolonged course with a
full course of antibiotics, CTA to rule out PE, and cardiac
workup. She continued to sound wheezy on exam with poor air
movement despite being on a prolonged prednisone taper and what
appears to be a good COPD regimen. She was found to have
significant mucous plugging, especially on her left lung. She
was evaluated by pulmonology. She was started on on ATC nebs and
N-acetylcysteine, and continued on home meds of montelukast and
advair. We also intiated aggresive pulmonary toilet with chest
___, IS, and acapella.
She underwent bronchoscopy under MAC on ___, but was unable to
tolerate the procedure to tachycardia and hypoxemia. She
continued to clinically deteriorate and was found to have
influenza A (amidst a flu outbreak on the floor) and also found
to have RLL opacities in the setting of presumed aspiration that
was concerning hospital acquired pneumonia. On ___ her
respiratory status remained tenuous with maximum oxygen therapy
on the floor, was triggerred and required NRB at times to
maintain oxygenation. Blood gases at time showed severe
hypoxemia and hypercarbia, likely due to poor ventillation in
the setting of mucos plugging.
At this time the team recommended broncoscopy under anesthesia
and intubation. After a family discussion, the patient agreed to
reverse her code status to allow intubation for the procedure.
She underwent bronchoscopy for mucous clearage and BAL.
Post-procedure, she was successfully extubated and after a short
ICU course (see below) was transferred back to the floor. Her
oxygen requirements were significant decreased and she was
weaned off oxygen. Her leukocytosis improved after bronchoscopy
and her white count normalized. Her thrombocytopenia normalized
as well.
She was treated for influenza with 5 day course of osteltamivir
(___) and 7 day course of cefepime (___). She was
given vancomycin initially for HAP, but this was discontinued as
there was no concern for MRSA. The BAL grew out bacillus which
could represent a GI or oropharyngeal contaminant, but given her
clinical improvement and the rare pneumo-pathogenicity of
bacillus, we did not initiate treatment (e.g., vancomycin or
clindamycin). Her steroids were tapered, as below.
#Corticosteroid use and withdrawal
#Immunosupression
She was started on steroids and treated like a reactive airway
disease exacerbation with IV methylprednisone, a week long
course of 60mg prednisone, with plan to taper down her steroids
as follows:
40mg (___)
20mg (___)
10mg (___)
Off
Given her recent multiple hospitalizations she has likely
received significant amounts of steroid use. While we plan to
taper as above, she should be monitored for adrenal
insufficiency after off steroids.
She was started on atovoquone for PCP ppx as she meets criteria.
She should continue to receive atovoquone until steroid dose is
under 20mg.
[] Monitor for BP, HPA axis deficiency.
[] Discontinue at___ on ___
#Elevated HCO3
Mostly likely representing some chronic compensation for
hypercarbia. Per pulmonology she may have very little reserve
and renal exchange of H+ for K+. Seemed to be improving. We
repleted her potassium with goal >4.0 to ensure she her H+/K+
renal exchange was optimized.
# Allergic/Eosinophilic Asthma
# Elevated IgE
It is likely that her presentation above is secondary to severe
allergic asthma. She has not been following up with her
outpatient pulmonologist for the last ___ years. During this
hospital stay she underwent diagnostic evaluation for etiologies
and potential treatment for her reactive airway disease. IgE
levels were significantly elevated at 784. Infectious mimics
(ABPA, stronyloides) were also evaluated. She was negative for
aspergillous Ab. Strongyloides Ab is pending.
[] f/u strongyloides Ab.
#Elevated Bicarb
#Respiratory acidosis and metabolic alkalosis
Her bicarb has been elevated during this hospital stay, and
looked like it was uptrending while at ___. It is most
likely ___ to metabolic compensation in setting of hypercarbia,
which improved. It appears to be improving with improvement in
her respiratory status. However, she was also re-started on her
diuresis which could be precipitating/prolonging her metabolic
acidosis.
[] f/u electrolytes and HCO3 in one week
# Chronic diastolic heart failure - No signs of current
exacerbation as above.
We initially held her home Lasix and spironolactone, but then
restarted her medication with careful evaluation of her volume
status.
# Sinus Tachycardia - Has been persistent since last
hospitalization at ___. It likely that a component of this
was in the setting of acute illness and hypoxemia. It did
improve after bronchoscopy. But still remains tachycardic to the
100s, though she appeared to be euvolemic. She may need follow
up as an outpatient if she remains tachycardic.
[]consider outpatient follow up of tachycardia
# Thrombocytopenia. Given timing of thrombocytopenia, there was
concern for HIT. However, PF4 Abs were negative at ___
making HIT significantly less likely
given high NPV. Per recommendation of blood bank, her ppx
anticoagulation was held to watch to see if her plts rebounded.
Her thrombocytopenia improved after bronchoscopy and clinical
improvement above. Per hematology there was very low for HIT and
they recommended restarting SQ heparin/lovenox. She was
restarted on SC heparin on ___, which was well tolerated.
CHRONIC/STABLE PROBLEMS:
# Hypertension - Because her blood pressures fluctuated during
this long hospital course we started and stopped her home
hypertension medications several times. As she was clinically
improving, we continued her home amlodipine, hydralazine. We
held her clonidine.
# Type II Diabetes - Recent diagnosis, likely in setting of
steroid use.
We continued her home lantus 15u QHS and HISS.
# Insomnia
We started ramelteon prn (held home melatonin as not on
formulary).
# GERD
We gave pantoprazole.
[] Consider discontinuing PPI or transitioning to H2 blocker
after steroid taper
# Allergies
We continued home cetirizine as above.
#? Hypothyroidism
Her TSH was normal.
TRANSITIONAL ISSUES
====================
[] Repeat electrolytes in 1 week
[] Monitor for BP, HPA axis deficiency (adrenal insufficiency)
as steroids are tapered
[] Discontinue atovoquone on ___
[] Pulmonology follow up ___ (Dr. ___
[] f/u strongyloides Ab results.
[] ___ benefit from outpt sleep evaluation for OSA/hypercarbia
[] Consider discontinuing PPI or transitioning to H2 blocker
after steroid taper
[] Consider DEXA scan given high risk for osteoporosis
[] consider outpatient follow up of tachycardia if does not
improve
- Code status: DNR/DNI- MOLST form filled out
___ ___, son ___ ___, or ___
___
Patient seen and examined on day of discharge. >30 minutes on
discharge activities.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Montelukast 10 mg PO DAILY
2. Vitamin D 1000 UNIT PO DAILY
3. HydrALAZINE 100 mg PO Q8H
4. CloNIDine 0.2 mg PO BID
5. amLODIPine 10 mg PO DAILY
6. Furosemide 20 mg PO DAILY
7. Bisacodyl 5 mg PO DAILY:PRN Constipation - Second Line
8. Tiotropium Bromide 1 CAP IH DAILY
9. Polyethylene Glycol 17 g PO DAILY
10. Cetirizine 10 mg PO DAILY
11. Docusate Sodium 100 mg PO BID
12. Spironolactone 25 mg PO DAILY
13. Pantoprazole 40 mg PO Q24H
14. Ipratropium Bromide MDI 2 PUFF IH QID
15. Levalbuterol Neb 0.63 mg NEB Q6H:PRN COPD
16. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
17. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4H:PRN shortness of breath
18. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
19. GuaiFENesin ER 1200 mg PO Q12H
20. Glargine 15 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
21. melatonin 3 mg oral QHS:PRN insomnia
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Asthma excerbation
Mucous plugging of airways, left lung lobes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital because of worsening breathing
that we think is related to your asthma disease. You were found
have lots of thick secretions (mucous) in your airways that
caused your left lung to collapse. We gave you medications to
treat your asthma and to break up the mucous. You were also
found to have the flu and to have a pneumonia. You were given
medication to treat the flu and the pneumonia. You underwent a
bronchoscopy procedure under anesthesia where they put a tube
into your airway to clear out the secretions. Your breathing
symptoms significantly improved after clearing out the
secretions and we were able to take you off the oxygen.
We will be tapering (decreasing slowly) your steroid dose. You
should follow up with your primary care doctor one week after
discharge to have you labs (blood work) rechecked. You also need
to follow up with the pulmonologist (lung doctors). We have
scheduled an appointment for you on ___ with Dr.
___. You will also have pulmonary function tests (tests of
your lung function) conducted at that time. You should get a
follow chest XR in 6 weeks.
Please continue to take your asthma medications and continue to
do the breathing treatments. This will help prevent the return
of your breathing problems.
Best,
Your ___ Team
Followup Instructions:
___
|
19555461-DS-6
| 19,555,461 | 20,391,136 |
DS
| 6 |
2128-07-21 00:00:00
|
2128-07-21 16:48:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Penicillins / adhesive tape / bee venom (honey bee) / Iodine
Attending: ___.
Chief Complaint:
seizures
Major Surgical or Invasive Procedure:
LTM EEG
History of Present Illness:
Ms. ___ is a ___ y/o right-handed woman with PMH significant
for temporal lobe epilepsy, stroke (no known history about this;
daughter said it was in ___ symptoms are unknown, and patient
was only told about it 6 months after the fact), migraines and
neuropathy who presents for evaluation of generalized
tonic-clonic seizures, which is a new semiology for her.
Regarding her prior seizure history, she is unable to provide
much history about this; her daughter is able to provide
history.
Her initial presentation was in ___. She was at a
___ in ___, when she developed numbness of her
right arm that migrated down to her leg; she is unsure of
duration of symptoms. Her daughter was concerned this may be a
TIA, so sent her for evaluation. Also beginning in ___,
her daughter began noticing she was having episodes of staring
off associated with word-finding difficulties. These episodes
lasted 30 sec-1 minute and would occur 5 times daily, on
average.
Her daughter said that if she is talking to her during one of
these episodes, she will not recall what was said during this
time and when asked what is last thing she remembers talking
about, it is always what was discussed prior to onset of staring
spell. Patient is not aware of any auras with these episodes.
After evaluation, it was discovered that she had temporal lobe
seizures. Patient and daughter do not recall any recent MRI of
her head. She was initially started on Keppra for the seizures,
but this resulted in forgetfulness and also onset of dangerous
behaviors, including leaning on hot stoves and opening car door
while car is moving. She was then started on Depakote.
On ___, she developed new seizure semiology of
generalized tonic-clonic seizures. The patient is unable to
provide any history regarding the seizures, so again history
obtained from her daughter, who witnessed these episodes. She
was
not feeling well that morning at her PCP, she was dizzy and
found
to be hypotensive (her BP runs low at baseline with SBP often in
___. She went to her daughter's house later that day to get her
pill-box filled, per usual routine. While there, she said she
was
not feeling well and had a weird sensation in her head that she
could not describe. She also reported constant left ear
tinnitus.
At 4:30 ___ that day, she was still not feeling well and was
saying it was too loud; her daughter said she looked
disoriented.
Her daughter then noted her pupils dilated and her eyes rolled
back in her head with unresponsiveness and generalized
convulsions. This lasted for about 1 minute and afterwards, she
was confused and repeated "I want to go home;" she then got up
and went to the door, but was disoriented and unsteady; she was
supported by her daughter and boyfriend, and then began having a
second generalized seizure, again lasting about 1 minute. She
was
held up and supported by her family during this time. She was
then helped to the chair and EMS was called and arrived in time
to see her have 2 further generalized convulsive seizures. Over
this time, she never returned to baseline. She reportedly had
her
typical staring spells en route to the hospital, but no further
generalized convulsions. The following day, while at OSH, she
had
2 more GTCs. With one of them, her daughter noted it began with
shaking of her right hand (she was holding a cup of ice so it
was
noticeable) prior to generalizing. This was the only seizure
that
was witnessed to have a focal onset. While at OSH, she was seen
by Neurology and had her AEDs adjusted, the plan was to haver
her
Depakote tapered off and she was started on Trieptal (the
documented plan was started on ___ and involved Depakote
250/500
x 5 days, then 250 bid x 5 days, then stop; Trileptal was
started
at 300 mg bid x 5 days and then increase to 450 mg bid). She was
d/c home yesterday. Today, she was on the phone with her
daughter
and was crying because of a headache. Her daughter came to her
house and while there, the patient had a GTC seizure lasting
about 30 seconds and was post-ictal afterwards. No aura
preceeding GTCs. No tongue biting. No incontinence of urine or
stool. She does not note any recent infectious symptoms. AED
adjustments as per above.
She has no history of febrile seizures. She recalls distant
history of trauma from her ex-husband resulting in shattered jaw
and broken ear-drum. No other history of head trauma. She was
never left back during school and compelted a high school
education. Her father had grand-mal seizures, but she is unsure
of any details about this and does not know if any other family
members have a seizure history.
Neuro ROS: Positive for throbbing headache, more severe than her
prior migraines (which she has not had in many years). No loss
of
vision, blurred vision, diplopia, dysarthria, dysphagia,
lightheadedness or vertigo (though she does have history of
this). She has chronic left ear tinnitus. No difficulties
producing or comprehending speech. She notes intermittent
numbness and parasthesias of her feet. No focal weakness. No
difficulty with gait.
General ROS: No fever or chills. No recent weight loss or gain.
No cough, shortness of breath, chest pain or tightness,
palpitations. She noted nausea earlier today, but no vomiting.
No diarrhea, constipation or abdominal pain. No dysuria. No
rash.
Past Medical History:
-temporal lobe epilepsy (dx ___
-migraines
-lower back fractures (she is uanble to provide further details)
-TIA/stroke ___, location and sxs unknown)
-neuropathy
-vertigo
Social History:
___
Family History:
Her father had generalized seizures, but she does not know
further details about this. No other known seizures in family.
She does not know any other family medical history.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T: 98.2 P: 79 R: 18 BP: 107/66 SaO2: 95% RA
General: Awake, cooperative, NAD, initially tearful due to
headache.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated.
Pulmonary: lcta b/l
Cardiac: RRR, S1S2
Abdomen: soft, NT/ND, +BS
Extremities: warm, well perfused
Neurologic:
Mental Status: Awake, alert, oriented to person, ___" (but not name of ___ and date. Attentive, able
to
name ___ backward (but with encouragement). Able to follow both
midline and appendicular commands. No right-left confusion. Able
to register 3 objects and recall ___ at 5 minutes. No evidence
of
apraxia or neglect
Language: speech is clear, fluent, nondysarthric with intact
naming, repetition and comprehension.
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.
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.
She has R>L UE tremulousness. No asterixis noted.
Delt Bic Tri WrE FFl FE IP Quad Ham TA Gastroc
L 5 ___ ___ 5 5 5 5
R 5 ___ ___ 5 5 5 5
Sensory: No deficits to light touch. There is decreased pinprick
in LLE (60% compared to right) Mild proprioceptive loss at great
toe b/l. Vibratory sense 12 seconds at great toe b/l. No
extinction to DSS.
DTRs:
Bi Tri ___ Pat Ach
L 2 1 1 1 0
R 2 1 1 1 0
Plantar response was flexor bilaterally.
Coordination: No intention tremor or dysmetria on finger-nose,
FNF. RAMs intact b/l.
Gait: Good initiation. Narrow-based, normal stride and arm
swing.
Difficulty with tandem gait. Romberg absent.
DISCHARGE PHYSICAL EXAM:
VITALS: T 98.2, BP 100/50, HR 60, RR 18, 96% on RA
GEN: middle aged woman lying in bed in NAD
HEENT: OP clear
CV: RRR
PULM: CTA-B
ABD: soft, NT, ND
EXT: No edema
NEURO EXAM:
MS - AAOx3
CN - PERRL 4->2mm, EOMI, VFF
MOTOR - full strength throughout
SENSORY - patchy areas of subjectively decreased light touch
sensation in ___ that change with each repeat exam
COORDINATION - FNF intact bilaterally
GAIT - deferred
Pertinent Results:
ADMISSION LABS:
___ 02:50PM BLOOD WBC-4.9 RBC-3.92* Hgb-12.5 Hct-38.3
MCV-98 MCH-31.9 MCHC-32.6 RDW-13.4 Plt ___
___ 02:50PM BLOOD Neuts-66.0 ___ Monos-3.0 Eos-1.5
Baso-0.5
___ 02:50PM BLOOD Glucose-84 UreaN-4* Creat-0.7 Na-128*
K-5.6* Cl-96 HCO3-24 AnGap-14
___ 06:30AM BLOOD Calcium-8.2* Phos-4.8* Mg-1.7
___ 02:50PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
DISCHARGE LABS:
___ 04:20AM BLOOD WBC-4.1 RBC-3.63* Hgb-11.2* Hct-34.5*
MCV-95 MCH-30.9 MCHC-32.5 RDW-13.0 Plt ___
___ 04:20AM BLOOD Glucose-86 UreaN-6 Creat-0.7 Na-134 K-4.4
Cl-98 HCO3-27 AnGap-13
___ 04:20AM BLOOD Calcium-8.5 Phos-4.9* Mg-1.8
___ 06:20AM BLOOD VitB12-538 Folate-8.4
___ 06:20AM BLOOD HCV Ab-POSITIVE*
REPORTS:
EEG ___: PRESSION: This is a normal video EEG monitoring
session. Background activity was normal. There were no
epileptiform discharges or
electrographic seizures. None of th
e patient's typical events were
recorded.
CT HEAD ___: IMPRESSION: Normal head CT.
CXR ___: IMPRESSION: Linear opacities at the left lung base
suggestive of atelectasis; however, if high clinical suspicion
for infection, two-view chest may offer additional detail.
EEG ___: IMPRESSION: This is a normal video EEG monitoring
session. Background activity was normal. There were no
epileptiform discharges or electrographic seizures. None of the
patient's typical events were
recorded.
MRI ___: IMPRESSION: Slightly prominent sulci for the
patient's age, no diffusion abnormalities or focal lesions are
identified in the brain. The high-resolution images throughout
the temporal lobes are grossly normal with no evidence of mesial
temporal sclerosis. There is no evidence of abnormal
enhancement.
EEG ___: IMPRESSION: This is a normal video EEG monitoring
session. There was one sitter pushbutton activation for
subjective feeling with no
electrographic seizures. No epileptiform discharges were present
in
the recording.
EEG ___: IMPRESSION: This is a normal video EEG monitoring
session. There were no pushbutton activations. No epileptiform
discharges were present in the recording.
L-SPINE ___: IMPRESSION:
1. Lower lumbar facet arthropathy and loss of disc height.
2. Age indeterminant T12 compression fracture with approximately
30% loss of vertebral body height.
EEG ___: IMPRESSION: This is a normal video EEG monitoring
session. There were no pushbutton activations. No epileptiform
discharges were present in the recording.
Brief Hospital Course:
Ms. ___ is a ___ y/o right-handed woman with PMH significant
for temporal lobe epilepsy, stroke (no known history about this;
daughter said it was in ___ symptoms are unknown, and patient
was only told about it 6 months after the fact), migraines and
neuropathy who presented for evaluation of generalized
tonic-clonic seizures, which is a new semiology for her. She had
had at least 7 GTCs since they first started on ___. On intial
exam, she had upper extremity tremulousness R>L and diminished
pinprick in the left lower extremity, but otherwise no focal
defecits noted. No recent infectious symptoms. It is also
unclear if her generalized seizures are primary or secondarily
generalized; there was one seizure her daughter witnessed with
focal onset, but otherwise no focality noted at seizure onset.
This is important because she was recently started on Trileptal,
which may not be the best AED if she is having new semiology of
primarily generalized seizures. Pt was admitted to the Neurology
Service for further evaluation with LTM and MRI for further
evaluation of new seizure semiology and treatment.
.
# NEURO: Patient was put on LTM, but here we did not see any
epileptic events. Therefore, during this stay we took her off
depakote and trileptal entirely, but she still had no seizures
on EEG. We decided to increase patient's gabapentin to 900mg
TID as she continued to have LBP from her known T12 fracture
(this is old). Patient will follow-up in epilepsy clinic to
determine if she needs any further workup. At this appointment
the daughter will bring in all of the patient's EEG recordings
on CD from her prior EEG recordings at OSHs.
.
# CARDS: we monitored pt on telemetry while she was here
without any events. We continued her home aspirin and statin.
.
# RENAL: Pt initially had SIADH (determined from serum and urine
labs) when she came, which was presumed to be secondary to her
trileptal ((which had already been stopped). She was fluid
restricted and this improved. By discharge, she was on a 2L
fluid restriction with normal electrolytes, however she was not
following this restriction and was drinking as much as she chose
(her family brought in drinks etc for her) and her labs remained
normal.
# GU: Patient reported vaginal discharge. OB/GYN team was
consulted and performed a pelvic exam, with a vaginal culture
returning positive for BV. Patient was put on flagyl for a 7
day course with improvement. Pt may need a pelvic U/S as an
outpatient for chronic vaginal pain. She was set up with an
OB/GYN f/u appt.
.
# CODE/CONTACT: Presumed Full; ___ (daughter) ___
PENDING RESULTS:
___ final EEG read
TRANSITIONAL CARE ISSUES:
Patient will need closer follow-up if she has any further
seizure episodes.
Medications on Admission:
-ASA 81 mg daily
-Simvastatin 10 mg daily
-Trazodone 100 mg qhs prn
-Depakote 250/500 (day 3 of planned 5 day taper as per HPI)
-Trileptal 300 mg bid (day 3 of planned titration as per HPI)
-Gabapentin ___ (for neuropathy per daughter)
-Oxycodone-Acetaminophen ___ tabs q6h prn
-Protonix 40 mg daily
-Tylenol ___ mg q4h prn
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every four
(4) hours as needed for pain.
6. gabapentin 300 mg Capsule Sig: Three (3) Capsule PO three
times a day.
Disp:*270 Capsule(s)* Refills:*2*
7. oxycodone 5 mg Tablet Sig: ___ Tablets PO every six (6) hours
as needed for breakthrough pain.
8. neomycin-bacitracnZn-polymyxin 3.5-400-5,000 mg-unit-unit/g
Ointment Sig: One (1) Appl Topical BID (2 times a day): Use
until rash on forehead disappears.
Disp:*1 tube* Refills:*1*
9. metronidazole 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 4 days: Last dose evening of ___.
Disp:*8 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Seizures
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms,. ___,
You were seen in the hospital for many recent seizures. While
you were here we did not note any seizures on your EEG.
Therefore, we decreased your home seizure medications in hopes
of capturing a seizure, but were unable to. You were sent home
with some medication changes.
We made the following changes to your medications:
1) We STOPPED your DEPAKOTE.
2) We INCREASED your GABAPENTIN to 900mg three times a day.
3) We STOPPED your TRILEPTAL.
4) We STARTED you on METRONIDAZOLE 500mg twice a day for a
vaginal infection. Your last dose will be on the evening of
___ to complete a ___) We STARTED you on NEOMYCIN OINTMENT to use on your forehead
rash until it disappears.
Please continue to take your other medications as previously
prescribed.
If you experience any of the below listed Danger Signs, please
contact your doctor or go to the nearest Emergency Room.
It was a pleasure taking care of you on this hospitalization.
Please follow the below seizure safety guidelines:
SEIZURE SAFETY
________________________________________________________________
The following tips will help you to make your home and
surroundings as safe as possible during or following a seizure.
Some people with epilepsy will not need to make any of these
changes. Use this list to balance your safety with the way you
want to live your life.
Make sure that everyone in your family and in your home knows:
- what to expect when you have a seizure
- correct seizure first aid
- first aid for choking
- when it is (and isn't) necessary to call for emergency help
Avoid things that are known to increase the risk of a seizure:
- forgetting to take medications
- not getting enough sleep
- drinking a lot of alcohol
- using illegal drugs
In the kitchen:
- As much as possible, cook and use electrical appliances only
when someone else is in the house.
- Use a microwave if possible.
- Use the back burners of the stove. Turn handles of pans toward
the back of the stove.
- Avoid carrying hot pans; serve hot food and liquids directly
from the stove onto plates.
- Use pre-cut foods or use a blender or food processor to limit
the need for sharp knives.
- Wear rubber gloves when handling knives or washing dishes or
glasses in the sink.
- Use plastic cups, dishes, and containers rather than breakable
glass.
In the living room:
- Avoid open fires.
- Avoid trailing wires and clutter on the floor.
- Lay a soft, easy-to-clean carpet.
- Put safety glass in windows and doors.
- Pad sharp corners of tables and other furniture, and buy
furniture with rounded corners.
- Avoid smoking or lighting fires when you're by yourself.
- Try to avoid climbing up on chairs or ladders, especially when
alone.
- If you wander during seizures, make sure that outside doors
are
securely locked and put safety gates at the top of steep stairs.
In the bedroom:
- Choose a wide, low bed.
- Avoid top bunks.
- Place a soft carpet on the floor.
In the bathroom:
- Unless you live on your own, tell a family member ___
before you take a bath or shower.
- Hang the bathroom door so it opens outward, so it can be
opened
if you have a seizure and fall against it.
- Don't lock the bathroom door. Hang an "Occupied" sign on the
outside handle instead.
- Set the water temperature low so you won't be hurt if you have
a seizure while the water is running.
- Showers are generally safer than baths. Consider using a
hand-
held shower nozzle.
- If taking a bath, keep the water shallow and make sure you
turn
off the tap before getting in.
- Put non-skid strips in the tub.
- Avoid using electrical appliances in the bathroom or near
water.
- Use shatterproof glass for mirrors.
At work:
___
Out and about:
- Carry only as many medications with you as you will need, and
2
spare doses.
- Wear a medical alert bracelet to let emergency workers and
others know that you have epilepsy.
- Stand well back from the road when waiting for the bus and
away
from the platform edge when taking the subway.
- If you wander during a seizure, take a friend along.
- Don't let fear of a seizure keep you at home.
Sports:
- Use common sense to decide which sports are reasonable.
- Exercise on soft surfaces.
- Wear a life vest when you are close to water.
- Avoid swimming alone. Make sure someone with you can swim
well
enough to help you if you need it.
- Wear head protection when playing contact sports or when there
is a risk of falling.
- When riding a bicycle or rollerblading, wear a helmet, knee
pads, and elbow pads. Avoid high traffic areas; ride or skate
on
side roads or bike paths.
Driving:
- You may not drive in ___ unless you have been
seizure- free for at least 6 months.
- Always wear a seatbelt.
Parenting:
- Childproof your home as much as possible.
- If you are nursing a baby, sit on the floor or bed with your
back supported so the baby will not fall far if you should lose
consciousness.
- Feed the baby while he or she is seated in an infant seat.
- Dress, change, and sponge bathe the baby on the floor.
- Move the baby around in a stroller or small crib.
- Keep a young baby in a playpen when you are alone, and a
toddler in an indoor play yard, or childproof one room and use
safety gates at the doors.
- When out of the house, use a bungee-type cord or restraint
harness so your child cannot wander away if you have a seizure
that affects your awareness.
- Explain your seizures to your child when he or she is old
enough to understand.
Followup Instructions:
___
|
19555686-DS-10
| 19,555,686 | 20,071,347 |
DS
| 10 |
2170-06-11 00:00:00
|
2170-06-11 19:17:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Imitrex
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization, PCI
History of Present Illness:
Dr. ___ is a ___ with no significant PMH who presents with
acute onset chest pain.
Her pain began acutely at 1430 this afternoon as she was writing
notes. She thought the pain was acid reflux, took Tums and advil
but her pain persisted. She described the pain as sharp,
burning. She denies SOB, nausea, back/jaw/arm pain. Of note, she
was recently on a ___ flight to ___ one week ago. Her pain has
resolved.
In the ED,
Initial vitals were: ___ 80 164/97 18 100% RA
Exam notable for:
General - well appearing, no acute distress
Cardiovascular - RRR, no appreciable murmur
Respiratory - CTA bilaterally, no wheezing or rhonchi
Skin - warm and well perfused
Labs notable for:
1) BMP: Na 139, K 4.1, Cl 99, HCO3 23, BUN 13, Cr 0.7
2) Trop-T <0.01 x2
3) CBC: WBC 10.2, Hb 13.4, plt 317
4) DDimer: 205
Studies notable for:
1) EKG: SR HR 77, STE I/AVL, STD II/III/AVF
2) CXR: No acute CP process
Patient was given:
___ 19:20 PO Aspirin 324 mg
Cardiology was consulted: and decided to take her to the cath
lab
In the cath lab: R Radial Access. 90% occlusion of OM, DES was
placed. Some ectopy was noted post re-perfusion, but currently
in SR. She received 180 mg ticagrelor intraoperatively.
Past Medical History:
None
Social History:
___
Family History:
Mother- CAD (CABG @ age ___, HLD
Father- HTN, HLD
MGM- Arthritis
MGF- DM
PGM- CAD
PGF- Parkinsons
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: T: 97.6, HR: 103, BP: 142/104, RR: 17, SpO2: 100% RA
GENERAL: Well developed, well nourished in NAD. Oriented x3.
Mood, affect appropriate.
HEENT: Normocephalic, atraumatic. Sclera anicteric. PERRL. EOMI.
NECK: Supple. No JVD.
CARDIAC: Normal rate, regular rhythm. No murmurs, rubs, or
gallops.
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. No adventitious breath
sounds.
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
DISCHARGE PHYSICAL EXAM:
========================
VS:
24 HR Data (last updated ___ @ 550)
Temp: 97.8 (Tm 99.0), BP: 117/66 (107-136/66-91), HR: 78
(78-90), RR: 18 (___), O2 sat: 100% (99-100), O2 delivery: RA
GENERAL: Well developed, well nourished in NAD. Oriented x3.
Mood, affect appropriate.
HEENT: NCAT, anicteric sclerae. PERRL. EOMI. MMMM
NECK: Supple. No JVD.
CARDIAC: RRR, S1 + S2 present, no mrg
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. No adventitious breath
sounds.
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
Pertinent Results:
===============
ADMISSION LABS:
===============
___ 05:24PM BLOOD WBC-10.2* RBC-4.50 Hgb-13.4 Hct-40.1
MCV-89 MCH-29.8 MCHC-33.4 RDW-11.9 RDWSD-38.8 Plt ___
___ 05:24PM BLOOD Neuts-63.3 ___ Monos-6.1 Eos-0.9*
Baso-0.4 Im ___ AbsNeut-6.44* AbsLymp-2.94 AbsMono-0.62
AbsEos-0.09 AbsBaso-0.04
___ 05:24PM BLOOD Glucose-103* UreaN-13 Creat-0.7 Na-139
K-4.1 Cl-99 HCO3-23 AnGap-17
___ 05:24PM BLOOD cTropnT-<0.01
___ 07:32PM BLOOD cTropnT-<0.01
___ 07:32PM BLOOD D-Dimer-205
===============
DISCHARGE LABS:
===============
___ 04:20AM BLOOD WBC-9.6 RBC-4.12 Hgb-12.4 Hct-36.8 MCV-89
MCH-30.1 MCHC-33.7 RDW-11.9 RDWSD-38.6 Plt ___
___ 04:20AM BLOOD ___ PTT-32.8 ___
___ 04:20AM BLOOD Glucose-97 UreaN-10 Creat-0.6 Na-139
K-4.6 Cl-103 HCO3-23 AnGap-13
___ 04:20AM BLOOD ALT-26 AST-35 LD(LDH)-251* AlkPhos-70
TotBili-0.8
___ 04:20AM BLOOD Triglyc-113 HDL-37* CHOL/HD-5.7
LDLcalc-152*
___ 04:20AM BLOOD CK-MB-30* cTropnT-0.47*
___ 03:00PM BLOOD CK-MB-20* cTropnT-0.20*
___ 04:20AM BLOOD Calcium-8.9 Phos-4.8* Mg-2.1 Cholest-212*
___ 04:20AM BLOOD %HbA1c-5.0 eAG-97
================
IMAGING STUDIES:
================
CXR (___):
The lungs are clear. There is no consolidation, effusion, or
pneumothorax. The cardiomediastinal silhouette is within normal
limits. No acute osseous abnormalities. IMPRESSION: No acute
cardiopulmonary process.
CARDIAC CATH REPORT (___):
Dominance: Right
The LMCA had no angiographically apparent CAD. The LAD had no
angiographically apparent CAD. The Cx had proximal 20% stenosis
and one large OM branch that was thrombotically ulcerated with
subtotal occlusion by a 90% stenosis. The RCA had no significant
stenosis.
TTE (___):
The left atrium is normal in size. The estimated right atrial
pressure is ___ mmHg. Left ventricular wall thicknesses and
cavity size are normal. There is mild regional left ventricular
systolic dysfunction with hypokinesis of the basal to mid
lateral wall. The remaining segments contract normally (LVEF =
56 % by biplane). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is no mitral valve prolapse.
The estimated pulmonary artery systolic pressure is normal.
There is no pericardial effusion.
IMPRESSION: Mild regional left ventricular systolic dysfunction
c/w CAD LCx territory).
Brief Hospital Course:
Dr. ___ is a ___ with no significant PMH who presented with
acute onset chest pain and was found to have a lateral STEMI w/
90% occlusion of OM s/p DES.
#CORONARIES: 90% OM branch/LCX
#PUMP: unknown
#RHYTHM: SR
ACUTE ISSUES:
=============
# STEMI/CAD: Pt presents with acute onset CP. EKG concerning for
lateral MI. Cath lab revealed 90% occlusion of the LCX now s/p
DES. Patient otherwise does not have any cardiac history, no
tobacco use, no DM. She has recent hyperlipidemia and family
history of early CAD (mother had CABG in ___ thus likely has
genetic risk factors. Post-STEMI TTE preliminary read shows no
reduced EF. Pt was started on aspirin 81 mg QD, atorvastatin 80
mg QD, lisinopril 2.5 mg QD, metoprolol succinate 25 mg QD, and
ticagrelor 90 mg BID.
TRANSITIONAL ISSUES:
====================
[ ] F/u with Dr. ___ further titration of metoprolol and
lisinopril
NEW MEDICATIONS
Lisinopril 2.5 mg QD
Metoprolol succinate 25 mg QD
Aspirin 81 mg QD
Atorvastatin 80 mg QHS
Ticagrelor 90 mg BID
# CODE: Full Code
# CONTACT/HCP: ___ (husband) c: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*6
2. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*6
3. Lisinopril 2.5 mg PO DAILY
RX *lisinopril 2.5 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*6
4. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*6
5. TiCAGRELOR 90 mg PO BID to prevent stent thrombosis
RX *ticagrelor [Brilinta] 90 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*3
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
ST Elevation Myocardial Infarction
Coronary artery disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Dr. ___,
___ was a pleasure to be part of your care.
Why was I here?
-You were admitted to the hospital because you had a STEMI that
required stent placement in a branch of your left circumflex
artery.
What happened while I was here?
-You tolerated the procedure well and were started on new
medications for your CAD: aspirin 81 mg QD, atorvastatin 80 mg
QD, ticagrelor 90 mg BID, metoprolol succinate 25 mg QD and
lisinopril 2.5 mg QD.
What should I do when I leave the hospital?
-You will follow up with Dr. ___ in clinic. Dr. ___
will call you with the appointment time.
- Take your medications as prescribed.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19555758-DS-10
| 19,555,758 | 29,894,814 |
DS
| 10 |
2130-11-20 00:00:00
|
2130-11-20 19:58:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Ibuprofen
Attending: ___.
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ year old male with a history of CAD, IMI in ___
s/p RCA stent, hypertension, aortic aneurysm s/p repair ___,
atrial fibrillation ___ who presented with weakness and
altered mental status with memory loss. The patient reports
that ___ evening he was having trouble sleeping so he drank
approximately 3 oz of bourbon to help him sleep at approximately
1AM ___ night. When he awoke, he was still tired and stayed
in bed until 2:30PM when he was feeling groggy and disoriented
with a difficulty selecting clothing and getting dressed. He
called ___ and was found on the floor in his home with a blood
glucose of 54 when the EMS arrived. At the time, he was unable
to give his correct birthday. The patient reports that he had no
PO intake since dinner the night before. Of note, the patient
reports that he has persistent difficulty sleeping for which he
takes tromazepam ___ times per week but was recently worried
about side effects. He also reports that he has had some
increased stress regarding one of his sons. He reports that
this was his first time using alcohol as a sleep aid since ___, and that he has only had 3 drinks since ___.
Upon arrival at the ED initial vitals were: T96.3 P70 BP146/89
RR16 SaO299%. 12 hours after his reported consumption of
alcohol, his serum alcohol was 213. An initial EKG was sinus
rhythm and normal rate and axis. A Chest Xray was negative.
Labs were remarkable for Cr. 0.9, HCT 44.5, WBC 8.7. While in
the ED, he got up to go to the bathroom, and was straining to
urinate, he felt light headed, he fell (witnessed by son) nurse
arrived and there was no palpable pulse x 4 seconds, triggered,
got chest compression x 2 and woke up. He was diaphoretic,
clammy FSG 118, pulse reported as initially "slow" however when
EKG by the time EKG performed, rate was 120 with atrial
fibrillation. He was treated with diltiazem 10mg IV followed by
diltiazem 30 PO. He was then admitted to medicine.
On the floor his vitals were: 98.4, 116/66, irregular
tachycardia, RR 16, 95 RA. His telemetry and an EKG are
concerning for atrial fibrillation. with a HR range from 100 -
140. This morning he reports feeling well; he denies
lightheadedness, palpitations, fever, chills, SOB, chest pain,
nausea, vomitting, weakness.
Past Medical History:
-- CAD s/p IMI with PCI to RCA, EF 45%, inferior Qs on ECG
-- Hypertension
-- Hyperlipidemia
-- Ascending aortic aneurysm: MRI in ___ with normal appearing
graft, followed every ___ years, family h/o aortic aneurysms
s/p Appendectomy
-- Atrial fibrillation ___ on dabigatran with plan for
cardioversion however he resumed sinus
-- s/p appendectomy
s/p thumb surgery
Social History:
___
Family History:
Sister: ___
Father: pernicious anemia; died at age ___
Mother: died at age ___, unknown cause
Physical Exam:
GENERAL: The patient is sitting comfortably in bed, in no acute
distress.
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM. Fundus
visualized.
NECK: Supple, no tenderness over cervical spine no thyroid
nodules
HEART: irregular and rapid, no MRG, nl S1-S2.
LUNGS: CTA bilat, no ronchi/rales/wheezes, good air movement,
resp unlabored.
ABDOMEN: Soft/NT/ND, no rebound/guarding. Liver percussed to 2
cm below the rib cage.
EXTREMITIES: no edema 2+ peripheral pulses. No clubbing,
cyanosis. Strength ___ bilaterally throughout; gross sensation
normal; joint position sense normal. Vibration sense at medial
maleolus bilaterally. Reflexes 2+ bilaterally.
NEURO: Awake, A&Ox3, CNs II-XII grossly intact
Pertinent Results:
___ 09:30PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 05:15PM GLUCOSE-138* UREA N-14 CREAT-0.9 SODIUM-144
POTASSIUM-4.3 CHLORIDE-105 TOTAL CO2-27 ANION GAP-16
___ 05:15PM estGFR-Using this
___ 05:15PM CK(CPK)-115
___ 05:15PM cTropnT-<0.01
___ 05:15PM CK-MB-5
___ 05:15PM TSH-0.70
___ 05:15PM CALCIUM-8.8 PHOSPHATE-3.2 MAGNESIUM-2.1
___ 05:15PM WBC-8.7# RBC-4.74# HGB-14.8# HCT-44.5# MCV-94
MCH-31.3 MCHC-33.4 RDW-13.5
___ 05:15PM PLT COUNT-284
___ 05:15PM NEUTS-74.1* LYMPHS-17.2* MONOS-3.3 EOS-4.5*
BASOS-0.8
.
CXR
PORTABLE UPRIGHT AP VIEW OF THE CHEST: The patient is status
post median
sternotomy. The cardiac, mediastinal and hilar contours are
essentially
unchanged with tortuosity of the thoracic aorta again noted. The
pulmonary
vascularity is normal. The lungs are clear without focal
consolidation. No
pleural effusion or pneumothorax is seen. There is no cardiac
silhouette
enlargement. Degenerative changes of left glenohumeral and
acromioclavicular
joint are noted.
IMPRESSION: No acute cardiopulmonary abnormality.
Brief Hospital Course:
This is a ___ year old gentleman with a history of CAD s/p PCI,
Hypertension, aortic aneurysm s/p repair ___, and atrial
fibrillation ___ who presented with weakness and was found to
be in atrial fibrillation with rapid ventricular response.
.
# Atrial Fibrillation: This is the second documented occurence
of atrial fibrillation in this patient, both prompted by heavy
ETOH intake. He was initially in RVR though he was asymptomatic
on the floor with no e/o heart failure. We controlled his heart
rate with metoprolol and stopped his atenolol. We also started
dabigatran. We also encouraged him to avoid alcohol. As he has
been asymptomatic, it is unclear whether he has been going in
and out of Afib. At the request of Dr. ___
___ was consulted: they recommended continuing ASA and
dabigatran, rate contol with metoprolol, outpatient Echo and
follow-up with Dr. ___.
.
# CAD, native vessel: He was on aspirin, atorvastatin, and
atenolol on presentation. He did not have symptoms of ischemia
during this admission. His EKGs were without ischemic changes
and two sets of cardiac enzymes were negative strongly arguing
against ACS. We switched the atenolol to metoprolol as above. We
also started dabigatran for anticoagulation and continued his
full dose aspirin.
.
# Anxiety: The patient reports some increased anxiety involving
his son; social stress may have triggered the alcohol use.
Additionally, the patient states that he drank the alcohol as a
sleep aid because he was not comfortable with the side effects
of temazepam which he recently read on the medication insert.
Social work spoke with him and helped to provide him with
options for managing his life stresses. We also changed his
temazepam to ambien for sleep.
.
TRANSITIONAL ISSUES
-Pt may benefit from an echo as an outpatient.
-WBC up to 11 on last check, no sign of infection. Can
follow-up as outpatient.
Medications on Admission:
-- Atorvastatin 40 mg daily
-- Aspirin 325 mg Daily
-- Atenolol 25 mg Daily
-- Lisinopril 10 mg Daily
-- Amlodipine 5 mg Daily
-- Temazepam 30 mg QHS
-- Co-Q10 Dose unknown
-- B12 injection Q month
-- ___ 4g daily
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Co Q-10 Oral
5. Vitamin B-12 1,000 mcg/mL Solution Sig: One (1) Injection
once a month.
6. Lovaza 1 gram Capsule Sig: Four (4) Capsule PO once a day.
7. Ambien 10 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
Disp:*10 Tablet(s)* Refills:*0*
8. dabigatran etexilate 150 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
9. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
1.5 Tablet Extended Release 24 hrs PO once a day.
Disp:*45 Tablet Extended Release 24 hr(s)* Refills:*2*
10. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Atrial fibrillation
Secondary Diagnosis:
Coronary artery disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
Thank you for coming to the ___
___. You were admitted to the hospital for atrial
fibrillation. We changed your atenolol to metoprolol and started
dabigatran (pradaxa). You should follow up with your primary
doctor as well as your cardiologist, Dr. ___.
Medication Recommendations
Please STOP:
Atenolol
Temazepam
Please START:
Metoprolol succinate 75mg daily
Dabigatran (pradaxa) 150 mg twice daily
Ambien 10 mg at night as needed for sleep
Followup Instructions:
___
|
19555848-DS-5
| 19,555,848 | 26,649,600 |
DS
| 5 |
2115-04-24 00:00:00
|
2115-04-24 08:39:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
bee venom (honey bee)
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
PCP - none
___ with O2 depending COPD, acute/chronic PE/DVT not
anticoagulated due to large GIbleed in setting of small bowel
angioectasias, PAfib (not anticoagulated), BPH admitted from ED
for abdominal pain. Was at rehab in ___, ate dinner at
6pm. At 8pm developed acute onselt, mild abdominal pain which
increased over the following 4 hours. Was epigatric and
___ and associated with nausea without vomiting. He
was brought to ER where VSS and he was without fever. Alk phos
was elevated, as were AST/ALT and a lipase was 1498. A CT abd
showed (+) multiple gallstones, calcified pleural palques c/w
___ asbestosis and retained capsule in the cecum without
obstruction. He pain resolved prior to arrival to ER and he did
not require any pain medication, antiemetics or IVF.
ROS: no fever, chest pain, acute SOB, dizziness,
___, diarrhea. Other 12 point detail is negative.
Past Medical History:
- COPD (on home O2 2L)
- BPH
- Paroxysmal Atrial Fibrillation (not on anticoagulation)
diagnosed ___
- GI Bleed: 7U PRBC ___ - ___ EGD w/ ___ PUD at
GE junction, ___ mucosa, with focal surface foveolar
hyperplasia, (+) H pyori EGD s/p treatment, colonoscopy revealed
old blood and hemorrhoids, ___ readmission required 2U PRBC
more while on anticoagulation for acute PE (anticoag
___ Capsule Endoscopy - gastric erythema, mild
duodenal erythema, Jejunal angioectasias, Lymphangiectasias, No
active bleeding seen, capsule does not reach cecum.
- Acute / Chronic Pulmonary Embolism (not anticoagulated due to
bleeding)
Social History:
___
Family History:
No history DVTs or PEs in his family
Physical Exam:
97.5, 124/81, 70, 18, 98%2L
anicteric, op clear, neck supple, JVP flat
lungs w/ decreased breath sounds throughout
regular heart sounds, s1, s2 no MRG
abd soft, ___, mild distended with mild tympany --
passing gas
ext no palpable cords, no edema
neuro sits unassisted, moves all extremities against gravity, no
sensory disturbances, fluent speech, nl cognition
skin w/o rash
psych pleasant cooperative
Pertinent Results:
___ 02:15AM ___
___
___ 02:15AM ___
___ IM ___
___
___ 02:15AM PLT ___
___ 02:15AM ___
___ 02:15AM ALT(SGPT)-94* AST(SGOT)-221* ALK ___
TOT ___
___ 02:15AM ___ UREA ___
___ TOTAL ___ ANION ___
___ 02:15AM ___
___ 02:33AM ___
___ ABD CT:
IMPRESSION:
1. No acute ___ process. Specifically, no evidence
of
diverticulitis.
2. Capsule in the cecum, no evidence of bowel obstruction.
3. Cholelithiasis.
4. Calcified pleural plaques, consistent with prior asbestos
exposure.
5. Severe emphysema.
___ KUB: Capsule is still present and projects over the
right pelvis, likely in the region of the cecum. Nonobstructive
bowel gas pattern.
___ CXR: 1. Hyperinflated lungs, but no focal consolidation
seen.
2. Calcified pleural plaque at the lung bases.
Brief Hospital Course:
___ with O2 dependent COPD, pAfib, ch PE/DVT s/p IVC filter
___ not anticoagulated due to GIBleed risk presents with 4
hours of epigastric pain which resolved. Labs suggest acute
pancreatitis and possible passed gallstonestone, abdominal
imaging confirms gallstones. Patient is hungry and without
abdominal pain at this time
# acute pancratitis
# Ch COPD - stable
# Paroxysmal Afib
# chronic PE/DVT s/p IVC filter (not anticoagulated due to large
GIbleed)
# Angioectasias small intestine
# ___
___ course:
He was food challenged with a full, then regular, diet and
tolerated it well. He did not require pain medications. His home
medication regiment was continued (with Omeperazole moved down
to 20mg BID. LFTS were repeated and improved in AM. Patient
refused to go back to ___ rehab, CM to speak with patient.
He continues on chronic stable O2 at 2L via NC at rest, though
is deconditioned and dyspneic with exertion.
DVT ppx: SC heparin
CODE full
HCP = sister ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN sob
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob
3. Omeprazole 20 mg PO Frequency is Unknown
4. Digoxin 0.125 mg PO DAILY
5. Tiotropium Bromide 1 CAP IH DAILY
6. Fluticasone Propionate 110mcg 2 PUFF IH BID
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q4H sob
2. Albuterol Inhaler 2 PUFF IH Q4H sob
3. Digoxin 0.125 mg PO DAILY
4. Fluticasone Propionate 110mcg 2 PUFF IH BID
5. Omeprazole 20 mg PO BID
6. Tiotropium Bromide 1 CAP IH DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
ACUTE
*****
(mild) Acute gallstone pancreatitis
CHRONIC
********
COPD w/ O2 dependency
Subacute DVT/PE (not anticoagulated due to large GI bleed)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
You were admitted with history of 4 hours of epigastric pain and
nausea. Your labs suggested a possible gallstone that had passed
from the gallbladder and into your intestine causing mild acute
pancreatitis (the pain was likely from transient obstruction of
the biliary and pancreatic duct). Abdominal CT imaging showed
gallstones in your gallbladder. Your diet was advanced and
___ and you did not need any pain medication. Please
speak with your primary doctor about consideration for
outpatient cholecystectomy (gallbladder removal) should this
___. You have scheduled ___ with hematology
Followup Instructions:
___
|
19555886-DS-10
| 19,555,886 | 21,879,374 |
DS
| 10 |
2166-05-16 00:00:00
|
2166-05-16 16:20:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Plavix
Attending: ___.
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ yo ___ speaking M with a significant
PMHx of HFrEF, CAD with 3VD (pLAD 50%, pLCx 40%, RCA T.O), CKD
(baseline Cr 1.7-2.0), PVD s/p L SFA artherectomy and POBA
(___) and Carotid stenosis s/p b/l CEA (___), who presents
with worsening dyspnea and lower extremity edema.
He was in his usual state of health until ___, when he
developed a productive cough. His family gave him hot tea and
over the counter medications to alleviate his symptoms. His
cough worsened and later that evening he developed significant
orthopnea, describing that his cough and dyspnea improved while
sitting up. Over the next 2 days, he had poor PO intake,
lethargy, and weakness, and his cough continued to worsen. On
___, his daughter visited him and noted he was unable to
ambulate and had severe RLE edema. At baseline, he was able to
use a walker to walk on flat surfaces. Given the progression of
his symptoms, his daughter called ___ and he was brought to
___ ED for further evaluation.
Notably, his daughter notes he has gained weight from his
baseline (dry weight = 197 lbs). She denies any dietary
indiscretions or medication noncompliance. She states the
patient denied any chest pain, palpitations, or
presyncope/syncope.
In the ambulance, the patient was hypoxemic on NRB to 40%. On
arrival to ___ ED, the patient was pale, tachypneic and
dyspneic.
Past Medical History:
- CAD s/p NSTEMI per notes (ETT-Echo: 4.5' MB ___ METS),
stopped for claudication); cath in ___ with (3 vessel)
multivessel CAD, was recommended for CABG eval
- Carotid atherosclerosis s/p bilateral CEA
- h/o CVA
- PAD s/p bilateral SFA angioplasty, restenosis (ABI ___:
right TBI 0.34, left TBI 0.25)
- Diabetes with neuropathy and nephropathy
- Chronic kidney disease (baseline 1.7-2.0)
- guaiac pos stool on colon cancer screening
- GERD
- Colon Polyps on colonoscopy ___
- Iron deficiency anemia with normal endoscopy
- Vitamin D deficiency
Social History:
___
Family History:
Mother ___ ___ OLD AGE
Father ___ ___ OLD AGE
Brother ___ 35 OSTEOSARCOMA OF PELVIC BONE
Daughter Living ___ HEALTHY
Physical Exam:
Admission Physical Exam:
GENERAL: intubated and sedated.
HEENT: Sclera anicteric. PERRL. EOMI. Supple. +JVD 12cm at 45
degrees. b/l carotid endarterectomy scars.
CARDIAC: Normal rate, regular rhythm. No murmurs, rubs, or
gallops.
LUNGS: Respiration is unlabored with no accessory muscle use.
Auscultated in the anterior fields with no adventitious breath
sounds.
ABDOMEN: Obese, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: Warm, well perfused. 1+ pitting edema b/l (R>L) to
knees. No clubbing, cyanosis.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
Discharge Physical Exam:
HEENT: Sclera anicteric. PERRL. EOMI. Supple. +JVD 12cm at 45
degrees. b/l carotid endarterectomy scars.
CARDIAC: Normal rate, regular rhythm. No murmurs, rubs, or
gallops.
LUNGS: Respiration is unlabored with no accessory muscle use.
Auscultated in the anterior fields with no adventitious breath
sounds.
ABDOMEN: Obese, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: Warm, well perfused. No edema No clubbing,
cyanosis.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetr
Pertinent Results:
Admission Labs:
___ 06:09PM BLOOD WBC-13.4*# RBC-3.14* Hgb-9.5* Hct-29.2*
MCV-93 MCH-30.3 MCHC-32.5 RDW-16.7* RDWSD-56.4* Plt ___
___ 06:09PM BLOOD Neuts-77.3* Lymphs-12.4* Monos-9.2
Eos-0.0* Baso-0.2 Im ___ AbsNeut-10.39*# AbsLymp-1.66
AbsMono-1.24* AbsEos-0.00* AbsBaso-0.03
___ 06:09PM BLOOD ___ PTT-31.1 ___
___ 06:09PM BLOOD Glucose-320* UreaN-78* Creat-3.0* Na-132*
K-7.7* Cl-92* HCO3-21* AnGap-19*
___ 01:05AM BLOOD ALT-203* AST-152* LD(LDH)-441*
CK(CPK)-473* AlkPhos-74 TotBili-0.4
___ 06:09PM BLOOD ___
___ 01:05AM BLOOD CK-MB-24* MB Indx-5.1 cTropnT-1.48*
___ 06:14AM BLOOD CK-MB-21* MB Indx-4.9 cTropnT-1.51*
___ 12:46PM BLOOD CK-MB-17* MB Indx-4.8 cTropnT-1.45*
___ 06:09PM BLOOD Calcium-8.3* Phos-6.8* Mg-2.2
___ 07:42PM BLOOD Lactate-2.4* K-4.9
___ 01:25AM BLOOD Lactate-1.5
imaging:
___ CXR:
1. Standard positioning of the endotracheal and enteric tubes.
2. Moderate pulmonary edema and small layering right pleural
effusion.
3. Bibasilar airspace opacities, likely atelectasis.
___: Right lower extremity US:
No evidence of deep venous thrombosis in the right lower
extremity veins.
Soft tissue edema in the right calf.
___: ECHO
IMPRESSION: Mild symmetric left ventricular hypertrophy with
regional left ventricular systolic dysfunction c/w CAD. Normal
right ventricular cavity size and systolic function. Mild mitral
regurgitation.
Compared with the prior study (images reviewed) of ___,
more extensive regional left ventricular dysfunction is seen
involving the anterolateral wall and mid inferior wall with a
corresponding reduction in ejection fraction.
Discharge Labs:
___ 06:10AM BLOOD WBC-9.4 RBC-2.74* Hgb-8.2* Hct-25.0*
MCV-91 MCH-29.9 MCHC-32.8 RDW-15.3 RDWSD-49.7* Plt ___
___ 06:30AM BLOOD Glucose-198* UreaN-88* Creat-2.5* Na-138
K-4.7 Cl-97 HCO3-26 AnGap-15
Brief Hospital Course:
PATIENT SUMMARY
===============
Mr. ___ is a ___ yo ___ speaking M with a significant
PMHx of HFrEF, CAD with 3VD (pLAD 50%, pLCx 40%, RCA T.O), CKD
(baseline Cr 1.7-2.0), PVD s/p L SFA artherectomy and POBA
(___) and carotid stenosis s/p b/l CEA (___), admitted for
worsening dyspnea and intubated for hypoxemia, consistent with
Acute on Chronic Heart Failure Exacerbation.
#CORONARIES: (___)
Dominance: Right
LM- normal
LAD- mild luminal irregularities throughout (maximum 30%), 70%
small D1
LCx- 40% proximal, 100% large bifurcating OM1.
RCA- 80% mid, 100% distal. Distal RCA/R-PDA fill mainly via left
to right collaterals
No clear culprit lesion for NSTEMI-- may have been secondary to
demand ischemia (Type II MI) due to
OM1 or RCA CTOs in setting of acute resp illness
Recommendations
Given lack of progression of CAD plus the fact that the patient
denies progression of cardiac
symptoms, would cont
#PUMP: EF 50% to 55%
#RHYTHM: NSR
ACUTE ISSUES
=============
#Acute Hypoxemic Respiratory Distress
#Acute on Chronic Heart Failure
Presented with acute onset dyspnea, orthopnea, and ___ edema X 3
days along with elevated BNP and JVD. Etiology for exacerbation
likely iso respiratory infection, either viral URI vs.
pneumonia, given the patient's prodrome of a productive cough
and leukocytosis, leading to high output HF. UA negative for
infection. EKG with unlikely ischemia and no evidence of acute
STEMI. Trop T elevated, likely ___ demand. Intubated due to
hypoxemia. Started on Ceftriaxone/Azithromycin due to concern
for possible pneumonia. Diuresed to 82.6kg. Ultimately was able
to be extubated on hospital day 1. Of note, the patient also
underwent cardiac catheterization that showed stable coronary
disease with LAD- mild luminal irregularities throughout
(maximum 30%), 70% small D1 LCx- 40% proximal, 100% large
bifurcating OM1. RCA- 80% mid, 100% distal. Distal RCA/R-PDA
fill mainly via left to right collaterals No clear culprit
lesion for NSTEMI-- may have been secondary to demand ischemia
(Type II MI) due toOM1 or RCA CTOs in setting of acute resp
illness.
___ on CKD
Baseline Cr 1.7-2.0. ___ likely in the setting of venous
congestion, cardiorenal syndrome, from HF exacerbation.
Ultimately downtrended to baseline after aggressive diuresis.
Admission Cr 3.0, after diuresis discharge Cr 2.5.
#Transaminitis
Consistent with congestive hepatopathy. Down trending with
diuresis.
CHRONIC ISSUES
===============
#H/O Ischemic Cardiomyopathy
#Coronary Artery Disease
#PVD
Pt has known triple vessel CAD, and was previously worked up for
a CABG however he did not wish to pursue surgery. Additionally,
pt has carotid atherosclerosis s/p bilateral CEA, h/o CVA, PAD
s/p bilateral SFA angioplasty, restenosis (ABI ___: right
TBI 034, left TBI 025). No evidence of active ischemia.
Continued ASA, Atorvastatin.
#HTN
Initially held in the setting of hypotension secondary to
hypotension and acute heart failure. Discharged on carvedilol
25mg BID, hydralizine 100mg TID, amlodipine 10mg, and Imdur
120mg. Held home clonidine and labetolol.
#NIDDM
FSBG and ISS while in house
#Iron Deficiency Anemia
#H/o GI bleed
Baseline Hb approx 9.5.
TRANSITIONAL ISSUES
====================
[ ] New/changed Meds: started carvedilol 25mg BID; started
Plavix 75mg daily; hydralazine 100mg increased to TID; Torsemide
60mg daily.
[ ] Held/Stopped Meds: clonidine, labetolol, and furosemide.
[ ] Please repeat chem 10 at f/u to monitor Cr and electrolytes
[ ] discharge weight: 82.56 kg (182.01 lb)
[ ] trend volume status and titrate diuretics as clinically
indicated
Code: Full, confirmed
Contact: Daughter, ___ ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
2. Aspirin 325 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Calcitriol 0.25 mcg PO DAILY
5. Furosemide 40 mg PO DAILY
6. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY
7. Labetalol 100 mg PO BID
8. Vitamin D 1000 UNIT PO DAILY
9. Polyethylene Glycol 17 g PO DAILY
10. Omeprazole 40 mg PO BID
11. Clonidine Patch 0.1 mg/24 hr 1 PTCH TD 1X/WEEK (___)
12. Ferrous Sulfate 325 mg PO DAILY
13. GlipiZIDE XL 2.5 mg PO DAILY
14. HydrALAZINE 100 mg PO BID
15. dulaglutide 0.75 mg/0.5 mL subcutaneous weekly
16. MetFORMIN (Glucophage) 500 mg PO DAILY
Discharge Medications:
1. Carvedilol 25 mg PO BID
RX *carvedilol 25 mg 1 tablet(s) by mouth every 12 hours Disp
#*60 Tablet Refills:*0
2. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth every day Disp #*30
Tablet Refills:*0
3. Torsemide 60 mg PO DAILY
RX *torsemide [Demadex] 20 mg 3 tablet(s) by mouth daily Disp
#*90 Tablet Refills:*0
4. HydrALAZINE 100 mg PO TID
5. Amlodipine 10 mg PO DAILY
6. Aspirin 325 mg PO DAILY
7. Atorvastatin 80 mg PO QPM
8. Calcitriol 0.25 mcg PO DAILY
9. dulaglutide 0.75 mg/0.5 mL subcutaneous weekly
10. Ferrous Sulfate 325 mg PO DAILY
11. GlipiZIDE XL 2.5 mg PO DAILY
12. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY
13. MetFORMIN (Glucophage) 500 mg PO DAILY
14. Omeprazole 40 mg PO BID
15. Polyethylene Glycol 17 g PO DAILY
16. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
CHF exacerbation
Acute Hypoxemic Respiratory Distress
___ on CKD
Pneumonia
Secondary Diagnosis:
HTN
CAD
NIDDM
Iron Deficiency Anemia
Secondary Hyperparathyroidism
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 part in your care here at ___!
Why was I admitted to the hospital?
- You were having problems breathing and leg swelling; we
believe this was because you were having a flare of your
congestive heart failure
What was done for me in the hospital?
- You were given medication to help you urinate off the extra
fluid in your body; this made you feel better
- You were given antibiotics for a lung infection
- You had a procedure done to look at the vessels in your heart;
it looked similar to the last time you had this procedure and
showed you have heart disease.
What should I do when I leave the hospital?
- Please take all of your medicines and attend all of your
follow-up appointments.
- Your dry weight is 197 pounds; you should weigh yourself every
morning; if your weight goes up by 3 pounds in one day or 5
pounds in one week, please call your cardiologist
- If you have fevers, chills, chest pain, problems breathing,
worsening leg swelling, or generally feel unwell, please call
your doctor, or go to the emergency room.
We wish you the best of luck in your health!
Sincerely,
Your ___ Treatment Team
Followup Instructions:
___
|
19555886-DS-13
| 19,555,886 | 23,868,275 |
DS
| 13 |
2167-08-02 00:00:00
|
2167-08-03 07:49:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Plavix
Attending: ___.
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with hx of HTN, CAD, PVD, insulin-dependent T2DM, CKD
(baseline 2.5-3.0, RLE DVT (on apixaban), HFmrEF (45-50%
___, and recent cardiac arrest s/p ICD placement on ___
who presented in acute respiratory distress and hypoxia a few
hours after being discharged from ___ and ___
(___).
He was admitted to ___ on ___ after VT/VF
cardiac arrest with resultant placement of an ICD on ___. His
daughter reports that cardiac arrest happened while playing pool
when he fell. He received CPR and was shocked prior to reaching
the hospital. Admitted to the ICU requiring pressors. He was
noted to have a right leg DVT and was suspected to have had a
pulmonary embolism resulting in his arrest, although CT scan did
not show any evidence of this. ICD was placed on ___ and he
was started on amiodarone for presumed VT/VF arrest. His
hospital course was complicated by anemia which required 2 blood
transfusions. Most recent Hgb after discharge of 8.9. He was
started on apixaban 2.5 mg twice daily because of the right
lower extremity DVT.
He is followed by Dr. ___ his heart failure with reduced
ejection fraction. Per most recent clinic note on ___ as a
follow-up visit for acute heart failure and recent type II MI,
plan was to continue him on his torsemide 120 mg daily and
metolazone 2.5 mg as needed. Reported to use the metolazone on a
weekly basis at that time. Given his CKD with creatinine of
___ he was felt to have no room for RAAS blockade.
At the ___, his torsemide was listed as 60 mg
daily. Weight on his arrival to the rehab of 186.4 pounds.
Records show that his weight steadily increased ___ pounds per
day reaching a peak of 194.4 pounds on ___ and torsemide was
increased to 80 mg daily.
On the morning of presentation to the ___ ED, he had shortness
of breath and EMS was called. Placed him on BiPAP and put
Nitropaste on his chest with some improvement in his breathing.
Initial oxygen saturations were in the ___. He improved with
BiPAP and IV Lasix in addition to the Nitropaste. He was weaned
off the BiPAP to 2 L nasal cannula saturating 94%.
In the ED: - Initial vitals: 97.9 HR 50 184/46 RR 18 95% BiPAP
-EKG Sinus bradycardia (rate of 47) with 1st degree AV
conduction delay. Left ventricular hypertrophy with
repolarization abnormality; LBBB. Prolonged QT interval.
- Labs/studies notable for: 1) WBC 10.7 Hgb 11.0, plt 161 2)
Trop-T 0.08--> 0.13; MB 4 3) VBG: 7.32/59; lactate 0.8 4) Na 133
BUN 84 Cr 2.6 5) CHEST PORTABLE: Moderate cardiomegaly with
congestion and mild to moderate pulmonary edema.
- Patient was given: IV furosemide 80 mg x 1, isosorbide
mononitrate 120 ER, Carvedilol 25 mg, ASA 81, amlodipine 10 mg,
hydralazine 75 mg - Vitals on transfer: 98.7 HR 47 140/45 RR 17
97% 2L NC On the floor patient reports significant improvement
in his breathing. He continues to have lower extremity edema but
is breathing comfortably on 2L NC. He does not have any chest
pain. He reports that he never wanted to be resuscitated and
that if his heart were to stop again he would not want chest
compression are a breathing tube. REVIEW OF SYSTEMS: Cardiac
review of systems: See HPI.
On further review of systems, denies any prior history of
stroke, TIA, deep venous thrombosis, pulmonary embolism,
bleeding at the time of surgery, myalgias, joint pains, cough,
hemoptysis, black stools or red stools. Denies exertional
buttock or calf pain. Denies recent fevers, chills or rigors.
All of the other review of systems were negative.
Past Medical History:
1. Cardiac Risk Factors
- HTN
- NIDDM c/b retinopathy and neuropathy
- CKD with macroalbuminuria (baseline 2.5)
2. Cardiac History
- CAD s/p MI (___)
- p-MIBI (___): Inferior/lateral ischemia, LVEF 43%.
- HFmrEF, LVEF = 40-45 %
- Peripheral Vascular Disease
-Carotid stenosis s/p b/l CEA (___)
-L SFA artherectomy and POBA (___)
-CVA (___)
3. Other PMH
- Iron deficiency anemia
- GI bleed ___
- Renal Osteodystrophy
- Secondary hyperparathyroidism
- RLE DVT
- Gout
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
Physical Exam:
ADMISSION EXAM
==============
VITALS: ___ 1224 Temp: 98.2 BP: 145/60 R Lying HR: 47 RR:
18 O2 sat: 97% O2 delivery: 2l FSBG: 113
GENERAL: Elderly male in no acute distress
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink, no
pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP of 12 cm.
CARDIAC: Bradycardic. Regular rhythm. Normal S1, S2. No
murmurs/rubs/gallops. R chest well ICD pocket clean, dry,
intact.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: 2+ pitting edema to the knees bilaterally.
SKIN: Scattered ecchymoses of the upper extremites.
PULSES: Distal pulses palpable and symmetric
DISHCARGE EXAM
==============
___ 2347 Temp: 97.8 PO BP: 128/50 HR: 44 RR: 18 O2 sat: 95%
O2 delivery: Ra
GENERAL: NAD
Neck: JVP flat
CARDIAC: Bradycardic. RRR, nl s1/s2, no m/r/g
LUNGS: CTAB
ABDOMEN: NT/ND
EXTREMITIES: 1+ edema of RLE to the knee.
Neuro: AOx3
Pertinent Results:
ADMISSION LABS
==============
___ 06:52PM BLOOD WBC-10.7* RBC-3.51* Hgb-11.0* Hct-33.8*
MCV-96 MCH-31.3 MCHC-32.5 RDW-17.0* RDWSD-59.8* Plt ___
___ 06:52PM BLOOD Neuts-85.5* Lymphs-5.2* Monos-6.6
Eos-0.8* Baso-0.4 Im ___ AbsNeut-9.13* AbsLymp-0.55*
AbsMono-0.70 AbsEos-0.09 AbsBaso-0.04
___ 06:52PM BLOOD Glucose-166* UreaN-84* Creat-2.6* Na-133*
K-5.2 Cl-92* HCO3-25 AnGap-16
___ 06:52PM BLOOD cTropnT-0.08*
___ 06:52PM BLOOD CK-MB-4
___ 01:32AM BLOOD cTropnT-0.13*
___ 06:41AM BLOOD CK-MB-3
___ 03:14PM BLOOD Calcium-8.9 Phos-4.2 Mg-2.4
___ 06:59PM BLOOD ___ pO2-42* pCO2-59* pH-7.32*
calTCO2-32* Base XS-1
___ 06:59PM BLOOD O2 Sat-69
___ 06:59PM BLOOD Lactate-0.8
INTERVAL LABS
=============
___ 11:27AM BLOOD %HbA1c-6.5* eAG-140*
DISCHARGE LABS
===============
___ 07:20AM BLOOD WBC-4.9 RBC-3.04* Hgb-9.6* Hct-29.0*
MCV-95 MCH-31.6 MCHC-33.1 RDW-15.5 RDWSD-54.0* Plt ___
___ 07:20AM BLOOD Glucose-83 UreaN-82* Creat-3.8* Na-133*
K-5.2 Cl-85* HCO3-29 AnGap-19*
___ 07:20AM BLOOD Calcium-8.7 Phos-4.4 Mg-3.8*
IMAGING
=======
CHEST PORTABLE AP (___)
AP portable upright view of the chest. Left chest wall AICD is
in place with single lead extending to the region the right
ventricle. Cardiomegaly is moderate. There is pulmonary
vascular congestion and mild to moderate
pulmonary edema. No large effusion is seen though the CP angles
are excluded. There is no pneumothorax. Bony structures are
intact. Surgical clips are noted in the left neck.
IMPRESSION: Moderate cardiomegaly with congestion and mild to
moderate pulmonary edema.
TTE (___)
The left atrial volume index is mildly increased. The right
atrium is mildly enlarged. There is no evidence ___ atrial
septal defect by 2D/color Doppler. The estimated right atrial
pressure is >15mmHg. There is mildsymmetric left ventricular
hypertrophy with a normal cavity size. There is normal regional
and global leftventricular systolic function.Quantitative
biplane left ventricular ejection fraction is 67 %.There is
noresting left ventricular outflow tract gradient. Tissue
Doppler suggests an increased left ventricular fillingpressure
(PCWP greater than 18 mmHg). Normal right ventricular cavity
size with normal free wall motion.Tricuspid annular plane
systolic excursion (TAPSE) is normal. The aortic sinus diameter
is normal for genderwith normal ascending aorta diameter for
gender. There is a normal descending aorta diameter. The
aorticvalve leaflets (3) are mildly thickened. There is no
aortic valve stenosis. There is no aortic regurgitation.
Themitral valve leaflets are mildly thickened with no mitral
valve prolapse. There is mild to moderate ___
regurgitation. The pulmonic valve leaflets are normal. The
tricuspid valve leaflets appear structurallynormal. There is
physiologic tricuspid regurgitation. Due to acoustic shadowing,
the severity of tricuspidregurgitation may be UNDERestimated.
The pulmonary artery systolic pressure could not be estimated.
Thereis no pericardial effusion.IMPRESSION: Mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global biventricular systolic function. Mild-moderate
mitral regurgitation. Increased right atrialpressure.Compared
with the prior TTE(images not available for review) of
___, the left ventricular systolicfunction is now
improved/normal.
PHARM STRESS (___)
INTERPRETATION: ___ yo man with HL, HTN, DM, CKD IV, PVD, s/p MI
and h/o 3-vessel CAD, chronic systolic CHF now recovered and
acute on chronic diastolic CHF was referred to evaluate his
shortness of breath and exclusively evaluate for anterior wall
myocardial ischemia. The patient was administered 0.4 mg
Regadenoson IV bolus over 20 seconds. No chest, back, neck or
arm discomforts were reported. During the procedure, 0.5-1 mm
horizontal/downsloping ST segment depression was noted in leads
II, V5 and V6. These ST segment changes persisted post-infusion
despite the administration of 60 mg caffeine IV and were nearly
resolved 20 minutes post-infusion. The rhythm was sinus with
rare isolated APBs and VPBs. The hemodynamic response to the
Regadenoson infusion was appropriate. IMPRESSION: Ischemic ST
segment changes persisting late post-infusion in the absence of
anginal symptoms. Nuclear report sent separately.
CARDIAC PERFUSION IMAGING (___)
IMPRESSION: 1. Moderate inferolateral, lateral and basal
portion of the
inferior wall partially reversible myocardial perfusion defects.
2. Global
hypokinesis with ejection fraction of 35%.
There has been a reduction in the ejection fraction (43%-35%)
and increase in
the end diastolic volume (161 ml-183 ml) since the prior study
in ___.
___ KUB
Nonspecific bowel gas pattern with moderate to large fecal
loading noted
within the ascending colon.
Brief Hospital Course:
___ with hx of HTN, CAD, PVD, type-II diabetes mellitus (on
insulin), CKD stage IV (baseline 2.5-3.0), RLE DVT (on
apixaban), CAD ___ LAD mild luminal irregularities
throughout (maximum 30%), 70% small D1; LCx 40% proximal, 100%
large bifurcating OM1; RCA 80% mid, 100% distal), HFmrEF (45-50%
___, and recent cardiac arrest s/p ICD placement on ___
who presented with acute hypoxemic respiratory failure in the
setting of acute on chronic heart failure exacerbation. He was
diuresed to a dry weight of 185 pounds. He will be discharged
with close cardiology follow up.
TRANSITIONAL ISSUES
===================
PCP:
[ ]#RLE DVT: Hospitalization for cardiac arrest recently was
notable for right lower extremity DVT for which he was started
on apixaban. Per ___ records, joint decision between
primary team and nephrology to place on reduced dose apixiban
(2.5 BID) for 3 month period (___).
[ ]___ discussions: Patient DNR/DNI but with recent ICD placed.
Would continue discussions regarding his goals of care.
[ ]Clonidine increased to .4 TID for hypertension, but should be
downtitrated as tolerated
Cardiology:
[ ] Weight 185 lbs at d/c, Cr 3.8. Patient Bradycardic in mid
40's at baseline
[ ] Given small ___ (Cr 3.8) and euvolemia at time of discharge,
torsemide was held. At ___ appointment, he should have a BMP
checked and strongly consider restarting torsemide, likely at a
dose of 40-60 mg daily, with close follow up for up-titration if
needed
[ ] EP follow-up: Has follow up scheduled in ___ clinic at ___.
___ ___
Rheumatology:
[ ] Home prophylactic prednisone 5mg was discontinued after
discussion with his outpatient cardiologist and rheumatologist
(due to concern of it precipitating volume overload). Patient
should have uric acid level checked ___ weeks after discharge
and faxed to his rheumatologist (Dr. ___,
___
[ ] Allopurinol was dosed reduced to 100 mg daily given ___, but
should be increased back to 300 mg daily if renal function
recovers
ACTIVE ISSUES
==============
#Acute on chronic diastolic HF (HF recovered EF)
#Acute hypoxemic respiratory failure
Likely secondary to insufficient diuretic dosing at rehab after
recent cardiac arrest(received 60 mg torsemide down from prior
dose of 120 daily). TTE EF this admission increased to 67% from
prior of 40-45% which seems out of proportion to LVEF 40-45% in
___ given CTOs. He was diuresed with IV Lasix from
admission weight of 85.5 kg to discharge dry weight of 84 kg
(185 lbs). P-MIBI was obtained to evaluate if evidence of new
anterior ischemia in which case would proceed with coronary
angiography; MIBI ultimately demonstrated only perfusion defects
of the inferolateral, lateral and basal portion of the inferior
wall consistent with prior known CAD, therefore cath was not
pursued. Continued home imdur 120 mg QD, Hydralazine 100 mg TID,
amlodipine 10 mg daily, clonidine increased to 0.4 mg TID.
Started spironolactone 25mg. Held home carvedilol in the setting
of bradycardia and 1st degree AV nodal conduction delay.
#Recent cardiac arrest
He had an ICD placed on ___ ___. Was also
started on amiodarone 200 mg daily. Patient did not undergo
cardiac catheterization/coronary angiography at the outside
hospital. Ordered for P-MIBI to evaluate if evidence of new
anterior ischemia as above; MIBI ultimately demonstrated only
perfusion defects of the inferolateral, lateral and basal
portion of the inferior wall consistent with prior known CAD,
therefore cath was not pursued. ICD placed ___ (single lead,
___ was interrogated by EP and showed functionality, no
arrhthymias.
#Type 2 DM
Suboptimal glucose control during inital period of this
admission (although HbA1c 6.5%). ___ was consulted to guide
insulin regimen.
#RLE DVT
Hospitalization for cardiac arrest recently was notable for
right lower extremity DVT for which he was started on apixaban.
Per ___ records, joint decision between primary team and
nephrology to place on reduced dose apixiban for 3 month period
(after 1 week of 5 mg BID) due to his CKD stage IV. Continued
apixaban 2.5 mg BID.
#Sinus bradycardia with 1st degree AV conduction delay
Sinus bradycardia and first-degree AV conduction delay have been
noted in past EKGs but not the most recent one prior to this
admission. ___ be exacerbated by beta blockade from amiodarone.
Carvedilol was discontinued in this setting.
#Code status
Patient reports that he would like to be DNR/DNI although he had
an ICD placed on ___. Code status was temporarily reversed
for MIBI and then reverted to DNR/DNI.
CHRONIC ISSUES
==============
#CKD (stage IV) baseline creatinine 2.5-3.0
Likely secondary to HTN and DM. At baseline. Continued home
calcitriol 0.25 mcg QD.
#Chronic Anemia
Patient had a GI bleed with work up ___ significant for
jejunal AVMs found that were non-bleeding with no other
potential source of bleed found on EGD, colonoscopy, and capsule
study. Most recent hospitalization for cardiac arrest required 2
units of PRBCs. Hgb this admission is stable. Continued home
ferrous sulfate 325 mg QD.
#CAD
Known 3 vessel CAD (CTO RCA and OM with likely inferior scar;
small diagonal diseased in ___. No clinical suspicion at time
of cardiac arrest of anterior STEMI, but cannot exclude disease
progression since ___ as above. Continued home aspirin
81 mg QD. Continued home atorvastatin 80 mg QD.
#Gout
Recently seen by his rheumatologist on ___. At that time his
medication regimen was titrated to prophylaxis of 300 mg
allopurinol daily and 5 mg prednisone daily. Continue
allopurinol ___ mg daily. Discontinued prednisone during this
admission per discussion with outpatient
rheumatologist/cardiologist given reassuring uric acid level
inpatient; will have uric acid checked as outpatient after
discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. amLODIPine 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Calcitriol 0.25 mcg PO DAILY
6. CARVedilol 3.125 mg PO BID
7. Ferrous Sulfate 325 mg PO DAILY
8. HydrALAZINE 100 mg PO TID
9. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY
10. GlipiZIDE XL 2.5 mg PO DAILY
11. Torsemide 80 mg PO DAILY
12. Glargine 23 Units Breakfast
Humalog 7 Units Lunch
Humalog 7 Units Dinner
Humalog 7 Units Bedtime
13. CloNIDine 0.1 mg PO TID
14. melatonin 3 mg oral QPM
15. Omeprazole 20 mg PO DAILY
16. PredniSONE 5 mg PO DAILY
17. Apixaban 2.5 mg PO BID
18. Senna with Docusate Sodium (sennosides-docusate sodium)
8.6-50 mg oral DAILY
19. Amiodarone 200 mg PO DAILY
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. CloNIDine 0.4 mg PO TID
3. Glargine 21 Units Breakfast
Humalog 8 Units Breakfast
Humalog 6 Units Lunch
Humalog 6 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
4. Amiodarone 200 mg PO DAILY
5. amLODIPine 10 mg PO DAILY
6. Apixaban 2.5 mg PO BID
7. Aspirin 81 mg PO DAILY
8. Atorvastatin 80 mg PO QPM
9. Calcitriol 0.25 mcg PO DAILY
10. Ferrous Sulfate 325 mg PO DAILY
11. GlipiZIDE XL 2.5 mg PO DAILY
12. HydrALAZINE 100 mg PO TID
13. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY
14. melatonin 3 mg oral QPM
15. Omeprazole 20 mg PO DAILY
16. Senna with Docusate Sodium (sennosides-docusate sodium)
8.6-50 mg oral DAILY
17. HELD- Torsemide 80 mg PO DAILY This medication was held. Do
not restart Torsemide until instructed to by your visiting nurse
or physician
___:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Acute on chronic heart failure with preserved ejection fraction
Secondary diagnosis:
CKD stage IV
Hypertension
Sinus bradycardia
Coronary artery disease
Thrombocytopenia
Right lower extremity DVT
Type II diabetes mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at the ___
___!
Why was I admitted to the hospital?
=================================
- You were admitted because you had shortness of breath.
What happened while I was in the hospital?
====================================
- You were given medications through the IV to remove the excess
fluid from your body which was making you short of breath.
You had an imaging study of the blood vessels that supply
oxygen to your heart which did not show any new heart disease
What should I do after leaving the hospital?
====================================
- Please take your medications as listed in discharge summary
and follow up at the listed appointments.
- Please weigh yourself every day in the morning after you go to
the bathroom and before you get dressed. If your weight goes up
by more than 3 lbs in 1 day or more than 5 lbs in 3 days, please
call your heart doctor or your primary care doctor and alert
them to this change.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Sincerely,
Your ___ Healthcare Team
Followup Instructions:
___
|
19555886-DS-9
| 19,555,886 | 21,666,117 |
DS
| 9 |
2164-06-24 00:00:00
|
2164-06-30 14:49:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Plavix
Attending: ___.
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
EGD
Colonoscopy
Small Bowel Capsule
History of Present Illness:
___ ___ speaking male vasculopath with PMHx systolic CHF (EF
45% on stress echo in ___, no prior exacerbations) CAD (NSTEMI
IN ___, no intervention), PAD (h/o bilateral SFA angioplasty),
T2DM, CVA
s/p bilateral CEA ,anemia and a prior history of upper GI bleed
years ago who presented on ___ w/ one week of worsening
weakness.
The patient and his daughter report that he has been having
significant dyspnea on exertion for approximately one week,
generalized weakness, noticed black stools starting
approximately one day ago. Does not know if he had been having
dark stools prior to this. He denies any chest pain, but
endorses a left chest ache and lightheadedness. He was
prescribed iron pills by his gastroenterologist due to her
history of anemia, however, he discontinued this medication last
___ over confusion that he did not need to take them anymore
in the setting of receiving iron infusions IV. Patient denied
abdominal pain, vomiting, dysuria.
On arrival to the the ED, patients initial vitals: 98.9 57
126/38 18 98% RA
His exam was significant for: pale appearance, Conjunctival
pallor, Guaiac positive melanotic stool, Bilateral lower
extremity edema.
Labs were significant for :
5.8**
5.9 >--< 191
19.0
MCV87
N:72.9 L:11.6 M:9.1 E:5.7 Bas:0.5 ___: 0.2 Absneut: 4.32
Abslymp: 0.69 Absmono: 0.54 Abseos: 0.34 Absbaso: 0.03
138 105 83
--------------< 254 AGap=16
4.3 21** 2.2**
proBNP: 2267
UA with trace protein otherwise negative
Patient was given IV Pantoprazole 40mg IV bolus and started on
IV pantoprazole ggt, Furosemide 20mg, transfused 1 unit of PRBC
Imaging showed
- CXR Mild pulmonary vascular engorgement.
EKG: Sinus brady@54 NA IVCD <1mm ST elevation III ST depressions
lateral leads, TWI I V4-V6
Former EKG ___: SB 52/min, PR 200, LVH with secondary
repolarization abnormalities. (No ST changes, TWI I, aVL, V4-6)
Patient went for EGD which was significant for:
Erythema in the antrum consistent with gastritis. Very small
nonbleeding erosions in the fundus. Non-bleeding angioectasia in
the duodenal bulb. (thermal therapy) Otherwise normal EGD to
third part of the duodenum.
Vitals prior to transfer
98.8 56 136/44 15 99% RA
On the floor, patient is feeling well and has no complaints. He
denies any Chest pain, diarrhea, nausea, vomiting, abdominal
pain, dysuria, hematuria.
ROS: see HPI, otherwise negative
Past Medical History:
- CAD s/p NSTEMI per notes (ETT-Echo: 4.5' MB ___ METS),
stopped for claudication); cath in ___ with (3 vessel)
multivessel CAD, was recommended for CABG eval
- Carotid atherosclerosis s/p bilateral CEA
- h/o CVA
- PAD s/p bilateral SFA angioplasty, restenosis (ABI ___:
right TBI 0.34, left TBI 0.25)
- Diabetes with neuropathy and nephropathy
- Chronic kidney disease (baseline 1.7-2.0)
- guaiac pos stool on colon cancer screening
- GERD
- Colon Polyps on colonoscopy ___
- Iron deficiency anemia with normal endoscopy
- Vitamin D deficiency
Social History:
___
Family History:
Mother ___ ___ OLD AGE
Father ___ ___ OLD AGE
Brother ___ ___ OSTEOSARCOMA OF PELVIC BONE
Daughter Living ___ HEALTHY
Physical Exam:
ADMISSION PHYSICAL EXAM
==============
VS: 98.2 149/51 58 20 100RA
GEN: Alert, lying in bed, no acute distress
HEENT: MMM, anicteric sclera, with positive conjunctival pallor,
and xanthomas on bilateral conjunctiva.
NECK: Supple without LAD
PULM: Clear, no wheeze, rales, or rhonchi
COR: bradycardic, regular rhythm, normal S1, soft S2, no
murmurs, no gallops
ABD: Soft, NT ND, hypoactive BS
EXTREM: Warm, 3+ bilateral lower extremity edema, hair loss up
to mid shin.
NEURO: CN II-XII grossly intact, motor function grossly normal
DISCHARGE PHYSICAL EXAM:
==============
Vitals: 98.1 163/48 51 15 96%RA
GEN: Alert, no acute distress
HEENT: MMM, anicteric sclera
PULM: Clear, no wheeze, rales, or rhonchi
COR: regular rhythm, normal S1, soft S2, no murmurs
ABD: Soft, NT ND, hypoactive BS
EXTREM: Warm, no edema,
NEURO: AOx3 motor function grossly normal
Pertinent Results:
ADMISSION LABS
==============
___ 11:45AM BLOOD WBC-5.9 RBC-2.19*# Hgb-5.8*# Hct-19.0*#
MCV-87# MCH-26.5# MCHC-30.5* RDW-15.5 RDWSD-49.5* Plt ___
___ 11:45AM BLOOD Neuts-72.9* Lymphs-11.6* Monos-9.1
Eos-5.7 Baso-0.5 Im ___ AbsNeut-4.32 AbsLymp-0.69*
AbsMono-0.54 AbsEos-0.34 AbsBaso-0.03
___ 09:12PM BLOOD ___ PTT-30.9 ___
___ 11:45AM BLOOD Glucose-254* UreaN-83* Creat-2.2* Na-138
K-4.3 Cl-105 HCO3-21* AnGap-16
___ 11:45AM BLOOD proBNP-2267*
___ 07:10AM BLOOD Calcium-9.1 Phos-4.7* Mg-2.3
___ 09:12PM BLOOD calTIBC-363 ___ Ferritn-9.3*
TRF-279
___ 08:55AM BLOOD tTG-IgA-1
___ 11:45AM URINE Color-Yellow Appear-Clear Sp ___
___ 11:45AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 11:45AM URINE RBC-3* WBC-0 Bacteri-NONE Yeast-NONE
Epi-<1
PERTINENT/DISCHARGE LABS
===================
___ 09:12PM BLOOD WBC-6.8 RBC-2.50* Hgb-6.8* Hct-21.2*
MCV-85 MCH-27.2 MCHC-32.1 RDW-15.2 RDWSD-46.6* Plt ___
___ 07:25AM BLOOD WBC-10.4* RBC-3.46* Hgb-9.5* Hct-29.9*
MCV-86 MCH-27.5 MCHC-31.8* RDW-15.2 RDWSD-47.7* Plt ___
___ 06:56AM BLOOD WBC-6.7 RBC-3.23* Hgb-8.7* Hct-27.8*
MCV-86 MCH-26.9 MCHC-31.3* RDW-14.6 RDWSD-46.3 Plt ___
___ 06:56AM BLOOD ___ PTT-31.7 ___
___ 06:56AM BLOOD Glucose-131* UreaN-27* Creat-1.5* Na-140
K-3.9 Cl-107 HCO3-23 AnGap-14
___ 06:56AM BLOOD Calcium-8.7 Phos-3.9 Mg-2.0
MICRO
====================
HELICOBACTER ANTIGEN DETECTION, STOOL
Test Result Reference
Range/Units
HELICOBACTER PYLORI AG, EIA, SEE NOTE
STOOL
HELICOBACTER PYLORI AG, EIA, STOOL
MICRO NUMBER: ___
TEST STATUS: FINAL
SPECIMEN SOURCE: STOOL
SPECIMEN QUALITY: ADEQUATE
RESULT: Not Detected
Antimicrobials, proton pump inhibitors, and
bismuth preparations inhibit H. pylori and
ingestion up to two weeks prior to testing
may
cause false negative results. If clinically
indicated the test should be repeated on a
new
specimen obtained two weeks after
discontinuing
treatment.
IMAGING
==========
FINDINGS:
Cardiac silhouette size is mildly enlarged. The mediastinal and
hilar
contours are similar. There is mild pulmonary vascular
congestion, improved
compared to the previous study. No focal consolidation, pleural
effusion or
pneumothorax is present. Linear opacities within the right mid
lung field may
reflect areas of atelectasis or scarring. Clips are
demonstrated in the left
aspect of the neck. There are moderate degenerative changes
seen in the
thoracic spine.
IMPRESSION:
Mild pulmonary vascular engorgement.
Brief Hospital Course:
___ ___ speaking male vasculopath with PMHx CHF (EF 50-55% on
stress echo in ___ CAD (NSTEMI IN ___, no intervention),
PAD(h/o bilateral SFA angioplasty), T2DM, CVA s/p bilateral CEA
,anemia and a prior history of upper GI bleed years ago
presented with one week of worsening generalized weakness,
dyspnea on exertion and melena found to be anemic (Hb 5.8).
Active Issues
=============
#Gastrointestinal Bleed: Patient with hx of melena and guaiac +
stool and profound anemia concerning for GI bleed found to be
anemic (Hb 5.8). Patient underwent EGD with Duodenal
angioectasia and ulcerations however this was not convincing as
source of blood loss per GI. He was transfused 3 units PRBC. He
underwent a colonoscopy with difficult prep with no evidence of
bleeding. He had a small bowel capsule endoscopy that on
preliminary read had no evidence of bleeding. Patient was
treated with IV PPI and transitioned to oral PPI.
# Iron deficiency Anemia: History of iron deficiency anemia
(Ferritin 15 on ___ with baseline Hb of 9.5-12. Was supposed
to be on Iron replacement but had not been taking it. Iron
studies during hospital stay were significant for profound iron
deficiency (Ferritin 9.3 Iron 16). Patient was transfused 3
units of PRBC and given 1 dose of IV ferric glucanate prior to
discharge. He will need continued iron therapy
#Diastolic CHF Exacerbation: Patient with bilateral lower
extremity edema that was more than his baseline with elevated
proBNP and pulmonary edema on CXR. Patient had been compliant
with his medications. He was diuresed with IV lasix. His edema
and pulmonary exam improved. He was discharged on home dose of
PO lasix that may need to be uptitrated. Discharge weight
85.7Kg.
#CAD/PVD- Hx of CAD s/p NSTEMI; cath in ___ with multivessel
CAD. EKG on admission demonstrates lateral T-wave inversions
and ST depressions which are slightly more significant than
prior. Concerning for demand ischemia in the setting of profound
anemia and known CAD. Patient had no active chest pain during
hospital stay. Repeat EKG showed improvement of ST depressions
in V4-V6. Patient continued on atorvastatin 80mg daily. Aspirin
325mg was initially held but was restarted during hospital stay
given high risk of CAD. Transfused for Hgb<8.
Chronic Issues
============
#Hypertension: patient was continued on Isosorbide Mononitrate
(Extended Release) 120 mg PO DAILY and Hydralazine 25 mg PO
BID. Labetalol and amlodipine were held initially in setting of
GI bleed. They were restarted on discharged.
# Type 2 Diabetes with neuropathy: Patient with A1C of 7.1,
GlipiZIDE 10 mg PO BID was held while inpatient and started on
SSI. Restarted on glipizide when discharged.
# Stage IIIB CKD with macroalbuminuria (baseline 1.7-2.0) and
peripheral neuropathy- patient presented with elevated
creatinine that improved with diuresis back to baseline.
# GERD: EGD with evidence of erosions and gastritis. H.pylori
stool antigen pending at discharge. Patient was on IV PPI BID
while inpatient and transitioned to PPI oral BID for 6 weeks
which should continue at least till follow up with GI.
# CODE STATUS: Full Code
# CONTACT: Daughter ___ ___
TRANSITIONAL ISSUES
====================
- iron deficiency anemia- patients iron deficit on admission was
calculated and patient still deficient after 3 units of PRBCs
and 1 dose of IV ferric gluconate
- Patient will need outpatient iron transfusion
- H.pylori stool antigen negative
- continue 40mg Omeprazole BID till follow up with
gastroentrology.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Labetalol 100 mg PO BID
2. Amlodipine 10 mg PO DAILY
3. HydrALAzine 25 mg PO BID
4. Atorvastatin 80 mg PO QPM
5. Furosemide 20 mg PO BID
6. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY
7. Omeprazole 40 mg PO DAILY
8. Aspirin 325 mg PO DAILY
9. GlipiZIDE 10 mg PO BID
10. Calcitriol 0.25 mcg PO EVERY OTHER DAY
11. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Aspirin 325 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Calcitriol 0.25 mcg PO EVERY OTHER DAY
5. Furosemide 20 mg PO BID
6. HydrALAzine 25 mg PO BID
7. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY
8. Labetalol 100 mg PO BID
9. GlipiZIDE 10 mg PO BID
10. Vitamin D 1000 UNIT PO DAILY
11. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram/dose 17g powder(s) by mouth
daily Refills:*0
12. Omeprazole 40 mg PO BID
RX *omeprazole 40 mg 1 capsule(s) by mouth twice daily Disp #*60
Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY: Gastrointestinal Bleed
SECONDARY: Iron deficiency anemia, diastolic CHF, HTN, DM, CAD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at the ___
___. You were hospitalized for low blood
counts. It was suspected that you were likely bleeding. You were
transfused 3 units of blood. You symptoms improved. You
underwent endoscopy and were found to have erosions in your
stomach. You had a colonoscopy that showed no evidence of
bleeding. You also had a capsule study that showed some blood
vessels but no evidence of active bleeding.
You should talk to your doctor about iron supplementation as an
outpatient. You will need to follow up with the gastroenterology
doctors for your stomach ulcers.
Please continue to take your medications as prescribed.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs please call your doctor. Discharge weight 85.7kg or
188lbs.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19555898-DS-16
| 19,555,898 | 26,722,568 |
DS
| 16 |
2176-09-03 00:00:00
|
2176-09-04 16:54:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HISTORY OF PRESENT ILLNESS: Ms. ___ is an ___ y/o female with
PMH notable for colovesical fistula (dx. ___ with residual
perineal/perianal skin maceration, severe malnutrition, severe
constipation, hx. of frequent UTIs often refusing antibiotics,
and hx. of recurrent CDiff who presents with lightheadedness and
abdominal pain.
Of note, pt. was recently admitted and discharged AMA on ___
from ___. There she was diagnosed with UTI ___
UCx grew pseudomonas CFUs>100 (sensitive to ceftazidime,
gentamycin, imipenem, zosyn, ampikacin, meropenem; resistant to
ciprofloxacin, levofloxacin; intermediate aztreonam), CDiff
negative on ___. A PICC line was recommended however
patient/family refused. She then left AMA.
On day of presentation today, pt. presented with lightheadedness
and abdominal pain. She awoke today and on standing noted
lightheadedness that quickly resolved. She also noted ongoing
abdominal pain, mostly localized in the suprapubic region. She
also had ongoing lightheadedness with sitting up and standing.
She denies chest pain, no shortness of breath, no new cough, no
nausea or vomiting, fevers, chills. No dysuria although notes
increased frequency (baseline incontinent).
In the ED, initial vitals were: 100.2 ___ 16 99%
- Labs were significant for UA w/>182 WBC, large leuks, negative
nitrites, lactate 2.2, BUN 21, blood cx pending, WBC 5.1
- Imaging revealed CXR without no acute cardiopulmonary process.
- The patient was given 1L NS and 1gram ceftriaxone
Vitals prior to transfer were: 98.9 ___ 18 99% RA
Upon arrival to the floor, pt. feels well. No longer with
lightheadedness. Mild suprapubic abdominal pain.
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. No recent change in bowel habits. No dysuria.
Denies arthralgias or myalgias.
Past Medical History:
- Hemmorhoidectomy ___
- Colovesical Fistula complicated by significant
perianal/perineal skin maceration (evaluated by
colorectal/urology ___ and offerred extensive surgical
repair, family elected not to proceed at this time)
- R ureteral trauma (initial injury ___ foley cath ___
s/p removal of nephrostomy tube (___)
- H/O Recurrent CDiff Colitis (Dx. ___
- Recurrent UTIs
- Rectal prolapse
- GERD
- Anemia
- Nephrolithiasis
- Hx of severe constipation complicated by rectal vault
distension
- Hx of severe malnutrition
Social History:
___
Family History:
Unable to answer
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
Vitals: 97.9, 101/69, 96, 16, 100% on RA
General: Cachectic, alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, mildly distended in suprapubic
region, bowel sounds present, no organomegaly, no rebound or
guarding
GU: No foley, no evidence of large skin wound on gross exam
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.
PHYSICAL EXAM ON DISCHARGE:
Vitals: Tc 97.6 BP 96/61 HR 85 RR 16 98%RA
I/O: 24 H 1580 PO + 1100 IV/incontinent, since MN 0/incontinent
General: very cachetic, AAOx3, in NAD
HEENT: MMM, conjuctiva pink, EOMI, PERRL.
Lungs: decreased breath sounds R base, otherwise clear, no
wheezes or crackles
CV: RRR, normal S1 and S2, no m/g/r
Abdomen: scaphoid, soft, nondistended, non-tender. +BS.
GU: no foley
Ext: WWP. 2+ peripheral pulses. Trace pedal edema b/l
Neuro: CN II-XII intact. Motor grossly intact. ___ strength
with knee extension, hip flexion
Pertinent Results:
LABS ON ADMISSION:
___ 04:36PM BLOOD WBC-5.1 RBC-3.47* Hgb-9.0* Hct-29.0*
MCV-84 MCH-26.0* MCHC-31.1 RDW-15.2 Plt ___
___ 04:36PM BLOOD Neuts-65.1 ___ Monos-4.4 Eos-2.5
Baso-0.4
___ 04:36PM BLOOD Glucose-116* UreaN-21* Creat-0.9 Na-134
K-4.0 Cl-98 HCO3-26 AnGap-14
___ 06:13AM BLOOD Calcium-7.8* Phos-2.5*# Mg-1.7
___ 05:50AM BLOOD Albumin-2.5*
___ 04:41PM BLOOD Lactate-2.2*
___ 04:50PM URINE RBC-75* WBC->182* Bacteri-MOD Yeast-NONE
Epi-0
___ 04:50PM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG
___ 04:50PM URINE Color-Straw Appear-Cloudy Sp ___
LABS ON DISCHARGE:
___ 05:50AM BLOOD WBC-4.5 RBC-3.06* Hgb-8.3* Hct-26.3*
MCV-86 MCH-27.0 MCHC-31.4 RDW-15.2 Plt ___
___ 05:50AM BLOOD Glucose-95 UreaN-28* Creat-0.6 Na-137
K-5.2* Cl-101 HCO3-34* AnGap-7*
___ 05:50AM BLOOD Calcium-8.6 Phos-2.7 Mg-2.0
___ 06:34AM BLOOD calTIBC-204* VitB12-538 Ferritn-148
TRF-157*
ADDITIONAL STUDIES:
C. difficile DNA amplification assay (Final ___: Negative
for toxigenic C. difficile by the Illumigene DNA amplification
assay.
CXR (___): The lungs are clear without focal consolidation,
effusion, or edema. The cardiomediastinal silhouette is within
normal limits. No acute osseous abnormalities identified.
IMPRESSION: No acute cardiopulmonary process.
___: Sinus tachycardia, normal axis, normal
intervals, no concerning ischemic changes.
URINE CULTURE - Preliminary Reported FROM ___:
___ 11:09
Pseudomonas aeruginosa > 100,000 CFU/ML
NEG/U COMBO 61
--------
AMIKACIN <=16 S
AZTREONAM 16 I
CEFTAZIDIME 4 S
CIPROFLOXACIN >2 R
GENTAMICIN <=4 S
IMIPENEM <=1 S
LEVOFLOXACIN >4 R
MEROPENEM <=1 S
PIPERACILLIN/TAZOBACTAM <=16 S
Brief Hospital Course:
___ yo F with hx of colovesical fistula (dx. ___ now
resolved, severe malnutrition, h/o severe constipation, h/o
frequent UTIs refusing central line for home or rehab
antibiotics, and h/o recurrent CDiff who presents with
lightheadedness and abdominal pain in the setting of known
pseudomonal UTI. She was treated with a 7 day course of cefepime
consistent with sensitivities from ___ where she had been
treated prior to presenting to ___.
# Severe urosepsis: The patient was found to have severe sepsis
with ___ on admission, with Cr 0.9 from 0.4 baseline, SBP<90, HR
100, and WBC 3.1 from 5.1 in setting on known UTI. Patient was
initially admitted to ___, diagnosed with complicated UTI
given known h/o colovesical fistula diagnosed in ___ that was
not repaired but resolved as patient never developed air/fecal
material in urine. Antibiotic course had been Ceftriaxone 1g
q24hrs (___), Levoquin 500mg q24hrs (___),
Cefatazidime 1g q24hrs (on ___, at which point the
patient left ___. At ___, she received 1 dose of
ceftriaxone in absence of culture data, was admitted and started
on meropenem (___) that was narrowed to cefepime for
a ___ased on urine culture results from ___ that
grew resistant pseudomonas sensitive to meropenem and cefepime.
She required 4 L NS fluid resuscitation to maintain SBPs>90 on
first 24 hours of admission. Of note, the patient and her HCP
refused PICC line, so she was treated for full course of 7 days
of anti-pseudomonal antibiotics while hospitalized. Her ___
resolved with Cr 0.6 and sepsis resolved with normalized WBC and
SBPs maintained in ___ with occasional IVF boluses ___ L per
24 hour period after initial fluid resuscitation.) Urine culture
from ___ at ___ grew <10,000 orgamisms/ml.
# Weakness: The patient has not been able to stand w/o
assistance since hemorroidectomy and recurrent c diff infections
beginning ___, which she attributes to weakness ___ ___
strength on exam laying, but unable to bear weight.) A physical
therapy consult found that the patient was not able to transfer
on her own from bed to chair and will require ___ care from
family as well as home ___.
# Diarrhea: The patient has a history of recurrent C diff. She
denies taking suppressive vancomycin therapy and family was very
opposed to vancomycin as both diarrhea and vanc coincided with
patient's weight loss ___ years ago from which she has never
recovered. C diff studies on this admission were negative on
___. Given high risk of recurrence in setting of cefepime,
vancomycin was offered and refused.
# Nutrition: The patient weighs 84 lbs and is severely cachetic.
Her albumin 2.5 on ___. She was treated with glucerna
supplement TID with meals, to which she adhered. We recommended
follow-up with her primary care doctor.
# Incontinence: The patient has mixed incontinence with both
stress and overflow components, which she reports has been going
on for last ___ years since her hemorroidectomy. We recommend
follow-up with ___ clinic.
# Anemia of chronic disease: The patient was found to have low
iron, low TIBC, and high-normal ferritin is consistent with
anemia of chronic disease. She was given ferrous sulfate and
vitamin C.
# Depression: The patient takes mirtazapine at home which was
continued in the hospital.
### Transitional issues ###
- patient is severely deconditioned, plan for discharge home
with services
- mixed incontinence should be evaluated with ___
___ clinic
- patient is severely cachectic. Follow-up with PCP
___ on ___:
The Preadmission Medication list is accurate and complete.
1. Mirtazapine 15 mg PO QHS
Discharge Medications:
1. Mirtazapine 15 mg PO QHS
2. Ferrous Sulfate 325 mg PO DAILY
RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*3
3. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*11
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Complicated urinary tract infection
Hypotension
Dehydration
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 during your admission. As you
know, you were admitted to the hospital for a urinary tract
infection that required antibiotics that can only be given by
IV. We treated you with this antibiotic and you got better.
You also had urinary incontinence during your admission, that we
learned has been going on for several years. We recommend that
you follow-up with a urogynecologist (women's bladder doctor).
You were found to be underweight and have low red blood cells
due to a lack of iron. We encourage you to keep taking Glucerna
or other nutritional supplements to help you gain weight as well
as take an iron supplement. Please follow-up with your primary
care doctor to discuss nutrition.
Again, it was a pleasure to care for you. We wish you all the
best.
-Your ___ team
Followup Instructions:
___
|
19555898-DS-18
| 19,555,898 | 20,109,768 |
DS
| 18 |
2177-06-15 00:00:00
|
2177-06-15 21:53:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
CC: ___ pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Per Dr. ___
___: ___ F with history of recurrent UTIs, recurrent C. Diff, and
known probable colovesical fistula for which she's refused care
who presents with focal infraumbilical abdominal pain. The pain
began around noon on ___ without provocation. Patient denies
any radiation, fevers, chills, bloating, cramping, n/v, changes
on bowel movements, SOB.
She was seen by her PCP one week prior for routine follow-up and
states she felt well at her usual baseline at that time.
On presentation to the ED, she is afebrile at 98deg, HR 102, BP
110/70, RR 20, 100% on RA
ACS was consulted for abdominal pain in the ED, she was no
longer having abdominal symptoms at the time of their evaluation
and the patient was referred for management of recurrent
cystitis on the HMED service
Past Medical History:
Per Dr. ___:
- Hemmorhoidectomy ___
- Colovesical Fistula complicated by significant
perianal/perineal skin maceration (evaluated by
colorectal/urology ___ and offerred extensive surgical
repair, family elected not to proceed at this time)
- R ureteral trauma (initial injury ___ foley cath ___
s/p removal of nephrostomy tube (___)
- H/O Recurrent CDiff Colitis (Dx. ___
- Recurrent UTIs
- Rectal prolapse
- GERD
- Anemia
- Nephrolithiasis
- Hx of severe constipation complicated by rectal vault
distension
- Hx of severe malnutrition
- Hx of urinary incontinence
Social History:
___
Family History:
Non-contributory.
Physical Exam:
Physical Exam:
VS: 98.2, 95/65, 95, 18, 100%RA
Gen: Cachectic, NAD
HEENT: PERRL, EOMI, poor dentition, dry MM
Neck: Supple, no JVD
Lungs: LCTA-bl, no w/r/r
Abd: Soft, NTND, no HSM
Ext: FROM, very thin, no edema
Neuro: CNII-XII intact strength ___ in all extremities
Pertinent Results:
Admission Labs:
___ 10:15PM BLOOD WBC-4.0 RBC-3.77* Hgb-9.5* Hct-32.1*
MCV-85 MCH-25.2* MCHC-29.6* RDW-15.4 RDWSD-48.1* Plt ___
___ 10:15PM BLOOD Neuts-60.9 ___ Monos-7.8 Eos-3.5
Baso-0.5 Im ___ AbsNeut-2.42 AbsLymp-1.07* AbsMono-0.31
AbsEos-0.14 AbsBaso-0.02
___ 11:00PM BLOOD ___ PTT-34.4 ___
___ 10:15PM BLOOD Glucose-107* UreaN-20 Creat-0.7 Na-138
K-3.6 Cl-104 HCO3-24 AnGap-14
___ 10:15PM BLOOD ALT-11 AST-15 AlkPhos-71 TotBili-0.2
___ 10:15PM BLOOD Lipase-42
___ 10:15PM BLOOD Albumin-3.3*
___ 11:17PM BLOOD Lactate-1.0
Other Relevant Labs:
___ 02:45AM URINE Color-Yellow Appear-Cloudy Sp ___
___ 02:45AM URINE Blood-LG Nitrite-POS Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-LG
___ 02:45AM URINE RBC-141* WBC->182* Bacteri-MANY
Yeast-NONE Epi-0 TransE-4
Discharge Labs:
___ 06:56AM BLOOD WBC-4.0 RBC-3.76* Hgb-9.6* Hct-32.0*
MCV-85 MCH-25.5* MCHC-30.0* RDW-15.5 RDWSD-47.7* Plt ___
___ 06:56AM BLOOD Glucose-92 UreaN-20 Creat-0.8 Na-137
K-4.7 Cl-101 HCO3-28 AnGap-13
___ 06:56AM BLOOD Calcium-9.2 Phos-3.6 Mg-2.0
Micro:
___ 2:45 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML..
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Imaging:
CT Abd/Pelvis ___:
IMPRESSION:
1. Large volume stool throughout the colon without bowel
obstruction.
2. Fluid distended loops of jejunum in the left upper quadrant
without a
transition zone less likely represent mechanical obstruction.
3. Interval progression of bilateral hydronephrosis with
thinning of the right
renal cortical parenchyma. There is bilateral hydroureter, the
ureters are
dilated and tortuous and are likely obstructed at the
ureterovesical junction
by a markedly thickened and trabeculated bladder wall. Uniform
enhancement of
the ureteric walls with periureteral soft tissue stranding along
with
extensive enhancement and thickening of the bladder wall may
reflect presence
of underlying urinary tract infection and chronic ureteritis,
possibly related
to infection or chronic reflux. Please note that evaluation for
any localized
bladder wall masses is limited given the extent of diffuse
bladder wall
thickening.
4. Known colovesicular fistula. However on today's exam there
is no material
or free air within the urinary bladder to suggest presence of
the same.
Dedicated imaging to look for the same has not been performed.
5. No localized intra-abdominal fluid collection present.
Brief Hospital Course:
___ with PMHx of colovesical fistula (having previously
declined repair), sp hemorrhoidectomy, h/o R ureteral trauma,
h/o c. diff, h/o recurrent UTI, GERD, anemia, and malnutrition
who pw abdominal pain and found to have UTI and bowel loop
dilation. sp CTX x 3d with partial coverage with PO flagyl given
hx of c. diff. Per pt and family request abx DC'd in setting of
diarrhea. C. diff negative.
# Klebsiella UTI:
In setting of probable colovesicual fistula as above. Pt
received 3d CTX and family/pt adamantly request DC abx. Risks of
this explained. Pt also declined Vancomycin PO, which was
offered as prophylaxis against c. diff (stating that po
vancomycin caused diarrhea). Pt acquiesced to flagyl for c. diff
ppx. Pt had diarrhea on ___ which had subsequently resolved (c.
diff ab negative). Per son, he does not believe pt has CV
fistula and per Dr. ___ note, there was question
of persistence of fistula during prior eval (popyseed test was
scheduled). Of note, pt and her son/HCP, appeared at times
mistrustful and antagonistic with the healthcare system (ie
requesting to determine the length of treatment and a list of
all antibiotic side-effects, doses, etc.). It was explained that
PO vancomycin would not be expected to result in diarrhea.
# Colovesical fistula:
Pt with hx of fistula and previously evaluated by Dr. ___.
At the time, testing was recommended to confirm presence of
fistula but this was not performed by pt. Pt also expressed
preference to avoid intervention for this. Given evidence of
progression of hydronephrosis with cortical thinning, Urology
re-evaluation was suggested. This was discussed with pt at great
detail. Pt prefer to not wait evaluation by Dr. ___
___ she was seen by Urology resident, Dr. ___. Per Dr.
___ of the data, outpatient follow-up is
appropriate prn.
# Diffuse abdominal pain:
Likely ___ UTI. Surgery evaluated abd pain and felt no
intervention necessary. C. diff negative. Pain resolved with rx
of UTI. Pt was noted to have stool in colon but given subsequent
diarrhea and pt's and her son's concerns re this, further bowel
regimen was not pursued.
# Severe protein calorie malnutrition:
Albumin 3.___ppears cachectic. Nutrition consulted and
calorie counts showed poor intake.
# Anemia of chronic disease
# Depression: Continued mirtazapine
Transitional Issues:
- Please ensure follow-up with Urology and Nutriton
- Please continue to assess abdominal exam, consider bowel
regimen and repeat abd imaging to ensure resolution of bowel
loop distension
- Please monitor for recurrence of UTI, as pt declined to
complete recommended 7d course of abx and completed a slightly
shorter 3d course
- Please encourage aggressive outpatient ___, given ___ opinion
that pt could regain significant functional capacity with this
Medications on Admission:
Denies, reports only
Multivitamins
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
2. Mirtazapine 15 mg PO HS
3. Multivitamins 1 TAB PO DAILY
4. Vitamin D 800 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Urinary tract infection
Abdominal pain
Hydronephrosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Ms. ___,
It was a pleasure to participate in your care at ___. You were
admitted for abdominal pain. You were found to have a urinary
tract infection and enlarged bowels. You were evaluated by
surgery who recommended treatment of your infection and
continued monitoring. You were also found to have obstruction of
your ureter causing long-term kidney damage. We strongly
recommend that you follow up with your PCP ___ 1 week of
discharge and arrange follow-up with Dr. ___. We
recommended a 7-day course of antibiotics but you opted for a
3-day course of treatment which we completed. There is risk of
recurrence of infection so please return if you develop
abdominal pain. Please continue aggressive physical therapy.
Best Regards,
Your ___ Medicine Team
Followup Instructions:
___
|
19555898-DS-19
| 19,555,898 | 27,862,390 |
DS
| 19 |
2177-07-12 00:00:00
|
2177-07-14 21:24:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with PMHx of colovesical fistula (having previously
declined repair), sp hemorrhoidectomy, h/o R ureteral trauma,
h/o c. diff, h/o recurrent UTI, GERD, anemia, and malnutrition
who pw abdominal pain.
Patient states the pain started this morning and woke her up
from sleep. Patient been feeling weak. He has been having some
nausea but no vomiting. Also endorses some watery diarrhea. No
chest pain or shortness of breath. Patient was recently seen
here for UTI and discharged with antibiotics. Patient has low
blood pressure at baseline. Patient has had similar abdominal
pain in the past all attributed to UTI.
In the ED, initial vitals were: 99.0 121 87/53 16 98% RA. She
did spike to 101.
Patient's WCC was 7.8, with H/H of ___. Potassium was 3.2.
Urine was positive for leukocytes and WBC > 182 and RBC > 182.
In the ED, patient was given 1L NS and 1g ceftriaxone.
On the floor, patient was alert and mentating well.
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:
Per Dr. ___:
- Hemmorhoidectomy ___
- Colovesical Fistula complicated by significant
perianal/perineal skin maceration (evaluated by
colorectal/urology ___ and offerred extensive surgical
repair, family elected not to proceed at this time)
- R ureteral trauma (initial injury ___ foley cath ___
s/p removal of nephrostomy tube (___)
- H/O Recurrent CDiff Colitis (Dx. ___
- Recurrent UTIs
- Rectal prolapse
- GERD
- Anemia
- Nephrolithiasis
- Hx of severe constipation complicated by rectal vault
distension
- Hx of severe malnutrition
- Hx of urinary incontinence
Social History:
___
Family History:
Non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vital Signs: T98.5 BP 104/64 HR 89 Sats 100 RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, slightly tender in lower abdominal region, 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.
DISCHARGE PHYSICAL EXAM:
Vitals: 98.1, 103/72, 93-103, 16, 98% RA
General: chronically malnourished appearing, alert, oriented, no
acute distress
HEENT: +temporal wasting; sclera anicteric, MMM, oropharynx
clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: very thin, soft, non-tender, non-distended, bowel
sounds present, no rebound tenderness or guarding, no
organomegaly
Ext: thin, with little musculature, warm, well perfused, 2+
pulses, no clubbing, cyanosis or edema
Skin: no rash
Neuro: CN2-12 grossly intact
Pertinent Results:
ADMISSION LABS:
___ 12:48PM BLOOD WBC-7.8# RBC-3.91 Hgb-10.0* Hct-32.9*
MCV-84 MCH-25.6* MCHC-30.4* RDW-16.7* RDWSD-50.4* Plt ___
___ 12:48PM BLOOD Neuts-81.7* Lymphs-9.7* Monos-6.6 Eos-1.0
Baso-0.4 Im ___ AbsNeut-6.35*# AbsLymp-0.75* AbsMono-0.51
AbsEos-0.08 AbsBaso-0.03
___ 12:48PM BLOOD ___ PTT-29.5 ___
___ 12:48PM BLOOD Glucose-147* UreaN-17 Creat-0.8 Na-135
K-3.2* Cl-99 HCO3-22 AnGap-17
___ 12:48PM BLOOD ALT-12 AST-16 AlkPhos-76 TotBili-0.4
___ 12:48PM BLOOD Albumin-3.5 Calcium-8.8 Phos-2.8 Mg-1.8
___ 12:55PM BLOOD Lactate-1.7
PERTINENT INTERVAL LABS:
___ 08:49AM BLOOD Albumin-2.6* Calcium-8.1* Phos-2.5*
Mg-1.6 Iron-15*
___ 08:49AM BLOOD calTIBC-202* Ferritn-96 TRF-155*
DISCHARGE LABS:
___ 07:55AM BLOOD WBC-5.1 RBC-3.21* Hgb-8.0* Hct-27.6*
MCV-86 MCH-24.9* MCHC-29.0* RDW-16.4* RDWSD-51.5* Plt ___
___ 07:55AM BLOOD Glucose-86 UreaN-11 Creat-0.6 Na-132*
K-4.0 Cl-101 HCO3-24 AnGap-11
___ 07:55AM BLOOD Calcium-8.4 Phos-3.1 Mg-1.6
IMAGING/STUDIES:
CXR ___
No acute cardiopulmonary process. No focal consolidation to
suggest pneumonia.
MICROBIOLOGY:
___ BCx pending
___ 1:05 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- 8 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Brief Hospital Course:
___ with PMHx of colovesical fistula (having previously
declined repair), sp hemorrhoidectomy, h/o R ureteral trauma,
h/o c. diff, h/o recurrent UTI, GERD, anemia, and malnutrition
who presented with abdominal pain, found to have a urinary tract
infection, treated with antibiotics.
# Abdominal Pain, urinary tract infection: Patient has a history
of recurrent UTIs. During her last hospitalization, patient was
diagnosed with Klebsiella UTI and was found on CT imaging to
have hydronephrosis thought to be related to chronic
inflammation from known vesico-ureteral fistula. Despite these
findings, the patient declined urologic evaluation at that time.
On this admission, the patient presented with supra-pubic
discomfort. UA was suggestive of infection. She was started on
ceftriaxone, narrowed to ciprofloxacin. Urine culture ultimately
grew E coli, sensitive to these antibiotics. The patient was
offered evaluation by urology, counseled on the risks of
recurrent UTI given her anatomy, but she declined this. The
patient's pain was controlled with acetaminophen, pyridium and
oxycodone with relief. The patient will follow up with urology
after discharge for further discussion of surgical intervention.
# Severe protein calorie malnutrition: The patient has a history
of malnutrition, found to have low albumin. The patient was
continued on nutritional supplementation with meals as well as
her home folate and vitamin D. The patient's MVI was held while
she completes her course of antibiotics for UTI as above.
# Anemia: The patient was noted to have anemia with Hgb near
baseline ___. She was evaluated with iron studies which were
consistent with mixed iron deficiency anemia and anemia of
chronic disease. The patient should follow up with PCP and
consider initiation of iron supplementation after she finishes
her course of antibiotics.
# Depression: continued mirtazapine
Transitional Issues:
-Please have ___ draw repeat CBC/CHEM 7 within 48 hours of
discharge and fax results to PCP: Dr. ___:
___.
-F/u with urology to continue discussion about repair of
colovesicular fistula (contact info above).
-Continue Ciprofloxacin through ___ (7 day course).
-Please start iron supplementation for iron-deficiency anemia
after completion of ciprofloxacin.
-Multivitamin held on discharge (due to iron) but should be
restarted after completion of ciprofloxacin.
CODE: Full Code
CONTACT: Son - ___ ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. FoLIC Acid 1 mg PO DAILY
2. Mirtazapine 15 mg PO HS
3. Multivitamins 1 TAB PO DAILY
4. Vitamin D 800 UNIT PO DAILY
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
2. Mirtazapine 15 mg PO HS
3. Vitamin D 800 UNIT PO DAILY
4. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*7 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
UTI
Secondary Diagnosis:
Colovesicular Fistula
Protein calorie malnutrition
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
Thank you for allowing us to participate in your care at ___.
You were admitted to the hospital with abdominal pain. You were
found to have a urinary tract infection. The fistula that
connects your bladder to your bowels likely contributed to this
infection. We treated you with antibiotics for which you should
complete a 7 day course (last day ___. You should follow up
with urology as an outpatient to discuss whether you might be
interested in any surgery to help correct this connection
between your bladder and your colon to help prevent this in the
future.
It is very important that you continue to eat well and continue
to work on your nutrition.
We wish you the best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19555898-DS-24
| 19,555,898 | 28,376,455 |
DS
| 24 |
2178-07-24 00:00:00
|
2178-07-26 13:56:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Suprapubic pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
PER ADMISSION NOTE FROM ___. ___:
___ w/ colovesicular fistula (previously declined repair),
recurrent UTIs, prior C diff, who presented with dysuria and
lower abdominal pain. These symptoms are similar to what she has
previously reported when admitted for UTIs.
In the ED, vitals were: temp 99.1, HR 89, BP 101/70, RR 18, SpO2
99% on RA. Basic labs were fairly unremarkable, including no
leukocytosis. UA showed WBCs, too numerous to count. She was
given CTX, IVF and admitted to medicine for presumed recurrent
UTI.
I have treated this patient on a previous admission for UTI.
Records were obtained from ___ at that time to verify that
she does in fact have a proven ___ fistula. She has
consistently declined definitive surgical intervention on this
because she decompensated significantly after a hemorrhoid
surgery in the past and she and her family felt that surgery was
not in her best interest. Limited culture is available because
her urine culture never grows a single, identifiable pathogen;
she generally improves clinically on CTX or Unasyn with
transition to PO Augmentin.
The patient lives at home under the care of her children. I have
found that her children are a very strong source of support for
her. However, they have limited health literacy and significant
mistrust of the healthcare system so shared decision making can
be at times challenging.
ROS
GEN: denies fevers/chills
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
Full 14-system review of systems otherwise negative and
non-contributory.
Past Medical History:
- Hemmorhoidectomy ___
- Colovesical Fistula (seen on ___ cystoscopy at ___ and
confirmed on CT with rectal contrast, also at ___
evaluated by colorectal/urology ___ and offerred extensive
surgical repair, but family elected not to proceed due to her
frailty and her functional decline after hemorrhoidectomy the
year prior)
- R ureteral trauma (initial injury ___ foley cath ___
s/p removal of nephrostomy tube (___)
- H/O Recurrent CDiff Colitis (Dx. ___
- Recurrent UTIs (E.Coli, Klebsiella)
- Rectal prolapse
- GERD
- Anemia
- Nephrolithiasis
- severe malnutrition
- urinary incontinence
Social History:
___
Family History:
- no family history of recurrent UTIs
Physical Exam:
ADMISSION EXAM
VITALS: last 24-hour vitals were reviewed.
General: Frail, cachectic-appearing, elderly woman in NAD.
HEENT: PERRL; EOMs intact, anicteric sclerae, MMM, very poor
dentition.
Neck: Supple. JVP flat.
CV: RRR, no MRGs. Normal S1/S2.
Pulm: CTA b/l; no wheezes, rhonchi, or rales.
Abd: Soft, mild suprapubic tenderness. NABS. No rebound or
guarding.
Back: No CVA tenderness.
Ext: Warm and well-perfused; no edema. 2+ DP pulses bilaterally.
Pertinent Results:
Admission labs ___
WBC-4.1 RBC-3.26* HGB-7.4* HCT-25.4* MCV-78* RDW-18.4* PLT
COUNT-458*
NEUTS-59.7 ___ MONOS-11.8 EOS-1.5 BASOS-0.7 IM ___
SODIUM-133 POTASSIUM-4.6 CHLORIDE-98 TOTAL CO2-25 GLUCOSE-105*
UREA N-14 CREAT-0.7
LACTATE-1.0
Urinalysis:
COLOR-Yellow APPEAR-Cloudy SP ___
BLOOD-MOD NITRITE-POS PROTEIN-300 GLUCOSE-NEG KETONE-NEG
BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-LG
RBC-20* WBC->182* BACTERIA-MANY YEAST-NONE EPI-2
*******
PERTINENT INTERVAL RESULTS
___ 06:35AM BLOOD WBC-3.9* RBC-3.16* Hgb-7.1* Hct-24.7*
MCV-78* MCH-22.5* MCHC-28.7* RDW-18.2* RDWSD-51.8* Plt ___
___ 06:50AM BLOOD ALT-7 AST-9 AlkPhos-62 TotBili-0.2
___ 06:50AM BLOOD Lipase-12
___ 06:50AM BLOOD Calcium-8.2* Phos-3.4 Mg-1.9
___ diff PENDING
___ mixed flora
___ CULTUREPENDING
CT AP W PO/IV CONTRAST
IMPRESSION:
1. Findings are compatible with enterocolitis of the distal
small bowel and ascending colon. There is no free air.
2. Persistent marked right and mild left hydroureteronephrosis
with interval increase in the degree of urothelial thickening
and enhancement on the right with new wedge-shaped cortical
areas of hypoenhancement in the right kidney, compatible with
pyelonephritis. No stones are seen.
3. Small focus of nondependent gas within the bladder and
circumferential bladder wall thickening is compatible with the
patient's history of colovesicular fistula. The uterus and
vagina are now fluid-filled which was not seen on prior studies
and is concerning for fistulization.
4. Massive stool burden in the remainder of the colon including
an 8.4 x 8.0 cm stool ball in the rectum with stercoral colitis.
5. Prominent mesenteric and retroperitoneal lymph nodes are not
enlarged by CT size criteria and are likely reactive.
Brief Hospital Course:
___ w/ reported colovesicular fistula (previously declined
repair), recurrent UTIs, prior C diff, admitted for recurrent
UTI, found to have colitis,
stercocoral colitis, pyelonephritis, possible (but not
confirmed)
fistula between colon and bladder as well as colon and uterus.
#RECURRENT UTI
#C/F COLOVESICULAR FISTULA
Per report of admitting MD, outside records confirm a
colovesicular fistula visualized on ___ cystoscopy, and family
refused intervention at that time, and this has since been
deferred by family and PCP given her poor nutritional status. CT
here with air in bladder, but not clearly fistulizing. MRI abd
pelvis was poor quality. The patient subsequently left AMA.
Please follow up with patient about this.
# ENTEROCOLITIS:
Abdominal pain likely due in large part due to this in small
bowel, large bowel and stercoral rectal colitis. Stool studies
showed no growth. She was initially treated with CTX (for ?UTI)
in ED, then broadened to unasyn ___, but after CT showed
colitis, was switched to cipro/flagyl ___- for empiric
treatment. Abdominal pain improved with this management.
# pyelonephritis, ? UTI: UCx with mixed flora, potentially ___
fistula. c/b
hydronephroureter, no stones. As above, s/p CTX, unasyn ___,
transitioned to cipro/flagyl. BCx NGTD. She left AMA and was
transitioned to Augmentin given prior benefit with this regimen.
# constipation, stool ball, stercoral colitis: refusing
disimpaction. Failed enemas, but aggressive mgmt with frequent
enemas. Please continue aggressive bowel regimen in the
outpatient setting.
# concern for colouterine fistula: based on fluid in the uterus
on CT, discussed with gyn who agreed with MR pelvis, which
patient declined with poor quality study. The patient left AMA
and this could not be fully addressed. Follow up is recommended
for this.
#iron deficiency anemia, guaiac positive in past
#anemia of chronic inflammation
Stable, continued home PO iron. Can consider colonoscopy if
within goals of care.
#SEVERE PROTEIN-CALORIE MALNUTRITION
Patient has significant muscle wasting and is well below her
ideal body weight. She was continued on MVI, and started on
Ensure TID. Her family was encouraged to bring food from home,
which she greatly prefers.
___ RESISTANT TO MEDICAL SYSTEM: per report, pt and
family mistrusting of medical system. Discussed with pt's PCP
who added that patient's son had been aggressive and "explosive"
with staff at ___ and so patient and family are therefore
no longer permitted at ___. SW saw the patient. Family was
kept in close contact.
- When patient left AMA, the son was at bedside and supportive
of this.
# GOC: discussed with PCP who reported that numerous goals of
care discussions had been had with patient and son (to whom she
defers all of her decisions) and that family is very unrealistic
about patient's prognosis. Family preferred patient to be full
code.
# DVT PPx: refused ppx.
# Communication: Son, ___ ___ is HCP (form
signed)
******
TRANSITIONAL ISSUES:
- consider colonoscopy given guaiac positive iron deficiency
anemia and weight loss
- continue to address goals of care
Medications on Admission:
1. Mirtazapine 15 mg PO QHS
2. Multivitamins 1 TAB PO DAILY
3. Vitamin D 1000 UNIT PO DAILY
4. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
5. cranberry 500 mg oral BID
6. Ferrous Sulfate 325 mg PO BID
7. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild
8. LOPERamide 2 mg PO QID:PRN Diarrhea
9. Simethicone 80 mg PO BID:PRN gas
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tab by mouth
twice daily Disp #*14 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
daily Disp #*60 Capsule Refills:*0
3. Fleet Enema (Saline) ___AILY:PRN constipation
RX *sodium phosphates [Fleet Enema] 19 gram-7 gram/118 mL 1
enema(s) rectally daily Refills:*0
4. Polyethylene Glycol 17 g PO BID
RX *polyethylene glycol 3350 [Miralax] 17 gram 1 powder(s) by
mouth twice daily Disp #*60 Packet Refills:*0
5. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 tab by mouth twice daily Disp
#*60 Tablet Refills:*0
6. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
7. cranberry 500 mg oral BID
8. Mirtazapine 15 mg PO QHS
9. Multivitamins 1 TAB PO DAILY
10. Simethicone 80 mg PO BID:PRN gas
11. Vitamin D 1000 UNIT PO DAILY
12. HELD- Nitrofurantoin (Macrodantin) 50 mg PO DAILY This
medication was held. Do not restart Nitrofurantoin (Macrodantin)
until after you've finished your Augmentin.
Discharge Disposition:
Home
Discharge Diagnosis:
enterocolitis
stercolar colitis
obstipation
pyelonephritis
acute on chronic hydronephroureter
colonic fistula
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted with abdominal pain. We found you had
infection of your colon (colitis), a urinary tract and kidney
infection (pyelonephritis), severe constipation with blockage
(obstipation), and connections between your colon and your
bladder. We treated you with antibiotics and stool medications,
but you only had a partial improvement by the time of discharge.
You requested to leave early against our best medical advice.
You endorsed an understanding of the risks and benefits of this
decision. Your family was present during this long discussion
and also endorsed their understanding, and agreed to take you
home and watch you closely.
Followup Instructions:
___
|
19555898-DS-26
| 19,555,898 | 28,904,631 |
DS
| 26 |
2179-08-22 00:00:00
|
2179-08-22 19:39:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
failure to thrive, diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ y/o woman with history of colovesicular
fistula, recurrent UTIs, recurrent C. diff presenting with
nausea, vomiting, and diarrhea.
The patient initially presented to the ED on ___ for nausea,
vomiting, and diarrhea. Her son reportedly had similar symptoms.
She was diagnosed with gastroenteritis, and was hydrated and
given anti-emetics and discharged home.
Patient reports that she has been unable to tolerate PO since
her discharge from the ED, and she continues to have nausea,
occasional emesis, and occasional loose, nonbloody stools (one
episode per day). The patient reports that she vomited once
today and had one episode of loose but not watery stool. She
reports that she feels extremely weak. She denies fevers or
chills. She denies dysuria, but does report urinary frequency.
She denies abdominal pain or cramping. No chest pain,
palpitations, shortness of breath, or cough.
In the ED, initial VS were: 98.2 98 102/63 18 95% RA
Exam notable for:
ECG: NSR at 99 bpm, indeterminate axis, Qtc 470, low voltages,
no acute ischemic changes
Labs showed: WBC 4.8 (74N, 4B) H/H 9.3/33.3 plt 377; Na 132, K
3.1, Cl 90, HCO3 14, BUN/Cr ___ AG 28; LFTs wnl; UA positive
Imaging showed:
- CT A/P:
1. Fluid-filled colon and hyperenhancement of small and large
bowel loops suggestive of enterocolitis.
2. Interval improvement of severe, chronic appearing
right-sided
hydronephrosis and hydroureter with a new 6 mm stone seen in
the distal right ureter. Interval resolution of left-sided
hydronephrosis. Chronic wall thickening and hyper enhancement of
the right renal collecting system and ureter, to be correlated
clinically with urinalysis as infection is not excluded
3. Fluid-filled vagina and uterus as seen on prior exam
concerning for
possible fistula given patient's history of previous
colovesicular fistula.
4. Mild compression deformity of the L4 vertebral body which is
new since prior though without CT evidence to suggest acuity, to
be correlatedclinically.
- CXR: No acute cardiopulmonary abnormality.
Consults: None
Patient received:
___ 13:29 IVF NS ___ Started
___ 13:31 IV Ondansetron 4 mg ___
___ 15:28 IVF NS ___ Not Started
___ 15:30 IVF NS ___ Delayed Start
___ 16:49 IVF NS 500 mL ___ Stopped (3h ___
___ 16:49 IVF LR ___ Started
___ 16:51 IVF NS 500 mL ___ Stopped (3h ___
___ 19:35 IV CefTRIAXone ___ Started
___ 20:52 IVF LR 1000 mL ___ Stopped (4h ___
___ 20:52 IV CefTRIAXone 1 gm ___ Stopped
(1h ___
Transfer VS were: 98.9 76 131/69 16 98% RA
On arrival to the floor, patient reports that she feels tired
and weak because she has not been able to eat much recently. She
does feel hungry and would like to eat something. She denies any
abdominal pain or nausea at present.
REVIEW OF SYSTEMS: 10 point ROS reviewed and negative except as
per HPI
Past Medical History:
- Hemmorhoidectomy ___
- Colovesical Fistula (seen on ___ cystoscopy at ___ and
confirmed on CT with rectal contrast, also at ___
evaluated by colorectal/urology ___ and offerred extensive
surgical repair, but family elected not to proceed due to her
frailty and her functional decline after hemorrhoidectomy the
year prior)
- R ureteral trauma (initial injury ___ foley cath ___
s/p removal of nephrostomy tube (___)
- H/O Recurrent CDiff Colitis (Dx. ___
- Recurrent UTIs (E.Coli, Klebsiella)
- Rectal prolapse
- GERD
- Anemia
- Nephrolithiasis
- severe malnutrition
- urinary incontinence
Social History:
___
Family History:
Reviewed and not relevant to present admission. Patient denies
family history of cancers, DMII, HTN.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: 98.4 103 / 66 92 16 96 Ra
GENERAL: Cachectic appearing woman in NAD
HEENT: EOMI, PERRL, anicteric sclera, poor dentition, dry MM
NECK: No JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi
ABDOMEN: BS+, soft, nontender in all quadrants without rebound
or guarding, nondistended
EXTREMITIES: No peripheral edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: Warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
=======================
24 HR Data (last updated ___ @ 700)
Temp: 97.9 (Tm 99.4), BP: 125/80 (104-129/65-80), HR: 119
(100-119), RR: 16 (___), O2 sat: 97% (96-98), O2 delivery: Ra
Fluid Balance (last updated ___ @ 526)
Last 8 hours Total cumulative 60ml
IN: Total 60ml, PO Amt 60ml
OUT: Total 0ml, Urine Amt 0ml
Last 24 hours Total cumulative 1501ml
IN: Total 1501ml, PO Amt 120ml, IV Amt Infused 1381ml
OUT: Total 0ml, Urine Amt 0ml
GENERAL: Cachectic elderly woman, curled up in bed, alert and
engaging in conversation
HEENT: EOMI, PERRL, anicteric sclera, poor dentition, dry MM
HEART: RRR, +S1/S2, no murmurs, gallops, or rubs
LUNGS: CTABL, no crackles, wheezes, rhonchi
ABDOMEN: minimal abdominal fat. BS+, soft, nontender in all
quadrants without rebound or guarding, nondistended
EXTREMITIES: No peripheral edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, CN2-12 intact. sensory intact in UE and ___. motor
and strength not tested
SKIN: Warm and well perfused, no decubitus ulcers, Mepilex on L
hip
Pertinent Results:
ADMISSION LABS:
===============
___ 11:56AM BLOOD WBC-4.8 RBC-4.34 Hgb-9.3* Hct-33.2*
MCV-77* MCH-21.4* MCHC-28.0* RDW-18.6* RDWSD-51.4* Plt ___
___ 11:56AM BLOOD Plt Smr-NORMAL Plt ___
___ 11:56AM BLOOD Glucose-107* UreaN-24* Creat-0.8 Na-132*
K-3.1* Cl-90* HCO3-14* AnGap-28*
___ 11:56AM BLOOD ALT-16 AST-25 AlkPhos-71 TotBili-0.3
___ 06:15AM BLOOD Calcium-8.2* Phos-2.5* Mg-1.6
___ 06:15AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-8*
Tricycl-NEG
___ 01:02PM BLOOD Lactate-1.0
___ 02:12AM BLOOD ___ pO2-159* pCO2-38 pH-7.29*
calTCO2-19* Base XS--7 Comment-GREEN TOP
PERTINENT IMAGING:
==================
+CXR ___:
FINDINGS:
Heart size is normal. Mediastinal and hilar contours are
unremarkable.
Pulmonary vasculature is not engorged. Lungs are hyperinflated
but otherwise
clear. No pleural effusion or pneumothorax is demonstrated. No
acute osseous
abnormality is detected.
IMPRESSION:
No acute cardiopulmonary abnormality.
+CT ABDOMEN AND PELVIS ___
IMPRESSION:
1. Fluid-filled colon and hyperenhancement of small and large
bowel loops
suggestive of enterocolitis.
2. Interval improvement of severe, chronic appearing right-sided
hydronephrosis and hydroureter with a new 6 mm stone seen in the
distal right
ureter. Interval resolution of left-sided hydronephrosis.
Chronic wall
thickening and hyper enhancement of the right renal collecting
system and
ureter, to be correlated clinically with urinalysis as infection
is not
excluded
3. Fluid-filled vagina and uterus as seen on prior exam
concerning for
possible fistula given patient's history of previous
colovesicular fistula.
4. Mild compression deformity of the L4 vertebral body which is
new since
prior though without CT evidence to suggest acuity, to be
correlated
clinically.
+KUB ___
FINDINGS:
There are no abnormally dilated loops of large or small bowel.
Supine assessment limits detection for free air; there is no
gross
pneumoperitoneum.
Osseous structures are unremarkable.
There are no unexplained soft tissue calcifications or
radiopaque foreign
bodies.
IMPRESSION:
Nonspecific, nonobstructive bowel gas pattern.
DISCHARGE LABS:
===============
___ 03:15PM BLOOD WBC-7.4 RBC-3.53* Hgb-7.8* Hct-26.3*
MCV-75* MCH-22.1* MCHC-29.7* RDW-19.0* RDWSD-51.8* Plt ___
___ 01:00PM BLOOD ___ PTT-32.8 ___
___ 06:55AM BLOOD Glucose-141* UreaN-3* Creat-0.5 Na-137
K-3.5 Cl-101 HCO3-___ AnGap-14
___ 06:55AM BLOOD Calcium-7.4* Phos-2.4* Mg-1.8
Brief Hospital Course:
Ms. ___ is a ___ y/o woman with history of a colovesicular
fistula, recurrent UTIs, prior C. diff infections, who presented
with nausea, vomiting, and diarrhea. She was found to have C.
diff and severe malnutrition. Her hospital course was
complicated by A fib with RVR. She was prescribed PO
Fidoxamicin, improving considerably during her hospital stay,
and was ready for discharge.
# Abdominal Pain:
# Enterocolitis: The patient presented with 1 week of nausea,
vomiting, diarrhea, and a sick contact. There was an initial
concern for viral vs bacterial enterocolitis, given that her CT
A/P showed evidenece of enterocolitis. The patient has a history
of C. diff colitis in ___, however declined PO vancomycin as
she had worsening diarrhea with this medication. C. diff was
positive again on ___, and was started on PO Flagyl. Notably,
she did not have a leukocytosis, however had bandemia on
admission, which was concerning for a chronic infection or an
inflammatory state from her previously diagnosed colovesicular
fistula. Stool cultures were negative other than C. diff. The
patient was started on IV flagyl on ___ without any improvement
in symptoms. Given worsening abdominal pain and lethargy, KUB
was obtained which was without any evidence of toxic megacolon
or obstruction. She was then started on PO fidaxomicin on ___
given the concern for resistance to Flagyl. She improved
significantly with less stool output. Throughout her
hospitalization, her abdominal pain resolved. She will complete
a 10 day course of Fidaxomicin 200 mg oral BID on ___. Her pain
was managed with IV Tylenol and Simethicone prn, as she refused
opioids.
#Nephrolithiasis: The patient has a chronic appearing
right-sided hydronephrosis, which has improved over prior
imaging. On CT Abdomen/ Pelvis this admisison, she was found to
have a previously unseen 6 mm stone in the distal right ureter
without evidence of focal renal lesions or left hydronephrosis.
There was also no evidence of any acute inflammation. Her pain
was non-colicky and she had no CVA tenderness. Urology was
consulted and state the stone is non-obstructive and likely not
infected given no evidence of inflammation on imaging and a
benign GU exam. They also recommended outpatient follow up for
her ureteral stone.
#Severe protein calorie malnutrition: The patient is cachectic
with a BMI of 14 this admission. Nutrition was consulted and
recommended a temporary NGT. The patient and son/HCP were both
very opposed to this intervention. They both felt she can eat on
her own, though they stated her poor PO intake brought her in.
Her son felt she was well nourished up until last week. The
patient had minimal PO intake throughout the majority of her
hospitalization, increasing our concern for malnutrition. Based
on family meeting on ___, the patient's diet was altered per
son's request to include pureed and home foods. As she continued
her antibiotics for C. diff, her abdominal pain resumed and
appetite improved. On the day of discharge, she was able to
tolerate solid foods without any pain or nausea. She was also
continued on her home mirtazapine.
#Goals of Care: The patient was firm that she wishes to be
DNR/DNI. When interviewed alone without her HCP, and SW, she
denied feeling unsafe at home. Her son prepares all her meals
and feeds her. He also moves her from wheelchair to bed as her
PCT. She states she was out in the community last week but had
gotten too weak over past few days. Her PCP confirmed that the
patient and son had presented to several hospitals since ___
and the son now has a security warning and is no longer allowed
at ___ for aggression. The son and patient refused
surgery for her possible colovesicular fistula and have refused
PO vanco for C diff treatment on several occasions. A family
meeting was held on ___. After discussing the severity of the
patient's illness, it was decided to continue to support her PO
intake, continue her current antibiotics, and avoid invasive
procedures or tests including an NG tube. ___ evaluated and
recommended home with ___ services.
#Pyuria:
#Possible Colovesicular fistula: The patient has a history of
recurrent urinary tract infections, noted to have pyuria on
initial urinalysis. She denied dysuria but did endorse frequency
on admission. She completed ceftriaxone in the ED, and was
transitioned to IV cefepime on admission. Prior microbiology was
notable for UTI with E. coli, Klebsiella, and Pseudomonas.
However, she had a polymicrobial UCx and given her new C. diff
diagnosis, and likely contamination. IV Cefepime was therefore
discontinued on ___. Urology was consulted regarding her
colovesicular fistula, and recommended a CT A/P with rectal
contrast and cystogram to further assess this. UCx neg. She was
bladder scanned without any evidence of urinary retention.
RESOLVED/CHRONIC ISSUES:
========================
#Anion gap metabolic acidosis: resolving. Delta gap 1.6,
suggestive of a more pure AGMA rather than NAGMA as expected
with gastrointestinal losses. The etiology of her acidosis was
unclear, given that she only had modest ketonuria, and her
lactate was within normal limits. The patient denied taking any
aspirin or other medications to treat the discomfort related to
her gastrointestinal illness. Starvation ketosis was the most
likely etiology. Of note, her serum tox was negative. She was
given IV fluids until her appetite improved, and her gap
eventually closed.
#A fib with RVR: RESOLVED. The patient triggered on ___ for
Afib with RVR with no prior history of A fib. She was
aysmptomatic and mentating well. She was given 5mg IV metoprolol
and 2L LR. Although she initially became hypotensive after
metoprolol administration, her blood pressure improved to her
baseline 110/60s. The etiology of her episode of A fib was
likely secondary to volume depletion from diarrhea vs sepsis
from C diff. Her troponin was negative, and her EKG was without
any ST changes. After this episode, she remained in sinus rhythm
for the remainder of her hospitalization.
CHRONIC ISSUES:
===============
#Anemia: Chronic, stable from prior. Continued to monitor. Hb at
discharge was 7.8 (ranged from 7.3-9.1)
#Depression: Continued home mirtazapine
TRANSITIONAL ISSUES:
====================
[] Please complete a 10 day course of Fidoxamicin on ___. At
discharge, she had ___ small BM
[] Continue to monitor nutritional status and encourage PO
intake/electrolyte supplementation (Gatorade). Please have close
nutrition follow up
[] Please consider outpatient follow up with urology for R
ureteral stone. Asymptompatic during hospitalization
[] CT A/P with rectal contrast and cystogram recommended to
further assess colovesicular fistula
[] Continue to monitor heart rate. Brief episode of A fib with
RVR during this hospitalization
CODE STATUS: DNR/DNI, ok to hospitalize (MOLST ___
CONTACT: ___ (son) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
2. Mirtazapine 15 mg PO QHS
3. Multivitamins 1 TAB PO DAILY
4. Simethicone 80 mg PO BID:PRN gas
5. Vitamin D 1000 UNIT PO DAILY
6. cranberry 500 mg oral BID
7. Fleet Enema (Saline) ___AILY:PRN constipation
8. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
9. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
10. Senna 8.6 mg PO BID:PRN Constipation - First Line
Discharge Medications:
1. fidaxomicin 200 mg oral BID
RX *fidaxomicin [Dificid] 200 mg 1 tablet(s) by mouth twice a
day Disp #*6 Tablet Refills:*0
2. Simethicone 40-80 mg PO QID:PRN abdominal pain
3. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
4. cranberry 500 mg oral BID
5. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
6. Mirtazapine 15 mg PO QHS
7. Multivitamins 1 TAB PO DAILY
8. Vitamin D 1000 UNIT PO DAILY
9. HELD- Fleet Enema (Saline) ___AILY:PRN constipation
This medication was held. Do not restart Fleet Enema (Saline)
until you see your PCP
10. HELD- Polyethylene Glycol 17 g PO DAILY:PRN Constipation -
First Line This medication was held. Do not restart
Polyethylene Glycol until you see your PCP
11. HELD- Senna 8.6 mg PO BID:PRN Constipation - First Line
This medication was held. Do not restart Senna until you see
your PCP
___:
Home With Service
Facility:
___
___:
PRIMARY DIAGNOSES:
==================
1. C. diff colitis
SECONDARY DIAGNOSES:
====================
1. A fib with RVR
2. Severe Protein Calorie Malnutrition
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
You came to ___ because you were feeling nauseated, and were
having diarrhea. You were found to have an infection called C.
diff. Please see more details listed below about what happened
while you were in the hospital and your instructions for what to
do after leaving the hospital.
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL:
- You were given an antibiotic called Fidoxamicin, which helped
your symptoms. Your diarrhea slowed down and your appetite
improved
- You also had 1 day of a fast heart rate called A fib. You
were given fluids which helped. This fast heart rate was likely
due to your ongoing diarrhea and low appetite because you were
sick
- Over the next few days, you improved considerably and were
ready to leave the hospital
WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL:
- Please follow up with your primary care doctor and other
health care providers (see below)
- Please take all of your medications as prescribed (see
below).
- Seek medical attention if you have any abdominal pain,
nausea, diarrhea, or other symptoms of concern.
It was a pleasure participating in your care. We wish you the
best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19555908-DS-22
| 19,555,908 | 23,664,219 |
DS
| 22 |
2141-07-26 00:00:00
|
2141-07-27 13:41:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Lisinopril
Attending: ___
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
___: TEE/___
History of Present Illness:
Mr. ___ this is a ___ man past medical history
significant for CAD status post four-vessel CABG, hypertension,
hyperlipidemia, who presents with new exertional dyspnea.
The patient reports that he started developing exertional
dyspnea
4 weeks prior to presentation. Over this period of time his
exertional dyspnea has slowly worsened and he has recently noted
episodes of PND. He denies shortness of breath at rest. He
denies
orthopnea, palpitations, chest pain, lower extremity edema,
lightheadedness, or syncope. He denies fevers or chills but
endorses a dry cough during that same time period. Review of
systems otherwise negative with the exception of severe hip pain
secondary to osteoarthritis.
Denies previous similar symptoms to this. States he does take
Aleve daily for his hip pain. Does not use other NSAIDs
frequently. Unsure about salt intake in his diet.
In regards to his CABG, this was done here in ___ (grafts
listed
below). He has not had further coronary angiography since then
per his history and review of ___ records. He had most recently
seen Dr. ___ in Cardiology clinic in ___ for followup, but
had not seen him since then and does not follow with cardiology.
In regards to Afib noted in the ED, per pharmacy patient had
previously been on diltiazem 240 XR, although is not taking this
currently. Per review of ___ records, Afib is not in the
patient's problem list, and there is no history of
anticoagulation.
ED EXAM:
Vitals: 98.3, ___, 20, 93% RA
General: Comfortable appearing man in no acute distress
Neck: JVP 12 cm.
Lungs: Bibasilar crackles. Decreased breath sounds at the bases
bilaterally.
Heart: Tachycardic. Irregularly irregular rhythm. No murmurs.
Abdomen: Soft, nondistended. Nontender.
Ext: Warm and well perfused. 1+ right lower extremity edema 2+
left lower extremity edema.
LABS:
Notable for Hgb 13, CO2 21 with normal gap, BUN/Cr ___,
troponin <0.01 x2, proBNP 7000, lactate 1.2, UA unremarkable.
EKG:
Atrial fibrillation with ventricular response of 129 bpm.
Leftward axis. Normal QRS. Prolonged QTc at 503 ms. ___ wave
progression in the precordial leads. Nonspecific lateral T wave
flattening.
IMAGING:
- Chest x-ray notable for cardiomegaly with congestion, mild
pulmonary edema, and bilateral small pleural effusions.
- CTA chest with no PE, but with pleural effusions and pulmonary
edema.
- Unilateral lower extremity noninvasive without evidence of DVT
in the left leg.
Upon arrival to the floor states his breathing is improved.
Denies ever or currently having chest pain/pressure, nausea,
vomiting, diaphoresis, radiation/numbness/tingling to arms or
jaw.
Past Medical History:
CAD s/p 4v CABG (LIMA to LAD, SVG to DIAG, SVG to PDA,
sequential
to PLV) ___
Hypertension
DLD
L Hip osteoarthritis
R Hip replacement for OA
Social History:
___
Family History:
Father with "heart issues"
Father died of lung cancer, mother died from complications of
alzheimer's
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
================================
Vitals: 98.0 146 / 84 103 20 93%RA
GENERAL: Well-developed, well-nourished. NAD. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink, no
pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP of 14 cm.
CARDIAC: PMI displaced laterally to anterior axillary line. RRR,
normal S1, S2. No murmurs/rubs/gallops. No thrills, lifts.
LUNGS: Bibasilar crackles bilaterally. Good air movement.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: Ankle 1+ edema bilat.
PULSES: Distal pulses palpable and symmetric
DISCHARGE PHYSICAL EXAM:
=======================
VITALS: 98.2 107/66 60 18 98 Ra
Gen: NAD, A&O x3
HEENT: MMM, scerla anicteric
CV: RRR, nl s1/s2, no m/r/g. JVP to 6 cm
Resp: CTAB. No w/r/r
Abd: soft NTND Normoactive BS
Ext: Trace ___ in LLE
Skin: warm, well perfused, no rashes
Pertinent Results:
===============
ADMISSION LABS:
===============
___ 11:48PM PTT-130.7*
___ 04:41PM GLUCOSE-98 UREA N-20 CREAT-1.3* SODIUM-140
POTASSIUM-4.4 CHLORIDE-101 TOTAL CO2-25 ANION GAP-14
___ 04:41PM CALCIUM-9.6 PHOSPHATE-4.0 MAGNESIUM-2.0
___ 02:06PM URINE HOURS-RANDOM
___ 02:06PM URINE UHOLD-HOLD
___ 02:06PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 02:06PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 12:45PM cTropnT-<0.01
___ 08:57AM LACTATE-1.7 CREAT-1.2
___ 08:57AM estGFR-Using this
___ 08:40AM GLUCOSE-148* UREA N-21* CREAT-1.3* SODIUM-142
POTASSIUM-4.7 CHLORIDE-105 TOTAL CO2-21* ANION GAP-16
___ 08:40AM estGFR-Using this
___ 08:40AM cTropnT-0.01
___ 08:40AM proBNP-7299*
___ 08:40AM CALCIUM-9.8 PHOSPHATE-3.8 MAGNESIUM-2.1
___ 08:40AM WBC-7.3 RBC-4.98 HGB-13.3* HCT-43.0 MCV-86
MCH-26.7 MCHC-30.9* RDW-19.1* RDWSD-58.8*
___ 08:40AM NEUTS-80.6* LYMPHS-10.9* MONOS-4.3* EOS-3.0
BASOS-0.6 IM ___ AbsNeut-5.85 AbsLymp-0.79* AbsMono-0.31
AbsEos-0.22 AbsBaso-0.04
___ 08:40AM PLT COUNT-216
===============
PERTINENT LABS:
===============
___ 08:28AM BLOOD ___ PTT-75.4* ___
___ 09:19AM BLOOD ___ PTT-98.4* ___
___ 07:09AM BLOOD ___ PTT-122.6* ___
___ 06:04AM BLOOD ___ PTT-60.7* ___
___ 08:05AM BLOOD Glucose-99 UreaN-20 Creat-1.5* Na-142
K-4.3 Cl-96 HCO3-32 AnGap-14
___ 09:15AM BLOOD ALT-13 AST-19 LD(LDH)-252* AlkPhos-82
TotBili-2.1*
___ 08:28AM BLOOD ALT-13 AST-18 AlkPhos-71 TotBili-1.2
___ 08:40AM BLOOD proBNP-7299*
___ 08:40AM BLOOD cTropnT-0.01
___ 12:45PM BLOOD cTropnT-<0.01
___ 09:15AM BLOOD calTIBC-360 Ferritn-178 TRF-277
___ 09:15AM BLOOD %HbA1c-5.3 eAG-105
___ 09:15AM BLOOD Triglyc-70 HDL-49 CHOL/HD-4.2
LDLcalc-144*
___ 09:15AM BLOOD TSH-7.1*
___ 04:55PM BLOOD T3-81 Free T4-1.1
___ 04:55PM BLOOD HBsAg-NEG HBsAb-POS HBcAb-POS*
___ 04:55PM BLOOD ___
___ 04:55PM BLOOD PEP-NO SPECIFI
___ 09:19AM BLOOD HIV Ab-NEG
___ 04:55PM BLOOD HCV Ab-NEG
===============
DISCHARGE LABS:
===============
___ 06:04AM BLOOD WBC-5.5 RBC-5.06 Hgb-13.5* Hct-42.5
MCV-84 MCH-26.7 MCHC-31.8* RDW-18.0* RDWSD-54.2* Plt ___
___ 06:04AM BLOOD ___ PTT-60.7* ___
___ 06:04AM BLOOD Glucose-96 UreaN-18 Creat-1.2 Na-141
K-4.2 Cl-101 HCO3-26 AnGap-14
___ 06:04AM BLOOD Calcium-9.5 Phos-4.0 Mg-2.0
==========================
PERTINENT IMAGING/STUDIES:
==========================
___ Imaging CTA CHEST
1. No pulmonary embolism or other acute process in the chest.
2. Moderate layering pleural effusions with interstitial
pulmonary edema and mild cardiomegaly.
3. Emphysema.
___ Echo Report
CONCLUSION:
The left atrial volume index is mildly increased. The right
atrium is moderately enlarged. There is no evidence for an
atrial septal defect by 2D/color Doppler. The estimated right
atrial pressure is ___ mmHg. There is normal left ventricular
wall thickness with a normal cavity size. There is
moderate-severe global left ventricular hypokinesis. The
visually estimated left ventricular ejection fraction is ___.
There is no resting left ventricular outflow tract gradient.
Tissue Doppler suggests an increased left ventricular filling
pressure (PCWP greater than 18mmHg). Mildly dilated right
ventricular cavity with SEVERE global free wall hypokinesis.
Intrinsic right ventricular systolic function is likely lower
due to the severity of tricuspid regurgitation. The aortic sinus
diameter is normal for gender with normal ascending aorta
diameter for gender. The aortic arch is mildly dilated. 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 moderate [2+] mitral regurgitation. Due to
acoustic shadowing, the severity of mitral regurgitation could
be UNDERestimated. The tricuspid valve leaflets are mildly
thickened. There is an
eccentric, interatrial sepal directed jet of moderate [2+]
tricuspid regurgitation. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion. A left pleural
effusion is present.
IMPRESSION: Normal left ventricular cavity size with moderate to
severe global biventricular hypokinesis. At least moderate
mitral
regurgitation. Mild pulmonary hypertension.
___ Echo Final Report
IMPRESSION: No spontaneous echo contrast or thrombus in the left
atrium/left atrial appendage/right atrium/right atrial
appendage. Complex atheroma in the ascending and descending
thoracic
aorta. Mildly depressed biventricular systolic function. Mild
mitral regurgitation. Mild tricuspid regurgitation.
___ STRESS TEST: INTERPRETATION: This ___ year old man s/p
PCIs ___ and CABG ___, HFrEF and PAF was referred to the lab for
evaluation. Due to limited mobility, the patient was infused
with 0.4 mg of regadenoson over 20 seconds, followed immediately
by isotope infusion. No arm, neck, back or chest discomfort was
reported by the patient throughout the study. There were no
significant ST segment changes during the infusion or in
recovery. The rhythm was sinus with rare isolated apbs and one
vpb. Appropriate hemodynamic response to the infusion and
recovery. The regadenoson was reversed with 40 mg of caffeine
IV. IMPRESSION: No anginal type symptoms or significant ST
segment changes. Nuclear report sent separately.
Pharmacologic MIBI ___: IMPRESSION: 1. No focal myocardial
perfusion defects. 2. Mildly decreased ejection fraction of 42%.
Brief Hospital Course:
___ y/o M, PMH notable for CAD s/p 4v CABG in ___, HTN, DLD,
presenting with 2 mo h/o DOE, found to have new diagnosis of
HFrEF and AFib. Workup notable for non-ischemic cause of HFrEF
who underwent successful TEE/DCCV on ___ for AFib.
====================
TRANSITIONAL ISSUES:
====================
[] Please repeat labs (Chem10 + INR) on ___. Please fax
results to ___ ___ and ___
clinic at ___
[] Patient is being discharged on warfarin. He will be followed
at the ___ clinic at Healthcare Associates at ___
[] Patient currently undergoing insurance approval process.
Recommend initiation of apixaban 5 mg PO BID in favor of
continued warfarin and starting Entresto instead of losartan
[] Avoid spironolactone as became hyperkalemic on this
medication
[] Consider repeat TTE to see if EF improved after cardioversion
=============
ACUTE ISSUES:
=============
#HFrEF
New diagnosis of HFrEF with LVEF ___ on TTE ___
Demonstrating global systolic dysfunction + RV dysfx, so could
be suggestive of NICM although iCM is certainly possible given
h/o grafts and CABG. pMIBI was done ___ demonstrating no focal
myocardial perfusion defects. Workup for nonischemic causes
including UPEP, SPEP, HIV, ___, hepatitis panel were notable for
Hep B cAb and sAb positive indicating past infection, but
otherwise negative. ___ have been secondary to
tachycardia-mediated cardiomyopathy He was diuresed with 80 IV
lasix pushes and discharge euvolemic on PO regimen.
PRELOAD: Lasix 40 mg PO daily
AFTERLOAD: Losartan 100 mg PO daily, Carvedilol 12.5 mg PO BID
NHBK: Carvedilol 12.5 mg PO BID
DISCHARGE WEIGHT: 88.6 kg (195.33 lb)
DISCHARGE SERUM CREATININE: 1.2
#CAD
#CABG history
___ CABG (LIMA to LAD, SVG to DIAG, SVG to PDA, sequential to
PLV). pMIBI ordered as above which demonstrated no focal
myocardial perfusion defects. He did not experience anginal
symptoms during his testing. His ASA was continued and high dose
atorvastatin was started.
#Atrial Fibrillation
CHADS2VASc of 4. New diagnosis. No CVA history. Underwent
successful TEE/DCCV on ___ and was subsequently in normal
sinus rhythm.
- AC: heparin bridged to daily warfarin. DOAC was precluded by
cost given patient does not have active insurance at time of
discharge. Discharge INR: 2.8 on ___
- Rate control: Carvedilol 12.5 mg PO BID
# ___
Baseline serum creatinine was ___ approximately ___ year ago.
Peaked at 1.5 and down to 1.2 on discharge. Likely ___
cardiorenal.
#HTN
Historically difficult to control HTN as outpatient. Discharge
regimen: Carvedilol, losartan. Holding amlodipine with further
titration of Carvedilol as an outpatient as HRs tolerate
#L hip OA
Gave Tylenol 1g q8h and Lidocaine patches.
==============
CORE MEASURES:
==============
# LANGUAGE: ___
# CODE: Full, confirmed
# CONTACT/Next of Kin: ___ (Wife) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 5 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Losartan Potassium 100 mg PO DAILY
4. Metoprolol Succinate XL 50 mg PO BID
5. Fish Oil (Omega 3) 1000 mg PO DAILY
Discharge Medications:
1. Acetaminophen (Liquid) 650 mg PO Q6H
RX *acetaminophen 500 mg/15 mL 15 mL by mouth four times a day
Disp #*1 Bottle Refills:*0
2. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth at bedtime Disp #*14
Tablet Refills:*0
3. CARVedilol 12.5 mg PO BID
RX *carvedilol 12.5 mg 1 tablet(s) by mouth twice a day Disp
#*28 Tablet Refills:*0
4. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*14 Tablet
Refills:*0
5. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine 5 % Please apply to hip once a day. Do not leave
in place for more than 12 horus in a 24hr period daily Disp #*14
Patch Refills:*0
6. Warfarin 2.5 mg PO DAILY16
RX *warfarin 2.5 mg 1 tablet(s) by mouth daily Disp #*14 Tablet
Refills:*0
7. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*14 Tablet
Refills:*0
8. Fish Oil (Omega 3) 1000 mg PO DAILY
9. Losartan Potassium 100 mg PO DAILY
RX *losartan 100 mg 1 tablet(s) by mouth daily Disp #*14 Tablet
Refills:*0
10.Outpatient Lab Work
Lab: ___, Chem10
Date: ___
ICD-9 code: ___
Please fax results to ___ ___ and ___
___ clinic at ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY
=======
Acute HFrEF exacerbation
Atrial Fibrillation
SECONDARY
=========
Hyperkalemia
CAD s/p CABG
CKD
HTN
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
WHY WAS I ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital because you were having
increasing difficulty breathing and decreased exercise tolerance
- This was because you had excess fluid in your lungs
WHAT WAS DONE FOR ME WHILE I WAS HERE?
- We examined your heart which showed the pumping function is
decreased. This condition is known as heart failure
- Heart failure can cause fluid to accumulate in your lungs and
your legs. We gave you medications to help remove the fluid
- You had tests evaluating the arteries that supply your heart,
which showed you did not have any
WHAT DO I NEED TO DO WHEN I LEAVE THE HOSPITAL?
- Please take your medications below as prescribed and keep all
your appointments
- Please weigh yourself daily. If your weight increases by 3lbs
in 24 hours, please contact your cardiologist.
- If you develop difficulty breathing, chest pain or pressure,
or other concerning symptoms, please seek urgent medical
attention or call ___.
- Please take your first dose of warfarin tonight
- Please have labs drawn on ___
We wish you the best with your health!
- Your ___ team
Followup Instructions:
___
|
19556353-DS-3
| 19,556,353 | 28,243,148 |
DS
| 3 |
2127-05-19 00:00:00
|
2127-05-20 23:22:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Codeine / E-Mycin
Attending: ___.
Chief Complaint:
abdominal pain, fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ yo G0 POD ___ s/p hysteroscopy/myomectomy
presented to GYN office today with lower abdominal pain, fever
and pleuritic chest pain. Patient referred to ED for possible
infection versus perforation and work up for possible PE.
Patient underwent hysteroscopy myomectomy on ___ for
menorrhagia and fibroid noted on ultrasound. Patient reports she
had lower abdominal pain following procedure which persisted.
Reports developed low grade fevers and yesterday patient reports
she developed pain/shortness of breath with deep inspiration.
Patient reports shortness of breath has improved, pain in
abdomen also improved and she feels less distended than this AM,
has had minimal vaginal bleeding over last several hours. She
had a bowel movement today. Denies nausea or vomiting but her
appetite is decreased.
Past Medical History:
OB/GYN History:
-G0
-Hx of menorrhagia, fibroid noted on ultrasound.
-Hx Genital herpes, no outbreak in ___ years, on valtrex
-Hx abnormal pap, repeat pap wnl, no further abnormal
Medical History:
-Seasonal Allergies
Surgical History:
-___ eye surgery
-T&A
Social History:
___
Family History:
Noncontributory
Physical Exam:
On admission:
VS T98.4 BP 121/75 HR 82 RR 18 O2sat 99RA Weight 59kg
Gen: NAD, comfortable
CV: RRR
Pulm: CTAB
Abd: soft nondistended, mildly tender lower abdomen, no
rebound/guarding, +BS
GU: minimal spotting on pad
Ext: warm well perfused, nontender to palpation
On discharge:
AF VSS
Gen: NAD, comfortable
CV: RRR
Lungs: CTAB
Abd: +BS, minimally tender in lower abdomen diffusely, no
rebound, no guarding, soft.
GU: no spotting on pad
Ext: WWP, NT
Pertinent Results:
___ 03:25PM BLOOD WBC-11.5* RBC-3.49* Hgb-10.9* Hct-31.8*
MCV-91 MCH-31.1 MCHC-34.1 RDW-12.7 Plt ___
___ 07:50AM BLOOD WBC-8.2 RBC-3.50* Hgb-11.2* Hct-31.6*
MCV-90 MCH-31.9 MCHC-35.4* RDW-12.8 Plt ___
___ 03:30PM BLOOD WBC-7.3 RBC-3.51* Hgb-10.8* Hct-32.0*
MCV-91 MCH-30.6 MCHC-33.6 RDW-13.8 Plt ___
___ 03:25PM BLOOD Neuts-61.9 ___ Monos-4.0 Eos-1.0
Baso-0.3
___ 07:50AM BLOOD Neuts-63.4 ___ Monos-6.1 Eos-2.1
Baso-0.2
___ 05:55PM BLOOD ___ PTT-27.4 ___
___ 03:25PM BLOOD Glucose-92 UreaN-10 Creat-0.7 Na-143
K-3.6 Cl-106 HCO3-31 AnGap-10
___ 03:25PM BLOOD ALT-14 AST-16 AlkPhos-91 TotBili-0.1
___ 03:25PM BLOOD Albumin-3.8
___ 05:55PM BLOOD D-Dimer-1820*
___ 06:17PM BLOOD Lactate-1.5
___ 09:00PM URINE Color-Straw Appear-Clear Sp ___
___ 09:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 09:00PM URINE UCG-NEGATIVE
Chlamydia trachomatis, Nucleic Acid Probe, with Amplification
(Final ___: Negative for Chlamydia trachomatis by PCR.
NEISSERIA GONORRHOEAE (GC), NUCLEIC ACID PROBE, WITH
AMPLIFICATION (Final ___: Negative for Neisseria
Gonorrhoeae by PCR.
URINE CULTURE (Final ___: NO GROWTH.
Blood Culture, Routine (Pending):
Blood Culture, Routine (Pending):
CXR ___: New small bilateral pleural effusions.
Pelvic U/S ___: Heterogeneous material within the pelvis,
concerning for hemorrhage. Further evaluation could be performed
with CT. Normal-appearing ovaries, without findings to suggest
torsion. Normal-sized uterus with scattered small fibroids, the
largest of which is within the fundus.
CT abdomen/pelvis ___: Small-to-moderate right pleural
effusion, No pulmonary embolism. Moderate amount of hemorrhage
within the cul-de-sac, Linear hypodensity in the myometrium
posteriorly on the left in setting of recent recent
hysteroscopy-guided myomectomy, hemoperitoneum may be related to
uterine perforation.
Brief Hospital Course:
On ___, Ms. ___ presented to the Emergency Department
with fever and abdominal pain on post-operative day #3 after
hysteroscopy myomectomy for a submucosal fibroid. She was
admitted to the gynecology service due to a concern for a
uterine perforation.
She was made NPO and started on IV gentamicin and clindamycin.
CT scan revealed a left uterine perforation with resulting
hemoperitoneum. She had a mildly elevated white blood cell count
at 11.5 with a hematocrit of 31.8 on admission. Lactate was
normal.
On hospital day #2, serial abdominal exams were performed and
continued to improve. Serial CBCs revealed improving white blood
cell counts and a stable hematocrit. She was then transitioned
to a regular diet and oral percocet/motrin for pain control. She
continued to void spontaneously and to have regular bowel
movements.
She was discharged on hospital day #2 in stable condition with
outpatient follow-up with Dr. ___. She was discharged home
with a seven-day course of oral antibiotics.
Medications on Admission:
Fish oil, zyrtec
Discharge Medications:
1. Ibuprofen 600 mg PO Q6H:PRN pain
RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours
Disp #*60 Tablet Refills:*0
2. Doxycycline Hyclate 100 mg PO Q12H Duration: 7 Days
RX *doxycycline hyclate 100 mg 1 tablet(s) by mouth twice a day
Disp #*14 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID:PRN constipation
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*1
4. MedroxyPROGESTERone Acetate 10 mg PO DAILY Duration: 10 Days
Take medroxyprogesterone for the last 10 days that ___ take
Estrace.
RX *medroxyprogesterone 10 mg 1 tablet(s) by mouth once a day
Disp #*10 Tablet Refills:*0
5. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal pain secondary to uterine perforation after
hysteroscopic myomectomy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
- ___ were admitted to the gynecology service with abdominal
pain concerning for a uterine perforation after undergoing a
hysteroscopic myomectomy on ___.
- Please continue to take the Estrace 2mg twice per day for a
total of 30 days. For the last 10 days of Estrace, overlap with
Medroxyprogesterone (Provera) 10mg daily. Approximately ___ days
after ___ complete these medications ___ will have a menstrual
bleed.
- Please take Doxycycline 100mg twice per day for a total of 7
days.
- Take Tylenol and/or Motrin for pain. If ___ have more
significant pain, ___ may take Percocet (narcotic).
- Do not drive while taking narcotics.
- Do not exceed 4000mg of Tylenol in 24 hours.
- Consider taking Colace 100mg twice per day (stool softener) to
prevent constipation.
- No heavy lifting or rigorous activity for 7 days.
- Nothing in the vagina, including no intercourse for 7 days.
Followup Instructions:
___
|
19556738-DS-15
| 19,556,738 | 20,802,062 |
DS
| 15 |
2116-10-19 00:00:00
|
2116-10-20 18:15:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Headache, chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old woman with a history of remote CAD (known angina),
hypertension, hyperlipidemia, presenting as a transfer from
___ with chest pain and arm pain since this morning.
The patient first experienced substernal chest pain/pressure 5
days ago after mild exertion (coming from Church). The pain
lasted a few hours and resolved without intervention. Yesterday,
she had a recurrent episode at rest that lasted until she fell
asleep. Today, she awoke chest pain free, but had recurrence of
___ chest pain/pressure radiating to the left arm starting at
10 am. She was seen by her PCP, and was referred to ___
for a cardiac evaluation. At ___, she was foun to have a
blood pressure of 228/98, pulse 54. Pain was ___. Patient
received a CT which showed no evidence of PE or dissection. Her
first troponin was negative. Nitropaste was placed, and chest
pain improved. Cardiology was consulted and recommended transfer
to ___ for possible catheterization. Nitropaste was removed
prior to transfer.
In the ___ ED, initial VS: 95.2 58 150/89 16 100%. EKG was
notable for normal sinus rhythm with a 1mm ST elevation in V2.
Repeat troponin < 0.01. The patient was started on a nitro drip
for ongoing hypertension and continued chest pain. She was
admitted to ___ for further management. VS prior to transfer:
143/58 12 96% RA.
On the floor, the patient denies chest pain, but does complain
of a lingering "nagging" pain in her left arm. Headache has
resolved. She denies shortness of breath, palpitations,
abdominal pain, nausea.
Past Medical History:
Remote diagnosis of angina, only on atenlol
Social History:
___
Family History:
Both parents died of ischemic strokes in old age.
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION:
VS: T=98.6 BP= 191/76 HR= 58 RR= 20 O2 sat=95%RA
GENERAL: Pleasant, WDWN woman in NAD. Oriented x3. Mood, affect
appropriate. Appears comfortable
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with no JVD
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: Trace ankle edema.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: DP 2+
NEURO: CN II-XII tested individually and intact, strength ___ in
upper and lower extremities
DISCHARGE:
VS: T=98.1 BP= 145/68 HR= 63 RR= 16 O2 sat=96%RA
Weight: 77.2 kg
GENERAL: NAD. Oriented x3.
HEENT: NCAT, EOMI.
NECK: Supple with no JVD
CARDIAC: RRR, normal S1, S2. No m/r/g.
LUNGS: CTAB
ABDOMEN: Soft, NTND.
EXTREMITIES: Trace ankle edema, L>R
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: DP 2+ bilaterally
Pertinent Results:
ADMISSION LABS:
___ 10:25PM BLOOD WBC-4.8 RBC-4.51 Hgb-14.8 Hct-44.5
MCV-99* MCH-32.7* MCHC-33.1 RDW-12.4 Plt ___
___ 10:25PM BLOOD Neuts-38.3* Lymphs-47.5* Monos-6.3
Eos-5.3* Baso-2.6*
___ 10:25PM BLOOD ___ PTT-33.1 ___
___ 10:25PM BLOOD Glucose-91 UreaN-19 Creat-0.8 Na-137
K-5.7* Cl-102 HCO3-24 AnGap-17
___ 10:25PM BLOOD cTropnT-<0.01
___ 06:40AM BLOOD Calcium-9.4 Phos-3.2 Mg-2.2 Cholest-216*
TREND LABS & RELEVANT LABS:
___ 10:25PM BLOOD cTropnT-<0.01
___ 06:40AM BLOOD CK-MB-3 cTropnT-<0.01
___ 02:45PM BLOOD CK-MB-3 cTropnT-<0.01
___ 06:13AM BLOOD Triglyc-77 HDL-63 CHOL/HD-3.3 LDLcalc-129
LDLmeas-136*
___ 03:31PM BLOOD %HbA1c-PND
___ 06:40AM BLOOD TSH-3.0
DISCHARGE LABS:
___ 06:13AM BLOOD WBC-4.6 RBC-4.11* Hgb-13.4 Hct-40.7
MCV-99* MCH-32.5* MCHC-32.8 RDW-12.9 Plt ___
___ 06:13AM BLOOD Glucose-103* UreaN-27* Creat-0.9 Na-143
K-4.6 Cl-104 HCO3-33* AnGap-11
___ 06:13AM BLOOD Calcium-9.9 Phos-3.3 Mg-2.2 Cholest-207*
IMAGING AND STUDIES:
CT head ___:
IMPRESSION: No acute intracranial abnormality.
Echocardiogram ___:
The left atrium and right atrium are normal in cavity size.
There is mild symmetric left ventricular hypertrophy with normal
cavity size and regional/global systolic function (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
The ascending aorta and aortic arch are mildly dilated. 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 mild [1+] mitral regurgitation. There is no mitral
valve prolapse. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved regional and global biventricular systolic function.
Mild mitral regurgitation with normal valve morphology.
Borderline pulmonary artery systolic hypertension. Mildly
dilated thoracic aorta.
ETT ___:
IMPRESSION: No ischemic ECG changes. No anginal type symptoms.
Resting hypertension. Exaggerated hypertensive response to
exercise. Fair functional capacity demonstrated.
Brief Hospital Course:
___ year old healthy woman who presented with constant chest pain
and headache, found to have hypertensive emergency.
ACTIVE ISSUES:
# Hypertensive emergency: BP 228/98 at OSH, 150/89 when brought
to our ED. Patient did have severe headache and chest pain in
the setting of hypertension, but no ischemic changes on EKG. She
was temporarily on nitro drip for blood pressure control. She
was started on lisinopril, HCTZ, and her home atenolol was
changed to metoprolol. Stress ETT with no EKG changes, no chest
pain, but exaggerated hypertensive response to exercise. We
uptitrated blood pressure medications to lisinopril 20mg daily
and HCTZ 25mg daily. LDL 136, not continued on statin.
# Chest pain: Patient presented with chest pain radiating to the
left arm in the setting of hypertension. No ischemic EKG
changes, troponin x 3 negative. She was started on heparin gtt
in addition to nitro gtt given concern for unstable angina. Also
started on aspirin, atorvastatin, in addition to metoprolol and
lisinopril. Chest pain improved. Given her symptoms of constant
chest pain, improved with BP control, and no signs of ischemia
with EKGs or troponins, it was felt her chest pain was secondary
to hypertension, and heparin gtt was discontinued. A TTE was
performed that showed preserved regional and global
biventricular systolic function, EF > 55%. Stress ETT with no
EKG changes, no chest pain, but exaggerated hypertensive
response to exercise (see above). Risk factor evaluation for
CAD: HbA1c pending; LDL 136, so statin was discontinued and she
will start with lifestyle modifications.
CHRONIC ISSUES:
# Hyperthyroidism: TSH WNL. Continued levothyroxine.
# Depression: Continued paroxetine.
# Incontinence: Continued oxybutinin.
TRANSITIONAL ISSUES:
- Monitor blood pressure: may need to uptitrate medications.
- Consider workup for secondary hypertension.
- Follow up HbA1C, result currently pending.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 25 mg PO DAILY
2. Levothyroxine Sodium 125 mcg PO DAILY
3. Paroxetine 10 mg PO DAILY
4. Oxybutynin 2.5 mg PO DAILY
5. Naproxen 250 mg PO Q12H:PRN pain
Discharge Medications:
1. Levothyroxine Sodium 125 mcg PO DAILY
2. Oxybutynin 2.5 mg PO DAILY
3. Paroxetine 10 mg PO DAILY
4. Acetaminophen 650 mg PO Q6H:PRN headache
5. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 (One) tablet extended release
24 hr(s) by mouth once a day Disp #*30 Tablet Refills:*0
6. Lisinopril 20 mg PO DAILY
RX *lisinopril 20 mg 1 (One) tablet(s) by mouth once a day Disp
#*30 Tablet Refills:*0
7. Hydrochlorothiazide 25 mg PO DAILY
RX *hydrochlorothiazide 25 mg 1 (One) tablet(s) by mouth once a
day Disp #*30 Tablet Refills:*0
8. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 (One) tablet,chewable(s) by mouth once a day
Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Hypertensive Emergency
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Ms. ___,
It was a pleasure participating in your care at ___. You were
admitted to the hospital because your blood pressure was very
high. You were having chest pain and a headache, which was
likely related to your elevated blood pressure. Your blood
pressure was controlled with IV medications, and then you were
transitioned to oral blood pressure medications. You underwent
an exercise stress test that did not show any strain of your
heart. However your blood pressure did become more elevated with
exercise. We have adjusted some of your oral blood pressure
medications, but it will be very important for you to follow up
with your primary care doctor so that they can continue to
montior your blood pressure and adjust your medications as
necessary.
Please avoid non-steroidal anti-inflammatory medications like
ibuprofen and naproxen. If you need to take pain medications,
take tylenol. Please also adhere to a low-salt diet, limit to
___ grams of sodium per day.
Followup Instructions:
___
|
19556915-DS-18
| 19,556,915 | 25,806,271 |
DS
| 18 |
2202-04-30 00:00:00
|
2202-04-30 22:41:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Penicillins / Lipitor / Anesthetics - Amide Type / Anesthetics -
___
Attending: ___.
Chief Complaint:
Abdominal pain.
Major Surgical or Invasive Procedure:
Laparoscopic appendectomy.
History of Present Illness:
___ s/p lap gastric band first developed nausea 2 nights ago.
When she awoke yesterday, she had LLQ pain that radiated to the
L back, followed by dry heaves and chills (not rigors). She
took a nap in the early afternoon, and when she awoke, the pain
had migrated to the RLQ. This morning, when she awoke, the pain
had resolved, but she was still tender in the RLQ. She ate
cookies w/ coffee for breakfast. She presented to her PCP and
underwent CT scan demonstrating early appendicitis.
She currently reports that she has no pain, although she is
still tender. She has no nausea and is in fact hungry. No
fevers. 1 episode of diarrhea, which she reports is normal for
her.
Past Medical History:
Past Medical History: Hypothyroidism, hyperlipidemia, fatty
liver, heartburn, gallstones, fibroids.
Past Surgical History: laparoscopic cholecystectomy in ___,
right ankle surgery.
Social History:
___
Family History:
Her family history is noted for father living age ___ with asthma
and hyperlipidemia; mother living age ___ with hyperlipidemia,
breast CA and obesity status post weight loss surgery; brother
living with diabetes and hyperlipidemia; grandmother deceased
with heart disease and cancer; there is several family members
with history of thyroid disease and many members with obesity.
Physical Exam:
Admission Physical Exam:
Vitals: 97.8 80 119/86 14 100%RA
GEN: A&Ox3, NAD, nontoxic appearance
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, mildly tender RLQ, no rebound or
guarding, normoactive bowel sounds, no palpable masses, no
Rovsing's/psoas/obturator sign
Ext: No ___ edema, ___ warm and well perfused
Discharge Physical Exam:
Vitals: 98.2 88 120/83 18 97%RA
GEN: A&Ox3, NAD, nontoxic appearance
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, mildly tender RLQ, no rebound or
guarding, normoactive bowel sounds, no palpable masses.
Incisions: clean, dry and intact.
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
___ 06:30AM WBC-10.0 RBC-4.23 HGB-12.9 HCT-38.4 MCV-91
MCH-30.5 MCHC-33.5 RDW-12.8
___ 10:47PM LACTATE-1.2
___ 08:20PM ___ PTT-32.7 ___
___ 07:20PM URINE UCG-NEGATIVE
___ 07:20PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 07:20PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 03:30PM UREA N-7 CREAT-0.7
___ 03:30PM ALT(SGPT)-19 AST(SGOT)-24 ALK PHOS-71 TOT
BILI-0.6
___ 03:30PM WBC-11.6* RBC-4.62 HGB-14.1 HCT-42.0 MCV-91
MCH-30.5 MCHC-33.5 RDW-13.0
___ 03:30PM NEUTS-69.3 ___ MONOS-5.2 EOS-0.4
BASOS-0.3
___ 03:30PM PLT COUNT-293
CT ABD & PELVIS WITH CONTRAST Clip # ___
Reason: r/o appendicitis
Contrast: OMNIPAQUE Amt: 130
IMPRESSION:
Findings compatible with acute uncomplicated appendicitis with a
small amount of free fluid in the pelvis.
The study and the report were reviewed by the staff radiologist.
___. ___
___. ___
___. ___
___: FRI ___ 1:14 ___
Brief Hospital Course:
Ms. ___ presented to the ___
___ Emergency Department with the aforementioned
symptoms suggestive of acute appendicitis (refer to HPI of this
document). The patient was initially evaluated by the Acute Care
Surery (___) team and underwent CT abdomen and pelvis which was
read to demonstrate acute appendicitis. She was admitted to the
___ Surgery team overnight with intravenous (IV)
antibiotics, nothing per mouth as diet, and IV pain medication.
She was observed overnight with serial abdominal exams and her
fever curves and other vital signs were carefully monitored.
She remained stable overnight and her abdominal exam improved.
The patient was seen in the morning of hospital day 1 (HD1) and
her vital signs and physical exam continued to remain stable.
The patient was taken to the operating room for a laparoscopic
appendectomy which she tolerated well. The procedure was
without complications, her Foley catheter was removed
post-procedure, and she was given a dose of ciprofloxacin and
metronidazole IV intraoperatively; a full operative report can
be found in her ___ medical record. Ms. ___ was
transferred to the post-operative care unit (PACU) where she
continued to recover with adequate pain control, her diet was
sequentially advanced, and she was encouraged to ambulate. She
was subsequently transfered back to the her room on the floor
and provided with prescriptions for 7 days of oral ciprofloxacin
and metronidazole, and pain medication, and discharge
instructions, including a follow up appointment with Dr. ___
in his ___ clinic. Ms. ___ was then discharged home.
Medications on Admission:
1. MVI 1 qdaily
2. Ca+vit D3+vit K 500-500U-40mcg BID
3. Vitamin D3 1000U qdaily
4. Celexa 40mg qdaily
5. Klonopin 0.5mg prn
6. Levothyroxine 0.05mg qdaily
Allergies: amides, esters, Lipitor, PCN
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*40 Capsule Refills:*0
2. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth q4hr Disp #*50 Tablet
Refills:*0
3. Ciprofloxacin HCl 750 mg PO Q12H Duration: 7 Days
RX *ciprofloxacin 750 mg 1 tablet(s) by mouth q12hr Disp #*14
Tablet Refills:*0
4. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H Duration: 7 Days
RX *metronidazole 500 mg 1 tablet(s) by mouth q8hr Disp #*21
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Acute appendicitis.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with acute appendicitis. You
were taken to the operating room and had your appendix removed
laparoscopically. You tolerated the procedure well and are now
being discharged home with the following instructions:
Please follow up at the appointment in clinic listed below. We
also generally recommend that patients follow up with their
primary care provider after having surgery.
ACTIVITY:
Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
You may climb stairs.
You may go outside, but avoid traveling long distances until you
see your surgeon at your next visit.
Don't lift more than ___ lbs for ___ weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
You may feel weak or "washed out" a couple weeks. You might want
to nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You could have a poor appetite for a couple days. Food may seem
unappealing.
All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressings you have small plastic bandages
called steristrips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay.
Your incisions may be slightly red around the stitches. This is
normal.
You may gently wash away dried material around your incision.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing or clothes. If the staining is severe, please call
your surgeon.
You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
Constipation is a common side effect of narcotic pain
medicaitons. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
If you go 48 hours without a bowel movement, or have pain moving
the bowels, call your surgeon.
PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your surgeon.
You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. Do not
take it more frequently than prescribed. Do not take more
medicine at one time than prescribed. Do not drink alcohol or
drive while taking narcotic pain medication.
Your pain medicine will work better if you take it before your
pain gets too severe.
Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
Remember to use your "cough pillow" for splinting when you cough
or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
You will be given a prescription for two antibiotics,
Ciprofloxacin and Metronidazole for 7 days. Please TAKE ALL of
your ANTIBIOTICS.
DANGER SIGNS:
Please call your surgeon if you develop:
- worsening abdominal pain
- sharp or severe pain that lasts several hours
- temperature of 101 degrees or higher
- severe diarrhea
- vomiting
- redness around the incision that is spreading
- increased swelling around the incision
- excessive bruising around the incision
- cloudy fluid coming from the wound
- bright red blood or foul smelling discharge coming from the
wound
- an increase in drainage from the wound
Followup Instructions:
___
|
19556941-DS-11
| 19,556,941 | 28,458,209 |
DS
| 11 |
2147-02-23 00:00:00
|
2147-02-23 08:30:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
Sinemet
Attending: ___.
Chief Complaint:
left valgus impacted femoral neck fracture
Major Surgical or Invasive Procedure:
Left hip closed reduction and percutaneous pin fixation ___,
Dr. ___
History of Present Illness:
___ PMH Parkinsons, HTN, R THA ___ p/w L valgus impacted
FNFx s/p mechanical fall down stairs. Normally ambulates with
walker but per pt minimally ambulatory. Endorses HS but no LOC.
Not on anticoagulation.
Past Medical History:
___
Social History:
___
Family History:
NC
Physical Exam:
___: Incision well approximated. No evidence of hematoma. Fires
FHL, ___, TA, GCS. SILT ___ n distributions. 1+ DP
pulse, wwp distally.
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 valgus impacted femoral neck fracture and was
admitted to the orthopedic surgery service. The patient was
taken to the operating room on ___ for CRPP, which the patient
tolerated well. For full details of the procedure please see the
separately dictated operative report. The patient was taken from
the OR to the PACU in stable condition and after satisfactory
recovery from anesthesia was transferred to the floor. The
patient was initially given IV fluids and IV pain medications,
and progressed to a regular diet and oral medications by POD#1.
The patient was given ___ antibiotics and
anticoagulation per routine. The patient's home medications were
continued throughout this hospitalization. The patient worked
with ___ who determined that discharge to rehab was appropriate.
The ___ hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
WBAT in the left lower extremity, and will be discharged on
Lovenox 40mg subcutaneous QHS 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:
See OMR.
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Atorvastatin 80 mg PO QPM
3. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - Second Line
while taking narcotics
4. Digoxin 0.125 mg PO DAILY
5. Enoxaparin Sodium 40 mg SC QHS
6. Furosemide 20 mg PO DAILY
7. Gabapentin 200 mg PO QPM
8. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 2.5-5 mg by mouth q6prn Disp #*20 Tablet
Refills:*0
9. Tamsulosin 0.4 mg PO QHS
10. Amantadine 100 mg PO BID
11. Pramipexole 0.25 mg PO FOUR TIMES DAILY
12. Rasagiline 1 mg PO Q8AM
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
L 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, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Touch down weight bearing for two months.
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 40mg QHS daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
- If you have a splint in place, splint must be left on until
follow up appointment unless otherwise instructed. Do NOT get
splint wet.
Physical Therapy:
Activity: Activity: Ambulate twice daily if patient able
Left lower extremity: Full weight bearing
Treatments Frequency:
Any staples or superficial sutures you have are to remain in
place for at least 2 weeks postoperatively. Incision may be
left open to air unless actively draining after POD3. If
draining, you may apply a gauze dressing secured with paper
tape. You may shower and allow water to run over the wound, but
please refrain from bathing for at least 4 weeks
postoperatively.
Call your surgeon's office with any questions.
Followup Instructions:
___
|
19557250-DS-13
| 19,557,250 | 28,239,597 |
DS
| 13 |
2168-12-17 00:00:00
|
2168-12-21 18:06:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Iodinated Contrast Media - IV Dye
Attending: ___.
Chief Complaint:
Motor Vehicle Collision, pneumomediastinum
Major Surgical or Invasive Procedure:
___: Flexible bronchoscopy + airway inspection
History of Present Illness:
This patient is a ___ year old male who complains of MVC,
Pneumothorax. ___ BIB EMS s/p restrained driver, T-boned at
moderate speed at 5pm by an SUV. Ambulatory at the scene.
Brought to ___. Seen after 3 hours complaining of L
shoulder/chest pain. CT showed L sided rib fractures ___ with
small pulmonary contusion and pneumomediastinum. Was
hypertensive/tachycardic. Sats 90% on RA, 98% on 4L NC. Had
possible allergic reaction to contrast (hives). Imaging obtained
at OSH: CT Chest with contrast.
Past Medical History:
HTN
Social History:
___
Family History:
Non-contributory
Physical Exam:
Admission Physical Exam:
Temp: 99.4 HR: 106 BP: 174/100 Resp: 18 O(2)Sat: 98 Normal
Constitutional: Comfortable
HEENT: Normocephalic, atraumatic
Oropharynx within normal limits
Chest: Anterior left-sided chest wall tenderness, +crepitus L
neck, chest
Cardiovascular: Regular Rate and Rhythm
Abdominal: Soft, Nontender
Extr/Back: No cyanosis, clubbing. +brawny edema, chronic venous
stasis changes.
Skin: No rash
Neuro: Speech fluent
Discharge Physical Exam:
VS: T: 98.2, HR: 94, BP: 153/78 RR: 18, O2: 93% RA
General: A+Ox3, NAD
CV: RRR
PULM: CTA b/l, decreased in left upper lobe
ABD: soft, non-distended, non-tender
Extremities: b/l ___ +1 edema and indicative of peripheral
vascular disease. Warm and + pulses in all extremities.
Pertinent Results:
___ 03:42AM ___ PO2-184* PCO2-51* PH-7.39 TOTAL
CO2-32* BASE XS-5 COMMENTS-GREEN TOP
___ 03:42AM GLUCOSE-157* LACTATE-1.7
___ 03:42AM freeCa-1.05*
___ 03:32AM GLUCOSE-166* UREA N-25* CREAT-1.1 SODIUM-140
POTASSIUM-4.4 CHLORIDE-100 TOTAL CO2-29 ANION GAP-15
___ 03:32AM CALCIUM-8.7 PHOSPHATE-4.1 MAGNESIUM-2.1
___ 03:32AM WBC-8.2 RBC-5.17 HGB-13.7 HCT-42.9 MCV-83
MCH-26.5 MCHC-31.9* RDW-15.2 RDWSD-45.8
___ 03:32AM PLT COUNT-199
___ 03:32AM ___ PTT-26.9 ___
___ 10:32PM GLUCOSE-161* UREA N-24* CREAT-1.1 SODIUM-140
POTASSIUM-4.4 CHLORIDE-99 TOTAL CO2-31 ANION GAP-14
___ 10:32PM ALT(SGPT)-26 AST(SGOT)-25 ALK PHOS-64 TOT
BILI-0.3
___ 10:32PM LIPASE-41
___ 10:32PM ALBUMIN-4.2
___ 10:32PM WBC-9.6 RBC-5.45 HGB-14.3 HCT-45.1 MCV-83
MCH-26.2 MCHC-31.7* RDW-15.3 RDWSD-45.1
___ 10:32PM NEUTS-75.2* LYMPHS-14.8* MONOS-9.2 EOS-0.2*
BASOS-0.3 IM ___ AbsNeut-7.22* AbsLymp-1.42 AbsMono-0.88*
AbsEos-0.02* AbsBaso-0.03
___ 10:32PM PLT COUNT-200
___ 10:32PM ___ PTT-26.5 ___
Imaging:
___ CT Head:
1. No acute intracranial hemorrhage or fracture.
2. Extensive subcutaneous emphysema, which may be extending from
the
mediastinum. Recommend clinical correlation.
___: CXR:
1. Left apical contusion is better demonstrated on the
subsequent CT. No
evidence of pneumothorax.
2. Known rib fractures involving the left ___ - 3rd ribs.
3. Pneumomediastinum and subcutaneous emphysema.
___: CT Chest:
1. Acute mildly displaced left 1st rib fracture. Acute
non-displaced
fractures of the left ___ and 3rd ribs.
2. Extensive pneumomediastinum and subcutaneous emphysema in the
neck and
upper chest is suspicious for airway injury. Possible wall
irregularity in
the proximal left mainstem bronchus at the tracheobronchial
junction may
represent site of injury.
3. Small focus of air along the left anterior cardiac border is
likely
extrapleural. No pneumothorax. Left apical pulmonary
contusion. No
pulmonary laceration.
4. No sequela of trauma within the abdomen or pelvis.
___: CT C-spine:
1. Study is mildly degraded by motion.
2. Within limits of study, no acute fracture or traumatic
malalignment within
the cervical spine.
3. Extensive subcutaneous emphysema.
4. Partially imaged left first rib fracture.
5. Multilevel degenerative changes results in severe spinal
canal stenosis at C4-C5, C5-C6 and C6-C7.
6. Please note MRI of the cervical spine is more sensitive for
the evaluation of ligamentous or spinal cord injury.
7. Please see concurrently obtained CT of the chest abdomen
pelvis study for description of non cervical structures.
___: CXR:
There is no pneumothorax or pleural effusion. Subcutaneous
emphysema in the left chest wall and neck is less pronounced
today than it was on ___, stable since ___.
Small pneumomediastinum is stable. Previous small contusion,
left lung apex has never been particularly visible on
conventional chest radiographs but is not substantial. Lungs
are essentially clear. Heart is top-normal size.
___: Esophagus:
1. No evidence of esophageal perforation or obstruction.
2. Mild gastroesophageal reflux.
3. Tertiary esophageal contractions.
___: ECHO:
Suboptimal image quality. No intracardiac manifestations of
trauma. Mild symmetric left ventricular hypertrophy with mildly
globally reduced left ventricular systolic function. Mild aortic
stenosis. Mild to moderate mitral regurgitation. Indeterminate
pulmonary artery systolic pressure.
___: MRA Neck:
1. The major arterial vessels of the neck appear patent with no
evidence of
dissection or stenotic lesions.
Brief Hospital Course:
Mr. ___ is a ___ year-old male who was transferred to ___
from an OSH s/p MVC. At the OSH, he had imaging which revealed
left-sided rib fractures ___ with a small left pulmonary
contusion with extrapleural air, pneumomediastinum, and an
impressive amount of subcutaneous emphysema. The patient had
been hypertensive/tachycardic. Sats were 90% on RA,98% on 4L NC.
He was admitted to the Trauma/Acute Care Surgery service and was
transferred to the ICU for pain control and respiratory
monitoring given concern for airway injury and occult vascular
injury.
While in the trauma surgical intensive care unit, he was
monitored closely on telemetry and continuous pulse oximetry for
any signs of respiratory compromise or arrhythmia. He had no
arrhythmias, but he did have an oxygen requirement, which was
new for him. On ___, interventional pulmonology was consulted
given concern for airway injury and he underwent an awake
flexible bronchoscopy. He tolerated this procedure well. A
right bronchus intermedius posterior wall mucosal defect was
seen and thoracic surgery was consulted. Dr. ___
thoracic surgery recommended conservative management of this
tear, and no acute intervention, as the patient was stable from
a respiratory standpoint without any signs of acute respiratory
failure. Interventional pulmonology recommended that Mr.
___ be kept on 100% FiO2 via face tent to expedite the
resolution of his pneumomediastinum. They also recommended that
he undergo a barium swallow before starting on a regular diet.
This was done and showed no evidence of leak, and his diet was
advanced to regular without incident. Additionally, Dr. ___
___ acute care trauma surgery felt it was important to look for
evidence of occult vascular injury and therefore Mr. ___
also underwent a formal TTE and MRA neck, which showed no
pericardial effusion or evidence of vascular injury. Throughout
his ICU stay, Mr. ___ remained hemodynamically stable. On
___, he was transferred to the hospital floor.
The remainder of his hospital course is summarized by systems
below:
Neuro: The patient was alert and oriented throughout
hospitalization; pain was managed with oral acetaminophen and
oxycodone once tolerating a diet.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored. PO metoprolol
was started to treat hypertension with good effect.
Pulmonary: The patient was weaned off of oxygen. He remained
stable from a pulmonary standpoint; vital signs were routinely
monitored. Good pulmonary toilet, early ambulation and incentive
spirometry were encouraged throughout hospitalization. The
patient was able to take in 1500-2000ml on his incentive
spirometer.
GI/GU/FEN: The patient's diet was advanced sequentially to a
Regular diet, which was well tolerated. Patient's intake and
output were closely monitored. The patient was provided with
nutrition and exercise counseling.
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
do NOT exceed 3gm in 24 hours
2. Docusate Sodium 100 mg PO BID
please hold for loose stool
3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
do NOT drink alcohol or drive while taking this medication
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*40 Tablet Refills:*0
4. Senna 8.6 mg PO BID
please hold for loose stool
5. Metoprolol Tartrate 25 mg PO BID
RX *metoprolol tartrate 25 mg 1 tablet(s) by mouth twice a day
Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Left ___ rib fractures
Left pneumothorax, pneumomediatinum, and large subcutaneous air
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You presented to the ___ on
___ after suffering a motor vehicle collision and were
found to have left rib fractures, and a small puncture of your
left lung. You were admitted to the Trauma/Acute Care Surgery
team and were transferred to the Intensive Care Unit for further
medical management.
When medically stable, you were transferred to the surgical
floor for pain control and respiratory monitoring. You are now
ambulating, tolerating a regular diet and your pain is better
controlled. You are now medically cleared to be discharged home
to continue your recovery.
Please note the following discharge instructions:
* Your injury caused left rib fractures which can cause severe
pain and subsequently cause you to take shallow breaths because
of the pain.
* You should take your pain medication as directed to stay ahead
of the pain otherwise you won't be able to take deep breaths. If
the pain medication is too sedating take half the dose and
notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to hold
against your chest and guard your rib cage while coughing and
deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non-steroidal ___ drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs (crepitus).
Followup Instructions:
___
|
19557250-DS-15
| 19,557,250 | 22,628,036 |
DS
| 15 |
2169-01-18 00:00:00
|
2169-01-19 11:43:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Iodinated Contrast Media - IV Dye
Attending: ___.
Chief Complaint:
shortness of breath, hypertension
Major Surgical or Invasive Procedure:
Intubated ___
Arterial line placement
Central line placement
Tracheostomy ___
Bronchoscopy
History of Present Illness:
Mr. ___ is a ___ year old man with a past medical history of
hypertension, recent motor vehicle accident complicated by rib
fractures and pneumomediastinum who presented to the ___ ED on
___ with dyspnea and chest pain. The patient was recently
admitted to the hospital for trauma after suffering 3 left-sided
rib fractures, left apical lung contusion, and
pneumomediastinum. He underwent a flexible bronchoscopy which
was initially concerning for a right bronchus intermedius
posterior wall mucosal defect; however, repeat evaluation was
not revealing so no intervention as done.
The patient was discharged to rehab and since that time he has
had worsening shortness of breath. The patient also reported
worsening lower extremity edema. He presented to the surgery
clinic for a followup appointment and was found to be markedly
hypertensive and hypoxemic with an SpO2 ___ the ___. He was sent
to the ___ ED for further evaluation.
___ the ED, his initial VS were T 96.9, BP 225/126, HR 106, RR
24, and SpO2 86% RA. The patient was placed on a nitro gtt and
received lasix 40 mg IV. He was placed on BiPAP. NIPPV was
transitioned to 4L NC. Surgery was consulted and recommended CTA
chest, diuresis and CAD workup. Blood pressure was controlled
and improved to 123/59. Labs were notable for a BNP 2152,
D-dimer 2756, Cr 0.9, lactate 1.9. ___ was negative for DVT.
CXR was performed and showed no acute process though very low
lung volumes.
On arrival to the floor, T 98.7, BP 154/88 on nitro gtt, HR 114,
96% 5L NC, RR 26. He triggered on the floor for dyspnea
requiring increase of O2 requirement to 6L. Repeat CXR showed
low lung volumes and some vascular congestion. He was noted to
have 700 cc ___ his foley from 40 mg IV Lasix and then got
another 60 mg IV Lasix with good UOP (300 cc initially). VBG was
7.35/___, lactate 1.2. He was still on the nitro gtt to the
floor. Later into the evening, he was briefly off nitro gtt and
then by morning was acutely short of breath and requiring face
mask. He received another 60 mg IV Lasix with 600 cc output.
Repeat ABG was ___, so decision was made to transfer the
patient to the ICU for BiPAP.
Past Medical History:
HTN
S/p MVC c/b pneumomediastinum s/p bronch
Lower extremity edema
Chronic anxiety
HTN urgency resulting ___ pulmonary edema
OSA (presumed)with evidence of obesity hypoventilation syndrome
(OHS) with HCO3 > 28
Chronic venous stasis
Obesity
Anxiety
___
___
Social History:
Pt is married and lives with his wife ___ ___ ___. Pt
has twin adult dtrs who live locally, an adult son with MS who
resides at ___ ___ Home, two grandsons, and a loving dog. Pt
described feeling very well-supported by his family and shared
that his dtr has already gone to the tow-lot to retrieve
personal belongings from his totaled car. Pt's wife has been ___
phone
contact but is planning to stay home today due to her own
injuries.
Pt described having a fear of doctors and thus being fairly
non-compliant with his blood pressure medications. Pt
acknowledged his need to do better so he can continue to be
healthy for his family. Pt expressed some anxiety related to
being ___ the hospital but actually appeared to be coping with it
relatively well.
Married, spouse ___
___ tobacco, none current
No IVDU
Occasional EtOH
Family History:
Mother - HTN
Father - HTN
Physical Exam:
ADMISSION EXAM:
===============
VS: 97.7 139/64 94 93% BiPAP
GENRAL: A+Ox3, tachypneic, not speaking ___ full sentences due to
BiPAP mask
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no LAD, unable to appreciate JVD
due to habitus; no crepitus
CARDIAC: mildly tachycardic, distant heart sounds, S1/S2, no
murmurs, gallops, or rubs
LUNG: poor effort, diminished throughout, unable to appreciate
crackles or wheezes
ABDOMEN: obese, nondistended, +BS, nontender ___ all quadrants,
no rebound/guarding
EXTREMITIES: no cyanosis; marked 3+ pitting edema to knees b/l
with lymphedema and erythema bilaterally up to knees, no calf
tenderness
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, venous stasis changes
DISCHARGE EXAM:
===============
Tmax: 38 °C (100.4 °F)
Tcurrent: 37.8 °C (100 °F)
HR: 93 (82 - 125) bpm
BP: 137/68(88) {112/45(63) - 192/105(106)} mmHg
RR: 15 (14 - 26) insp/min
SpO2: 98%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 114.7 kg (admission): 130 kg
Height: 64 Inch
Gen: obese male, sitting ___ chair, on PMV, speaking ___ full
sentences
CV: RRR
Pulm: bilateral breath sounds
Abd: Obese. Non-tender, non-distended
Ext Trace peripheral edema
Pertinent Results:
ADMISSION LABS:
================
___ 09:13AM BLOOD WBC-8.1 RBC-5.22 Hgb-13.9 Hct-44.9 MCV-86
MCH-26.6 MCHC-31.0* RDW-14.9 RDWSD-46.7* Plt ___
___ 09:13AM BLOOD Neuts-73.8* Lymphs-15.9* Monos-9.1
Eos-0.2* Baso-0.6 Im ___ AbsNeut-6.00 AbsLymp-1.29
AbsMono-0.74 AbsEos-0.02* AbsBaso-0.05
___ 09:13AM BLOOD Plt ___
___ 09:13AM BLOOD Glucose-165* UreaN-75* Creat-1.2 Na-136
K-6.1* Cl-97 HCO3-32 AnGap-13
___ 09:13AM BLOOD ALT-14 AST-16 AlkPhos-97 TotBili-0.2
___ 09:13AM BLOOD cTropnT-<0.01 proBNP-<5
___ 09:13AM BLOOD Albumin-4.2
___ 06:30PM BLOOD D-Dimer-1499*
___ 09:19AM BLOOD pO2-91 pCO2-113* pH-7.17* calTCO2-43*
Base XS-8
___ 09:19AM BLOOD Lactate-0.8
___ 09:19AM BLOOD O2 Sat-95
___ 09:50AM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-TR
___ 09:50AM URINE RBC-12* WBC-2 Bacteri-NONE Yeast-NONE
Epi-0
PERTIENT/DISCHARGE LABS
========================
___ 02:21AM BLOOD WBC-3.1* RBC-2.72*# Hgb-7.2*# Hct-23.1*#
MCV-85 MCH-26.5 MCHC-31.2* RDW-14.6 RDWSD-45.1 Plt ___
___ 11:16AM BLOOD WBC-6.0 RBC-4.46* Hgb-11.7* Hct-36.9*
MCV-83 MCH-26.2 MCHC-31.7* RDW-14.7 RDWSD-44.6 Plt ___
___ 04:38AM BLOOD WBC-5.9 RBC-3.44* Hgb-9.2* Hct-29.4*
MCV-86 MCH-26.7 MCHC-31.3* RDW-15.8* RDWSD-48.4* Plt ___
___ 04:38AM BLOOD Glucose-141* UreaN-31* Creat-0.7 Na-141
K-3.8 Cl-98 HCO3-34* AnGap-13
___ 04:38AM BLOOD Calcium-8.8 Phos-2.7 Mg-2.1
___ 09:19AM BLOOD pO2-91 pCO2-113* pH-7.17* calTCO2-43*
Base XS-8
___ 09:23AM BLOOD Type-ART pO2-129* pCO2-78* pH-7.27*
calTCO2-37* Base XS-6
___ 03:25PM BLOOD Type-ART pO2-109* pCO2-64* pH-7.37
calTCO2-38* Base XS-9
___ 03:54AM BLOOD Lactate-0.7
___ 09:13AM BLOOD cTropnT-<0.01 proBNP-<5
___ 06:30PM BLOOD D-Dimer-1499*
___ 04:00PM URINE Color-Yellow Appear-Cloudy Sp ___
___ 04:00PM URINE RBC-17* WBC-1 Bacteri-NONE Yeast-NONE
Epi-<1
___ 09:43PM URINE CastGr-2* CastHy-7*
___ 04:00PM URINE Uric AX-MOD
ACETYLCHOLINE RECEPTOR ANTIBODY
Test Result Reference
Range/Units
ACETYLCHOLINE RECEPTOR <0.30 <=0.30 nmol/L
BINDING ANTIBODY
Reference Range:
Negative: <=0.30 nmol/L
Equivocal: 0.31-0.49 nmol/L
Positive: >=0.50 nmol/L
___ 12:27
___ SYNDROME ANTIBODY PANEL Results Pending
MICRO
=====
___ 9:13 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 11:20 am BRONCHOALVEOLAR LAVAGE Site: NOT SPECIFIED
R/O ATYPICAL MYCOBACTERIUM.
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CHAINS.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final ___:
>100,000 ORGANISMS/ML. Commensal Respiratory Flora.
LEGIONELLA CULTURE (Final ___: NO LEGIONELLA
ISOLATED.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
___ 11:43 am Rapid Respiratory Viral Screen & Culture
BRONCHIAL LAVAGE.
**FINAL REPORT ___
Respiratory Viral Culture (Final ___:
No respiratory viruses isolated.
Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
1,2 & 3, and Respiratory Syncytial Virus..
Detection of viruses other than those listed above ___
only be
performed on specific request. Please call Virology at
___
within 1 week if additional testing is needed.
Respiratory Viral Antigen Screen (Final ___:
Less than 60 columnar epithelial cells;.
Inadequate specimen for DFA detection of respiratory
viruses..
Interpret all negative DFA and/or culture results from
this specimen
with caution..
Negative results should not be used to discontinue
precautions..
Recommend new sample be submitted for confirmation..
Refer to respiratory viral culture and/or Influenza PCR
(results
listed under "OTHER" tab) for further information..
Reported to and read back by ___ (CC7D) ___
AT 1155
___ 12:40 am SPUTUM Source: Endotracheal.
**FINAL REPORT ___
GRAM STAIN (Final ___:
___ PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final ___: NO GROWTH.
___ 3:57 pm URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 5:30 pm BLOOD CULTURE Source: Line-arterial.
Blood Culture, Routine (Pending):
IMAGING
=======
CHEST (PORTABLE AP) Study Date of ___
1. Persistent retrocardiac opacity which could be secondary to
atelectasis, however an underlying focal consolidation cannot be
entirely excluded ___ this portable examination.
2. Blunting of the left costophrenic angle reflect moderate
amount of pleural fluid. Small right pleural effusion
3. Low lung volumes and cardiomegaly.
CHEST (PORTABLE AP) Study Date of ___
Comparison to ___. Low lung volumes. Moderate
cardiomegaly.
Minimal left pleural effusion with subsequent basal atelectasis.
No pneumonia or pulmonary edema.
___HEST W/O CONTRAST
FINDINGS:
The thyroid is normal. Supraclavicular, axillary, mediastinal
and hilar lymph nodes are not enlarged. Aorta and pulmonary
arteries are normal size. Cardiac configuration is normal and
there is no appreciable coronary calcification. The heart is
mildly enlarged. There is no pericardial effusion. The thyroid
is unremarkable.
A small left pleural effusion is new. There is no right pleural
effusion. There is been resolution of the previously seen
pneumothorax and extensive pneumomediastinum and subcutaneous
gas.
ET tube is present, terminating 5.1 cm above the carina. The
central airways are patent. There is interval resolution of the
left apical pulmonary contusion. Bibasilar consolidations are
increased since the ___ study, with air bronchograms on the
left. These consolidations appear homogeneous and are most
consistent with atelectasis. No suspicious pulmonary nodule or
mass is present.
An enteric tube is present with tip terminating ___ the distal
stomach near the pylorus. The upper abdomen is otherwise
unremarkable ___ appearance. Healing fracture of the left
anterior ribs 1 through 3 noted. No other fractures are
visualized. Multilevel degenerative changes are
mild-to-moderate.
IMPRESSION:
1. Basilar consolidations, most likely representing
atelectasis. Small left pleural effusion.
2. Resolution of left apical pulmonary contusion.
___ Imaging BILAT LOWER EXT VEINS
FINDINGS:
There is normal compressibility, flow, and augmentation of the
bilateral
common femoral, femoral, and popliteal veins. The peroneal
veins were not
visualized bilaterally.
There is normal respiratory variation ___ the common femoral
veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
The peroneal veins were not seen bilaterally. Otherwise, no
evidence of deep venous thrombosis ___ the right or left lower
extremity veins.
___ Imaging MR HEAD W/O CONTRAST
FINDINGS:
Study is moderately degraded by motion, especially on FLAIR
imaging.
There is no evidence of acute hemorrhage, edema, masses, mass
effect, midline
shift or infarction. A punctate focus of susceptibility ___ the
right
cerebellar hemisphere ___ 12:5 likely represents chronic
microhemorrhage. The
ventricles and sulci are normal ___ caliber and configuration.
The paranasal sinuses and mastoid air cells are clear. The
orbits are
unremarkable.
The major intracranial flow voids are preserved.
IMPRESSION:
1. Study is moderately degraded by motion, as described.
2. No acute intracranial abnormality.
3. No evidence of acute infarct.
CHEST (PORTABLE AP) Study Date of ___ 3:49 AM
IMPRESSION:
Lung volumes remain low, and the left lower lobe is persistently
opacified. Since the left hilus is depressed, this is due to
either substantially or
exclusively left lower lobe atelectasis. Pleural effusions are
small if any. Moderate enlargement of cardiac silhouette is
long-standing but there is no pulmonary edema.
ET tube and right internal jugular line are ___ standard
placements and an
esophageal drainage tube passes into the stomach and out of
view.
___ Imaging CHEST (PORTABLE AP)
___ comparison with the study of ___, the tracheostomy tube
and
nasogastric tube are unchanged. Low lung volumes accentuate the
enlargement
of the cardiac silhouette. Obscuration of the left
hemidiaphragm is
consistent with substantial volume loss ___ the left lower lobe
and some
pleural fluid. The right lung is essentially clear and there is
no definite
vascular congestion.
Brief Hospital Course:
___ year old man with hypertension, suspected obstructive sleep
apnea with concomitant obesity hypoventilation syndrome, and
recent MVC c/b rib fractures and pneumomediastinum who presented
with hypercarbic respiratory failure ultimately felt secondary
to idiopathic bilateral diaphragmatic paralysis for which he
underwent tracheostomy placement.
#Hypercarbic respiratory failure: The patient presented with
what was felt to be flash pulmonary edema ___ the setting of
diastolic heart failure and hypertensive crisis. However, he
ultimately developed refractory hypercarbic respiratory failure
that required prolonged BiPAP. He was ultimately intubated on
___. On evaluation, he had evidence of suspected OSA and
his baseline hypercapnia with morbid obesity was suggestive of
OHS. He was treated for a possible pneumonia through ___ with
cefepime and adequately diuresed. His blood pressure was
controlled with captopril. However, his neurologic and pulmonary
evaluation ultimately demonstrated isolated bilateral
diaphragmatic paralysis without a clear reversible etiology
(normal brain MRI, no cord injury, no evidence of a myopathy or
NMJ problem). The decision as ultimately made to proceed with
tracheostomy and he underwent surgical tracheostomy on ___
___ 8 adjustable flange, essentially hubbed due to large
neck size). Soon after placement the patient was found to have
intermittent distal occlusion of the tracheostomy by the
posterior wall of the trachea with intermittent high PIPs to the
___. He underwent repeat bronchoscopy to confirm this. Given his
body habitus there are limited options and the tracheostomy was
left as is. He was successfully weaned to PMV and tracheostomy
mask during the day with nocturnal ventilator support. After
decannulation he ___ need nocturnal BiPAP titration and formal
sleep study. We hope his idiopathic diaphragmatic paralysis
improves with time. He should follow up ___ the ___ sleep
clinic.
#HCAP- treated with cefepime as per above. Patient completed 8
day treatment on ___. See above for further details.
# Hypertension: Patient has a long standing history of
hypertension and reported compliance with medications,
previously on Lisinopril which was discontinued recently given
___ and transitioned to amlodipine. Patient has had a
significant amount of pain recently from rib fractures likely
contributing to his hypertensive episodes along with baseline
anxiety. On this admission, patient's BPs appeared fairly well
controlled, with no signs of HTN emergency. A line was placed
for better BP control, though BPs have continued to be
exceedingly labile. He was transitioned to captopril which was
uptitirated to 50mg TID. His anxiety was controlled (see
below). He was restarted on his home medications ___ to
discharge. Can transition to lisinopril at rehab.
# Chronic Diastolic CHF: Patient had a recent TTE with EF >55%,
and had reported worsened lower extremity edema initially.
Patient was intermittently diuresed with IV Lasix during the
hospital stay. He was restarted on 20mg of Lasix daily on
discharge.
#Anxiety: Patient likely anxious from apneic moments and
significant distress, but likely also has underlying generalized
anxiety, started on Sertraline 25mg qd, previous admission was
on Klonopin 0.5mg BID, which was held now ___ ventilatory
concerns. His anxiety led to fluctuating blood pressures. He was
intermittently given Ativan. He was started on Seroquel which
improved his symptoms.
#C. difficile infection: Pt noted to be C Diff+ ___ to last
DC, continued Metronidazole 500 mg PO q8H. Since he was treated
with with IV antibiotics for HCAP during this admission his
C.diff treatment was prolonged. Patient was started on PO
vancomycin which ___ be continued till ___ (14 days after
completion of antibiotics).
# Rib fracture, pneumomediastinum, lung contusion: Held off on
home oxycodone given concern for hypoventilation, consider NCCTC
to evaluate for bronchial airway damage ___ previous imaging
from ___. Patient likely suffering from diaphragmatic paralysis,
see above.
========================
TRANSITIONAL ISSUES:
========================
- PO vancomycin to be completed on ___ for ___ C. diff
infection (2 week taper after completion of antibiotics for an
HCAP)
- Avoid clonazepam and other benzos or opioids given respiratory
depression. Instead was started on Seroquel for anxiety, which
has worked well. Can be uptitrated as needed.
- Consider converting captopril to lisinopril
- Voiding trial ___ at 9PM and if fails re-insert foley
- Ongoing speech and swallow eval, he is currently cleared for
regular diet
- Goal for maximum PMVtrach mask time during day and for now
vent at night
- Decannulation at some point
- Patient eventually ___ need reevaluation for OSA/OHS and
BiPAP titration
# CODE: Full
# CONTACT: wife, HCP, ___ ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Docusate Sodium 100 mg PO BID
2. Acetaminophen 650 mg PO Q6H:PRN pain
3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
4. Senna 8.6 mg PO BID
5. Aspirin 81 mg PO DAILY
6. Sertraline 25 mg PO DAILY
7. Metoprolol Succinate XL 50 mg PO DAILY
8. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
9. Amlodipine 5 mg PO DAILY
10. ClonazePAM 0.5 mg PO BID
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Amlodipine 5 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Senna 8.6 mg PO BID
6. Sertraline 25 mg PO DAILY
7. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheeze, SOB
8. Captopril 50 mg PO TID
9. Famotidine 20 mg PO Q12H
10. Furosemide 20 mg PO DAILY
11. Ipratropium Bromide MDI 2 PUFF IH QID
12. QUEtiapine Fumarate 50 mg PO QHS
13. QUEtiapine Fumarate 25 mg PO QAM AND QNOON
14. Simethicone 40-80 mg PO QID:PRN gas
15. Vancomycin Oral Liquid ___ mg PO Q6H
to be completed on ___. Metoprolol Succinate XL 50 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY: HYPERCARBIC RESPIRATORY FAILURE, BILATERAL
DIAPHRAGMATIC PARLYSIS
SECONDARY: ANXIETY, HYPERTENSION
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at the ___
___. You were hospitalized for difficulty
breathing. You were treated ___ the intensive care unit. You had
a breathing tube placed and needed a breathing machine. You were
found to have paralysis (lack of function) of your diaphragm,
the muscles that help you breathe. You underwent tracheostomy
placement (tube ___ your trachea to help you breathe). You ___
be discharged to rehab where you can continue to improve your
strength and hopefully get the tracheostomy out before you go
home.
Please weigh yourself every morning, call your doctor if your
weight goes up more than 3 lbs.
Please continue to take your medications as prescribed.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19557307-DS-12
| 19,557,307 | 27,707,519 |
DS
| 12 |
2183-08-17 00:00:00
|
2183-08-21 20:21:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
NSAIDS (Non-Steroidal Anti-Inflammatory Drug)
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This patient is a ___ year old male with PMHx of IDDM and
HLD presents with exertional epigastric and chest discomfort
for 3 days. Patient was seen as an outpatient for his
symptoms along with constipation, nausea, and heartburn, and
had a KUB that was concerning for an SBO. Patient states
that his pain is worsening, so he presented here. Per
family, patient had similar symptoms last year.
Timing: Gradual
Severity: Moderate
Duration: 3 Days
Location: GI
Associated Signs/Symptoms: Constipation and nausea
Past Medical History:
T1DM, congenital absence of L kidney, R kidney cyst, hx ___
with NSAIDS, hld, colon adenomas x4, chronic contipation, iron
deficiency anemia
Social History:
___
Family History:
NC
Physical Exam:
Physical Exam: ___: upon admission
Vitals: 97.8 106 140/87 18 95% RA
GEN: A&O, NAD
CV: RRR
PULM: Clear to auscultation b/l
ABD: Soft, severely distended, moderately tender to palpation in
epigastrium
Ext: No ___ edema, ___ warm and well perfused
Physical examination upon discharge: ___:
general: NAD
vital signs: t=99, hr 100, bp=126/76, rr=20, 97% room air
CV: ns1, s2, s-3, -s4
LUNGS: clear
ABDOMEN: soft, non-tender, no hepatomegaly, no splenomegaly
EXT: no pedal edema bil., no calf tenderness
NEURO: alert and oriented x 3
Pertinent Results:
___ 06:40AM BLOOD WBC-6.4 RBC-4.62 Hgb-14.0 Hct-40.6 MCV-88
MCH-30.2 MCHC-34.4 RDW-14.5 Plt ___
___ 06:35AM BLOOD WBC-10.6 RBC-5.09 Hgb-15.1 Hct-43.3
MCV-85 MCH-29.7 MCHC-34.9 RDW-14.7 Plt ___
___ 07:00PM BLOOD WBC-16.6*# RBC-5.11 Hgb-15.5 Hct-43.4
MCV-85 MCH-30.4 MCHC-35.9* RDW-14.5 Plt ___
___ 07:00PM BLOOD Neuts-91.3* Lymphs-4.3* Monos-3.6 Eos-0.5
Baso-0.4
___ 06:40AM BLOOD Plt ___
___ 06:40AM BLOOD Glucose-243* UreaN-14 Creat-0.9 Na-140
K-3.8 Cl-102 HCO3-29 AnGap-13
___ 07:00PM BLOOD ALT-24 AST-23 AlkPhos-66 TotBili-1.5
___ 07:00PM BLOOD cTropnT-<0.01
___ 06:35AM BLOOD %HbA1c-7.9* eAG-180*
EKG:
Sinus tachycardia. Prior inferior wall myocardial infarction.
Compared to the previous tracing of ___ the rate has
increased. Otherwise, no diagnostic
interim change.
___: cat scan of abdomen and pelvis:
. Multiple, dilated, fluid-filled loops of adjacent small bowel
compatible with a small bowel obstruction. A single transition
point is identified in the right lower pelvis. There is no
evidence of free intra-abdominal fluid or pneumoperitoneum.
2. 4-mm right lower lobe subpleural nodule, stable for ___ year
and no longer requiring followup imaging.
3. Congenitally absent left kidney and left seminal vesicle.
4. Distal esophageal thickening may be related to esophagitis
from recent
vomiting and clinical correlation is recommended.
___: x-ray of the abdomen:
No radiographic evidence of bowel obstruction
Brief Hospital Course:
___ year old gentleman who was admitted to the hospital with
epigastric pain and abdominal distention. Upon admission, he
was made NPO, given intravenous fluids and underwent imaging. A
cat scan and x-ray of the abdomen were both suggestive of small
bowel obstruction. A ___ tube was placed for bowel
decompression.
Shortly after admission, the patient reported decreased
abdominal pain and had return of bowel function. His white blood
cell count upon admission was 16, later that day, it had
decreased to 6.0.
The ___ Diabetes service was consulted for management of his
blood sugar and a new sliding scale was designed. On HD #2, the
patient's ___ tube was removed and the patient was
started on a regular diet. He had no further recurrence of
abdominal pain. He was ambulating without difficulty and
reported return of bowel function.
On HD #2, the patient was discharged home in stable condition.
Discharge instructions were reviewed including a bowel regimen.
An appointment for follow-up was made with the acute care
service.
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. Simvastatin 20 mg PO QPM
4. Glargine 40 Units Bedtime
Insulin SC Sliding Scale using Aspart Insulin
5. Omeprazole 20 mg PO BID
6. Loratadine 10 mg PO DAILY:PRN Allergies
7. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
q4-6 hours Wheezing
8. Cyanocobalamin 500 mcg PO DAILY
9. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Fluticasone Propionate NASAL 1 SPRY NU DAILY
3. Omeprazole 20 mg PO BID
4. Simvastatin 20 mg PO QPM
5. Cyanocobalamin 500 mcg PO DAILY
6. Loratadine 10 mg PO DAILY:PRN Allergies
7. ProAir HFA (albuterol sulfate) 90 mcg/actuation INHALATION
Q4-6 HOURS Wheezing
8. Docusate Sodium 100 mg PO BID
hold for diarrhea
9. Senna 8.6 mg PO BID:PRN constipaton
10. Glargine 38 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
11. Vitamin D 1000 UNIT PO DAILY
12. Polyethylene Glycol 17 g PO DAILY:PRN constipation
Discharge Disposition:
Home
Discharge Diagnosis:
small bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with abdominal pain. You
underwent a cat scan of the abdomen and you were found to have
findings suggestive of a small bowel obstruction. You were
placed on bowel rest with placement of a nasogastric tube. You
had return of bowel function and the ___ tube was
removed. Your abdominal pain has decreased in intensity. You
also had elevated blood sugars during your hospitalization, and
your insulin regimen was reviewed with a member of the ___
Diabetes service. You are planning for discharge with the
following instructions:
Please call your doctor or return to the emergency room if you
have any of the following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
Continue to closely monitor your blood sugar
Followup Instructions:
___
|
19557342-DS-11
| 19,557,342 | 20,131,555 |
DS
| 11 |
2172-10-13 00:00:00
|
2172-10-14 13:58:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Iodine
Attending: ___.
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
intubation ___
extubation ___
History of Present Illness:
___ with depression, anxiety, HTN, chronic pain on multiple pain
medications presenting after being found increasingly somnolent
in her home.
Per report of her sister, patient had been reporting issues with
worsened depression over past months and had been struggling
with insomnia. Her sister lent her ___ 100 mg x2 pills
last night. This morning her sister went to check on her and
found her to be somewhat somnolent. Her home health aide stopped
in and suggested she may be close to baseline. Her sister
re-checked in in the evening, found her more somnolent so she
called ___. Per report, EMS found the patient hypotensive SBP
___, hypoxia to 88% on RA, stating "I don't want to wake up ever
again."
In the ED, initial vitals: 98 83 73/48 14 96% Nasal Cannula
Per ED report, patient took ___ 100 mg x2 at 1600 (never
taken before), sangria this AM, marijuana lollipop this AM. Pt
reported to have taken medications today, including metoprolol.
ED exam notable for patient being somnolent but arousable.
Bradypneic.
___ Glucose 124
Labs notable for CBC wnl, BUN/Creat 52/4.6, Bicarb 32
AST/ALT 101/42 AP/TBili/lipase wnl
Lactate 1.8
Patient trialed on Narcan 0.04 x4 with minimal response. Pt
reported to be alert, but still somnolent.
Admitted to ICU for mental status monitoring.
On transfer, vitals were: 87 107/65 10 96% Nasal Cannula
On arrival to the MICU, pt somnolent but arousable to verbal
stimulation. She briefly answers questions then falls asleep.
Repeats full name, that she's in the hospital but falls asleep
describing dates.
Past Medical History:
1. Hypertension
2. Endometriosis
3. Depression
4. Migraine
5. Spinal stenosis
6. GERD
7. Fibromyalgia
8. ?OSA
Social History:
___
Family History:
Mother and maternal grand-mother with breast cancer. Mother
also with hypertension and recent stroke. Father with colon
cancer.
Physical Exam:
ADMISSION:
Vitals: 98.4 86 89/55 15 100%RA with intermittent
desaturations to high 80%s during apneic breaths during sleep
GENERAL: Somnelent but arousable to verbal stimulation
HEENT: Sclera anicteric, MMM, oropharynx clear, PERRLA, 3mm and
equal
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, protuberant, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: Warm, well profused
NEURO: AAOx2-3
DISCHARGE:
Vitals: 98.0 109/63 (SBPs 127-48) 56 (50s) 18 100%CPAP
GENERAL: well appearing, NAD
HEENT: Sclera anicteric, PERRL, EOMI, 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. (+) small scar
above epigastrium
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Back: no obvious ecchymoses, (+) TTP over R posterior iliac
crest
NEURO: AAOx3, moves all extremities spontaneously
Psych: tearful, crying
Pertinent Results:
=============
ADMISSION:
=============
___ 06:30PM BLOOD WBC-7.5# RBC-4.65 Hgb-13.3 Hct-42.8
MCV-92 MCH-28.6 MCHC-31.1* RDW-14.5 RDWSD-48.7* Plt ___
___ 06:30PM BLOOD Neuts-73.5* Lymphs-17.9* Monos-7.0
Eos-0.9* Baso-0.3 Im ___ AbsNeut-5.50 AbsLymp-1.34
AbsMono-0.52 AbsEos-0.07 AbsBaso-0.02
___ 06:30PM BLOOD Glucose-130* UreaN-52* Creat-4.6*# Na-139
K-3.6 Cl-93* HCO3-32 AnGap-18
___ 06:30PM BLOOD ALT-42* AST-101* AlkPhos-88 TotBili-0.3
___ 06:30PM BLOOD Albumin-4.3
___ 06:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-POS Barbitr-NEG Tricycl-NEG
___ 09:50PM BLOOD TSH-0.83
___ 09:50PM BLOOD Folate-10.8
___ 09:57PM BLOOD ___ Temp-38.1 O2 Flow-3 pO2-30*
pCO2-61* pH-7.29* calTCO2-31* Base XS-0 Intubat-NOT INTUBA
Comment-NASAL ___
___ 06:46PM BLOOD Lactate-1.8
___ 09:57PM BLOOD Lactate-1.4
___ 02:29AM BLOOD freeCa-1.05*
=============
DISCHARGE:
=============
___ 06:39AM BLOOD WBC-3.3* RBC-4.58 Hgb-13.1 Hct-41.4
MCV-90 MCH-28.6 MCHC-31.6* RDW-14.3 RDWSD-46.2 Plt ___
___ 06:39AM BLOOD Plt ___
___ 06:39AM BLOOD Glucose-99 UreaN-9 Creat-1.1 Na-145 K-3.7
Cl-104 HCO3-31 AnGap-14
___ 06:39AM BLOOD ALT-287* AST-262* CK(CPK)-194 AlkPhos-96
TotBili-0.2
___ 06:39AM BLOOD Calcium-9.9 Phos-5.2* Mg-1.9 Iron-99
___ 06:39AM BLOOD calTIBC-286 ___ Ferritn-261* TRF-220
___ 06:39AM BLOOD ___
___ 06:39AM BLOOD IgG-973
___ 06:39AM BLOOD Acetmnp-NEG
=============
MICRO:
=============
___ 06:55PM URINE Color-Yellow Appear-Hazy Sp ___
___ 06:55PM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 06:55PM URINE RBC-0 WBC-1 Bacteri-FEW Yeast-NONE Epi-1
___ 06:55PM URINE CastHy-13*
___ 06:55PM URINE AmorphX-FEW
___ 06:55PM URINE UCG-NEGATIVE
=============
IMAGING:
=============
___ CXR
IMPRESSION: No acute cardiopulmonary process.
___ CXR
IMPRESSION: Compared to chest radiographs since ___
most recently ___ and ___. Previous left
lower lobe consolidation has improved following tracheal
extubation, presumably resolved atelectasis. Cardiomegaly is
mild, but there
is no pulmonary edema. Pleural effusions small on the left if
any. No
pneumothorax.
___ LIVER OR GALLBLADDER US
1. Normal liver echotexture.
2. A 1.___ased lesion in the gallbladder fundus
may be a sludge however possibly a polypoid lesion. Follow up
ultrasound is recommended ___ months.
RECOMMENDATION(S): Follow up gallbladder ultrasound is
recommended ___
months.
Brief Hospital Course:
___ F with depression, anxiety, HTN, chronic pain on multiple
pain medications presenting after being found somnolent in her
home in setting of suspected polysubstance abuse s/p MICU stay
notable for hypercarbic respiratory failure requiring intubation
s/p extubation, rhabdomyolysis improved w/IVF, and depression
s/p psych evaluation with plans for transition to inpatient
psychiatry.
# Hypercarbic respiratory failure: on admission pt was sedated
in setting of multiple ingestions (reported taking trazodone,
BZD, alcohol, marijuana, oxycodone). Patient trialed with Narcan
0.04 x4 in ED with minimal response. Patient was admitted to
MICU for monitoring given somnolence, tenuous respiratory
status. Lab work notable for acidosis, low oxygenation prompting
intubation on ___. Thought to be ___ multiple ingestions of
sedating medications. She was successfully extubated on ___.
After extubation, pt had desaturations c/f volume overload in
the setting of IVF resuscitation for rhabdomyolysis. Received IV
Lasix x1 with improvement. Also noticed to be desatting
overnight, started on CPAP due to c/f OSA with improvement.
Sedating home medications (gabapentin, diazepam, oxycodone) were
held. Patient will need outpatient sleep study to determine need
for home CPAP.
# Rhabdomyolysis: CK initially elevated to 5450 with ___ she
received aggressive IVF boluses with downtrend. Possibly ___
trauma given patient was found down. No evidence of compartment
syndrome, no obvious seizure activity, no myositis. As CK
downtrended, ___ resolved.
# LFT abnormalities: on admission pt was noted to have 2:1
AST/ALT ratio initially concerning for alcohol effect. Her LFTs
initially downtrended; however following transfer to the floor
she had an increasing hepatocellular transaminitis. RUQ U/S
notable for normal liver, gallbladder sludge. Hepatitis
serologies, ___, IgG, serum/urine tox, and iron studies were
checked and were normal; ___ was pending at discharge. Concern
for ___ rhabdomyolysis vs viral vs medication-induced. She will
need LFTs rechecked in x1 week; if uptrending (AST, ALT >200),
please contact PCP to determine further work-up.
# Suicidal ideation/concern for suicide attempt: per EMS report,
patient stated she "did not want to wake up." Psychiatry was
consulted who felt patient was not actively suicidal/homicidal.
She was restarted on her home paroxetine/duloxetine. She was
discharged from medicine to inpatient psych.
# Hypertension: pt hypotensive on admission, with transient
pressor requirement in MICU. Following stabilization, she was
restarted on her home lisinopril. Metoprolol/HCTZ were held
given low HRs and normotension.
# Substance abuse (etoh, benzos, opiods): Utox positive for
benzos/opiods, patient also reported taking EtOH/MJ on day of
admission. She was monitored on CIWA with no signs of
withdrawal. She was started on thiamine/folate/MVI.
# Fibromyalgia/chronic pain: home pain/neuropathic medications
were held given concern for overdose. She was restarted on
lidocaine patches and she remained stable without complaints of
pain.
# Urinary tract infection: patient developed dysuria, with
urinalysis concerning for large leuks, WBCs. Due to recent foley
removal, concern for catheter-related UTI. She was originally
started on macrobid; however due to concern for transaminitis,
she was transitioned to Bactrim DS BID with plan to complete a
x7 day course (___).
TRANSITIONAL ISSUES:
=====================
[] Please recheck LFTs in x1 week ___ if uptrending (AST
and ALT > 200), please contact patient's PCP (Dr. ___ to
determine further work-up. If AST, ALT ___, consider
return to the hospital.
[] Will complete course of Bactrim BID after ___ for UTI
[] Would benefit from outpatient sleep study to evaluate for OSA
[] Home metoprolol XL 25mg was held due to low HRs; consider
restarting if persistently hypertensive
[] Atorvastatin 10mg held ___ rhabdomyolysis; please restart
once safe
[] Substance abuse: started on thiamine/MVI/folate. Would
benefit from enrollment in relapse prevention program.
[] Pt was scheduled for outpatient hysterectomy with Dr. ___
___ during hospitalization; will need follow up to reschedule
[] If patient continues to have pain, consider uptitration of
gabapentin.
[] Patient is both on H2 blocker and PPI for GERD. Consider
tailoring therapy as an outpatient as tolerated.
[] ___ and HCV Ab pending at the time of discharge.
Radiology Follow up:
====================
[] RUQ U/S (___): 1.___ased lesion in the
gallbladder fundus may be a sludge however possibly a polypoid
lesion. Follow up ultrasound is recommended ___ months.
# Communication: HCP: ___ (___) ___,
___
# Code: Full (confirmed)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 40 mg PO DAILY
2. Magnesium Oxide 400 mg PO DAILY
3. Gabapentin 300 mg PO QAM
4. Gabapentin 600 mg PO DAILY16
5. Gabapentin 600 mg PO QHS
6. Diphenoxylate-Atropine 1 TAB PO Q8H:PRN diarrhea
7. DiCYCLOmine 20 mg PO QID:PRN diarrhea
8. Leuprolide Acetate 3.75 mg IM QMONTH
9. Lidocaine 5% Ointment 1 Appl TP BID:PRN pain at affected area
10. Diazepam 10 mg PO Q8H:PRN anxiety
11. Metoprolol Succinate XL 25 mg PO DAILY
12. Docusate Sodium 100 mg PO BID:PRN constipation
13. Senna 8.6 mg PO Frequency is Unknown
14. Ranitidine 150 mg PO BID
15. Atorvastatin 10 mg PO DAILY
16. OxycoDONE (Immediate Release) 15 mg PO Q6H:PRN pain
17. Omeprazole 40 mg PO DAILY
18. Duloxetine 30 mg PO DAILY
19. Paroxetine 30 mg PO DAILY
20. Hydrochlorothiazide 25 mg PO DAILY
21. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. Duloxetine 30 mg PO DAILY
2. Omeprazole 40 mg PO DAILY
3. Paroxetine 30 mg PO DAILY
4. Ranitidine 150 mg PO BID
5. Acetaminophen 650 mg PO Q6H:PRN pain
RX *acetaminophen 325 mg ___ tablet(s) by mouth every six (6)
hours Disp #*60 Tablet Refills:*0
6. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
7. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
8. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth daily
Disp #*30 Tablet Refills:*0
9. DiCYCLOmine 20 mg PO QID:PRN diarrhea
10. Diphenoxylate-Atropine 1 TAB PO Q8H:PRN diarrhea
11. Docusate Sodium 100 mg PO BID:PRN constipation
12. Magnesium Oxide 400 mg PO DAILY
13. Senna 8.6 mg PO DAILY:PRN constipation
14. Vitamin D ___ UNIT PO DAILY
15. Leuprolide Acetate 3.75 mg IM QMONTH
16. Lidocaine 5% Ointment 1 Appl TP BID:PRN pain at affected
area
17. Medical Equipment
Rolling Walker
Diagnosis: Gait Instability (ICD10 R26.2)
Prognosis: Good
Length of Need: Lifetime
18. Rolling walker
Please provide patient with rolling walker
Diagnosis: gait instability
Prognosis: good
Length of need: 13 months
19. Hydrochlorothiazide 25 mg PO DAILY
20. Lisinopril 40 mg PO DAILY
21. Nicotine Patch 21 mg TD DAILY
RX *nicotine 21 mg/24 hour (28)-14 mg/24 hour (14)-7 mg/24 hour
(14) Apply to skin daily Disp #*56 Patch Refills:*0
22. Sulfameth/Trimethoprim DS 1 TAB PO BID
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1
tablet(s) by mouth twice a day Disp #*6 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
-Hypercarbic respiratory failure requiring intubation
-Polysubstance abuse
-Depression
-Anxiety
-Rhabdomyolysis
-Acute kidney injury
-Urinary tract infection
-Transaminitis
SECONDARY DIAGNOSES:
-Transaminitis
-Fibromyalgia
-Chronic pain
-Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ after getting very sleepy from taking
too many sedating medications. Due to your sleepiness and
difficulty breathing, you were monitored in the Intensive Care
Unit and required a ventilator to help you breathe. As the
medication effects wore off your breathing got better and you
were able to breathe well on your own. It is very important that
you avoid medications that can make you sleepy. We noticed that
your oxygen number would decrease overnight, concerning for
Obstructive Sleep Apnea; you should have a sleep study as an
outpatient.
During your hospitalization, you expressed feeling very
depressed. You were evaluated by the Psychiatry team who felt
you would benefit from some time in a Psychiatric facility. You
should continue your duloxetine and paroxetine daily and follow
up with your Psychiatrist.
In addition, you developed a urinary tract infection. You will
need to take Bactrim twice daily through ___.
Thank you for letting us be a part of your care!
Your ___ Team
Followup Instructions:
___
|
19557391-DS-10
| 19,557,391 | 25,991,225 |
DS
| 10 |
2181-07-05 00:00:00
|
2181-07-05 18:01:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Hypoxia
Major Surgical or Invasive Procedure:
___ - Infra-renal Denali IVC filter placed
History of Present Illness:
Ms. ___ is a ___ year old woman with a history of breast
cancer s/p mastectomy and XRT in ___ (___), DM2, HFpEF (EF
50%),
cerebral amyloid angiopathy c/b hemorrhage ___ and recent
hospitalization at ___ for sepsis ___ pneumonia and new
AF
who was transferred from ___ to ___ with findings of
new
pulmonary emboli found on CTA chest.
She had been home for only 1 day when her daughters noted she
had
increased work of breathing (she had reportedly had a 2L NC
requirement during the hospitalization but was discharged on
room
air). On arrival back to ___ she was requiring up to 6L NC
and reporting chest pain and shortness of breath. Her CXR showed
bilateral infiltrates and pleural effusions and a CTA was
obtained that showed emboli along with multifocal opacities and
a
L>R pleural effusion. She has no recent history of trauma or
surgery, no recent MI, and does not take anticoagulants.
Her initial labs at ___ were notable for: Cr 1.0, K 5.4,
Trop < 0.01, INR 1.2, NT-BNP 8k.
On arrival to the ___ ED, initial vitals were: T 98.8, HR 90,
BP 121/86, RR 44, O2 94% on 2L NC.
Labs notable for:
- WBC 9.2, Hgb 10.3
- pro-BNP 9356
- trop < 0.01
- ABG 7.48/32/___
- VBG 7.44/41, lactate 1.5
Imaging notable for:
- ___ Bilateral LENIs:
Occlusive DVT within the left popliteal vein. No signs of DVT
within the right leg.
- ___ CT head w/o contrast:
1. No acute intracranial hemorrhage. No calvarial fractures. No
large territorial infarcts.
2. Numerous bilateral periventricular and subcortical white
matter
hypodensities are nonspecific and likely correspond with sequela
of chronic microangiopathy, however without priors for
comparison
again acute etiology cannot be completely excluded.
- ___ CT chest w/o contrast:
1. Pulmonary emboli within the segmental and subsegmental
branches of the right lower and middle lobes. Filling defects
within the subsegmental left apical branches are equivocal for
pulmonary embolism. No secondary signs of right heart strain.
2. Consolidation at the left lung base is suspicious for
pneumonia or
aspiration.
3. Moderate left and small right simple pleural effusions.
Loculated
low-density fluid within the major fissure on the right is
likely
additional pleural effusion.
4. Multilevel bridging osteophytosis which is suggestive of
diffuse idiopathic hyperostosis (DISH).
Consults:
- MASCOT:
- Agree with admission to MICU
- Please consult neurology and obtain CT head (if was not
obtained
at OSH) to determine if there is a contraindication to
therapeutic anticoagulation from a neurologic perspective.
- Please obtain LENIs
- If there is residual ICH or any contraindication to
therapeutic
anticoagulation from a neurologic perspective and there is
significant proximal DVT on LENIs, then we will discuss IVC
filter placement. If neurology deems anticoagulation not
strictly
contraindicated and the family and patient accept the risks,
would start heparin GTT
- Please obtain TTE
- Given evidence of volume overload, recommend diuresing with
Lasix 20 mg IV x1
- Defer to medical teams whether she requires antibiotics.
- Neurology:
- Consider IVC placement iso DVT to prevent further
propogation
- Consider CT torso to evaluate for malignancy reoccurance iso
new DVT and PE, though could be provoked by recent
hospitalization for pneumonia
- Though microhemorrahges are not an absolute contraindication
for therapeutic AC, there is a real risk of hemorrhage that must
be weighed against benefit of treatment for PE. In a life
threatening situation, reasonable to start AC but risk of
hemorrhage around 33%
Patient received:
___ 05:08 IV Furosemide 20 mg
___ 08:50 IV CefTRIAXone
___ 08:50 PO/NG Azithromycin 500 mg
___ 08:50 PO/NG Escitalopram Oxalate 20 mg
___ 08:50 SC Insulin 2 Units
___ 13:03 SC Insulin 6 Units
On arrival to the FICU, the patient is accompanied by her
extended family who interprets for her. She initially developed
cough and fever at the beginning of ___ and presented to
___.
___. Her family believes her pneumonia was right-sided but is
not sure what antibiotics she was treated with. After leaving
___, she started to notice lower extremity swelling and
worsening shortness of breath. She denies orthopnea or PND.
Denies weight gain or loss. Denies fevers but endorses night
sweats. Endorses poor appetite for several months.
Past Medical History:
PAST MEDICAL HISTORY:
Breast Cancer
DM2
CAA
HFpEF
HTN
HLD
pAF
Social History:
___
Family History:
Sister with PE (unclear etiology, treated with warfarin)
Brother with "clot in neck that caused a stroke"
Physical Exam:
.
.
==================
ADMISSION EXAM:
VS: T 98.4 BP 145/87 HR 92 RR 35 O2 97% on 3L NC
GEN: Well-appearing woman, laying in bed at 45 degrees, in no
acute distress
HEENT: NC/AT, EOMI, R surgical pupil, L pupil 3mm constricting
to
2mm with light, MMM
NECK: No appreciable JVD at 90 degrees
CV: Irregularly irregular, normal S1/S2, no m/r/g
RESP: Bibasilar crackles L>R extending halfway up lung fields
GI: Non-distended, active bowel sounds, soft, non-tender
EXT: Trace pitting edema in bilateral lower extremities
SKIN: Warm, well-perfused, no rashes
NEURO: Alert, CN II-XII intact, ___ strength in bilateral upper
and lower extremities, decreased sensation in V1 distribution of
trigeminal nerve on L side and in LLE
.
.
===================
DISCHARGE EXAM:
___ 1713 Temp: 98.6 PO BP: 119/59 HR: 89 RR: 18 O2 sat: 98%
O2 delivery: RA
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: MMM
CV: Heart irregular, +systolic murmur heard throughout the
precordium; JVP visible at angle of jaw with patient sitting up
but no JVD present
RESP: bibasilar crackles present, otherwise CTAB with normal WOB
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present.
SKIN: No rashes or ulcerations noted
NEURO: Awake, alert, conversant in her native language, follows
2-step commands without difficulty
MSK: was able to walk stairs with ___ this afternoon
PSYCH: calm, cooperative
Pertinent Results:
Initial Labs
============
___ 11:33PM BLOOD WBC-9.2 RBC-4.01 Hgb-10.3* Hct-34.3
MCV-86 MCH-25.7* MCHC-30.0* RDW-15.1 RDWSD-47.0* Plt ___
___ 11:33PM BLOOD Neuts-70.5 ___ Monos-5.5 Eos-0.8*
Baso-0.7 Im ___ AbsNeut-6.51* AbsLymp-2.04 AbsMono-0.51
AbsEos-0.07 AbsBaso-0.06
___ 11:33PM BLOOD ___ PTT-UNABLE TO ___
___ 11:33PM BLOOD Glucose-167* UreaN-16 Creat-1.0 Na-144
K-5.4 Cl-105 HCO3-22 AnGap-17
___ 06:40AM BLOOD ALT-8 AST-12 LD(LDH)-218 AlkPhos-59
TotBili-0.5
___ 11:33PM BLOOD proBNP-9356*
___ 11:33PM BLOOD cTropnT-<0.01
___ 11:33PM BLOOD Calcium-8.6 Phos-4.0 Mg-1.6
___ 11:45PM BLOOD Type-ART pO2-68* pCO2-32* pH-7.48*
calTCO2-25 Base XS-0
___ 11:45PM BLOOD Glucose-173* Na-143 K-5.6* Cl-106
calHCO3-25
___ 11:45PM BLOOD Hgb-10.8* calcHCT-32 O2 Sat-91
.
.
Micro
=========
-___ BCx: no growth (final)
-___ BCx: no growth (final)
.
.
Imaging
=========
- ___ Bilateral LENIs:
Occlusive DVT within the left popliteal vein. No signs of DVT
within the right leg.
- ___ CT head w/o contrast:
1. No acute intracranial hemorrhage. No calvarial fractures. No
large territorial infarcts.
2. Numerous bilateral periventricular and subcortical white
matter
hypodensities are nonspecific and likely correspond with sequela
of chronic microangiopathy, however without priors for
comparison
again acute etiology cannot be completely excluded.
- ___ CT chest w/o contrast:
1. Pulmonary emboli within the segmental and subsegmental
branches of the right lower and middle lobes. Filling defects
within the subsegmental left apical branches are equivocal for
pulmonary embolism. No secondary signs of right heart strain.
2. Consolidation at the left lung base is suspicious for
pneumonia or
aspiration.
3. Moderate left and small right simple pleural effusions.
Loculated
low-density fluid within the major fissure on the right is
likely
additional pleural effusion.
4. Multilevel bridging osteophytosis which is suggestive of
diffuse idiopathic hyperostosis (DISH).
HIP xray:
IMPRESSION:
Mild degenerative changes in the bilateral hip joints. No acute
fracture
seen.
CT abd/pelvis:
IMPRESSION:
1. No acute intra-abdominopelvic or hip abnormality.
2. Severe lumbar spine degenerative change.
3. Appropriately positioned IVC filter. Contrast bolus timing
limits
assessment of the IVC in the extremity veins. No asymmetry or
stranding to
suggest venous abnormality. If persistent concern, evaluation
for extension of
the previously seen left popliteal deep venous thrombosis could
be pursued
with ultrasound.
4. 1.4 cm left adrenal myelolipoma.
5. Small bilateral pleural effusions with moderate to severe
left basilar
atelectasis.
6. Redemonstrated pulmonary embolus in the right lung base,
partially
visualized.
CT hip:
IMPRESSION:
1. Mild degenerative changes of the right hip without evidence
of fracture or dislocation.
2. Sigmoid colon diverticulosis without evidence of
diverticulitis. Please refer to separate report of same day CT
abdomen and pelvis for description of the intra-abdominal and
intrapelvic findings.
.
.
Discharge labs:
================
___ 08:10AM BLOOD WBC-6.7 RBC-4.00 Hgb-10.1* Hct-33.7*
MCV-84 MCH-25.3* MCHC-30.0* RDW-15.2 RDWSD-46.2 Plt ___
___ 08:10AM BLOOD Glucose-172* UreaN-31* Creat-1.1 Na-141
K-4.2 Cl-100 HCO3-29 AnGap-12
___ 08:10AM BLOOD Albumin-4.2 Calcium-9.1 Phos-3.8 Mg-2.3
Brief Hospital Course:
Ms.. ___ is an ___ year-old female with history significant
for breast cancer s/p mastectomy and XRT in ___ (___), HFpEF
(EF 50%), and CAA c/b prior cerebral hemorrhage ___ who
initially presented to ___. ___ with dyspnea and chest pain,
found to have new segmental PE and proximal DVT, HD stable
without right heart strain, admitted initially to ICU for closer
monitoring, then managed on the wards. Her course was further
complicated by new acute systolic heart failure and afib with
RVR.
.
.
# Low risk segmental PE
# Proximal L popliteal DVT
HD stable, no trop elevation, no RH strain on echo. Deferred
systemic anticoagulation in setting of known CAA with high risk
of intracerebral hemorrhage. Per risk/benefit discussion with
MASCOT and neuro stroke team, would consider AC if patient were
to become hemodynamically unstable. IVC filter placed ___ IVC.
Anti phospholipid antibodies sent and returned with IgG
elevated. Given risk of ICH, pt was NOT started on
anticoagulation during admission.
*Going home w/ IVC filter in place. No anticoagulation.
# Acute systolic heart failure exacerbation
# Severe MR
# Moderate TR
Echo with new reduced EF to 30%. CXR with evidence of volume
overload. Responded well to gentle IV diuresis. She was going
to nuclear stress test but this was considered to be too high
risk in the setting of untreated PE's and MASCOT felt this could
be deferred to outpt setting. She was continued on low-dose BB
which was titrated up as needed for rate control. Hydralazine
was held to promote more blood pressure room. ACE-I was started
with captopril 6.25 TID which she tolerated (BPs 100s-110s/60s)
and this was transitioned to lisinopril 5 mg on discharge. She
will need f/u with cardiology after discharge and potentially
undergo stress testing to assess for reversible ischemia.
*For HFrEF: discharged on lisinopril 5 mg, Toprol XL 100 mg, and
instructed patient and family to weigh patient daily and notify
PCP/Cardiologist if weight increasing by more than 3 lbs from
current weight. Patient will also have visiting nurse services
who should be able to help with this.
# Afib with RVR
She developed this shortly into her hospitalization, likely
secondary to the new HFrEF and PEs. Rates were managed with BB.
Anticoagulation was NOT initiated despite high CHADS2-vasc
score of 8, due to high risk of ICH with CAA (30%). Rates were
controlled with BID metoprolol tartrate that was increased to
achieve excellent rate control by the day of discharge; she was
transitioned to Toprol XL 100 mg on discharge.
# Hypoxia
Improved with diuresis suggesting pulmonary edema may have been
a significant contributor in addition to the acute PE. Was not
requiring oxygen at rest or with significant exertion (climbed
stairs with ___ on day of discharge.
# CAA c/b microhemorrhages
Neurology was initially consulted in setting of new PE and afib;
given high risk for ICH, decision was made to pursue IVC filter
and no anticoagulation given risk of ICH. We advised patient
arrange follow-up in the Cerebrovascular/Stroke division of the
___ Neurology clinic.
# HTN
- Increased home beta blocker (for Afib rate control)
- Stopped home hydralazine
- Initiated lisinopril (for HFrEF)
# HLD
- Continued home atorvastatin 20mg daily
# GERD
- Continued home omeprazole 20mg daily
# T2DM
- Held home metformin while inpatient
- Held home standing Humalog while NPO; treated with HISS
# Depression
- Continued home escitalopram 20mg daily and venlafaxine 75mg
BID
# Anemia:
- *Stopped* home oral iron tabs, given poor expected absorption
in setting of chronic acid suppression therapy with omeprazole
[] consider repeating iron studies, if iron deficient consider
iron infusions (rather than oral iron) as long as patient is on
PPI
#Dispo - discussed rehab with the pt and HCP/dtr, they preferred
home with services ___.
# Emergency Contact: ___
Phone number: ___
.
.
.
.
.
.
Time in care: > 60 minutes in discharge-related activities
today.
.
.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 50 mg PO DAILY
2. Atorvastatin 20 mg PO QPM
3. Cyanocobalamin 1000 mcg PO DAILY
4. Escitalopram Oxalate 20 mg PO DAILY
5. Ferrous GLUCONATE 324 mg PO DAILY
6. HydrALAZINE 10 mg PO Q6H
7. Humalog 10 Units Breakfast
Humalog 10 Units Dinner
8. lidocaine 4 % topical DAILY
9. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
10. Omeprazole 20 mg PO DAILY
11. TraZODone 50 mg PO QHS
12. Venlafaxine 75 mg PO BID
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. Lisinopril 5 mg PO DAILY
RX *lisinopril 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*6
3. Humalog 10 Units Breakfast
Humalog 10 Units Dinner
4. Metoprolol Succinate XL 100 mg PO DAILY
RX *metoprolol succinate [Toprol XL] 100 mg 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*6
5. Atorvastatin 20 mg PO QPM
6. Cyanocobalamin 1000 mcg PO DAILY
7. Escitalopram Oxalate 20 mg PO DAILY
8. lidocaine 4 % topical DAILY
9. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
10. Omeprazole 20 mg PO DAILY
11. Venlafaxine 75 mg PO BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Acute PE & DVT
Atrial fibrillation with RVR
Acute HFrEF (LEF 30%)
Severe mitral regurgitation
Moderate tricuspid regurgitation
Moderate pulmonary hypertension
Cerebral amyloid angiopathy
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:
Why was I in the hospital?
- you were admitted after presenting with shortness of breath
and found to have blood clots in your lungs
What happened while I was in the hospital?
- you had a filter placed in your vein to prevent future blood
clots in the lung as it was decided it was too high risk to
start blood thinner medications with your brain blood vessels.
- you had a new fast heart rate that was treated with
medications
What will I need to do when I go home?
-You will need to work with ___
-You will need to see the cardiology doctors and to consider a
stress test as an outpt.
-You will need to weigh yourself each day on a standing scale,
record your weight in a log, and notify your doctor if you gain
more than 3 lbs (or 1.4 kg) from your current weight, as you may
need to be started on a new medication. **This is very
important.**
Followup Instructions:
___
|
19557391-DS-11
| 19,557,391 | 21,552,747 |
DS
| 11 |
2181-07-22 00:00:00
|
2181-07-22 19:58:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Leg pain/swelling
Major Surgical or Invasive Procedure:
___ Intubation
___ Central venous line insertion
___ HD line placement
History of Present Illness:
Ms. ___ is an ___ with PMHx notable for breast cancer s/p
mastectomy and XRT ___, HFrEF (LVEF 30%) with mod-severe MR,
cerebral amyloid angiopathy with microhemorrhages, pAF and
recent hospitalization at ___ from ___ to ___
for hypoxemia found to have new diagnosis of bilateral pulmonary
emboli with left popliteal DVT. During this recent
hospitalization, extensive discussion was had treatment of her
VTE and AF in the setting of brain microhemorrhages and systemic
AC was deferred. An IVC filter was placed on ___.
Ms. ___ was discharged to home and shortly thereafter noted
progressive painful leg swelling prompting evaluation at ___.
___ and subsequent transfer to ___. ___
ultrasound was notable for "echogenic material filling the right
common femoral vein, right proximal femoral vein, right mid
femoral vein, right distal femoral vein, right popliteal vein,
right posterior tibial and right peroneal vein".
In the ED, initial vitals were:
T97 HR113 BP121/64 RR20 99%RA
Exam notable for:
Palpable DP and ___ pulses. Able to move both extremities. No
focal tenderness.
Labs notable for:
Hgb ___, INR 1.2, Plt 158, Cr 2.9 K 5.7 HCO3 16 AG 22 lactate
4.6
Imaging was notable for:
___ U/S IVC & renal veins notable for thrombus within
bilateral common iliac veins extends into the IVC to the level
of an infrarenal IVC filter. Bilateral renal veins appear
patent with appropriate waveforms.
___ CXR notable for small bilateral pleural decreased from
prior, mild cardiomegaly, no vascular engorgement.
Patient was given:
___ 02:14 IV Morphine Sulfate 4 mg
___ 04:12 IV Morphine Sulfate 4 mg
___ 05:54 IV Morphine Sulfate 4 mg
___ 07:06 IV Metoprolol Tartrate 5 mg
___ 08:02 IVF LR Started 125 mL/hr
___ 08:02 IV Ondansetron 4 mg
___ 08:42 PO Metoprolol Tartrate 12.5 mg
___ 09:20 IV Morphine Sulfate 4 mg
___ 10:33 PO/NG Metoprolol Tartrate 25 mg
___ 10:33 PO/NG Escitalopram Oxalate 20 mg
___ 10:33 PO/NG MetFORMIN (Glucophage) 1000 mg
___ 10:40 SC Insulin 6 Units
___ 13:00 IVF LR Stopped - Unscheduled
___ 13:00 IVF NS Started
___ 14:00 IVF NS 250 mL Stopped (1h ___
___ 14:13 IV Morphine Sulfate 4 mg
___ 14:16 IVF NS (250 mL ordered) Started
Cardiology was consulted in the ED and recommended admission to
MICU for close monitoring of lower extremities given significant
tense bilateral swelling and neuro checks if decision is made
for anticoagulation. Cardiology recommended heparin IV if
family/patient accepts high risks of intracranial hemorrhage.
Recommended starting oral metoprolol for rate control.
Regarding anticoagulation, the decision was made to hold off
while in the ED.
Upon arrival to the ICU, patient reports that her pain is a
___, and that after 0.25 mg of IV hydromorphone is down to
___ (via translation from her daughter ___. Daughter and
granddaughter confirm that the patient has progressively been in
more pain throughout the day, worsening swelling and that her
feet now appear more mottled and cool.
Review of systems was negative except as detailed above.
Past Medical History:
- Breast cancer s/p mastectomy and XRT ___
- HFrEF (LVEF 30%) with mod-severe MR
- Cerebral amyloid angiopathy with microhemorrhages
- pAF
- Type II DM
- HLD
- GERD
- Depression
Social History:
___
Family History:
Sister with PE (unclear etiology, treated with warfarin).
Brother with "clot in neck that caused a stroke"
Physical Exam:
========================
ADMISSION PHYSICAL EXAM:
========================
VITALS: Reviewed in MetaVision.
GENERAL: Appears to be in acute pain
HEENT: NC/AT, EOMI, PERRL, MM dry
CARDIAC: Tachycardic, irregularly irregular, no m/r/g
PULMONARY: CTAB no wheezes/rales/rhonchi
ABDOMEN: Soft, non-distended, slight diffuse tenderness
EXTREMITIES: Upper ext are warm and well perfused. Lower
extremities, bilaterally, below the knees are swollen and tender
to touch out of proportion to exam. The ankles and distal areas
are mottled with delayed capillary refill (though still <2
seconds), and cold to touch. Bilateral DP and ___ pulses are
still faintly palpable.
SKIN: Other than above in the extremity exam, the skin is warm,
dry and intact elsewhere
NEURO: AO to self, place, not time. Following commands prior to
intubation. Purposeful movement of all limbs. CN II-XII intact.
========================
DISCHARGE PHYSICAL EXAM:
========================
VS: Temp: 97.9 (Tm 98.8), BP: 110/62 (96-120/48-67), HR: 63
(63-80), RR: 18, O2 sat: 97% (95-98), O2 delivery: Ra, Wt:
166.01 lb/75.3 kg
GENERAL: NAD, ___ speaking
NECK: Dressings over former right IJ and left HD line sites,
C/D/I
CARDIAC: irregularly irregular, S1 and S2 normal, holosystolic
murmur over mitral area
LUNGS: CTAB, no increased work of breathing
ABDOMEN: soft, non-tender, no distention, BS normoactive
EXTREMITIES: bilateral lower extremity edema, wrapped in ace
bandages, warm to touch, no significant discoloration
Pertinent Results:
ADMISSION LABS:
===============
___ 04:00AM BLOOD WBC-9.3 RBC-3.85* Hgb-9.9* Hct-33.1*
MCV-86 MCH-25.7* MCHC-29.9* RDW-16.2* RDWSD-50.5* Plt ___
___ 04:00AM BLOOD Neuts-81.3* Lymphs-12.2* Monos-5.6
Eos-0.0* Baso-0.4 Im ___ AbsNeut-7.57* AbsLymp-1.14*
AbsMono-0.52 AbsEos-0.00* AbsBaso-0.04
___ 04:00AM BLOOD ___ PTT-21.8* ___
___ 04:00AM BLOOD Glucose-227* UreaN-70* Creat-2.5*# Na-140
K-5.7* Cl-102 HCO3-16* AnGap-22*
___ 04:00AM BLOOD proBNP-9505*
___ 06:28AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
___ 04:17PM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
___ 04:09AM BLOOD PEP-NO SPECIFI
___ 04:26AM BLOOD FreeKap-146.4* FreeLam-72.5* Fr K/L-2.02*
___ 06:28AM BLOOD HCV Ab-NEG
___ 04:17PM BLOOD HCV Ab-NEG
___ 11:35AM URINE Hours-RANDOM Creat-166 TotProt-92
Prot/Cr-0.6*
___ 11:35AM URINE U-PEP-MULTIPLE P IFE-NEGATIVE F
___ 04:00AM BLOOD proBNP-9505*
___ 01:14PM BLOOD proBNP-8434*\
DISCHARGE LABS:
===============
___ 06:15AM BLOOD WBC-6.5 RBC-3.15* Hgb-8.4* Hct-28.1*
MCV-89 MCH-26.7 MCHC-29.9* RDW-17.8* RDWSD-56.1* Plt ___
___ 06:15AM BLOOD Plt ___
___ 06:15AM BLOOD Heparin-0.47
___ 06:15AM BLOOD Glucose-164* UreaN-35* Creat-1.0 Na-143
K-5.0 Cl-104 HCO3-27 AnGap-12
___ 06:30AM BLOOD ALT-41* AST-43* AlkPhos-232* TotBili-0.5
___ 06:15AM BLOOD Calcium-8.6 Phos-1.6* Mg-1.8
___ 06:00AM BLOOD PTH-207*
___ 06:00AM BLOOD 25VitD-20*
PERTINENT STUDIES:
==================
Radiology Report CT HEAD W/O CONTRAST Study Date of ___
5:47 ___
COMPARISON: CT head performed ___.
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass.
There is
prominence of the ventricles and sulci suggestive of
involutional changes.
Extensive periventricular and subcortical white matter
hypodensities are
unchanged and nonspecific, likely reflecting the sequelae of
chronic small
vessel ischemic disease.
There is no evidence of fracture. The visualized portion of the
paranasal
sinuses, mastoid air cells, and middle ear cavitiesare
essentially clear. The
visualized portion of the orbits are notable for bilateral lens
replacement.
IMPRESSION:
No evidence of acute intracranial abnormality.
Radiology Report CHEST PORT. LINE PLACEMENT Study Date of
___ 12:47 ___
COMPARISON: Chest radiograph dated ___
FINDINGS:
There is interval placement of a left internal jugular dialysis
catheter,
terminating at the right atrium. The previously place right
internal jugular
central venous line ends at the lower SVC. There is interval
removal of the
endotracheal and enteric tubes.
There is mildly increased pulmonary edema, most prominent at the
right lower
lobe. The left lung is unremarkable. There is no pneumothorax.
The
appearance of the cardiomediastinal silhouette is unchanged.
IMPRESSION:
1. Interval placement of a left internal jugular dialysis
catheter,
terminating at the right atrium.
2. Right internal jugular central venous catheter terminates in
the lower
SVC.
3. Interval removal of the endotracheal and enteric tubes.
4. Increased pulmonary vascular congestion and borderline edema
in the right
lower lobe, suggest volume overload and/or cardiac
decompensation.
Radiology Report LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT
Study Date of ___ 10:14 AM
COMPARISON: The report from the CT abdomen and pelvis ___
FINDINGS:
Liver: The hepatic parenchyma is within normal limits. No
focal liver
lesions are identified. There is no ascites.
Bile ducts: There is no intrahepatic biliary ductal dilation.
The common
hepatic duct measures 2 mm.
Gallbladder: The gallbladder appears within normal limits,
without stones,
abnormal wall thickening, or edema. Gallbladder polyp is
identified measuring
6 mm.
Pancreas: The pancreas is obscured by overlying bowel gas.
Spleen: The spleen demonstrates normal echotexture, and
measures 11.3 cm.
Multiple calcifications are identified within the spleen.
Doppler evaluation:
The main portal vein is patent, with flow in the appropriate
direction.
Right and left portal veins are patent, with antegrade flow.
The main hepatic artery is patent, with appropriate waveform.
Right, middle and left hepatic veins are patent, with
appropriate waveforms.
Splenic vein and superior mesenteric vein are obscured by
overlying bowel gas.
IMPRESSION:
Patent hepatic vasculature. No biliary dilatation is
identified.
Radiology Report US RENAL ARTERY DOPPLER Study Date of
___ 9:13 AM
COMPARISON: The report from the CT abdomen and pelvis ___
FINDINGS:
There is no hydronephrosis, stones, or masses on the right.
Normal cortical
echogenicity and corticomedullary differentiation are seen.
Views of the left
kidney are severely limited due to body habitus, positioning,
and limited
sonographic windows.
Right kidney: 10.4 cm. A simple cyst is seen arising from the
upper pole of
the right kidney measuring 6.0 x 5.8 x 6.7 cm. The intrarenal
arteries show
normal waveforms with sharp systolic peaks a continuous
antegrade diastolic
flow. The resistive indices of the right intrarenal arteries
are elevated
ranging from 0.77 to 0.97. The main renal artery on the right
is patent with
a peak systolic velocity of 116 centimeters/second. The main
renal vein is
patent.
Left kidney: 9.3 cm. A simple cyst arises from the lower pole
of the left
kidney measuring 2.5 x 2.8 x 2.9 cm. Doppler examination of the
left kidney
is suboptimal due to technical limitations described above.
Vascularity is
identified within the kidney on color Doppler imaging limited
Doppler
waveforms demonstrate similar and symmetric RI is when compared
to the right
ranging between 0.86 and 0.94. The main renal artery and vein
are not
identified.
The bladder is not distended.
IMPRESSION:
Patent symmetric vascularity and intrarenal resistive indices
bilaterally,
however visualization and Doppler examination of the left kidney
is suboptimal
due to body habitus, limited sonographic windows, and patient
positioning.
Normal arterial waveforms with elevated resistive indices are
identified,
which is of unclear etiology.
Radiology Report CHEST PORT. LINE PLACEMENT Study Date of
___ 8:24 ___
COMPARISON: ___
FINDINGS:
The tip of the endotracheal tube projects over the midthoracic
trachea. An
enteric tube extends to the stomach and the tip of a right
internal jugular
central venous catheter projects over the cavoatrial junction.
There is a
right basilar atelectasis as well as a small right pleural
effusion. The
opacities at the left lung base have significantly decreased in
extent. There
is no pneumothorax or left pleural effusion. The size and
appearance of the
cardiomediastinal silhouette is unchanged.
IMPRESSION:
The tip of the endotracheal tube projects over the midthoracic
trachea and the
tip of a right internal jugular central line projects over the
cavoatrial
junction.
Right basilar atelectasis.
Radiology Report IVC AND TRIBUTARIES US Study Date of ___
1:22 ___
COMPARISON: CT abdomen pelvis ___
FINDINGS:
Occlusive thrombus is seen within the right common and left
common iliac
veins. Thrombus extends into the inferior aspect of the IVC.
An infrarenal
IVC filter is noted. Bilateral main renal veins appear patent
with
appropriate waveforms.
IMPRESSION:
Thrombus within bilateral common iliac veins extends into the
IVC to the level
of an infrarenal IVC filter. Bilateral renal veins appear
patent with
appropriate waveforms.
Radiology Report CHEST (PORTABLE AP) Study Date of ___
12:47 ___
COMPARISON: Chest radiograph ___
FINDINGS:
Portable upright AP view of the chest provided.
Left basilar opacity appears improved compared to prior exam.
There are
persistent small bilateral pleural effusions, decreased on both
sides. No
focal consolidation. No pneumothorax. Cardiomediastinal
silhouette stable.
IMPRESSION:
Lungs are clear. No pneumonia or pulmonary edema. Small
bilateral pleural
effusions are decreased from prior exam. Mild cardiomegaly
persists there is
no pulmonary or mediastinal vascular engorgement.
MICROBIOLOGY:
=============
__________________________________________________________
___ 1:00 pm BLOOD CULTURE Source: Line-VIP port 2 OF
2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 11:02 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
__________________________________________________________
___ 10:05 am BLOOD CULTURE Source: Line-RIJ 1 OF 2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 4:00 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 2:27 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from only one set in the previous five days.
SENSITIVITIES PERFORMED ON REQUEST..
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN CLUSTERS.
Reported to and read back by ___ (___) @10:40
(___).
Brief Hospital Course:
___ with PMH significant for breast cancer s/p mastectomy and
XRT ___, HFrEF (LVEF 30%) with mod-severe MR, cerebral amyloid
angiopathy with microhemorrhages, pAF, and recent
hospitalization at ___ from ___ to ___ for
hypoxemia found to have new diagnosis of bilateral pulmonary
emboli with left popliteal DVT, status post IVC filter placement
on ___ due to up to 33% risk of brain bleed on anticoagulation
given her cerebral amyloid angiopathy. Presented with worsening
bilateral lower extremity pain and concern for limb ischemia,
found to have phlegmasia cerulea dolens, risks and benefits of
anticoagulation revisited and decision was made to start
anticoagulation, which significantly improved symptoms.
====================
ACUTE/ACTIVE ISSUES:
====================
# Phlegmasia cerulea dolens
# Possible recurrence of cancer
# Possible antiphospholipid syndrome
# Hypercoagulability
# Unreliable PTT levels
Patient with recent PE, left popliteal DVT, discharged with IVC
filter in place of systemic anticoagulation given that neurology
felt there was as high as a 33% risk of head bleed with her
cerebral amyloid angiopathy. Hypercoagulability is new, could be
further provoked by the IVC filter itself but she was forming
clots before that, raising concern especially with recent head
CT incidental finding that she could have recurrence of her
cancer. APLS workup notable for low positive cardiolipin IgG,
will need to repeat in 12 weeks to confirm diagnosis. Multiple
myeloma workup notable for kappa and lambda light chains and
ratio all elevated, however SPEP nonspecific and UPEP without
monoclonal band. Initially managed in the ICU, complicated by
shock requiring neo briefly and hypercarbic respiratory failure
requiring intubation. Decision was made to start heparin gtt
which significantly improved symptoms. Transitioned to Apixaban
2.5mg BID. PTT levels were labile, monitored heparin with factor
Xa levels for goal 0.3-0.7. Apixaban dose also titrated to this
factor Xa goal, though this practice is not routine. Patient
will need repeat factor Xa level one week post discharge (goal
0.3-0.7).
# Hypotension
Distributive. Driven by low diastolic. On neo briefly in MICU.
# Hypercarbic respiratory failure, resolved
# Lactic acidosis, resolved
Lactic acidosis ___ limb ischemia. Patient became more obtunded
iso worsening acidosis. Intubated ___ for airway protection
and ventilating the patient. Extubated ___.
# ATN requiring temporary RRT
Likely in the setting of critical limb ischemia, with associated
severe lactic acidosis. ___ temporary RRT in ICU, kidney
function recovered to baseline on floor. Has CKD stage 3 with
baseline Cr 1.0-1.1.
# Paroxysmal Afib with RVR
On Metoprolol 100mg XL at home. Worsened RVR iso pain, limb
ischemia, rising lactate. Metop initially held given patient
went into shock requiring neo briefly, restarted close to
discharge as baseline HRs approaching 100s again. Started on
Apixaban as above.
# Transaminitis
Likely iso shock. Non-obstructive on RUQUS. Progressively
downtrended following resolution of shock, not yet normalized at
discharge, recommend repeat LFTs as outpatient in 1 week.
# GPC bacteremia
Coag negative staph on admission blood cultures. Further blood
cx NGTD. Likely contaminant. Initially treated with vancomycin,
was d/c'ed.
===============
CHRONIC ISSUES:
===============
# HFrEF (EF 30%)
# Severe MR & moderate TR
Newly noted on last admission in ___. Previous team
discussed case with vascular/cards and decision was made to hold
off on stress testing and defer cardiology consultation and
potential stress testing to outpt setting. On metop as above for
afib, lisinopril 5mg was started previous admission, held this
admission iso ___ and ___ because of low-normal blood
pressures. Not on PO diuretics. Restart Lisinopril 5mg daily as
outpatient as BP tolerates.
# Normocytic Anemia
Stable at baseline ___. Consumption from extensive clots vs
anemia of chronic disease vs iron deficiency. Recommend checking
iron studies.
# DM2
Held home metformin and on HISS while in house. Metformin
restarted on discharge.
# Depression
Continued home venlafaxine, escitalopram.
# GERD
Continued home PPI
# HLD
Held home atorvastatin 20mg QPM iso transaminitis later
determined to likely be from ___ from shock. Restarted on
discharge.
====================
TRANSITIONAL ISSUES:
====================
New Medications:
- Apixaban 2.5mg BID
- Multivitamin with minerals
Held Medications:
- Lisinopril 5mg QD
[] Cardiology follow-up to initiate care for newly discovered
HFrEF. Lisinopril 5mg QD held at discharge given low-normal
blood pressures.
[] Repeat Factor Xa level in 1 week. If below 0.3, increase
Apixaban to 5mg BID and recheck Factor Xa in another week.
[] Due to cerebral amyloid angiopathy, anticoagulation presents
a very high (up to 33% per neurology) risk of brain bleeds in
her, would continue to address whether the benefits of ongoing
anticoagulation are worth the risks
[] Left occipital bone lesion noted incidentally on ___
head MRI and ___annot exclude malignancy,
concerning for recurrent metastatic breast cancer iso of
unexplained hypercoagulability. Recommend comparison with prior
head imaging to assess stability of lesion if available, and if
clinically warranted, further evaluation with a nuclear medicine
bone scan.
[] Had low positive anti-cardiolipin antibodies iso unexplained
hypercoagulability. Repeat APLS work up in 12 weeks to confirm
diagnosis
[] Has stable normocytic anemia, baseline Hb ___, consumption
from extensive clots vs anemia of chronic disease vs iron
deficiency. Recommend checking iron studies.
===================================================
#CODE: full (confirmed with HCP)
#CONTACT: HCP: ___ (daughter) ___
Medications on Admission:
1. Atorvastatin 20 mg PO QPM
2. Cyanocobalamin 1000 mcg PO DAILY
3. Escitalopram Oxalate 20 mg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Venlafaxine 75 mg PO BID
6. lidocaine 4 % topical DAILY
7. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
8. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
9. Metoprolol Succinate XL 100 mg PO DAILY
10. Lisinopril 5 mg PO DAILY
Discharge Medications:
1. Apixaban 2.5 mg PO BID
2. Multivitamins W/minerals 1 TAB PO DAILY
3. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
4. Atorvastatin 20 mg PO QPM
5. Cyanocobalamin 1000 mcg PO DAILY
6. Escitalopram Oxalate 20 mg PO DAILY
7. lidocaine 4 % topical DAILY
8. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
9. Metoprolol Succinate XL 100 mg PO DAILY
10. Omeprazole 20 mg PO DAILY
11. Venlafaxine XR 75 mg PO DAILY
12. HELD- Lisinopril 5 mg PO DAILY This medication was held. Do
not restart Lisinopril until you discuss with your doctor.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Phlegmasia cerulea dolens
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 ___,
It was a pleasure taking care of you at ___.
Why you were in the hospital
- The blood clots in your leg had enlarged and spread to both
sides, seriously impacting your circulation.
What was done for you in the hospital
- We started you on anticoagulation to treat the blood clot. Due
to a condition called cerebral amyloid angiopathy making your
brain blood vessels more fragile, anticoagulation gives you a
very high risk of brain bleeds. However, because the extent of
your blood clots were threatening your life, we felt the
benefits outweighed the risks at the time. Please continue to
discuss whether you need to continue anticoagulation (Apixaban)
with your doctors.
What you should do after you leave the hospital:
-Please call the ___ Neurology clinic at ___ to
schedule an appointment to be evaluated in the "Cerebrovascular
Disorders/Stroke" division of the Neurology department.
-You will follow-up with a PCP at rehab, then resume follow-up
with your regular doctor once you leave rehab.
-You have a cardiology appointment on ___ (see below) to
address your new diagnosis of heart failure.
- Please take your medications as detailed in the discharge
papers. If you have questions about which medications to take,
please contact your regular doctor to discuss.
- Please monitor for worsening symptoms. If you do not feel like
you are getting better or have any other concerns, please call
your doctor to discuss or return to the emergency room.
We wish you the best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19557459-DS-8
| 19,557,459 | 28,946,189 |
DS
| 8 |
2183-11-22 00:00:00
|
2183-11-22 13:21:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left ankle fracture
Major Surgical or Invasive Procedure:
ORIF left trimalleolar ankle fracture ___, Dr. ___
History of Present Illness:
___ w/hx type I DM otherwise healthy s/p mechanical fall,
sustaining a left ankle fracture. She was running to catch a
taxi when she slipped and fell, and felt a crunch in her left
ankle. No HS/LOC. Immediately unable to WB. She was brought to
___, where XR revealed a left trimalleolar ankle fracture, for
which orthopaedics is consulted. This was a closed, isolated
injury. NVI.
Past Medical History:
Type I diabetes
Hypothyroidism
Social History:
___
Family History:
Non-contributory
Physical Exam:
Left lower extremity:
- Skin intact
- Swelling/deformity noted about ankle
- ___ fire
- SILT SPN/DPN/TN/saphenous/sural distributions
- foot warm and well-perfused; <1s cap refill
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 trimalleolar ankle fracture and was admitted to
the orthopedic surgery service. The patient was taken to the
operating room on ___ for ORIF left trimalleolar ankle
fracture, which the patient tolerated well. For full details of
the procedure please see the separately dictated operative
report. The patient was taken from the OR to the PACU in stable
condition and after satisfactory recovery from anesthesia was
transferred to the floor. The patient was initially given IV
fluids and IV pain medications, and progressed to a regular diet
and oral medications by POD#1. The patient was given
___ antibiotics and anticoagulation per routine. The
patient's home medications were continued throughout this
hospitalization. The patient worked with ___ who determined that
discharge to home with services was appropriate. The ___
hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
non-weight-bearing in the left 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
postoperative precautions and the appropriate follow-up care.
The patient expressed readiness for discharge.
Discharge Medications:
1. Lantus (insulin glargine) 26 units subcutaneous QHS
2. Levothyroxine Sodium 50 mcg PO DAILY
3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
5. Acetaminophen 650 mg PO Q6H
6. Aspirin 325 mg PO DAILY Duration: 2 Weeks
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Left ankle fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week. - Resume your
regular activities as tolerated, but please follow your weight
bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Non-weight-bearing on the left leg
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 325mg daily for 2 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.
- No dressing is needed if wound continues to be non-draining.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
Physical Therapy:
Non-weight-bearing on left lower extremity
Treatments Frequency:
Splint/sutures to be removed at follow up appointment in 2 weeks
Followup Instructions:
___
|
19557488-DS-12
| 19,557,488 | 21,248,712 |
DS
| 12 |
2174-01-14 00:00:00
|
2174-01-14 22:38:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Painful Swallowing
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo female with a history of esophageal cancer who is admitted
with esophagitis. The patient was recent admitted from ___ -
___
with similar symptoms and was discharged on fluconazole. The
patient states she has been unable to eat or drink or take
pills.
She has limited ___ but it appears her symptoms have
progressively worsening since she was discharged and she was
likely not taking the medications as prescribed. She denies any
fevers, shortness of breath, diarrhea, or dysuria. She denies
any
abdominal pain but has had midline pain in her chest which she
attributes to her esophagus.
REVIEW OF SYSTEMS:
- All reviewed and negative except as noted in the HPI.
Past Medical History:
PAST ONCOLOGIC HISTORY:
Pathology ___ at ___:
Moderately differentiated invasive squamous cell cancer
EUS ___:
Fully circumferential ulcerated friable mass at 27-31cm
obstructing ~60% of the lumen with evidence of invasion beyond
the muscularis layer and 3 ___ enlarged lymph nodes in
the ___ mediastinum (largest 12mm). Therefore,
staging by EUS criteria was T3N2.
PET ___:
Highly FDG avid (SUV max 32.19) concentric wall thickening of a
5cm stretch of the mid to distal esophagus, FDG avid cervical
level VII, mediastinal, paraesophageal, and left gastric
lymphadenopathy, and sub-centimeter nodules in RLL and LLL that
were too small to be characterized by PET.
Started Carbotaxol on ___.
PAST MEDICAL/SURGICAL HISTORY:
Mild hypertension
Hyperlipidemia
Glaucoma
Hypothyroidism
Social History:
___
Family History:
Mother: died of probable oropharyngeal cancer, CHF
Father: died of old age (___), diabetes
Siblings: Brother died of CAD s/p CABG; sister with breast
cancer
Offspring: 1 child died at birth, 1 son with autoimmune
arthritis, other 8 children healthy
Other: Cousin with brain tumor, niece and cousin with lymphoma
Physical Exam:
ADMISSION PHYSICAL EXAM:
General: NAD
VITAL SIGNS: T 99.4 BP 118/70 HR 82 RR 18 O2 95%RA
HEENT: EOMI, neck supple, White plagues in mouth, dry mucous
membranes.
CV: RR, NL S1S2
PULM: CTAB
ABD: Soft, NTND, no masses or hepatosplenomegaly
LIMBS: No edema, clubbing, tremors, or asterixis
SKIN: No rashes or skin breakdown
NEURO: Alert and oriented, no focal deficits.
DISCHARGE PHYSICAL EXAM:
Vitals: 98.6 145/90 106 18 97% RA
Gen: Lying in bed in NAD
HEENT: EMOI, moist mucous mems, plaque on surface of tongue has
resolved.
NECK: Supple
CV: RRR. Normal S1,S2. No m/r/g.
LUNGS: Normal WOB. CTAB. No wheezes, rales, or rhonchi.
ABD: Soft, NTND, no masses or hepatosplenomegaly.
EXT: Pulses strong and equal bilaterally. Lower extremities WWP.
No peripheral edema.
SKIN: No rashes/lesions, or skin breakdown.
NEURO: A&Ox3. No focal deficits.
Pertinent Results:
ADMISSION LABS:
=================
___ 07:46PM NEUTS-60.9 ___ MONOS-13.3* EOS-0.3*
BASOS-0.3 IM ___ AbsNeut-2.06 AbsLymp-0.84* AbsMono-0.45
AbsEos-0.01* AbsBaso-0.01
___ 07:46PM WBC-3.4* RBC-3.17* HGB-9.5* HCT-30.8* MCV-97
MCH-30.0 MCHC-30.8* RDW-18.2* RDWSD-62.4*
___ 07:46PM GLUCOSE-136* UREA N-12 CREAT-0.7 SODIUM-133
POTASSIUM-3.9 CHLORIDE-93* TOTAL CO2-27 ANION GAP-17
___ 11:30PM URINE MUCOUS-MANY
___ 11:30PM URINE HYALINE-4*
___ 11:30PM URINE RBC-5* WBC-59* BACTERIA-NONE YEAST-NONE
EPI-0
___ 11:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-4* PH-6.0 LEUK-LG
___ 11:30PM URINE COLOR-Yellow APPEAR-Hazy SP ___
DISCHARGE LABS:
================
___ 07:15AM BLOOD WBC-2.4* RBC-3.04* Hgb-9.1* Hct-29.0*
MCV-95 MCH-29.9 MCHC-31.4* RDW-18.0* RDWSD-60.8* Plt ___
___ 07:15AM BLOOD Neuts-55.9 ___ Monos-16.1*
Eos-0.8* Baso-0.8 Im ___ AbsNeut-1.35* AbsLymp-0.62*
AbsMono-0.39 AbsEos-0.02* AbsBaso-0.02
___ 07:15AM BLOOD Glucose-109* UreaN-5* Creat-0.6 Na-136
K-4.1 Cl-98 HCO3-27 AnGap-15
___ 07:15AM BLOOD Calcium-9.3 Phos-4.4 Mg-1.9
STUDIES:
=========
None
Brief Hospital Course:
Ms. ___ is a ___ year old ___ woman with
esophageal squamous carcinoma, on chemo-radiation (carbotaxol)
with esophagitis who was admitted with increased dysphagia and
pain.
# Esophagitis/Throat Pain:
Patient recently discharged from the hospital on ___. She
was sent home on liquid morphine. Her esophagitis is likely ___
to recent XRT and systemic chemotherapy. She has completed a
course of fluconazole, however had thrush on tongue on
admission, greenish color of plaque on tongue most likely due to
green color of liquid morphine. ___ infection was present on
admission, however she completed a full course of fluconazole
prior to admission so we felt that this was unlikely to be the
source of her pain. She was given nystatin swish and swallow for
her thrush, which eventually resolved. She was started on
acyclovir to cover for possible HSV esophagitis. Prior to
discharge she was switched to PO acyclovir, which should be
continued until ___ for total of a 7 day course. Her PO liquid
morphine was continued for pain control. She was also started on
magic mouthwash and oral lidocaine, which should be continued as
needed as an outpatient. Her fentanyl patch was continued.
# Nausea: she had intermittent reports of nausea this admission.
She received zofran and ativan IV during the course of her
admission, and these medications were converted to PO prior to
discharge.
# Hypokalemia: patient was continued on standing 20mEq of
potassium repletion daily, with additional repletion as
necessary.
# Severe Malnutrition: patient had poor PO intake due to her
pain. She was given clear ensures to supplement her diet. Her PO
intake has improved with pain control however still remained
inadequate. She should still maximize her diet with additional
calories from PO supplements. Decision was made to hold off on
tube feeds or a J-tube, as her esophagitis and pain should
improve within the next week. Her nutritional status should be
readdressed and optimized prior to surgical resection.
TRANSITIONAL ISSUES:
=====================
-patient with poor nutritional status, improving with pain
control but still inadequate. She should maximize her diet with
additional calories from PO supplements. We expect her pain to
improve over the next week. Her nutritional status should be
addressed prior to surgery.
-she should follow up with her PCP ___ week
-___ was started on acyclovir, which she should continue as an
outpatient until ___, for a total 7 day course
-Please check labs at next outpatient visit given that she is
receiving potassium 20 mEq daily. Adjust this as needed.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fentanyl Patch 25 mcg/h TD Q72H
2. bimatoprost 0.01 % ophthalmic BID
3. Maalox/Diphenhydramine/Lidocaine 15 mL PO QID:PRN throat pain
4. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
5. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN dry
eyes
6. Bisacodyl 10 mg PO DAILY:PRN constipation
7. Docusate Sodium 100 mg PO BID
8. Fluconazole 400 mg PO Q24H
9. LORazepam 0.25 mg PO Q6H:PRN nausea
10. Potassium Chloride 20 mEq PO DAILY
11. Omeprazole 20 mg PO BID
12. Metoprolol Succinate XL 100 mg PO QPM
13. Morphine Sulfate (Oral Solution) 2 mg/mL ___ mg PO Q4H:PRN
Pain - Moderate
14. Morphine Sulfate (Oral Solution) 2 mg/mL 10 mg PO TID
W/MEALS
15. Ondansetron ODT 4 mg PO Q8H:PRN nausea
16. Atorvastatin 40 mg PO QPM
17. Polyethylene Glycol 17 g PO DAILY
18. Senna 8.6 mg PO BID
19. Sodium Chloride Nasal ___ SPRY NU QID:PRN dry nose
Discharge Medications:
1. Acyclovir 400 mg PO Q8H
RX *acyclovir 400 mg 1 tablet(s) by mouth every 8 hours Disp #*6
Tablet Refills:*0
2. Lactulose 30 mL PO DAILY
RX *lactulose 20 gram/30 mL ___ mL by mouth daily Disp #*900
Milliliter Refills:*0
3. Lidocaine Viscous 2% 15 mL PO TID:PRN Mouth/Throat Pain
RX *lidocaine HCl [Lidocaine Viscous] 2 % Take 15 mL three times
daily as needed for throat pain Disp #*600 Milliliter Refills:*0
4. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
5. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN dry
eyes
6. Atorvastatin 40 mg PO QPM
7. bimatoprost 0.01 % ophthalmic BID
8. Bisacodyl 10 mg PO DAILY:PRN constipation
9. Docusate Sodium 100 mg PO BID
10. Fentanyl Patch 25 mcg/h TD Q72H
RX *fentanyl 25 mcg/hour Apply one patch every 72 hours Disp #*5
Patch Refills:*0
11. LORazepam 0.25 mg PO Q6H:PRN nausea
12. Maalox/Diphenhydramine/Lidocaine 15 mL PO QID:PRN throat
pain
13. Metoprolol Succinate XL 100 mg PO QPM
14. Morphine Sulfate (Oral Solution) 2 mg/mL ___ mg PO Q4H:PRN
Pain - Moderate
RX *morphine 10 mg/5 mL 5 mL by mouth three times a day Disp
#*225 Milliliter Refills:*0
15. Morphine Sulfate (Oral Solution) 2 mg/mL 10 mg PO TID
W/MEALS esophagitis
RX *morphine 10 mg/5 mL ___ mg by mouth AS DIRECTED Disp #*340
Milliliter Refills:*0
16. Omeprazole 20 mg PO BID
17. Ondansetron ODT 4 mg PO Q8H:PRN nausea
18. Polyethylene Glycol 17 g PO DAILY
19. Potassium Chloride 20 mEq PO DAILY
20. Senna 8.6 mg PO BID
21. Sodium Chloride Nasal ___ SPRY NU QID:PRN dry nose
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
====================
Esophageal squamous cell carcinoma
Esophagitis, mucositis
Secondary Diagnoses:
=====================
Hypokalemia secondary to poor oral intake
Nausea
Constipation
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
throat pain and difficulty eating/swallowing food. This is
likely due to your esophagitis, which is a side effect of the
chemoradiation that you received for treatment of your
esophageal cancer.
We made sure your pain was controlled with liquid medicines as
well as IV medicines. You were started on a medicine called
acyclovir to protect you against HSV, a virus that can make your
throat pain worse. Since your pain medications are known to
cause constipation, we had you take daily medications to help
you have regular bowel movements. You should continue taking
these medications after you leave the hospital.
Please follow up next week with Dr. ___. It is important that
you continue to take your medications as prescribed and that you
continue to eat food to maintain your nutritional status and
help with healing. Please contact Dr. ___ if you
have any questions or concerns.
We wish you the best in your health,
Your ___ Care Team
Followup Instructions:
___
|
19557488-DS-13
| 19,557,488 | 26,166,130 |
DS
| 13 |
2174-04-22 00:00:00
|
2174-04-24 14:10:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Persistent odynophagia, dehydration
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
___ year old female with T3 N2 esophageal squamous cancer treated
with chemoradiation which completed in early ___, course c/b
significant RT esophagitis requiring several hospital
admissions,
and narcotics for pain, now presents with presents with poor PO
intake, nausea, and frequent spitting (known 70-80% espophageal
stenosis). No fevers, chills, cough, ST, rhinorrhea, dyspnea, or
diarrhea. No dysuria or frequency. Mild epigastric pain when she
vomits, otherwise without pain. No back pain. No h/o DVT or PE
or
risk factors aside from esophageal cancer. No history of known
aortic disease. Recently adm to ___ for dehydration. 20lb
weight loss over past month.
Regarding her RT esophagitis, her last hospital admission was in
___ for this (2 admits for this in ___ this year) at which
time it ws noted she had completed course of PO fluc - had
thrush
on tongue during that admit, nystatin swish and swallow resolved
this, she was started on ___ to cover for possible HSV
esophagitis, she completed 7d course through ___ for this. She
had folloupw endoscopy ___ which still had significant
inflammation with segmental exudate with marked erythema and
friability particularly in the upper and
middle third of the esophagus compatible with her radiation
esophagitis. There was narrowing of the lumen in this
particular
segment, allowing passage of the pediatric scope. The limited
exam of the stomach and the duodenum was negative. EUS was done
and there was no adenopathy noted in the upper esophagus. The
rest of the esophagus could not be examined. Biopsies were done
and these showed ulceration and plasmacytic inflammation of some
atypical cells consistent with radiation. No tumor was seen and
several levels were evaluated.
she was seen by Dr. ___ ___ for follow up at which time
she noted ongoing difficulty with swallowing, only taking
liquids
and pureed foods. Weight at that time was down only 2 pounds
from
6 weeks prior however, breathing comfortably, no swelling.
History obtained today with assistance of her son who served as
interpreter (___) during the interview. He states the
odyophagia and constant spitting and substernal chest pain have
all been going on for months but have flared recently. She
refuses Carafate at home and stopped her PPI, has been using
zyrtec instead. Otherwise she denies having had any abd pain at
all nor diarrhea, if anything trends towards constipation. NO
hematochezia/melena. NO dyspnea, coughing. THe patient states
the
reason she spits frequently is "too much saliva" and a feeling
that it is painful when she swallows it. Per son this spitting
is
not new. No dysuria, headache, fever, all other 10 point ROS
neg.
ED COURSE:
Triggered on arrival for tachycardia, HR 144, BP 159/96 -->
137/85, RR 18 100% RA. Got 500c IVF, last TTE ___ showed EF
55%. HR down to 128, SR on EKG. UA with 52 WBC, mod leuks, few
bact, but 4 epi. Lactate 1.6. Chem reassuring other than
slightly
hemolyzed K at 5.2. BUn / cr ___. CBC WNL (elevated Hct
compared to prior likely reflecting hemoconcentration). She was
given CTX for possible UTI. WBC 4.3 with 65% pmns. HR down to
90.
EKG with some mild nonspecific ST changes (TWI and Qwaves in
III,
right bundle morphology in ant leads - but all changes stable
and
present on EKG ___.
Past Medical History:
PAST ONCOLOGIC HISTORY:
Pathology ___ at ___:
Moderately differentiated invasive squamous cell cancer
EUS ___:
Fully circumferential ulcerated friable mass at 27-31cm
obstructing ~60% of the lumen with evidence of invasion beyond
the muscularis layer and 3 ___ enlarged lymph nodes in
the ___ mediastinum (largest 12mm). Therefore,
staging by EUS criteria was T3N2.
PET ___:
Highly FDG avid (SUV max 32.19) concentric wall thickening of a
5cm stretch of the mid to distal esophagus, FDG avid cervical
level VII, mediastinal, paraesophageal, and left gastric
lymphadenopathy, and sub-centimeter nodules in RLL and LLL that
were too small to be characterized by PET.
Started Carbotaxol on ___.
Now s/p radiation therapy as above
PAST MEDICAL/SURGICAL HISTORY:
Mild hypertension
Hyperlipidemia
Glaucoma
Hypothyroidism
Social History:
___
Family History:
Mother: died of probable oropharyngeal cancer, CHF
Father: died of old age (___), diabetes
Siblings: Brother died of CAD s/p CABG; sister with breast
cancer
Offspring: 1 child died at birth, 1 son with autoimmune
arthritis, other 8 children healthy
Other: Cousin with brain tumor, niece and cousin with lymphoma
Physical Exam:
VITAL SIGNS: T 98 BP 150/82 HR 73 RR 18 O2 99%RA
General: NAD
HEENT: EOMI, MMM, no OP lesions
CV: RR, NL S1S2
PULM: CTAB
GI: Soft, NTND, no masses or hepatosplenomegaly
LIMBS: No edema, clubbing, tremors, or asterixis
SKIN: Mild ecchymosis right buttocks.
NEURO: Alert and oriented, no focal deficits.
Pertinent Results:
___ 07:10PM BLOOD WBC-4.3 RBC-3.92# Hgb-11.5 Hct-35.6
MCV-91 MCH-29.3 MCHC-32.3 RDW-13.0 RDWSD-41.8 Plt ___
___ 07:35AM BLOOD WBC-2.4* RBC-3.44* Hgb-10.2* Hct-31.0*
MCV-90 MCH-29.7 MCHC-32.9 RDW-12.8 RDWSD-42.2 Plt ___
___ 06:15AM BLOOD ___ PTT-28.8 ___
___ 07:35AM BLOOD Glucose-98 UreaN-3* Creat-0.5 Na-139
K-3.6 Cl-100
___ 06:15AM BLOOD ALT-11 AST-16 AlkPhos-93 TotBili-0.4
___ 06:15AM BLOOD Calcium-8.7 Phos-3.7 Mg-2.0
CTA Chest and Abdomen:
1. No pulmonary embolism or acute aortic abnormality.
2. New radiation fibrosis changes in the right lung.
3. Diffuse circumferential wall thickening of the mid to distal
esophagus is similar to prior and consistent with radiation
esophagitis.
4. Diverticulosis, with no evidence of acute diverticulitis.
Brief Hospital Course:
___ year old female with T3 N2 esophageal squamous cancer treated
with chemoradiation which completed in early ___, course c/b
significant RT esophagitis requiring several hospital
admissions, and narcotics for pain, who presented with
persistently poor PO intake, nausea, and frequent spitting due
to persistent odynophagia/dysphagia(known 70-80% espophageal
stenosis).
Radiation esophagitis
- Cause of her current symptoms. Patient has had prolonged
radiation esophagitis for at least 2 months now since completion
of radiation with most recent EGD ___ showing esophagitis and
stenosis. Per patient and son in giving history, these issues
were just acute worsening of same symptoms she had struggled
with for the last 2 months. GI was consulted. Given persistent
symptoms and concern for alternative cause of esophagitis by
primary oncologist given length of time since radiation an EGD
was done. Per GI similar findings to last EGD with radiation
esophagitis and stricture present. Biopsies were taken.
Recommended PPI and carafate and possible repeat EGD and
consideration of dilation in future when inflammation has
decreased. Patient was discharged with these prescriptions and
to continue symptomatic treatment. Per recommendation of the
patient's primary oncologist a feeding tube was offered to the
patient given the persistent pain with eating and lack of
ability to eat much but she declined that at this time.
Esophageal Cancer
- No current treatment. She will follow up with her primary
oncologist as an outpatient.
Thrush
- Continue nystatin.
Sinus Tachycardia
- Possible component of hypovolemia, responded to IVF. CTA
negative. Improved after home atenolol restarted.
Gluteal Lesion
- Likely irriation due to flu vaccine. No obvious signs of
infection. Originally erythematous. Resolved to mild ecchymosis.
Positive Urinalysis
- Patient without dysuria. Received one dose of ceftriaxone in
the ED which was not continued due to patient being
asymptomatic. Culture negative.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Sucralfate 1 gm PO QID
2. Cetirizine 10 mg PO DAILY
3. Pravastatin 20 mg PO QPM
4. Atenolol 50 mg PO DAILY
5. Lumigan (bimatoprost) 0.01 % ophthalmic QHS
6. Fentanyl Patch 25 mcg/h TD Q72H
7. fosinopril 10 mg oral Q24H
8. Ondansetron 8 mg PO Q8H:PRN nausea
9. Nystatin Oral Suspension 5 mL PO QID:PRN thrush
10. Lidocaine Viscous 2% 15 mL PO TID:PRN mouth/throat pain
Discharge Medications:
1. Acetaminophen (Liquid) 650 mg PO Q6H
2. LORazepam 0.5 mg PO Q4H:PRN Nausea or Anxiety
RX *lorazepam 0.5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
3. Prochlorperazine 10 mg PO Q6H:PRN Nausea
RX *prochlorperazine maleate 10 mg 1 tablet(s) by mouth every
six (6) hours Disp #*30 Tablet Refills:*0
4. Protonix (Granules for ___ ___ 40 mg PO Q12H
RX *pantoprazole [Protonix] 40 mg 40mg granules(s) by mouth
every twelve (12) hours Disp #*60 Packet Refills:*2
5. Atenolol 50 mg PO DAILY
6. Cetirizine 10 mg PO DAILY
7. Fentanyl Patch 25 mcg/h TD Q72H
8. fosinopril 10 mg oral Q24H
9. Lidocaine Viscous 2% 15 mL PO TID:PRN mouth/throat pain
10. Lumigan (bimatoprost) 0.01 % ophthalmic QHS
11. Nystatin Oral Suspension 5 mL PO QID:PRN thrush
12. Ondansetron 8 mg PO Q8H:PRN nausea
13. Pravastatin 20 mg PO QPM
14. Sucralfate 1 gm PO QID
RX *sucralfate 1 gram/10 mL 1gm suspension(s) by mouth four
times a day Refills:*3
Discharge Disposition:
Home
Discharge Diagnosis:
Esophagitis
Esophageal Cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with nausea, vomiting, and esophageal pain.
You underwent an endoscopy which was unchanged from your last
one. You will need to take protonix and sucralfate regularly for
the next few weeks. You were offered the option of a feeding
tube so you would not have to try eating given the pain and
could get more nutrition than you do now. You decided not to do
this. If you change your mind your primary oncologist can always
set this up.
Followup Instructions:
___
|
19557488-DS-15
| 19,557,488 | 21,021,098 |
DS
| 15 |
2174-10-26 00:00:00
|
2174-10-26 21:16:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
dark vomitus
Major Surgical or Invasive Procedure:
EGD ___
History of Present Illness:
___ female with history of esophageal cancer s/p
chemo/radiation with radiation esophagitis, severe malnutrition
and gtube placed in ___, who presented with acute
onset of brownish vomitus after undergoing esophageal stent on
the day prior to admission.
She was recently diagnosed with recurrent squamous cell
carcinoma of the esophagus with PET avid new intra-abdominal
nodes (not a candidate for salvage esophagectomy given nodes).
She also has severe malnutrition and gtube placed in ___ to support nutritional needs. Per last oncology note, plan
is to follow up in a month for discussion of low-dose chemo,
though she tolerated chemo very poorly in the past.
Course has been complicated by dysphagia for which she
underwent stenting of her esophagus on ___. Recent EGD, ___: A
circumferential, friable, ulcerated lesion consistent with the
known esophageal malignancy was found in the esophagus at 30cm -
34cm from the incisors. Under fluroscopic guidance a fully
covered metal stent was advanced over guidewire and placed
traversing the stricture. No bleeding noted.
Since 4 AM on the day of presentation, she has had several
episodes of vomiting of brownish material (a reported total
vomit volume of 750 cc). Patient stated that she tried Zofran ___s lorazepam 1 mg without relief. She has vomited
approximately ___ times. She endorses mild epigastric abdominal
pain. She denies a complete review of systems otherwise. ROS
otherwise negative.
In ED initial VS: 98.1 110 168/95 18 95% RA
Exam: soft abd, rectal: light brown, guaiac neg
Patient was given:
___ 09:30 IV Pantoprazole 80 mg ___
___ 09:30 IV Ondansetron 4 mg ___
___ 09:30 IVF NS ( 1000 mL ordered) ___ Started
Imaging notable for: CXR with unchanged positioning of the
esophageal stent. Low lung volumes and mild bibasilar
atelectasis.
Labs notable for hgb 12.3 and lactate 2.3.
Consults: GI, ERCP
On arrival to the MICU, patient was awake and alert. She was
accompanied by her son in law. She was nauseous and reported not
having any more episodes of vomiting for several hours. She was
taken foe EGD shortly after arrival to the ___.
REVIEW OF SYSTEMS: She reported a temperature of 100 and
elevated BP at home (up to 190 systolic) during the episodes of
vomiting. She denies any episodes of melena, lightheadedness,
syncope. ROS is otherwise negative.
Past Medical History:
PAST ONCOLOGIC HISTORY:
Pathology ___ at ___:
Moderately differentiated invasive squamous cell cancer
EUS ___:
Fully circumferential ulcerated friable mass at 27-31cm
obstructing ~60% of the lumen with evidence of invasion beyond
the muscularis layer and 3 ___ enlarged lymph nodes in
the ___ mediastinum (largest 12mm). Therefore,
staging by EUS criteria was T3N2.
PET ___:
Highly FDG avid (SUV max 32.19) concentric wall thickening of a
5cm stretch of the mid to distal esophagus, FDG avid cervical
level VII, mediastinal, paraesophageal, and left gastric
lymphadenopathy, and sub-centimeter nodules in RLL and LLL that
were too small to be characterized by PET.
Started Carbotaxol on ___.
Now s/p radiation therapy as above
PAST MEDICAL/SURGICAL HISTORY:
Mild hypertension
Hyperlipidemia
Glaucoma
Hypothyroidism
Social History:
___
Family History:
Mother: died of probable oropharyngeal cancer, CHF
Father: died of old age (___), diabetes
Siblings: Brother died of CAD s/p CABG; sister with breast
cancer
Offspring: 1 child died at birth, 1 son with autoimmune
arthritis, other 8 children healthy
Other: Cousin with brain tumor, niece and cousin with lymphoma
Physical Exam:
ADMSSION EXAMPHYSICAL EXAM:
VITALS: Tmax 99.9 HR 110's BP 140-160/90-100 94% on ___ L
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 rhythm, tachycardic, normal S1 S2, no murmurs,
rubs, gallops
ABD: Soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly, Gtube noted
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: No skin lesions
NEURO: A&Ox3, answers questions appropriately, speaks full
sentences
Pertinent Results:
___ 09:25AM BLOOD WBC-8.7# RBC-3.86* Hgb-12.3 Hct-36.6
MCV-95 MCH-31.9 MCHC-33.6 RDW-12.4 RDWSD-42.5 Plt ___
___ 07:00AM BLOOD WBC-6.0 RBC-3.62* Hgb-11.3 Hct-34.6
MCV-96 MCH-31.2 MCHC-32.7 RDW-12.3 RDWSD-42.7 Plt ___
___ 09:25AM BLOOD Glucose-172* UreaN-15 Creat-0.6 Na-143
K-3.3 Cl-96 HCO3-31 AnGap-19
___ 07:00AM BLOOD Glucose-146* UreaN-15 Creat-0.5 Na-139
K-3.7 Cl-101 HCO3-25 AnGap-17
___ 09:44AM BLOOD Lactate-2.3*
___ 05:14AM BLOOD Lactate-1.1
EGD ___
The previously placed metal stent was found in the middle third
and lower third of the esophagus. The stent was in excellent
position with the proximal end at 25cm from the incisors and the
distal end at the GEJ. A non-bleeding, superficial
circumferential ulceration was noted above the stent from 25cm
to 23cm.
Previously placed gastric tube
Normal mucosa in the whole duodenum
No stigmata or evidence of recent bleeding was noted on this
examination.
Otherwise normal EGD to third part of the duodenum
Brief Hospital Course:
___ primarily speaking ___ female with history of
esophageal cancer s/p chemo/radiation with radiation
esophagitis, severe malnutrition and gtube placed in ___, who presented with acute onset of brownish vomitus
concerning for
hematemesis after undergoing esophageal stent placement the day
prior to admission, done for dysphagia.
# possible hematemesis - Presented with dark vomitus which was
felt could possibly represent hematemesis after having
esophageal stent placed ___, so she was admitted to the FICU
and immediately had EGD ___ which which showed excellent
position of the stent with a non-bleeding, superficial
circumferential ulceration noted above the stent. Etiology of
the black vomitus was thought to be expected debris in the
setting of recent esophageal stent placement. Hct remained
stable stable at baseline throughout admission(initially on
arrival hemoconcentrated slightly) and no further emesis since
procedure. She resumed her post esophageal stent diet per prior
and home tube feed regimen.
# Esophageal cancer c/b dysphagia - esophageal stent had been
previously placed ___ as above. Felt normal debris post
procedure. H/H stable, no further episodes of vomiting since she
has been here. per Dr. ___ note in early ___, further
chemotherapy not likely to be helpful or well tolerated.
# malnutrition/nausea/vomiting/esophagitis - pt has had prior
admissions for
all of the above as recurrent issues w/ esophagitis and
nausea/vomiting difficult to treat. She develops substernal
irritation which has been ongoing for months when she tries to
take po or swallow. Previously in ___ was treated with
valgancyclovir for CMV positive biopsies on prior EGD but has
been off since ___ at least but reports her symptoms never
really improved. Her prn antiemetics were continued. She is on a
fentanyl patch, and she was encouraged to use liquid morphine as
previously prescribed by Dr. ___ her pain, but insisted
she only wanted to use Tylenol as needed even though it was
recommended she try a stronger agent given her ongoing pain.
Ultimately she did agree to try low dose codeine and we sent her
home with prescription for this. She also agreed to resume
sucralfate (prior to stent placement this was making her
nauseated, but we discussed worth a trial now that she has had
stent placed and swallowing/tolerating po better). She will
continue her tube feeds at home as she has been doing. Continue
BID PPI, avoid bolus feeds late at night, and keep head of bed
up at least 30 degrees.
# Question of low oxygen saturation - there was concern post
procedure in ICU that she was developing hypoxia as she was
intermittently satting 90% on RA (for periods lasting only a few
seconds at a time) and therefore was put on 1L NC with sats
96-100%. She was monitored out of the ICU on continuous O2 sat
monitoring and never had any further desaturations <95% on RA.
She never had dyspnea or tachypnea. Initial CXR had been
suggestive of atelectasis. She was instructed on use of
incentive spirometer while here. She denied dyspnea, EKG stable
from prior without any changes, she had no chest pain other than
her chronic esophageal pain per patient and family. She was
never hypotensive, in fact she required antihypertensives, so it
was felt that other more serious etiology of any suppressed
oxygenation was very unlikely especially given she never had O2
sats below 90% and that finding was short lived and largely post
procedure (possibly related to sedating medications vs
aspiration, though CXR showed no evidence of the later or of any
infiltrate and she was never coughing so less likely).
# Tachycardia - ___ has longstanding history of unexplained
tachycardia as outlined by prior OMR notes. Providers who took
care of her in the FICU had cared for her previously and
corroborated this history as well as noted that she was at her
baseline compared to prior admissions. The patient was
asymptomatic and she and her son in law also reinforced that she
has had longstanding (years, decades) unexplained asymptomatic
tachycardia with HR up as high as even 160 at times, short
lived, but occurring frequently in the past. She was monitored
on telemetry and HR seemed at baseline (per outpatient OMR
sheets has been HR in 1teens and 120 range for some time, even
predating her most recent focused workup for this in ___
which was unrevealing, including negative CTA) with occasional
increases to 130s during this hospitalization with activity. HR
did not improve much with volume resuscitation and remained in
1teens. She was not dizzy or lightheaded. Hct was stable. She
was never truly hypoxic and not hypotensive without EKG changes.
It was felt that she was largely at her baseline and pulmonary
embolism very unlikely etiology as she had prior workup for this
problem with similar HR in ___ with CTA at that time
showing no PE. At time of discharge HR was consistently 98-108
clearly c/w prior baseline. She had no signs or symptoms of DVT
either. She resumed her home tube feeds which should prevent any
component of hypovolemia going forward, and was encouraged to
use prn narcotics to eliminate any component of pain driving her
tachycardia.
# HTN - takes fosinopril at home. Not on formulary so given
captopril while hospitalized but resumed fosinopril at home.
# reported low grade temperature prior to admit: Temperature of
100.1 documented at home, no reported fever during admission.
Not immunosuppressed, no recent chemotherapy. No localizing
signs of infection. CXR notable for atelectasis with no evidence
of consolidation and she denied cough and dyspnea throughout.
Low grade temperature could have been reactive in the setting of
vomiting, and was never reproduced in the hospital. She never
received antibiotics and never was febrile (not even low grade
temp). Cultures were all negative. She had no leukocytosis.
CODE: per discussion w/ pt and ___ and confirmed w/ unrelated
___ translator pt would be ok with resuscitation (short
lived, call ___ if required) but would not want to be
intubated.
HCP: son in law ___, confirmed w/ pt he is her HCP.
___
Greater than 30 minutes were spent in planning and execution of
this discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Baclofen 10 mg PO TID
2. bimatoprost 0.03 % ophthalmic DAILY
3. Fentanyl Patch 75 mcg/h TD Q72H
4. fosinopril 10 mg oral QHS
5. Gabapentin 100 mg PO TID
6. LORazepam 0.25 mg PO Q4H:PRN nausea, vomiting
7. Omeprazole 20 mg PO BID
8. Ondansetron ODT 8 mg PO Q8H:PRN severe nausea
9. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
10. Psyllium Powder 1 PKT PO TID:PRN constipation
Discharge Medications:
1. Codeine Sulfate ___ mg PO Q6H:PRN pain
RX *codeine sulfate 15 mg ___ tablet(s) by mouth every 6 hours
as needed Disp #*60 Tablet Refills:*0
2. Docusate Sodium 100 mg PO DAILY
3. Morphine Sulfate (Oral Solution) 2 mg/mL ___ mg PO Q4H:PRN
Pain - Moderate
4. Sucralfate 1 gm PO QID
RX *sucralfate 1 gram/10 mL 1 suspension(s) by mouth four times
a day Refills:*0
5. Acetaminophen (Liquid) 650 mg PO Q4H:PRN Pain - Moderate
6. Baclofen 10 mg PO TID
7. bimatoprost 0.03 % ophthalmic DAILY
8. Fentanyl Patch 75 mcg/h TD Q72H
9. fosinopril 10 mg oral QHS
10. Gabapentin 100 mg PO TID
11. LORazepam 0.25 mg PO Q4H:PRN nausea, vomiting
12. Omeprazole 20 mg PO BID
13. Ondansetron ODT 8 mg PO Q8H:PRN severe nausea
14. Psyllium Powder 1 PKT PO TID:PRN constipation
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Esophageal cancer
Esophagitis
Malnutrition
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with black vomiting and low grade temperature
after esophageal stent placement. Repeat endoscopy showed no
active bleeding. The dark vomit was likely expected debris after
the procedure. Your blood count was stable.
We started a medication called codeine, which is not as strong
as morphine, for your pain. Please use this if you find it
effective!
Also, I have attached prescriptions for sucralfate suspension
which you have used in the past and coats the esophagus, we
would recommend this to prevent pain and irritation of the
esophagus.
Followup Instructions:
___
|
19557552-DS-8
| 19,557,552 | 23,145,989 |
DS
| 8 |
2124-08-14 00:00:00
|
2124-08-14 16:38:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
povidone-iodine / allopurinol / chlorhexidine
Attending: ___
Chief Complaint:
nausea, vomiting, fevers/chills
Major Surgical or Invasive Procedure:
Indwelling port removal
TEE
History of Present Illness:
___ year-old M with mantle cell lymphoma, last cycle
Bendamustine/Rituxan ___, s/p portacath ___, who
presents with 4 days of nausea, vomiting, chills and shakes.
Patient was in his usual state of health until last ___,
___, when he woke up with nausea and vomited the food he ate
the evening prior. He also developed chills, shakes, sweats,
myalgias, arthrlagias, and stiffness. He has been having a
headache, which is unusual for him, in his left upper head. And
he measured fevers up to 101.6'F on ___ has
been helping control his temperature. His symptoms have not been
improving so he went ot ___ ED.
No congestion, sneezing, coughing, SOB, chest pain, abdominal
pain, diarrhea, constipation, throat pain, odynophagia. No
dysuria.
In the ED initial vitals were: 101.8 115 123/79 18 94%RA. Labs
were significant for WBC 12.6, HCT 34.5 PLT 132. Na 123. He had
a CXR with atelectasis RLL and normal NCHCT. He had a clear U/A.
LP showed normal protein, glucose, and cell counts. CSF gram
stain showed no PMNs or microorganisms. Blood cx x2 and urine cx
were sent. He was given azythromycin and oseltamivir then
started on empiric IV Vancomycin/Cefepime. Patient on acyclovir
prophylaxis.
Patient was given acetaminophen 1000mg x2, Azithromycin 500 mg,
OSseltamivir 75 mg, Lorazepam 1mg, Ketorolac 30mg.
Overnight, the patient was given an additional 1L NS (after 3L
NS in ED). He continued to have severe muscle aches,
chills/fevers.
This morning, patient reports total body aches and chills with
headache.
Past Medical History:
--Mantle Cell Lymphoma
- Patient was diagnosed in ___ on routine colonoscopy. He
received 2 doses of Bendamustine in ___ and ___,
tolerated them well. He was schedules for his ___ cycle today.
--Intraductal papillary mucinous tumor of the pancreas, with
low-grade (mild-moderate) dysplasia; free margins s/p Whipple
--Hyperlipidemia - ___
--Appendectomy ___
--Shingles - ___
--Gastritis, chronic - ___ by EGD
DM s/p whipple procedure for IPMN removal ___
Social History:
___
Family History:
No family history of cancer. Brother (___) had valve
replacement in early childood, died of stroke at age ___.
Physical Exam:
Admission exam:
====================================
Vital Signs: T:98.6 BP:132/79 HR:98 RR:18 O2Sat:98%RA
HA pain: ___
GEN: mildly diaphoretic middle aged man laying in bed, breathing
comfortably. Exquisite tenderness of all muscles with
movement/re-positioning.
HEENT: NCAT. PERRL, MMM, OP clear, nares patent.
Neck: No neck stiffness on chin-to-chest. Supple, no
preauricular, submandibular, anterior/posterior cervical,
supraclavicular, subclavicular LAD.
CV: RRR. S1 and S2. No m/r/g.
LUNGS: CTAB, No w/c/r.
ABD: soft, NT/ND, normoactive BS, TTP.
EXT: warm, well-perfused. 2+ DP pulses.
SKIN: Portacath entry site scabbed but not erythematous,
edematous. No other rashes.
Discharge Physical:
=====================================
Tm99.2, BP122-130/70-84, P88-105, R18-20, ___
General: moving easily in bed, pleasant, NAD
HEENT: OP clear, MMM, PERRL
CV: regular rate, normal S1/S2, possible systolic murmur at ___
Lungs: CTA b/l, no wheezes/rales/rhonchi
Abd: Soft, NT/ND, normoactive BS
Ext: Pt able to lift all extremeties off of bed. No joints warm
to touch, no longer any blotchy erythema on legs.
Skin: Raised erythema on R chest, around port removal site, is
no longer pustular. Rash at creases of eyelids at lateral
boundaries, has completely resolved
Pertinent Results:
Admission labs:
=======================================
___ 12:50PM BLOOD WBC-12.6*# RBC-3.90* Hgb-12.5* Hct-34.3*
MCV-88 MCH-31.9 MCHC-36.4* RDW-14.9 Plt ___
___ 12:50PM BLOOD Neuts-89.9* Lymphs-2.6* Monos-6.9 Eos-0.3
Baso-0.3
___ 12:50PM BLOOD Glucose-249* UreaN-15 Creat-0.8 Na-123*
K-4.1 Cl-88* HCO3-22 AnGap-17
___ 12:50PM BLOOD ALT-50* AST-47* AlkPhos-178* TotBili-1.1
___ 01:26PM BLOOD Lactate-1.8
___ 09:30PM URINE Color-Yellow Appear-Hazy Sp ___
___ 09:30PM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-300 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 09:30PM URINE RBC-2 WBC-8* Bacteri-FEW Yeast-NONE Epi-0
___ 09:30PM URINE Hours-RANDOM UreaN-828 Creat-107 Na-24
K-41 Cl-34
___ 09:30PM URINE Osmolal-531
DISCHARGE LABS:
==================================
___ 12:01AM BLOOD WBC-6.8 RBC-3.64* Hgb-10.9* Hct-32.9*
MCV-90 MCH-29.9 MCHC-33.1 RDW-15.2 Plt ___
___ 06:15AM BLOOD Neuts-82.2* Lymphs-5.7* Monos-6.1
Eos-5.8* Baso-0.2
___ 12:01AM BLOOD ___ PTT-29.0 ___
___ 12:01AM BLOOD Glucose-282* UreaN-17 Creat-0.9 Na-135
K-4.5 Cl-97 HCO3-29 AnGap-14
___ 12:01AM BLOOD ALT-56* AST-27 LD(LDH)-229 AlkPhos-248*
TotBili-0.4
___ 12:01AM BLOOD Calcium-8.3* Phos-3.0 Mg-2.3 UricAcd-2.6*
PERTINENT STUDIES:
============================================
___ 04:00PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-1* Polys-48
___ ___ 04:00PM CEREBROSPINAL FLUID (CSF) TotProt-33
Glucose-135
___ 12:50 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STAPH AUREUS COAG +.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus, yeast or other
fungi.
FINAL SENSITIVITIES.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN-------------<=0.25 S
TRIMETHOPRIM/SULFA---- <=0.5 S
Aerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___ @ ___ ON
___ -
___.
GRAM POSITIVE COCCI.
IN CLUSTERS.
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI.
IN CLUSTERS.
___ 5:39 pm FOREIGN BODY RIGHT PORT.
**FINAL REPORT ___
WOUND CULTURE (Final ___:
STAPH AUREUS COAG +.
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---------- 0.25 S
OXACILLIN-------------<=0.25 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
Blood Cx ___: No Growth To Date
PERTINENT IMAGING:
=============================================
___ (PA & LAT)
IMPRESSION: Atelectatic changes at the right lung base.
___ HEAD W/O CONTRAST
IMPRESSION: No acute intracranial process.
___
The left atrium and right atrium are normal in cavity size. No
atrial septal defect is seen by 2D or color Doppler. The
estimated right atrial pressure is ___ mmHg. There is mild
symmetric left ventricular hypertrophy with normal cavity size
and regional/global systolic function (LVEF>55%). The estimated
cardiac index is normal (>=2.5L/min/m2). Diastolic function
could not be assessed. Right ventricular chamber size and free
wall motion are normal. The aortic root is mildly dilated at the
sinus level. The aortic valve leaflets (3) are mildly thickened
but aortic stenosis is not present. No masses or vegetations are
seen on the aortic valve. No aortic regurgitation is seen. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. No mass or
vegetation is seen on the mitral valve. No masses or vegetations
are seen on the pulmonic valve, but cannot be fully excluded due
to suboptimal image quality. There is a trivial/physiologic
pericardial effusion.
IMPRESSION: No echocardiographic evidence of endocarditis or
pathologic flow. Mild symmetric left ventricular hypertrophy
with preserved global and regional biventricular systolic
function. Mildly dilated aortic root. 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.
___ PORT REMOVAL ___:
Successful removal of a right upper chest port.
TEE ___:
No atrial septal defect is seen by 2D or color Doppler. Overall
left ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion. No masses or vegetations are seen on the
aortic valve. No aortic valve abscess is seen. Trace aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. No mass or vegetation
is seen on the mitral valve. No masses or vegetations are seen
on the pulmonic valve, but cannot be fully excluded due to
suboptimal image quality. There is no pericardial effusion.
IMPRESSION: No echocardiographic evidence of endocarditis.
Normal biventricular global systolic function. Trace aortic
regurgitation.
CT A/P ___:
1. No evidence of an infectious focus in the abdomen or pelvis.
2. Previously visualized inguinal and external iliac adenopathy
has resolved. Previously visualized periportal and
retroperitoneal lymphadenopathy is less delineated on this
study.
3. Mild splenomegaly is again noted.
CT CHEST ___:
1. Multiple new peripheral bilateral ground-glass nodules are
concerning for septic emboli, metastatic disease is a less
likely possibility. Recommend followup chest CT ___ weeks after
treatment to assess for resolution.
2. 2.0 cm collection in the region of the Previous Port-A-Cath
with
surrounding fat stranding and soft tissue thickening is likely
infectious, ultrasound can be obtained for further evaluation.
3. Bibasilar opacities most likely atelectasis, however
infection cannot be excluded.
Brief Hospital Course:
BRIEF HOSPITAL COURSE:
====================================
___ w/mantle cell lymphoma who initially p/w headache and fever
found to have high grade MSSA bacetermia likely due to port
infection, w/ negative TTE/TEE, initially w/ multiple warm
joints c/f polyarticular involvement (though knee aspirate
negative), who is now s/p port removal by ___, who was found to
have likely septic emboli to lungs and small fluid collection at
port site, who was switched to Nafcillin prior to discharge for
expected 6 wk course of IV antibiotics.
ACTIVE ISSUES:
====================================================
#MSSA Bacteremia
Pt found to have high grade bacteremia on admission, MSSA, with
suspected source being R subclavian port. Pt started on
vancomycin but trough on ___ suggested dosing was insufficient
so was uptitrated to 1g q6h thereafter. Pt w/ multiple warm
joints c/f polyarticular infolvement, which confers high
mortality, but aspirate of left knee (most symptomatic) was
negative, and joints appeared normal on ___ s/p increased
frequency of antibiotics. Given concern that port was source of
bacteremia, it was removed by ___ on ___ without issue and later
grew MSSA. TTE/TEE were both negative for cardiac involvement.
CT Chest was consistent w/ septic emboli to lungs (peripheral
ground glass nodules, new since ___ and small 2cm fluid
collection at previous port site (which ___ declined to drain).
Pt remained afebrile s/p switch to nafcillin on ___ as per ID.
Given septic emboli to lungs, ID felt that up to 6 wk course may
be required. Accordingly, he had PICC placed and had home
infusion services set up for 6 wks with the possibility of
shortening course in future if all goes well. Pt will need
repeat CT scan 6wks post treatment to ensure that septic emboli
have resolved. Pt was enrolled in OPAT and will need to have
weekly labs checked and faxed to infectious disease clinic.
#Mantle Cell Lymphoma
Pt is s/p 2 cycles of bendamustine/rituxan, and was due to
recieve his ___ cycle on ___. Given pt's current state, he was
unable to recieve chemotherapy. Accordingly, he was
aggressively treated for bactermia as above. CT Abdomen/Pelvis
during this admission showed decreased LAD in inguinal, iliac,
and periportal regions suggesting improvement w/ treatment. Pt
was scheduled w/ outpt follow up appointment following discharge
to recieve next infusion.
#Contact Dermatitis
Pt developed erythematous maculopapular rash on R anterior chest
c/w contact dermatitis likely ___ chlorhexadine used during port
removal, so it was listed as an allergy. Pt was given
triamcinolone cream 0.1% BID to good effect. He was given
prescription to continue applications for 7 days or until rash
resolves. He was also given prescription for fexofenadine and
hydroxyzine.
#Hyponatremia
Initially pt presented w/ hyponatremia ___ hypovolemia in
setting of vomiting, but was later due to SIADH in setting of
pain and excessive H2O intake based on urine lytes. After mIVF
was stopped, and pt was fluid restricted to 2L/day his Na
normalized. Cortisol was normal.
#DM
Pt is diabetic s/p whipple for mucinous tumor of pancreas. He
was written for home dose lantus and sliding scale and sugars
remained within acceptable range.
#Gastritis
Pt was continued on home meds
#HLD
Simvastatin was held in the setting of increased LFTs. LFTs will
need to be trended as an outpatient and statin restarted once
they normalize.
TRANSITIONAL ISSUES:
============================================
1. Pt will need to attend outpatient oncology appointment to
recieve ___ cycle of bendamustine/rituxan
2. Pt will need to f/u w/ ID and have weekly labs checked and
sent to Infectious Disease clinic. ID clinic will call pt with
an appointment after discharge.
3. Pt will need to have LFTs trended and statin restarted once
they normalize.
4. Pt will need to have rash followed at subsequent
appointments.
5. Pt will need repeat CT Chest as an outpatient 6 weeks after
treatment of septic emboli to ensure resolution
6. Pt will need his blood glucose closely monitored and insulin
regimen uptitrated accordingly.
CODE: FULL CODE
CONTACT: Patient, Sister HCP ___ ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO Q8H
2. Glargine 18 Units Breakfast
3. Lorazepam 0.5 mg PO Q6H:PRN anxiety
4. MetFORMIN (Glucophage) 1000 mg PO BID
5. Omeprazole 40 mg PO DAILY
6. Prochlorperazine ___ mg PO Q6H:PRN nausea
7. Simvastatin 20 mg PO DAILY
8. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Nafcillin 2 g IV Q4H
RX *nafcillin in dextrose iso-osm 2 gram/100 mL 2 g IV every
four (4) hours Disp #*252 Intravenous Bag Refills:*0
2. Acyclovir 400 mg PO Q8H
3. Lorazepam 0.5 mg PO Q6H:PRN anxiety
RX *lorazepam 0.5 mg 1 tablet by mouth q6h:prn Disp #*30 Tablet
Refills:*0
4. Omeprazole 40 mg PO DAILY
5. Prochlorperazine ___ mg PO Q6H:PRN nausea
6. Fexofenadine 60 mg PO BID
RX *fexofenadine 60 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
7. HydrOXYzine 25 mg PO Q4H:PRN itching
RX *hydroxyzine HCl 25 mg 1 tablet by mouth q4h:prn Disp #*30
Tablet Refills:*0
8. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID Duration: 4
Days
RX *triamcinolone acetonide 0.1 % 1 application twice a day
Refills:*0
9. Aspirin 81 mg PO DAILY
10. MetFORMIN (Glucophage) 1000 mg PO BID
11. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
12. Glargine 18 Units Breakfast
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
MSSA Bacteremia ___ indwelling port (now removed) c/b septic
emboli to lungs
Mantle Cell Lymphoma
DM
Discharge Condition:
Discharge Condition: Stable
Mental Status: AOx3 (baseline)
Ambulatory Status: Independent (baseline)
Discharge Instructions:
Mr. ___
It was a pleasure taking care of you while you were hospitalized
at ___. As you know, you were
found to have a blood stream infection from your indwelling port
which was removed shortly thereafter. Unfortunately, the
bacteria seems to have spread to the lungs, which means you will
require a prolonged course of antibiotics (nafcillin). You were
set up with a home infusion nursing company so you can continue
to recieve this medication through your ___ line as an
outpatient. You will need to follow up reguarly with your
primary oncologist to have labs checked (weekly) and to ensure
that you are doing well. You will also need to follow up with
the infectious disease specialists who will trend your progress
and determine your need for continued antibiotics. They will
call you with an appointment in 2 weeks after discharge.
If you feel unwell in anyway you should take your temperature
and call the clinic immediately for further instructions.
We wish you a speedy recovery!!
Followup Instructions:
___
|
19557552-DS-9
| 19,557,552 | 28,053,844 |
DS
| 9 |
2124-09-16 00:00:00
|
2124-09-16 12:30:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
povidone-iodine / allopurinol / chlorhexidine
Attending: ___
___ Complaint:
fever
Major Surgical or Invasive Procedure:
PICC placement ___
History of Present Illness:
Mr. ___ is a a ___ year-old gentleman with mantle cell
lymphoma diagnosed in ___ on routine colonoscopy undergoing
treatment on research protocol of Bendamustine/Rituxan x 3
cycles followed by Rituximab/Cytarabine. He has completed his
initial 3 cycles. Today is cycle 3 day 23.
He presents with shaking chills since ___ evening he
noted that he started developing some pain in his right shoulder
and had some decreased appettite. That night he felt warm then
developed shaking chills which he describes as like "a seizure."
His temp was 100.9. He had multiple similar episodes the
following day and on his way in to see Dr. ___ in ___ clinic.
The only other symptom that he had was he vomited once ___
night. He had no sore throat, mouth sores, diarrhea, abdominal
pain, chest pain, dysuria, cough or any other infectious
symptoms.
On evaluation in clinic he was found to have a HR of 144 and BP
of 100 systolic. He was referred to the ED for treatment.
Of note he recently had bacteremia (MSSA) related to a
Port-A-Cath which was placed for chemotherapy. The Port-A-Cath
was removed in ___ and he has been receiving nafcillin throuhg
a PICC.
In ED/Clinic, initial vitals were: 0 98.5 136 104/68 20 96% RA
-UA with glucosuria(300) but otherwise negative
-CBC with WBC of 2.0 and ANC 1750
-Na of 132 with glucose of 277
-Lactate of 2.1
-Blood and Wound Cx pending
-Picc was pulled and tip was sent for culture
Patient was given vanc 1gram/ceftriaxone 1gram, as well as IV
fluids
Patient underwent chest xray
Final vitals prior to transfer were:99 114/68 16 99% RA
Past Medical History:
--Mantle Cell Lymphoma
- Patient was diagnosed in ___ on routine colonoscopy. He
received 2 doses of Bendamustine in ___ and ___,
tolerated them well. He was schedules for his ___ cycle today.
--Intraductal papillary mucinous tumor of the pancreas, with
low-grade (mild-moderate) dysplasia; free margins s/p Whipple
--Hyperlipidemia - ___
--Appendectomy ___
--Shingles - ___
--Gastritis, chronic - ___ by EGD
DM s/p whipple procedure for IPMN removal ___
Social History:
___
Family History:
No family history of cancer. Brother (___) had valve
replacement in early childood, died of stroke at age ___.
Physical Exam:
ADMISSION:
Vitals: T: 98.3 BP: 125/81 HR: 88 RR: 18 02 sat: 100% on RA
GENERAL: Well appearing middle aged male in NAD
HEENT: MMM, no ulcerations in the oropharynx
CARDIAC: normal rate, regular rhythm
LUNG: CTAB
GI: Soft NT, ND, NABS
Skin: No rashes, PICC site with a dressing C/D/I in RUE
PULSES: 2+ radial
NEURO: No gross deficits on limited exam
Psych: mood/affect appropriate
DISCHARGE:
Vitals: 98.3 122/87 89 18 99% on RA
exam unchanged
Pertinent Results:
ADMISSION
___ 12:10PM BLOOD WBC-1.7*# RBC-3.79* Hgb-12.0* Hct-35.0*
MCV-93 MCH-31.8 MCHC-34.3 RDW-17.1* Plt Ct-96*#
___ 12:10PM BLOOD Neuts-87.5* Lymphs-8.6* Monos-1.5*
Eos-1.7 Baso-0.7
___ 12:45PM BLOOD WBC-2.0* RBC-3.54* Hgb-11.5* Hct-32.6*
MCV-92 MCH-32.5* MCHC-35.3* RDW-16.5* Plt Ct-88*#
___ 12:45PM BLOOD Neuts-87.4* Lymphs-5.8* Monos-4.8 Eos-1.5
Baso-0.5
___ 07:15AM BLOOD WBC-1.6* RBC-3.41* Hgb-10.4* Hct-31.7*
MCV-93 MCH-30.6 MCHC-32.9 RDW-17.7* Plt Ct-89*
___ 08:05AM BLOOD WBC-11.5*# RBC-3.51* Hgb-11.0* Hct-32.7*
MCV-93 MCH-31.4 MCHC-33.7 RDW-17.1* Plt Ct-86*
___ 12:10PM BLOOD ESR-58*
___ 12:45PM BLOOD Glucose-277* UreaN-18 Creat-0.9 Na-132*
K-3.4 Cl-100 HCO3-19* AnGap-16
___ 12:10PM BLOOD ALT-28 AST-38 AlkPhos-96 TotBili-0.9
___ 05:00AM BLOOD Calcium-8.9 Phos-2.6* Mg-1.9
___ 12:10PM BLOOD CRP-205.3*
___ 12:50PM BLOOD Lactate-2.1*
___ 11:57AM BLOOD Lactate-0.9
PA&LAT CHEST XRAY ___
FINDINGS:
Frontal lateral radiographs of the chest demonstrate well
expanded lungs. Mild bibasalar atelectasis is present. The
cardiomediastinal and hilar contours are unchanged. A
right-sided PICC line ends in the distal SVC. There is no
consolidation, pneumothorax, or pleural effusion.
IMPRESSION:
No acute cardiopulmonary process.
TTE ___:
The left atrium is elongated. The estimated right atrial
pressure is ___ mmHg. Left ventricular wall thickness, cavity
size and regional/global systolic function are normal (LVEF
>55%). Right ventricular chamber size and free wall motion are
normal. The aortic root is mildly dilated at the sinus level.
The aortic valve leaflets (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 masses
or vegetations are seen on the mitral valve, but cannot be fully
excluded due to suboptimal image quality. Trivial mitral
regurgitation is seen. The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion.
IMPRESSION: Normal biventricular size and global/regional
function. No clinically significant valvular disease is seen. No
valvular vegetations are detected. Mildly dilated aortic root.
The absence of vegetations seen on transthoracic echo is
insufficient to exclude endocarditis in the presence of high
clinical suspicion. Consider TEE if clinically indicated.
Compared with report of the prior exam dated ___ (images not
available for direct review), probably no significant interval
change
___ CT CHEST/ABD/PELVIS:
CHEST:
1. Marked interval improvement in previously detected bilateral
poorly
defined nodules since ___onsistent with a
resolving infectious or inflammatory process.
2. New 1 cm polygonal-shaped opacity at extreme right lung base
laterally, which is likely infectious or inflammatory in
etiology. This finding may be reassessed for resolution at the
time of next scheduled followup CT.
ABD/PELVIS
1. No etiology to account for patient's bacteremia is
identified in the
abdomen or pelvis.
2. No evidence of residual or recurrent lymphoma in the abdomen
or pelvis.
MICRO:
___ 2:30 pm CATHETER TIP-IV Source: ___.
**FINAL REPORT ___
WOUND CULTURE (Final ___:
KLEBSIELLA PNEUMONIAE. >15 colonies.
Cefazolin interpretative criteria are based on a dosage
regimen of 2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
all blood cultures NGTD
Brief Hospital Course:
___ year old male with mantle cell lymphoma diagnosed ___,
C3D25 on Bendamustine/Rituximab, presenting with sepsis,
secondary to PICC-line associated Klebsiella blood stream
infection.
# Klebsiella Blood stream infection: Originally met sepsis
criteria with fever (100.9), tachycardia (144) and WBC (2.0).
Given his recent history of MSSA bacteremia and his new line,
the PICC line was removed. He had a line holiday for 2 days
with only peripheral lines and was on empiric vanc/cefepime
until the identification and sensitivty of the culture returned
with pansensitive Klebsiella. Infectious disease team was
following and recommended cefazolin 2 gm IV q8h to cover both
prior MSSA and new Klebsiella. This course will be for 2 weeks
until ___, followed in ID OPAT.
#2. Mantle cell lymphoma with pancytopenia: C3. Was neutropenic
upon presentation and recieved 2 doses of neupogen with good
effect. He remained afebrile once antibiotics were started as
above. Continue home acyclovir.
#3. Diabetes: Continued insulin with lantus 12 units in the AM
and sliding scale, as well as metformin. On 18 units lantus at
home though he doesn't always give himself the dose.
TRANSITIONAL ISSUES:
- Needs to have labs checked in one week and sent to ___
clinic per the fax number on the prescription
- Needs to have PICC line care
- Has follow up appointment on ___ for next cycle of chemo
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Nafcillin 2 g IV Q4H
2. Lorazepam 0.5 mg PO Q6H:PRN anxiety
3. Prochlorperazine ___ mg PO Q6H:PRN nausea
4. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID
5. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
6. Acyclovir 400 mg PO Q8H
7. Omeprazole 40 mg PO DAILY
8. Fexofenadine 60 mg PO BID
9. HydrOXYzine 25 mg PO Q4H:PRN itching
10. Aspirin 81 mg PO DAILY
11. MetFORMIN (Glucophage) 1000 mg PO BID
12. Glargine 18 Units Breakfast
Discharge Medications:
1. Acyclovir 400 mg PO Q8H
2. Aspirin 81 mg PO DAILY
3. Fexofenadine 60 mg PO BID
4. HydrOXYzine 25 mg PO Q4H:PRN itching
5. Glargine 18 Units Breakfast
6. Lorazepam 0.5 mg PO Q6H:PRN anxiety
7. Omeprazole 40 mg PO DAILY
8. Prochlorperazine ___ mg PO Q6H:PRN nausea
9. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
10. CefazoLIN 2 g IV Q8H
last day ___
RX *cefazolin in dextrose (iso-os) 2 gram/50 mL 2 g IV every
eight (8) hours Disp #*42 Intravenous Bag Refills:*0
11. MetFORMIN (Glucophage) 1000 mg PO BID
12. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID
13. Outpatient Lab Work
Please draw CBC with differential, BUN, creatinine on ___.
Fax results to Infectious Disease ___ clinic at ___.
ICD9: 790.7 Bacteremia
Provider: ___ Disease
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Klebsiella PICC line infection
mantle cell lymphoma
MSSA bacteremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You came to the hospital with fever and were found to have an
infected PICC line. The line was growing a different bacteria
called Klebsiella. You will be discharged on an antibiotic
called Cefazolin which you will need to take for 2 weeks and
will cover both the Klebsiella and staph bacteria that you had
before. You will need to have lab work done in one week which
your ___ can coordinate.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19557627-DS-21
| 19,557,627 | 22,263,174 |
DS
| 21 |
2197-08-13 00:00:00
|
2197-08-14 16:22:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HISTORY OF PRESENTING ILLNESS: ___ yo F with CHFrEF (EF 30%),
severe (?rheumatic) MR ___ MV repair ___ ring in
___, asthma, obesity, hypertension who presents with CHF
exacerbation.
She presented to her cardiologist's office today with one week
of progressive dyspnea, 9 lb weight gain, peripheral edema,
orthopnea (sleeping sitting upright) and left subcostal pain.
She normally becomes dyspneic walking up a flight of stairs but
is now unable to walk up 1 flight. ROS otherwise negative aside
from nonproductive cough. No fevers chills. +epigastric pain
(chronic) and shoulder pain.
In the office, noted to have BP 148/110 (of note she did not
make changes to increase antihypertensive regimen at last
visit). O2 sat 98% on RA at rest, pulse 90/min. JVP elevated to
angle of jaw, lungs CTA b/l, ___ HSM apex to axilla, abdomen
distended, peripheral edema 2+ to knee; ECG unchanged without
ischemic changes.
A ___ was performed via outpatient cardiologist. Per her read:
mildly dilated LV with severe global HK, severe pulmonary
hypertension, 3+ MR in mitral annuloplasty site, 2+ TR. LV more
dilated, more HK, increase in MR and worsening PH compared with
prior study from ___.
At baseline she does have occasional dyspnea when climbing
stairs. This has not changed over the past six months. She
denies orthopnea or PND and sleeps on three pillows chronically
for comfort.
Of note last cardiology outpt note from ___ noted worsening
MR over recent ECHOs and need for a TEE to better evaluate valve
function in the future.
In the ED initial vitals were: 98.0 72 186/106 18 92% Nasal
Cannula then RA. She endorsed substernal CP on admission.
EKG: NSR, unchanged from prior.
Labs/studies notable for: Trop neg. Cr 1.1 (baseline 0.9 to
1.0), Alt and AST 50/50 (previously normal). proBNP: ___. ___
___ w/o clot. CT w/o evidence of PE. CXR Mild cardiomegaly and
moderate pulmonary edema.
Patient was given: nothing.
Vitals on transfer: 78 175/101 16 99% RA
On the floor she feels SOB.
ROS: On review of systems, denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. Denies recent fevers, chills or rigors.
Denies exertional buttock or calf pain. All of the other review
of systems were negative. Cardiac review of systems is notable
for absence of chest pain, dyspnea on exertion, paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope
or presyncope.
Past Medical History:
Cardiovascular Issues:
1. Severe (?rheumatic) MR, ___. ___- ___ ring (28
mm) on ___ ___ resection. 2+ MR on 12.12 ___.
2. Moderately depressed EF (30% ___ 2.15)
3. Obesity. BMI 35.4.
4. Hypertension. (lisinopril, metoprolol, furosemide).
5. Glucose intolerance, A1C 5.9
Other Relevant Medical Issues:
-Asthma.
-GERD
-Postoperative PE after cholecystectomy.
-Cervical cancer
-Prior tobacco abuse.
-Hx cocaine use
Social History:
___
Family History:
Mother: diabetes, HTN, renal disease
Father: unknown
Physical ___:
ADMISSION PHYSICAL EXAM:
VS: 98.2 159/86 76 16 98 RA
weight 188 at last cardiolovy visit in ___, 83.6 today (184
lbs)
GENERAL: WDWN woman in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP of 8cm.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No murmurs/rubs/gallops. No thrills,
lifts.
LUNGS: Faint bibasilar crackles.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: 1+ pitting edema to the mid calf b/l.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric
DISCHARGE PHYSICAL EXAM:
VS: Tm 98.6 HR ___ BP 94-145/57-90s RR 18 SatO2
97-100/RA
I/O 24 Hr: 1080/1730
weight: 78.6 kg (188 lbs at last cardiology visit in ___, 83.
___, 80.7 ___, 78.6 ___
GENERAL: WDWN woman 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 JVD flat
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. Diastolic murmur. No thrills, lifts.
LUNGS: CTAB
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: no pitting edema
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric
Pertinent Results:
*********LABS*************
ADMISSION LABS:
___ 12:20PM PLT COUNT-242
___ 12:20PM NEUTS-62.2 ___ MONOS-7.1 EOS-1.1
BASOS-0.8 IM ___ AbsNeut-5.96 AbsLymp-2.75 AbsMono-0.68
AbsEos-0.11 AbsBaso-0.08
___ 12:20PM WBC-9.6 RBC-4.80 HGB-12.2 HCT-40.5 MCV-84
MCH-25.4* MCHC-30.1* RDW-17.2* RDWSD-52.0*
___ 12:20PM ALBUMIN-4.2
___ 12:20PM proBNP-4267*
___ 12:20PM cTropnT-<0.01
___ 12:20PM LIPASE-50
___ 12:20PM ALT(SGPT)-50* AST(SGOT)-50* ALK PHOS-91 TOT
BILI-0.5
___ 12:46PM ___ PTT-31.1 ___
___ 06:40PM URINE RBC-1 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-6
___ 06:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 06:40PM URINE COLOR-Yellow APPEAR-Clear SP
___
PERTINENT RESULTS:
___ 06:47AM BLOOD ALT-53* AST-46* AlkPhos-91 TotBili-0.7
___ 12:20PM BLOOD ALT-50* AST-50* AlkPhos-91 TotBili-0.5
___ 12:20PM BLOOD proBNP-4267*
___ 12:20PM BLOOD cTropnT-<0.01
___ 12:20PM BLOOD Lipase-50
DISCHARGE LABS:
___ 05:30AM BLOOD WBC-7.3 RBC-4.87 Hgb-12.3 Hct-40.1 MCV-82
MCH-25.3* MCHC-30.7* RDW-17.0* RDWSD-49.0* Plt ___
___ 08:15AM BLOOD Glucose-101* UreaN-35* Creat-1.2* Na-138
K-4.5 Cl-98 HCO3-26 AnGap-19
___ 08:15AM BLOOD Calcium-10.1 Phos-5.1* Mg-2.3
*******STUDIES********
___ Bilateral Lower Extremity Ultrasound:
No evidence of deep venous thrombosis in the left lower
extremity veins.
___ CXR:
Mild cardiomegaly and moderate pulmonary edema.
___ CTA Chest
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Cardiomegaly, diffuse ground-glass opacity, and small
bilateral pleural
effusions, consistent with pulmonary edema.
3. Enlarged main pulmonary trunk suggestive of pulmonary artery
hypertension.
4. Mildly enlarged mediastinal lymph nodes, likely reactive.
___ ___:
The left atrium is mildly dilated. Left ventricular wall
thicknesses is normal. Cavity size is top normal. There is
severe global left ventricular hypokinesis (LVEF = 25 %).
Systolic function of apical segments is relatively preserved. A
mass is seen in the left ventricle. The right ventricular cavity
is mildly dilated with normal free wall contractility.
[Intrinsic right ventricular systolic function is likely more
depressed given the severity of tricuspid regurgitation.] The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic stenosis or aortic
regurgitation. A mitral valve annuloplasty ring is present. The
mitral annular ring appears well seated with normal gradient.
Moderate to severe (3+) mitral regurgitation is seen. [Due to
acoustic shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] Moderate to severe [3+] tricuspid
regurgitation is seen. There is severe pulmonary artery systolic
hypertension. [In the setting of at least moderate to severe
tricuspid regurgitation, the estimated pulmonary artery systolic
pressure may be underestimated due to a very high right atrial
pressure.] Significant pulmonic regurgitation is seen. The
end-diastolic pulmonic regurgitation velocity is increased
suggesting pulmonary artery diastolic hypertension. There is no
pericardial effusion.
IMPRESSION: Top normal left ventricular cavity size with severe
global hypokinesis in a pattern most c/w non-ischemic
cardiomyopathy. Well seated mitral annuloplasty ring with normal
gradient but moderate to severe mitral regurgitgation. Severe
pulmonary artery systolic hypertension. Modeerate to severe
mitral regurgitation. Moderate to severe tricuspid
regurgitation. Right ventricular cavity dilation.
Compared with the prior study (images reviewed) of ___,
the severity of mitral regurgitation, tricuspid regurgitation
and estimated PA systolic pressure are all higher. Left
ventricular size is slightly larger and global LVEF is now
slightly worse.
If clinically indicated, a cardiac MRI may be best able to
assess the volumetric severity of valvular regurgitation and
biventricular volumes/ejection fraction.
___ Right Shoulder Plain Films:
In comparison with the study of ___, there has been a
surgical procedure performed with suture anchors in the region
of the greater tuberosity. The opacification adjacent to the
greater tuberosity, consistent with calcific tendinosis in the
rotator cuff, suggests that there has been rotator cuff repair
surgery.
Degenerative changes are seen in the AC and glenohumeral joints.
MICRO:
___ 6:40 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Brief Hospital Course:
___ yo F with CHFrEF (EF 25%), severe (?rheumatic) MR ___ MVR
___, asthma, obesity, hypertension who presented with 1.5 weeks
of dyspnea, orthopnea, weight gain. She came in for a cardiology
apt and was found to be volume overloaded and was sent over to
the ED. BNP was elevated, CXR suggestive of mild pulmonary
edema. ECHO showed worsening mitral regurgitation. Inciting
factor for exacerbation was likely hypertension (BPs 170s/110s
on admission). She diuresed well to 20 IV Lasix daily, later
discharged on torsemide 20 mg PO daily.
TRANSITIONAL ISSUES:
-Discharged on 20 PO Torsemide daily. Please ___ lytes and cr as
an outpatient.
-Please follow up blood pressure. She was continued on home 40
of lisinopril, metoprolol switched to carvedilol and amlodipine
added.
-___ mild transaminitis seen on admission (thought to be
congestion in setting of chf exacerbation)
-Concern for worsening MR on ___. She needs a TEE vs cardiac MRI
to better evaluate her valve function. Patient was seen by
cardiac surgery prior to discharge with initial pre-surgical
recommendations placed in webOMR.
-Discharge weight: 78.6 kg
-PCP ___ for R shoulder pain, rotator cuff injury, arthritis
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 40 mg PO DAILY
2. Gabapentin 100-200 mg PO QHS:PRN pain
3. Metoprolol Succinate XL 50 mg PO DAILY
4. Omeprazole 20 mg PO BID
5. Fluticasone Propionate 110mcg 2 PUFF IH BID
6. Aspirin 81 mg PO DAILY
7. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q6H:PRN sob
Discharge Medications:
1. Fluticasone Propionate 110mcg 2 PUFF IH BID
RX *fluticasone [Flovent HFA] 110 mcg/actuation 2 puff IH twice
a day Disp #*1 Inhaler Refills:*0
2. Gabapentin 100-200 mg PO QHS:PRN pain
do not mix with alcohol or take while driving
RX *gabapentin 100 mg ___ capsule(s) by mouth QHS: prn Disp #*14
Capsule Refills:*0
3. Lisinopril 40 mg PO DAILY
RX *lisinopril 40 mg 1 tablet(s) by mouth daily Disp #*14 Tablet
Refills:*0
4. Omeprazole 20 mg PO BID
RX *omeprazole 20 mg 1 capsule(s) by mouth twice a day Disp #*28
Capsule Refills:*0
5. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*14 Tablet
Refills:*0
6. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q6H:PRN sob
RX *albuterol sulfate [ProAir HFA] 90 mcg 1 puff IH prn: Disp
#*1 Inhaler Refills:*0
7. Torsemide 20 mg PO DAILY
RX *torsemide 20 mg 1 tablet(s) by mouth daily Disp #*14 Tablet
Refills:*0
8. Carvedilol 12.5 mg PO BID
RX *carvedilol 12.5 mg 1 tablet(s) by mouth twice a day Disp
#*28 Tablet Refills:*0
9. Amlodipine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth daily Disp #*14 Tablet
Refills:*0
10. Outpatient Lab Work
chem 7
please fax results to: ___
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
acute on chronic systolic CHF
mitral regurgitation status post valve repair
hypertensive emergency
SECONDARY DIAGNOSES:
hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___:
You were admitted to ___ with shortness of breath. This was
due to fluid backing up from your heart. You were treated with
Lasix to take the fluid off.
You were discharged on Lasix. It is extremely important that you
see a doctor within 1 week of discharge to check your
electrolytes on this new medication. You should have bloodwork
drawn by ___ of this week (___) so the results can be
faxed to your doctor.
You will need to have further imaging as an outpatient to take a
look at your repaired mitral valve. Your Cardiologist will
determine which.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
It was a pleasure to care for you!
Your ___ team
Followup Instructions:
___
|
19557745-DS-13
| 19,557,745 | 28,778,659 |
DS
| 13 |
2145-05-15 00:00:00
|
2145-05-15 17:43:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
nuts
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
ERCP ___
History of Present Illness:
___ h/o atrial fibrillation on rivaroxaban, HLD, and GERD who
presents with
abdominal pain to the ED. The patient about a year ago began
having episodes of abdominal pain characterized by a sharp
sensation stretching across right to left in a band over the
epigastrum, nonradiating otherwise, associated with nausea,
belching, lightheadedness and malaise. Episodes would last for a
couple hours at a time roughly one episode per month. On
___ after his meal he experienced it again in a
more severe and intense manner. He went to his PCP but in the
office his symptoms were gone for days already and was referred
to gastroenterology, which he had not done yet. 3 days prior to
admission he began having the same episode with much more
pronounced abdominal pain intensity than ever before. He also
had a fever, which he has not had in the past, so he went to the
ED.
He has never had abdominal surgery or gallbladder issues to his
knowledge. His wife is at bedside and corroborates the history.
Past Medical History:
-HTN, HLD, GERD, A fib on rivaroxaban, BPH, osteoarthritis
-Tonsillectomy, Appendectomy
Social History:
___
Family History:
Mother passed away of leukemia. Father lived to be ___. There is
no family history of premature coronary artery disease or sudden
death.
Physical Exam:
-Vitals: reviewed, tmax 99.8F, HR 71-220, BP 90/55-134/70
-HEENT: atraumatic, normocephalic, moist mucus membranes, PERRL,
EOMi
-Cardiovascular: RRR, no murmur
-Pulmonary: clear b/l, no wheeze
-GI: Soft, nontender, nondistended, bowel sounds present
-GU: no foley, no CVA/suprapubic tenderness
-MSK: No pedal edema, no joint swelling, left upper extremity
midline IV
-Skin: No rashes, ulcerations, or jaundice
-Neuro: no focal neurological deficits, CN ___ grossly intact.
Intermittent confusion.
-Psychiatric: appropriate mood and affect
Pertinent Results:
ADMISSION LABS
___ 02:07PM BLOOD WBC-17.3* RBC-4.90 Hgb-15.1 Hct-47.7
MCV-97 MCH-30.8 MCHC-31.7* RDW-13.9 RDWSD-49.9* Plt ___
___ 02:07PM BLOOD Neuts-91* Bands-0 Lymphs-4* Monos-5 Eos-0
Baso-0 ___ Myelos-0 AbsNeut-15.74* AbsLymp-0.69*
AbsMono-0.87* AbsEos-0.00* AbsBaso-0.00*
___ 02:58PM BLOOD ___ PTT-26.7 ___
___ 02:07PM BLOOD Glucose-137* UreaN-26* Creat-1.4* Na-136
K-4.8 Cl-98 HCO3-13* AnGap-25*
___ 02:07PM BLOOD ALT-87* AST-117* AlkPhos-168*
TotBili-4.0*
___ 02:58PM BLOOD DirBili-2.8*
___ 02:07PM BLOOD Lipase-230*
___ 06:35AM BLOOD proBNP-4501*
___ 02:07PM BLOOD Albumin-4.0 Calcium-8.9 Phos-2.8 Mg-1.8
___ 11:00PM BLOOD TSH-0.67
___ 02:27PM BLOOD Lactate-3.5*
DISCHARGE LABS
___ 07:00PM BLOOD WBC-11.1* RBC-4.33* Hgb-12.8* Hct-38.0*
MCV-88 MCH-29.6 MCHC-33.7 RDW-14.3 RDWSD-46.0 Plt ___
___ 07:10AM BLOOD Neuts-80.3* Lymphs-7.3* Monos-11.1
Eos-0.1* Baso-0.3 Im ___ AbsNeut-13.02* AbsLymp-1.19*
AbsMono-1.81* AbsEos-0.02* AbsBaso-0.05
___ 07:00PM BLOOD Glucose-100 UreaN-14 Creat-1.0 Na-135
K-3.7 Cl-99 HCO3-23 AnGap-13
___ 07:10AM BLOOD ALT-21 AST-23 LD(LDH)-248 AlkPhos-136*
TotBili-1.3
___ 06:45AM BLOOD Lipase-22
___ 01:09AM BLOOD Lactate-1.1
MICRO: All blood and urine cultures negative.
IMAGING/STUDIES
-CT HEAD W/OUT CONTRAST ___: No acute intracranial process.
-CT ABDOMEN/PELVIS W/ CONTRAST ___:
1. Mild central intrahepatic biliary ductal dilatation and
slightly more
peripherally on the left. This can be further characterized by
MRCP given
clinical concern for cholangitis.
2. Distended gallbladder containing gallstones. No surrounding
inflammatory changes however clinical correlation is suggested.
3. Slightly hyperdense left renal cyst, incompletely
characterized. This can be evaluated at time of MRI. If not
performed, dedicated non urgent renal ultrasound is suggested.
4. Small pericardial effusion.
-ERCP ___: Placement of stent. Sphincterotomy not done due
to anticoagulation. Repeat ERCP in 4 weeks and re-evaluate for
sphincterotomy (hold anticoagulation prior to procedure).
-CXR ___: New pulmonary edema
-CT ABDOMEN W/ CONTRAST ___:
1. New regions of hyper enhancement in the periphery of the
liver are
worrisome for microabscesses related to cholangitis. No
discrete or drainable hepatic fluid collection.
2. Expected pneumobilia status post CBD stent placement.
3. New small bilateral pleural effusions.
-MRI ABDOMEN ___:
1. Findings worrisome for hypervascular hepatic metastases with
an abnormal
celiac axis lymph node measuring 1.2 cm.
2. Incompletely evaluated upper thoracic vertebral body,
suspicious for
metastatic involvement.
3. No hepatic abscess.
4. Cholelithiasis without evidence of acute cholecystitis.
5. Small bilateral pleural effusions and pericardial effusion.
Brief Hospital Course:
___ h/o A fib presented w/ RUQ pain and fever found to have
cholangitis w/ choledocholithiasis s/p ERCP ___. Hospital
course complicated by recurrent fever.
1. Sepsis from cholangitis and choledocholithiasis w/
transaminitis & cholestasis
-CT abdomen/pelvis on admission noted biliary duct dilation
undergoing ERCP ___ w/ stent placement (sphincterotomy not
performed due to anticoagulation. He underwent ERCP with stent
placement on ___. He was placed on ceftriaxone/flagyl on
admission that was changed to cefepime/flagyl ___ due to fever.
He continued to have fever prompting repeat CT ___ that was
concerning for hepatic microabscesses and switched to zosyn.
MRI abdomen ___ was actually more consistent w/ metastatic
disease and not infectious process. ID was consulted who
recommended total 2 weeks of IV zosyn. By time of discharge ___
he was afebrile for 48 hours and continued on zosyn through ___
via left upper extremity midline. He will need repeat ERPC in 4
weeks.
2. Atrial fibrillation with RVR
-He developed rapid ventricular response on multiple occasions
in the setting of his acute illness. He required multiple doses
of IV metoprolol and diltiazem throughout his hospitalization.
He was eventually titrated up on diltiazem and metoprolol, but
with significant fatigue attributed to the betablocker, and thus
just diltiazem was continued, which was transitioned back to
home verapamil at discharge. He was continued on rivaroxaban.
3. Orthostatic hypotension
-In the setting of acute illness w/ poor PO intake patient noted
to have orthostatic hypotension that was treated with IV fluids.
4. Acute on chronic systolic/diastolic heart failure
-He developed acute congestive failure with volume resuscitation
and required IV diuresis. By the time of discharge he was
euvolemic not on diuretic.
5. Acute Encephalopathy h/o mild cognitive impairment
-Suspect toxic metabolic encephalopathy in setting of acute
illness worsened by hospital acquired delirium. Continue with
supportive care. Continue outpatient neurocognitive follow up.
6. ___ with hyponatremia
-He had acute kidney injury on admission in setting of sepsis
and volume depletion with poor PO intake that improved with
hydration.
7. ?Metastatic liver disease
-MRI concerning for metastatic disease of the liver w/ radiology
recommending liver biopsy. After discussion with patient and his
wife they want to defer further workup/management (ie liver
biopsy) until after discharge from rehab. Notified ERCP team
and PCP of this plan.
CHRONIC MEDICAL PROBLEMS
1. HLD: resume statin at discharge
2. Chronic BPH w/ hematuria: stable
3. CKD: ___ resolved
4. GERD: continue omeprazole
TRANSITIONAL ISSUES
[ ] ERCP in 4 weeks for stent pull. HOLD RIVAROXABAN BEFORE
PROEDURE.
[ ] Follow up with PCP after rehab to determine workup for
possible metastatic liver lesion ?biopsy
[ ] Continue zosyn via left upper extremity midline through
___.
[ ] Obtain CBC and CMP ___ for surveillance
[ ] Follow up with ___ clinic for mild cognitive
impairment
>30 minutes spent on discharge planning
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Verapamil SR 120 mg PO Q24H
2. Pravastatin 40 mg PO QPM
3. Rivaroxaban 15 mg PO 1800
4. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild/Fever
2. Mirtazapine 15 mg PO QHS
3. Piperacillin-Tazobactam 4.5 g IV Q8H
Continue through ___
4. Polyethylene Glycol 17 g PO DAILY
5. Sodium Chloride 0.9% Flush ___ mL IV Q8H and PRN, line
flush
6. Rivaroxaban 15 mg PO DINNER
7. Omeprazole 20 mg PO DAILY
8. Pravastatin 40 mg PO QPM
9. Verapamil SR 120 mg PO Q24H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Cholangitis
Atrial fibrillation with rapid ventricular response
Acute on chronic systolic congestive heart failure
Acute encephalopathy
Abnormal MRI concerning for metastatic disease of the liver
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Mr. ___,
You were admitted with abdominal pain and fever found to have an
infection in your bile ducts (called cholangitis) from a
gallstone that was stuck in your gallbladder. You had a
procedure called an ERCP (Endoscopic retrograde
cholangiopancreatography) on ___ that removed the stone with
placement of a stent. You required IV antibiotics following the
procedure due to ongoing fever. You were changed to a different
antibiotic with resolution in your fever. You were seen by
infectious disease who recommends continuing IV antibiotics
(zosyn) through ___. You will follow up with the ERCP team to
have the stent removed in 4 weeks.
You had an MRI of the abdomen that was concerning for cancer in
the liver. After discussion of your wishes we will defer liver
biopsy at this time. We will plan for close outpatient follow
up with your PCP and the ERCP to determine the next step, which
could include monitoring with imaging or biopsy.
It was a pleasure taking care of you.
-Your ___ team
Followup Instructions:
___
|
19557807-DS-16
| 19,557,807 | 26,281,887 |
DS
| 16 |
2163-04-01 00:00:00
|
2163-04-03 19:18:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Cogentin / spironolactone / Crestor
Attending: ___.
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ with HFpEF (last in chart ___, T2DM,
schizoaffective disorder who presented to ED with lower
extremity
swelling. Patient noted that it was hard to move her legs
because
they are heavy. She is able to move her toes with no tingling.
Feet move well. Unclear if she has had weight gain. She also
endorses difficulty breathing, harder to breathe when other
people are around, also notes DOE for the last month.
Is on furosemide daily, 20 mg/tab, 0.5 tabs (10 mg) daily. Last
ED visit, we suspected worsening CHF failure, but she declined
IV
diuretics and left AMA to follow-up with her outpatient care.
She
reports taking all her meds but is unable to report dose or
frequency.
Past Medical History:
. Hypertension, poorly controlled.
2. Hypertrophic cardiomyopathy.
3. Left heart failure with a BNP of 4900 and EF of 50%.
4. Diabetes mellitus, type 2 uncontrolled with an A1c of 8.1.
5. Morbid obesity.
6. Iron deficiency anemia.
7. Epigastric pain, now resolved.
8. Schizo-affective disorder
9. CKD
Social History:
___
Family History:
no early cardiac deaths, diabetes mellitus, or hyperlipidemia
Physical Exam:
Admission Exam:
===============
VITALS: 98.6 PO 146 / 75 L Sitting 66 20 98 RA
GENERAL: Well-developed, well-nourished. NAD. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink, no
pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: JVP to mandible
CARDIAC: Murmurs in RUSB and apex. RRR, normal S1, S2. No
murmurs/rubs/gallops. No thrills, lifts.
LUNGS: Crackles bilaterally, scattered wheezes
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: Pitting edema to thighs. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric
Discharge Exam:
===============
___ 0521 Temp: 97.6 PO BP: 135/83 R Sitting HR: 69 RR: 20
O2
sat: 95% O2 delivery: RA
GENERAL:. Mood, affect appropriate.
NECK: JVP to slightly 11-12cm sitting
CARDIAC: RRR, normal S1, S2, +S3. Systolic murmurs in RUSB and
apex. No rubs.
LUNGS: Mild wheezes in lower lung fields, no ronchi
ABDOMEN: non-distended, soft, non-tender
EXTREMITIES: trace edema, no pitting in ankles and feet.
Pertinent Results:
Admission Labs:
===============
___ 06:20PM BLOOD WBC-5.6 RBC-4.00 Hgb-10.5* Hct-33.6*
MCV-84 MCH-26.3 MCHC-31.3* RDW-17.3* RDWSD-53.8* Plt ___
___ 06:20PM BLOOD Glucose-107* UreaN-10 Creat-1.0 Na-132*
K-4.8 Cl-94* HCO3-24 AnGap-14
___ 06:20PM BLOOD Albumin-2.8* Calcium-8.3* Phos-4.0 Mg-1.9
___ 07:35AM BLOOD calTIBC-278 Ferritn-79 TRF-214
Microbiology:
============
___ 9:08 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
Imaging:
========
CXR ___:
IMPRESSION:
Marked cardiomegaly, worse from prior, congestion with mild
edema.
ECHO ___:
IMPRESSION: Severe left ventricular systolic dysfunction.
Moderate right ventricular systolic dysfunction. Mild aortic
regurgitation. At least moderate mitral regurgitation. Moderate
tricuspid regurgitation. Mild pulmonary hypertension.
Compared with the prior study (images reviewed) of ___,
biventricular systolic function has deteriorated. There is more
mitral and tricuspid regurgitation.
L Knee X-ray ___:
IMPRESSION:
No acute osseous abnormality. Tricompartmental degenerative
changes as
described above, most pronounced about the lateral tibiofemoral
compartment.
Discharge Labs:
===============
___ 05:55AM BLOOD Glucose-105* UreaN-13 Creat-1.1 Na-136
K-5.0 Cl-97 HCO3-27 AnGap-12
___ 05:55AM BLOOD Calcium-9.1 Phos-4.0 Mg-2.0
Brief Hospital Course:
Ms. ___ is a ___ with HFpEF (last in chart ___, T2DM,
schizoaffective disorder who presented to ED with lower
extremity
swelling, complicated by TTE showing new HFrEF.
# CORONARIES: unknown
# PUMP: EF 26%; Compared with the prior study (images reviewed)
of ___, biventricular systolic function has deteriorated.
There is more mitral and tricuspid regurgitation.
# RHYTHM: NSR
=============
Acute Issues:
=============
# HFrEF: Patient presents with edema and found to have newly
depressed EF of 26% due to unclear etiology which is a
significant change from ECHO on ___. On presentation she noted
worsening dyspnea on exertion over the last few months as well
as ___ weight gain (250.88 LBS). Her ECHO did show bilateral
atrial enlargement suggestive of infiltrative cardiomyopathy.
Spep/Upep were normal. Standard workup for hear failure was
unremarkable (please see result section of details). The patient
would have benefited from a cardiac MRI, however this was unable
to be obtained while inpatient as the cardiac MRI machine was
not working. She should undergo cardiac MRI as an outpatient.
She was scheduled for right heart cath with coronary
angiography; however, the patient stated that she would not
choose to have stent placement or cardiac surgery if an
intervenable lesion was found. The patient was diuresed with
40mg IV lasix boluses to her presumed dry weight of (228.9 LBS).
Her discharge regimen is as follows:
Preload: Lasix 40mg PO BID
Afterload: Lisinopril 40 Daily, Hydralazine 50mg TID, isordil
30mg TID
NHBK: Spironolactone to 25mg daily, carvedilol 25mg BID
She will have outpatient follow-up with her PCP physician in ___
weeks after discharge. She should have a BMP drawn on ___
___ to asses her potassium and Creatinine.
===============
Chronic Issues:
===============
# L knee pain:
In setting of recent syncopal episode. The patient initially
complained of left knee pain. and X-ray of her left knee show
osteoarthritis which has been chronic. She was treated with
Tylenol PRN with good effect.
# Hyperlipidemia:
Continued home crestor and aspirin
# T2DM:
Metformin was held on admission. Patient was treated with home
insulin regimen and HISS with good effect. She was transitioned
to home metformin at discharge.
Transitional Issues:
====================
Discharge Weight: 228.9 lb
Discharge Cr: 1.1
Discharge Diuretics: Lasix 40mg PO BID
[] Please obtain chem-10 on ___ to asses renal
function and potassium. Please fax the results to ___
___ at ___.
[] Please consider converting Isosorbide dinitrate 30mg TID to
once daily Isosorbide mononitrate
[] Please ensure patient has scheduled monthly paloperidone
Full Code
No contact person identified: ___ (Home)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 40 mg PO DAILY
2. PALIperidone Palmitate 234 mg IM Q1MO (MO)
3. Atenolol 100 mg PO DAILY
4. MetFORMIN (Glucophage) 1000 mg PO BID
5. Docusate Sodium 100 mg PO BID
6. amLODIPine 10 mg PO DAILY
7. Rosuvastatin Calcium 10 mg PO QPM
8. Ferrous Sulfate 325 mg PO DAILY
9. Furosemide 10 mg PO DAILY
10. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Carvedilol 25 mg PO BID
RX *carvedilol 25 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
2. HydrALAZINE 50 mg PO Q8H
RX *hydralazine 50 mg 1 tablet(s) by mouth three times a day
Disp #*90 Tablet Refills:*0
3. Isosorbide Dinitrate 30 mg PO Q8H
RX *isosorbide dinitrate 30 mg 1 tablet(s) by mouth three times
a day Disp #*90 Tablet Refills:*0
4. Spironolactone 25 mg PO DAILY
RX *spironolactone [Aldactone] 25 mg 1 tablet(s) by mouth Daily
Disp #*30 Tablet Refills:*0
5. Furosemide 40 mg PO BID
RX *furosemide 40 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
6. Aspirin 81 mg PO DAILY
7. Docusate Sodium 100 mg PO BID
8. Ferrous Sulfate 325 mg PO DAILY
9. Glargine 18 Units Bedtime
10. Lisinopril 40 mg PO DAILY
11. MetFORMIN (Glucophage) 1000 mg PO BID
12. PALIperidone Palmitate 234 mg IM Q1MO (MO)
13. Rosuvastatin Calcium 10 mg PO QPM
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
==================
HFrEF
Secondary Diagnoses:
====================
Hyperlipidemia
Schizoeffective Disorder
Diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
WHY WERE YOU ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital because you had been feeling
short of breath and you were found to have fluid on your lungs.
This was felt to be due to a condition called heart failure,
where your heart does not pump hard enough and fluid backs up
into your lungs.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- You were given a diuretic medication through the IV to help
get the fluid out. You improved considerably and were ready to
leave the hospital.
- We began new medications for your heart failure.
- We offered you a procedure to look for blockages in the blood
vessels around the heart, but you declined as you did not want
anything done to fix the potential blockages.
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
- Weigh yourself every morning, call your heart failure doctor
(___ if your weight goes up more than 3 lbs over 24
hours or 5 lbs over 48 hours.
- Call your heart failure doctor (___ if you have
new or concerning symptoms or you develop swelling in your legs,
abdominal distention, or shortness of breath at night.
Your ___ Team
Followup Instructions:
___
|
19557807-DS-18
| 19,557,807 | 25,837,998 |
DS
| 18 |
2164-01-20 00:00:00
|
2164-01-22 10:29:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Cogentin / Crestor
Attending: ___.
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ yo woman with
history of HFrEF (LVEF 26% in ___ with 2+ MR/TR), T2DM, HLD,
HTN, stage III CKD, and schizoaffective disorder who presents
after inability to get off the toilet this AM ___ generalized
weakness and ___ edema.
Patient reports that over the past ___ months, she has noted
increasing bilateral ___ edema, orthopnea, weight gain, and
generalized weakness. Denies PND or SOB at rest. Reports that
her
weight was 241 lbs (109.5 kg) this AM. Denies F/C, CP, N/V,
abdominal pain, B/B sx. She presents from her psychiatric group
home and states that an RN typically gives her meds. She took
her
PO torsemide 100mg this AM.
Of note, multiple encounters in OMR reporting that patient has
been gaining weight over the past few months in the setting of
medication non-adherence/omission (e.g. not able to take 5 pills
at once) and dietary indiscretion. Her discharge weight in
___
was 92 kg, and she has been noted on CHF outpatient visits to be
progressively volume overloaded, up to 108 kg on ___. Her
torsemide had recently been uptitrated to 100mg BID. Dry weight
is 205 lbs/93 kg. On admission in ___, she was diuresed with
Lasix gtt 20mg/hr for overall diuresis of 34.5L (25.7 kg).
Last admission in ___, she again presented to ___
with
progressive dyspnea on exertion and lower extremity edema over
the period of 1 month. She was admitted to the heart failure
service and
diuresed with IV lasix and transitioned to torsemide 60 mg
daily.
Other discharge medications included hydralazine 50 mg every 8
hours, isosorbide 30 mg three times daily, lisinopril 40 mg
daily, spironolactone 25 mg daily, and carvedilol 25 mg twice
daily. She also was counseled on possible benefits of CRT and
declined consideration at the time. Her weight on discharge was
92 kg.
In the ED, initial vitals notable for temp 96.6 BP 107/70- SaO2
97% on 4 L NC
- Exam notable for: Gen: Audibly wheezing but generally
well-appearing
HEENT: NCAT, JVP elevated to ear
CV: S1, S2, RRR
Pulm: Diffusely rhonchorous throughout with expiratory wheeze
Abd: Soft, NDNT
Ext: Venous stasis changes and edema bilaterally
- Labs notable for: WBC 5.6, INR 1.1, NTproBNP 5937, Na 129,
TropT 0.6
- Imaging notable for: CXR w/ persistent moderate to severe
cardiomegaly with pulmonary vascular congestion and mild
interstitial pulmonary edema.
- Pt given: Furosemide 200 mg IV and then placed in furosemide
10mghr
Upon arrival to the floor, the patient corroborates the above
history. She notes that she has had difficulty at home with
weight gain and has recently had difficulty breathing. She does
not weigh herself consistently at home but thinks she has gained
about 40lbs since ___. She does not adhere to a low sodium
diet.
She also had difficulty recalling her recent medications and
notes she does not take insulin although was discharged on
___ and Humalog in ___. She lives in an apartment with room
mates and has an aid who helps with medication administration.
Past Medical History:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS
- Diabetes, type II
- Hypertension
- Dyslipidemia
2. CARDIAC HISTORY
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY
-Hypertrophic cardiomyopathy
-Morbid obesity
-Iron deficiency anemia
-Schizoaffective disorder
-CKD
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: ___ 2329 Temp: 98.0 PO BP: 145/88 HR: 93 RR: 18 O2
sat: 98% O2 delivery: neb
GEN: Sitting comfortably and in no acute distress; speaking
in full sentences, slight expiratory wheezing
HEENT: conjunctiva pink; sclera anicteric
CV: regular rate and rhythm; normal S1; there are no murmurs,
rubs, or gallops appreciated; the JVD to mid neck at 90 degrees
PULM: Bilateral rhonci with mild expiratory wheezing and
bibasilar crackles
ABD: non-distended; normoactive bowel sounds; soft and
non-tender
to palpation; there is no appreciable organomegaly or mass
EXT: warm; tense edema bilaterally
SKIN: healing blisters and chronic venous stasis changes.
NEURO: sensation is grossly intact to light touch in all
extremities; there are no gross motor deficits on basic
screening
neurologic exam
PSYCH: normal mood and affect
DISCHARGE PHYSICAL EXAM:
========================
VS: ___ 0754 Temp: 97.6 PO BP: 112/69 R Sitting HR: 54 RR:
18 O2 sat: 95% O2 delivery: RA FSBG: 184
GEN: NAD; speaking in full sentences
HEENT: sclera anicteric
NECK: JVP not appreciated
CV: RRR, no murmurs rubs or gallops appreciated
PULM: faint bibasilar crackles
ABD: soft, nontender, nondistended
EXT: no pitting edema
SKIN: dry skin
NEURO: alert, moves all four extremities
PSYCH: normal mood and affect
Pertinent Results:
ADMISSION LABS:
===============
___ 03:20PM BLOOD WBC-5.6 RBC-5.07 Hgb-14.2 Hct-45.0 MCV-89
MCH-28.0 MCHC-31.6* RDW-18.0* RDWSD-57.8* Plt ___
___ 03:20PM BLOOD Neuts-58.1 ___ Monos-13.3*
Eos-1.3 Baso-0.9 Im ___ AbsNeut-3.24 AbsLymp-1.41
AbsMono-0.74 AbsEos-0.07 AbsBaso-0.05
___ 03:20PM BLOOD ___ PTT-31.9 ___
___ 03:20PM BLOOD Glucose-170* UreaN-11 Creat-1.0 Na-129*
K-4.4 Cl-86* HCO3-30 AnGap-13
___ 03:20PM BLOOD proBNP-5937*
___ 03:20PM BLOOD cTropnT-0.06*
___ 07:40AM BLOOD CK-MB-4 cTropnT-0.07*
___ 09:32PM BLOOD Mg-1.6
___ 09:32PM BLOOD %HbA1c-10.2* eAG-246*
___ 07:40AM BLOOD calTIBC-264 Ferritn-135 TRF-203
___ 03:27PM BLOOD Lactate-2.1*
___ 09:36PM BLOOD Lactate-1.9
___ 09:40PM URINE Color-Straw Appear-Clear Sp ___
___ 09:40PM URINE Blood-NEG Nitrite-NEG Protein-100*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
___ 09:40PM URINE RBC-<1 WBC-<1 Bacteri-FEW* Yeast-NONE
Epi-1
DISCHARGE LABS:
===============
___ 06:42AM BLOOD WBC-4.2 RBC-4.56 Hgb-12.8 Hct-40.9 MCV-90
MCH-28.1 MCHC-31.3* RDW-19.1* RDWSD-62.7* Plt ___
___ 06:42AM BLOOD Glucose-211* UreaN-40* Creat-1.4* Na-135
K-4.6 Cl-91* HCO3-28 AnGap-16
___ 06:42AM BLOOD Calcium-9.4 Phos-4.4 Mg-2.0
MICROBIOLOGY:
=============
___ 9:40 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
IMAGING AND REPORTS:
====================
CHEST (PORTABLE AP) ___
Persistent moderate to severe cardiomegaly with pulmonary
vascular congestion
and mild interstitial pulmonary edema.
Brief Hospital Course:
___ y/o woman with history of HFrEF (LVEF 26% in ___ with 2+
MR/TR), T2DM, HLD, HTN, stage III CKD, and schizoaffective
disorder who presented after inability to get off the toilet
secondary to generalized weakness and ___ edema, concerning for
decompensated heart failure. She was significantly volume
overloaded and was diuresed with improvement in her symptoms.
She declined further workup of her HFrEF as consistent with her
prior history and was transitioned to Torsemide 120 mg BID for
maintenance.
#Coronaries: unknown
#EKG: Sinus rhythm, LBBB
#Pump: EF 26%
#ACUTE ON CHRONIC SYSTOLIC HEART FAILURE, NONISCHEMIC
CARDIOMYOPATHY:
Patient presented with progressive weakness, orthopnea, and ___
edema and 30 lb weight gain. Last TTE ___ w/ EF 26% was
worsened from prior TTE in ___ with EF >55%, with reduction
in EF of unclear etiology. Patient continued to decline further
workup of her heart failure as consistent with her prior
decision making on other hospitalizations. Her current
decompensated state is likely in the setting of dietary
indiscretion and medication difficulty. There is no obvious
infectious source as trigger and EKG without obvious ischemic
changes. She was diuresed with Lasix gtt and symptoms and weight
improved steadily with diuresis. Last dry weight was noted to be
205lb, but she appeared overloaded even under this weight, with
discharge weight of 192.24 lbs which is her new dry weight. She
was transitioned to PO torsemide 120 mg BID for maintenance. She
was continued on her home medications with hydralazine 50 mg
q8h, isordil 30mg TID, spironolactone 25mg daily, lisinopril
40mg daily, carvedilol 25mg BID, and HCTZ.
#Chronic venous stasis wounds. She was provided with compression
stockings and wound care.
#Acute on Chronic Hyponatremia. Na 129 on presentation and
asymptomatic, which was likely secondary to hypervolemic
hyponatremia given improvement to normal Na with diuresis.
#DM2. Poorly controlled during last admission. On admission
patient adamantly denied use of Insulin but her ___ reports that
she does take insulin. She also reported an allergy to lantus.
Home Linagliptin was held while inpatient. ___ was consulted
and she was transitioned to Detemir 15u AM and Humalog 5u TID AC
+ HISS while inpatient with good control of FSBGs. She will
reduce her home ___ to 15u (from 30u) and continue Humalog
5u TID AC + HISS as well as Linagliptin on discharge.
___ on CKD: Baseline Sr Cr 1.1. Bumped to 1.5 as she became
dry, with discharge Cr being 1.4.
CHRONIC Issues:
===============
#HTN:
Continued Hydralazine, isosorbide, coreg, and lisinopril as
above.
#HLD:
Continued rosuvastatin.
#SCHIZOAFFECTIVE DISORDER: Receives monthly IM injections of
paliperidone as outpatient. Per ___ she
receives paliperidone 234 mg every 4 weeks. Her last dose was on
___. She is due to have her next injection on ___.
====================
TRANSITIONAL ISSUES:
====================
Discharge weight: 192.24 lbs
Discharge Cr: 1.4
Heart Failure Meds:
Torsemide 120 mg BID
Hydralazine 50 mg q8h
Isordil 30mg TID
spironolactone 25mg daily
lisinopril 40mg daily
carvedilol 25mg BID
[] Torsemide increased to 120 mg BID for maintenance.
[] HCTZ held as she is on Torsemide. If need better BP control,
can uptitrate hydralazine and isordil as needed
[] Home insulin regimen reduced such that she was taking detemir
15 U in AM rather than 30 U ___ continue reduced
insulin regimen on discharge (15 U ___, 5 U Humalog with
each meal, and ISS). Please continue to monitor ___
[] Patient declined further workup of HFrEF as consistent with
prior hospitalizations
[] Continue to engage patient in dialogue regarding benefits of
possible CRT therapy in the future.
[] Please ensure she receives her scheduled IM injections of
paliperidone 234 mg every 4 weeks. Her last dose was on ___. She is due to have her next injection on ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. linaGLIPtin 5 mg oral Daily
2. Aspirin 81 mg PO DAILY
3. Ferrous Sulfate 325 mg PO DAILY
4. Spironolactone 25 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. HydrALAZINE 50 mg PO Q8H
7. Isosorbide Dinitrate 30 mg PO Q8H
8. Lisinopril 40 mg PO DAILY
9. Rosuvastatin Calcium 10 mg PO QPM
10. Torsemide 100 mg PO BID
11. PALIperidone Palmitate 234 mg IM Q1MO (MO)
12. Carvedilol 25 mg PO BID
13. Hydrochlorothiazide 25 mg PO DAILY
14. Humalog 5 Units Breakfast
Humalog 5 Units Lunch
Humalog 5 Units Dinner
___ 30 Units Breakfast
Discharge Medications:
1. Nicotine Patch 7 mg/day TD DAILY
RX *nicotine 7 mg/24 hour 1 patch daily Disp #*14 Patch
Refills:*2
2. Humalog 5 Units Breakfast
Humalog 5 Units Lunch
Humalog 5 Units Dinner
___ 15 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
3. Torsemide 120 mg PO BID
4. Aspirin 81 mg PO DAILY
5. Carvedilol 25 mg PO BID
6. Docusate Sodium 100 mg PO BID
7. Ferrous Sulfate 325 mg PO DAILY
8. HydrALAZINE 50 mg PO Q8H
9. Isosorbide Dinitrate 30 mg PO Q8H
10. linaGLIPtin 5 mg oral Daily
11. Lisinopril 40 mg PO DAILY
12. PALIperidone Palmitate 234 mg IM Q1MO (MO)
13. Rosuvastatin Calcium 10 mg PO QPM
14. Spironolactone 25 mg PO DAILY
15. HELD- Hydrochlorothiazide 25 mg PO DAILY This medication
was held. Do not restart Hydrochlorothiazide until you see your
cardiology team
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES
=================
Acute on chronic systolic heart failure
Hyponatremia
Diabetes
Acute kidney injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital for weight gain, leg
swelling, and weakness.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
- You were found to be severely overloaded with fluid due to
your heart failure.
- You were given medications (diuretics) to remove fluid from
your body. Your weakness, leg swelling, and weight improved with
diuretics.
WHAT SHOULD I DO WHEN I GO HOME?
- Your diabetes medications were adjusted and you should take 15
units of ___ at breakfast (and not 30 units)
- You should continue to take your medications as prescribed.
- You should attend the appointments listed below.
- Weigh yourself every morning. Call your doctor if your weight
goes up more than 3 lbs.
- Seek medical attention if you have new or concerning symptoms
or you develop swelling in your legs, abdominal distention, or
shortness of breath at night.
- Your discharge weight: 192.24 lbs. You should use this as your
baseline after you leave the hospital.
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
19557807-DS-19
| 19,557,807 | 24,554,398 |
DS
| 19 |
2164-08-07 00:00:00
|
2164-08-07 16:42:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Cogentin / Crestor / Lantus U-100 Insulin
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
PPM placement
History of Present Illness:
___ yo woman with history of HFrEF (LVEF 26% in ___ with 2+
MR/TR), T2DM, HLD, HTN, stage III CKD, and schizoaffective
disorder who p/w dyspnea.
She reports a 1w hx of dyspnea with a 10 lb weight gain over the
past day. She denies chest pain, dizziness/lightheadedness,
palpitations, N/V. She endorses occasional productive cough over
the past month, though denied any fevers/chills.
In the ED, she initially appeared comfortable with a normal
heart rate but quickly developed bradycardia with rates in the
___. She remained hemodynamically stable and tolerated this
rhythm well, except for 1 ___ episode of unresponsiveness that
was a/w hypotension and hypoxia, both of which resolved upon
arousing her.
- Initial vitals were: T 98.0 HR 83 BP 125/70 RR 18 SpO2 100%
RA
- Exam notable for: Bradycardic & irregular heart sounds.
CTAB.
- Labs notable for: TropT 0.03, Cr 1.4 (baseline), chronic
hyponatremia, BNP 9191
- Studies notable for: CXR w/ mild interstitial pulmonary edema
- Patient was given: Dopamine gtt
On arrival to the CCU, patient denies any shortness of breath,
chest pain, palpitations, dizziness/lightheadedness, fevers or
chills. She reiterates HPI as above. She explained to me that
she was tired this morning and simply fell asleep when she was
found to have the unresponsive episode.
She explained to me that she is "feeling fine," and does not
want a pacemaker. On further discussion, she would not elaborate
as to why she did not want this procedure aside from saying that
she was "fine now." She became progressively more frustrated
with
questioning aimed at elucidating her capacity throughout the
interview.
Past Medical History:
1. CARDIAC RISK FACTORS
- Diabetes, type II
- Hypertension
- Dyslipidemia
2. CARDIAC HISTORY
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY
-Hypertrophic cardiomyopathy
-Morbid obesity
-Iron deficiency anemia
-Schizoaffective disorder
-CKD
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
GENERAL: Sitting up in bed, intermittently dozing off during
interveiw
HEENT: Normocephalic, atraumatic. Sclera anicteric. PERRL.
EOMI.
NECK: Supple. JVP elevated to mid neck
CARDIAC: Bradycardic, regular rate. No murmurs appreciated
LUNGS: No chest wall deformities or tenderness. Bibasilar
crackles. Inspiratory and expiratory wheezes. No accessory
muscle
use
ABDOMEN: Soft, non-tender, non-distended. No palpable
hepatomegaly or splenomegaly.
EXTREMITIES: Warm, well perfused. ___ peripheral edema
extending proximally to knees bilaterally.
SKIN: No significant lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
NEURO: No focal deficits
PSYCH: Frustrated and while she maintains consistent refusal,
does not appear to have capacity on questioning
DISCHARGE PHYSICAL EXAM
=======================
GENERAL: Alert and interactive. In no acute distress.
MENTAL STATUS: Appropriately oriented to conversation
PSYCH: Appropriate affect
HEENT: Normocephalic, atraumatic.
CARDIAC: RRR, JVP improved
LUNGS: CTAB
EXTREMITIES: Nonpitting edema b/l up to almost knee
NEUROLOGIC: Moving limbs appropriately
Pertinent Results:
ADMISSION LABS/REPORTS:
___ 04:13PM GLUCOSE-154* UREA N-22* CREAT-1.4*
SODIUM-129* POTASSIUM-3.7 CHLORIDE-87* TOTAL CO2-24 ANION GAP-18
___ 04:13PM CALCIUM-9.4 PHOSPHATE-4.0 MAGNESIUM-2.6
___ 07:45AM LACTATE-1.5
___ 07:34AM GLUCOSE-169* UREA N-19 CREAT-1.6* SODIUM-128*
POTASSIUM-3.9 CHLORIDE-89* TOTAL CO2-25 ANION GAP-14
___ 07:34AM ALT(SGPT)-12 AST(SGOT)-25 ALK PHOS-92 TOT
BILI-0.8
___ 07:34AM cTropnT-0.02*
___ 07:34AM ALBUMIN-3.3*
___ 07:34AM WBC-5.8 RBC-3.84* HGB-12.2 HCT-36.8 MCV-96
MCH-31.8 MCHC-33.2 RDW-13.9 RDWSD-48.1*
___ 07:34AM NEUTS-59.0 ___ MONOS-12.5 EOS-2.1
BASOS-1.0 IM ___ AbsNeut-3.41 AbsLymp-1.44 AbsMono-0.72
AbsEos-0.12 AbsBaso-0.06
___ 07:34AM PLT COUNT-227
___ 07:34AM ___ PTT-27.0 ___
___ 06:03AM ___ PTT-29.5 ___
___ 05:33AM GLUCOSE-191* UREA N-18 CREAT-1.4* SODIUM-128*
POTASSIUM-4.0 CHLORIDE-86* TOTAL CO2-25 ANION GAP-17
___ 05:33AM estGFR-Using this
___:33AM ALT(SGPT)-13 AST(SGOT)-26 ALK PHOS-96 TOT
BILI-0.9
___ 05:33AM cTropnT-0.03*
___ 05:33AM proBNP-___*
___ 05:33AM ALBUMIN-3.5 CALCIUM-9.0 PHOSPHATE-3.5
MAGNESIUM-1.7
___ 05:33AM WBC-5.7 RBC-4.05 HGB-12.7 HCT-38.2 MCV-94
MCH-31.4 MCHC-33.2 RDW-13.9 RDWSD-47.4*
___ 05:33AM NEUTS-60.2 ___ MONOS-11.4 EOS-2.3
BASOS-0.9 IM ___ AbsNeut-3.43 AbsLymp-1.41 AbsMono-0.65
AbsEos-0.13 AbsBaso-0.05
___ 05:33AM PLT COUNT-249
___: CXR, portable AP
1. Unchanged severe cardiomegaly with pulmonary vascular
congestion and mild interstitial pulmonary edema.
2. Severe cardiomegaly may be due to cardiomyopathy or
pericardial effusion.
___: Transthoracic echo report
The left atrial volume index is SEVERELY increased. The right
atrium is moderately enlarged. There is no evidence for an
atrial septal defect by 2D/color Doppler. The estimated right
atrial pressure is >15mmHg.
There is mild symmetric left ventricular hypertrophy with a
moderately increased/dilated cavity. There is moderate-severe
global left ventricular hypokinesis. No thrombus or mass is seen
in the left ventricle. The
visually estimated left ventricular ejection fraction is ___.
Due to severity of mitral regurgitation, intrinsic left
ventricular systolic function is likely lower. There is no
resting left ventricular outflow tract gradient. No ventricular
septal defect is seen. Mildly dilated right ventricular cavity
with mild global free wall hypokinesis. Tricuspid annular plane
systolic excursion (TAPSE) is depressed. There is abnormal
septal motion c/w conduction abnormality/paced rhythm. The
aortic sinus diameter is normal for gender. The aortic arch
diameter is normal. There is no evidence for an aortic arch
coarctation. The aortic valve leaflets (3) appear structurally
normal. There is no aortic valve stenosis. There is mild to
moderate [___] aortic regurgitation. The mitral valve leaflets
are mildly thickened with no mitral valve prolapse. The
transmitral E-wave
deceleration time is short (less than 140ms) c/w restrictive
filling. There is an eccentric, inferolateral directed jet of
moderate to severe [3+] mitral regurgitation. The pulmonic valve
leaflets are normal. 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: Mild symmetric left ventricualr hypertrophy with
moderate cavity dilation and moderate to severe global systolic
dysfunction in the setting of intraventricular dyssynchrony.
Restrictive filling pattern. Mild right ventricular cavity
dilation with mild systolic dysfunction. Mild
to moderate aortic regurgitation. At least moderate to severe
mitral regurgitation. Mild tricuspid regurgitation. Moderate
pulmonary artery systolic hypertension.
KEY RESULTS:
___ 07:34AM BLOOD Glucose-169* UreaN-19 Creat-1.6* Na-128*
K-3.9 Cl-89* HCO3-25 AnGap-14
___ 07:30PM BLOOD Glucose-98 UreaN-23* Creat-1.3* Na-135
K-3.6 Cl-93* HCO3-31 AnGap-11
___ 02:37AM BLOOD PEP-NO SPECIFI FreeKap-75.2*
FreeLam-28.4* Fr K/L-2.65*
KEY REPORTS:
___: EP Brief Procedure Report
___ woman with episodes of high degree AV block presents for ___
implant.
A dual chamber ___ ___ MRI compatible) implanted via left
cephalic vein.
Other Labs:
___ 07:45AM BLOOD Lactate-1.5
___ 07:48AM BLOOD WBC-4.8 RBC-3.77* Hgb-12.0 Hct-36.8
MCV-98 MCH-31.8 MCHC-32.6 RDW-14.6 RDWSD-51.6* Plt ___
___ 07:48AM BLOOD Glucose-129* UreaN-22* Creat-1.4* Na-137
K-5.6* Cl-96 HCO3-28 AnGap-13
___ 05:33AM BLOOD proBNP-9191*
___ 05:33AM BLOOD cTropnT-0.03*
___ 07:34AM BLOOD cTropnT-0.02*
___ 07:48AM BLOOD Calcium-9.7 Phos-3.9 Mg-2.3
___ 01:00PM BLOOD calTIBC-241* Ferritn-178* TRF-185*
___ 02:37AM BLOOD PEP-NO SPECIFI FreeKap-75.2*
FreeLam-28.4* Fr K/L-2.65*
___ 01:00PM BLOOD Lyme Ab-NEG
Brief Hospital Course:
___ yo woman with history of HFrEF (LVEF 26% in ___ with 2+
MR/TR), T2DM, HLD, HTN, stage III CKD, and schizoaffective
disorder who p/w dyspnea and found to be high-grade heart block
with rates in the ___. She was admitted to the CCU and
initially was refusing all treatment, including PPM placement,
but after consulting psychiatry and legal, she eventually agreed
to PPM placement, which was done on ___. She was then
transferred to the floor for continued management. Patient was
diuresed with IV Lasix on the floor and then transitioned to PO
Torsemide (see below) prior to discharge.
TRANSITIONAL ISSUES:
====================
[] Patient came in robustly volume overloaded. ___ need
titration of home torsemide regimen. Consider addition of
metolazone as needed.
[] Complex issue of capacity during admission. Recommend PCP
touch base regarding patients code status.
[] Will need close follow-up for her device and of incision
site.
[] Follow-up on UPEP, SPEP, and light chain ratio.
- Discharge weight: 87.7kg (193.34lb).
- Discharge creatinine: 1.4
ACUTE ISSUES:
=============
#High-grade Block
Patient presenting with 2:1 high-grade block and was admitted to
the CCU for eval for PPM placement. Patient initially refused
pacemaker placement and there was
concern for lack of capacity as below. She changed her mind on
___ after further conversation with a private physician, so ___
PPM was placed later that day and she was transferred to the
floor for further management. Tolerated well with improved heart
rates. She has follow-up in device clinic.
#Acute Hypoxemic Respiratory Failure
#Acute on chronic HFrEF
CHF exacerbation in the context of bradycardia given elevated
BNP (9191) and clinical volume overload. BNP elevated at 9191.
Sig hx of medication and diet non-compliance, though patient
denies missing any doses of medications. No reported history of
COPD, though wheezing on exam. Given IV diuresis and then
transitioned to Torsemide 120 BID. Dry weight of 87.7kg
(193.34lb).
#Iron deficiency
Iron studies notable for ferritin 178 with Tsat 12% qualifying
for IV iron, which was given for 4 days.
#Capacity Assessment
On extensive interview with patient, she initially was refusing
pacemaker placement. Led to complex issue of if patient had
capacity to make decision. Eventually amenable to pacemaker.
Would continue to discuss goals of care.
___ on CKD
Baseline 1.3-1.4. Cr uptrended to 1.6 on admission. Possibly
precipitated by decreased end-organ perfusion in setting of
bradycardia, though patient has maintained MAPS. Also to
consider cardiorenal source given volume overload. At baseline
on discharge.
#Hyponatremia
Known to be chronically hyponatremic. Na 128 on admission,
likely due to hypervolemia and improved with diuresis.
CHRONIC ISSUES:
===============
#HTN
Multiple meds initially held but were slowly titrated back to
home doses during hospitalizations.
#Dyslipidemia
Coninued home statin.
#Schizoaffective Disorder
Psych was consulted. Her home medications were continued.
#Diabetes
She was continued on insulin with detemir and a sliding scale.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Torsemide 120 mg PO BID
2. Lisinopril 40 mg PO DAILY
3. Rosuvastatin Calcium 10 mg PO QPM
4. Aspirin 81 mg PO DAILY
5. Spironolactone 25 mg PO DAILY
6. Isosorbide Dinitrate 30 mg PO TID
7. CARVedilol 25 mg PO BID
8. PALIperidone Palmitate 234 mg IM Q1MO (MO)
9. Ferrous Sulfate 325 mg PO DAILY
10. HydrALAZINE 50 mg PO TID
11. Humalog 5 Units Breakfast
Humalog 5 Units Lunch
Humalog 5 Units Dinner
Levemir 15 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
12. Docusate Sodium 100 mg PO BID
Discharge Medications:
1. Hydrocerin 1 Appl TP QID:PRN dry legs
RX *white petrolatum-mineral oil apply to dry legs four times a
day Disp #*1 Package Refills:*0
2. Humalog 5 Units Breakfast
Humalog 5 Units Lunch
Humalog 5 Units Dinner
Levemir 15 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
3. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
4. CARVedilol 25 mg PO BID
RX *carvedilol 25 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
5. Docusate Sodium 100 mg PO BID
6. Ferrous Sulfate 325 mg PO DAILY
RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth
once a day Disp #*30 Tablet Refills:*0
7. HydrALAZINE 50 mg PO TID
RX *hydralazine 50 mg 1 tablet(s) by mouth three times a day
Disp #*90 Tablet Refills:*0
8. Isosorbide Dinitrate 30 mg PO TID
RX *isosorbide dinitrate 30 mg 1 tablet(s) by mouth three times
a day Disp #*90 Tablet Refills:*0
9. Lisinopril 40 mg PO DAILY
RX *lisinopril 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
10. PALIperidone Palmitate 234 mg IM Q1MO (MO)
11. Rosuvastatin Calcium 10 mg PO QPM
RX *rosuvastatin 10 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
12. Spironolactone 25 mg PO DAILY
RX *spironolactone 25 mg 1 tablet(s) by mouth once a day Disp
#*30 Tablet Refills:*0
13. Torsemide 120 mg PO BID
RX *torsemide 100 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
RX *torsemide 20 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
High Degree AV Block
Heart Failure exacerbation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital because your heart was
beating slow and you had extra fluid in your body.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
- You were given a pacemaker to keep your heart beating fast
enough.
- You were given medications to help remove fluid from your
body.
WHAT SHOULD I DO WHEN I GO HOME?
- You should continue to take your medications as prescribed.
- If you are experiencing new or concerning chest pain that is
coming and going you should call the heartline at ___.
- You should also call the heartline if you develop swelling in
your legs, abdominal distention, or shortness of breath at
night.
- You should attend the appointments listed below.
- Weigh yourself every morning, call your doctor if your weight
goes up more than 3 lbs.
- Your discharge weight: 87.7kg (193.34lb). You should use this
as your baseline after you leave the hospital.
- Please do not use your left arm for lifting for ___ weeks to
prevent migration of your pacemaker.
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
19557987-DS-17
| 19,557,987 | 27,501,521 |
DS
| 17 |
2173-01-03 00:00:00
|
2173-01-04 19:26:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Thorazine / codeine / Sulfa (Sulfonamide Antibiotics) /
phenobarbital / Ergotrate
Attending: ___.
Chief Complaint:
Slurred speech, unstable gait
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ woman with a past medical
history of CKD (unknown baseline), CAD, DMII, bradycardia s/p
pacemaker who presented to the ED with slurred speech and
dizziness with unstable gait. The patient was scheduled for
surgery today for her back (radiofrequency for her back pain),
but her long-term surgeon noted her slurred speech upon arrival
to the clinic at ___. She was promptly sent to
ambulatory care at ___, then sent to ___ ED.
Patient also reports difficulties walking for the past five
days, worst since this past ___ at which time she started
using a cane. Of note, the patient reports having had a viral
gastrointestinal-like illness with nausea, vomiting, and
diarrhea, but these symptoms have resolved. Denies any fevers or
chills currently. Patient reports that she has been struggling
with vertigo for a year, but has not had any workup for these
symptoms.
In the ED, initial vitals were: 97.8 64 80/50 16 100%. Her labs
were notable for WBC 11.6 (neut 73.5), H/H 8.5/27.5 (MCV 94),
plt 517, bicarb 14, BUN 71, Cr 5.9. Her UA was notable for
moderate leuk, 30+ protein, and 4+ granular and hyaline casts.
Neurology was consulted and noted that she had no focal
neurologic deficits. CT head was negative for hemorrhage or
acute territorial infarction. She received IVF (total of 1.9L
over the day per the patient) and oxycodone 5 mg PO. Vital Signs
prior to transfer were: 60 95/58 15 100% RA.
On the floor, initial vitals were: T 98.2, HR 62, BP 121/75, 94%
RA. Patient was alert and oriented x3, but continued to have
slurred speech.
Past Medical History:
- CAD (stress test recently done, which was normal per pt)
- CKD (reported baseline BUN 48, Cr 3.8, however last documented
creatinine 1.45 in ___
- Acute intermittent porphyria
- Raynauds
- Gastric ulcer, recurrent H pylori
- Glaucoma
- DMII, diet controlled
- sick sinus syndrome s/p pacemaker
- Gout
- Anxiety
- Depression
- Hip surgery ___ avascular necrosis
- ___ factor deficiency (prekallikrein deficiency, results
in prolonged PTT)
- Right knee surgery
- Chronic low back pain
- Orthostatic hypotension (of unclear etiology)
- h/o HTN, spontaneously resolved
Social History:
___
Family History:
- Father deceased at age ___ ___AD, kidney disease on
dialysis
- Grandfather and paternal uncles with colon CA
- Father's side with strong history of CAD, HF
- Mother's side with acute inteintermittent porphyria
- Maternal uncles with leukemia
- ___ grandmother with leukemia
- Two sisters deceased from HF
- Sister with CAD (two open heart surgeries)
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
VS: T 98.2, HR 62, BP 121/75, 94% RA.
GENERAL: Alert, oriented x3, NAD
HEENT: PERRL, EOMI, sclera anicteric, dry mucus membranes, clear
oropharynx
NECK: supple, JVP not elevated, no carotid bruits
LUNGS: Clear to auscultation bilaterally, bibasilar faint
crackles, no wheezes or rhonchi
CV: distant heart sounds, regular rhythm, no MRG
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
NEURO: CNII-XII grossly intact, ___ UE strength (proximal and
distal), ___ LLE strength, RLE strength limited by R knee pain,
one beat clonus on left ankle, toes down b/l, no asterixis
PHYSICAL EXAM ON DISCHARGE:
VS: 98.3 100/63 71 18 100RA
GENERAL: Alert, oriented x3, NAD. No dysarthria. speech more
clear.
HEENT: Sclera anicteric, slightly dry mucus membranes, supple
neck, No JVD
LUNGS: Clear to auscultation bilaterally, no wheezes or rhonchi
CV: distant heart sounds, regular rhythm, ___ systolic murmur
LLSB, no rubs or 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; wearing TEDs
NEURO: CNII-XII grossly intact, moves all extremities
Pertinent Results:
==============
ADMISSION LABS
==============
___ 11:40AM BLOOD WBC-11.6* RBC-2.92*# Hgb-8.5*# Hct-27.5*
MCV-94# MCH-28.9 MCHC-30.8* RDW-13.9 Plt ___
___ 11:40AM BLOOD Neuts-73.5* ___ Monos-5.0 Eos-1.6
Baso-0.8
___ 11:40AM BLOOD Glucose-136* UreaN-71* Creat-5.9*# Na-137
K-4.0 Cl-108 HCO3-14* AnGap-19
___ 11:40AM BLOOD ALT-13 AST-18 AlkPhos-62 TotBili-0.2
___ 11:40AM BLOOD Lipase-68*
___ 11:40AM BLOOD Albumin-3.7
___ 11:40AM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
___ 11:42AM BLOOD Lactate-0.9
==============
PERTINENT LABS
==============
Retic 1.8%, reticulocyte index
Vitamin B12 363*
Iron 40, Ferritin 215, TIBC 303
Haptoglobin 257
HbA1c 6.9%*
TSH 0.96
T4 3.1
PTH 207*
25OH Vitamin D 33
CRP 57.4*
ESR 106*
AM cortisol 18.4
ANCA negative
___ negative
Sjogren's (Ro, La) negative
ACTH wnl
Acetylcholine receptor ab negative
Renin wnl
Methylmalonic acid ___
Homocysteine 26.9*
Catecholamines pending
Paraneoplastic panel pending
Aldosterone pending
SPEP wnl
UPEP wnl
RPR negative
HCV Ab negative
==============
MIRCO
==============
___ 1:22 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ 11:33 pm SEROLOGY/BLOOD
**FINAL REPORT ___
RAPID PLASMA REAGIN TEST (Final ___:
NONREACTIVE.
Reference Range: Non-Reactive.
___ 4:00 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
==============
URINE STUDIES
==============
___ 01:22PM URINE Color-Straw Appear-Clear Sp ___
___ 01:22PM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-MOD
___ 01:22PM URINE RBC-1 WBC-2 Bacteri-FEW Yeast-NONE Epi-3
TransE-<1
___ 01:22PM URINE CastGr-4* CastHy-4*
___ 05:06AM URINE Hours-RANDOM UreaN-229 Creat-33 Na-91
K-14 Cl-92 TotProt-9 Prot/Cr-0.3*
___ 03:00PM URINE Porphob-NEGATIVE
___ 05:06AM URINE U-PEP-MULTIPLE P IFE-NO MONOCLO
Osmolal-302
___ 01:22PM URINE bnzodzp-POS barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
==============
IMAGING
==============
CT head without contrast ___: No acute findings.
EKG ___: Baseline artifact. Sinus rhythm with P-R interval
prolongation with notable U waves. Borderline left axis
deviation suggesting left anterior fascicular block. Slightly
delayed anterior R wave progression of uncertain significance.
Diffuse non-specific ST segment flattening in the inferolateral
leads. Prior anteroseptal myocardial infarction cannot be
excluded. Clinical correlation is suggested. No previous tracing
available for comparison.
CXR ___: No acute intrathoracic process.
EKG ___: Sinus rhythm. A-V conduction delay. Low limb lead
voltage. Delayed R wave transition. Compared to the previous
tracing of ___ no diagnostic interim change.
Renal US ___: Normal renal ultrasound.
TEE ___: EF 60-65%. Mild symmetric left ventricular
hypertrophy with preserved global and regional biventricular
systolic function. Normal diastolic function. No pathologic
valvular abnormality seen.
Carotid ultrasound ___: Less than 40% stenosis in the
bilateral carotid arteries with minimal atherosclerotic plaque.
Transcranial dopplers ___:
Mildly abnormal TCD evaluation.
1. There was no evidence of intracranial stenosis or
vertebrobasilar insufficiency. The vertebral arteries and
basilar
artery had normal mean velocities, normal waveforms, and
antegrade direction of blood flow.
2. This study was mildly abnormal due to below normal mean
velocities in the M2 segment of the right MCA, right proximal
MCA, and right PCA. This result may have been artifactual
secondary to operator dependent poor angle of insonation.
Another
possibility is that these low mean velocities could be related
to
low systemic blood pressure. Clinical correlation is needed.
==============
DISCHARGE LABS
==============
___ 07:15AM BLOOD WBC-8.2 RBC-2.84* Hgb-8.0* Hct-27.0*
MCV-95 MCH-28.3 MCHC-29.7* RDW-14.4 Plt ___
___ 07:15AM BLOOD Glucose-97 UreaN-30* Creat-4.0* Na-140
K-3.3 Cl-106 HCO3-24 AnGap-13
___ 07:15AM BLOOD Calcium-9.2 Phos-3.3 Mg-1.7
Brief Hospital Course:
Ms. ___ is a ___ woman with a past medical
history of CKD, CAD, DMII, AIP, bradycardia s/p pacemaker, and
orthostatic hypotension who presented to the ED with slurred
speech and dizziness with unstable gait, most likely due to
metabolic encephalopathy in the setting of acute on chronic
renal failure. Hospital course is outlined below by problem:
ACUTE ISSUES
=========================
# Acute metabolic encephalopathy: Patient presented to the ED
with slurred speech and unstable gait, initially concerning for
a CVA. CT head was w/o acute intracranial process. Neurology
evaluated the patient and thought her presentation was most
consistent with a metabolic process, as she had no focal
deficits on exam. She was found to be uremic and academic in the
setting of ___. Please read below for ___ management and workup.
She reported using benzodiazepines and opioids for her anxiety
and pain, but had not taken more than prescribed. Her workup
consisted of normal thyroid function, normal calcium, negative
RPR, and negative urine PBG. Her B12 level was low normal.
Homocysteine and MMA levels returned after discharge and were
elevated. A brain MRI was not performed due to her pacemaker.
Transcranial dopplers did not show evidence of vertebrobasilar
insufficiency, however did show below normal mean velocities in
the right MCA region. Ultimately, her encephalopathy was
attributed to uremia, acidemia, and possibly a medication effect
in the setting of impaired creatinine clearance. Her slurred
speech and gait significantly improved with hydration and
decreasing her benzodiazepines and opioids. She was started on
thiamine 100 mg daily given her past history of alcoholism.
# Acute on chronic renal failure: CKD III at baseline Cr 1.45
reported in ___. She was thought to have developed ___ in
the setting of pre-renal azotemia from hypovolemia, as patient
reported a week long history of nausea, vomiting, and diarrhea
before presentation. Patient was also hypotensive with BP ___ on
arrival. Her Cr on admission was 5.9 with a BUN in the ___.
Urine was notable for granular casts. FeNa was approximately 9%.
She received IVF with improvement of her Cr to 4.0-4.4, but
renal function did not return to baseline. Renal US did not show
hydronephrosis or atrophic kidneys. SPEP and UPEP were normal.
Nephrology suspected a renal salt wasting syndrome given the
elevated FeNa. Nephrology recommended continuing the workup as
an outpatient which will include a renal biopsy.
# Orthostatic hypotension: Patient reported that she once had
poorly controlled hypertension, however eventually developed
orthostatic hypotension of unclear etiology. She was on
midodrine in the past however did not tolerate the medication
well. On admission, she was noted to be hypotensive which was
attributed to hypovolemia from poor PO intake. She was fluid
resuscitated, however continued to complain of orthostasis
despite adequate hydration. Neurology was consulted and
recommend initiating an autonomic workup. TSH was wnl. B12 was
low normal, with elevated homocystine and MMA (which returned
after discharge). AM cortisol was normal. ESR and CRP were
elevated. Paraneoplastic panel was sent and was pending at the
time of discharge. Carotid ultrasound was negative. TTE showed
mild LVH but otherwise was normal. EP was consulted as her HR
was noted to not increase with standing. The lower limit of her
pacemaker was increased from 60 to 70 BPM. Patient was started
on fludrocortisone, however she refused the medication and
preferred to increase her fluid and salt intake. Neurology
recommended outpatient tilt table testing. ___ was consulted and
recommended discharge home with ___. Workup will continue in the
outpatient ___ clinic. Of note, patient was not
discharged on B12 repletion (as her MMA and homocysteine were
pending), however would recommend initiating B12 repletion as an
outpatient.
# Acute on chronic nausea: Patient reports having had nausea at
baseline, however presented with acute worsening of her chronic
symptoms, which was attributed to a viral gastroenteritis.
Patient received Zofran and low dose Ativan with good effect.
Reglan did not help her symptoms. Started omeprazole 20 mg daily
given history of gastritis. Patient was able to tolerate POs
prior to discharge, however needed anti-emetics to assist with
intake. Chronic nausea may be a manifestation of an autonomic
neuropathy, however still unclear. Recommend outpatient EGD and
gastric emptying study.
# Normocytic anemia: Presented with a Hct of 27.5 from a
baseline of 35. There was no report of acute blood loss. Stool
guiac was negative. Hemolysis was thought to be unlikely with
normal LDH, Tbili, and elevated haptoglobin. SPEP/UPEP were
normal. Iron panel was within normal limits. B12 was low normal,
however homocysteine and MMA were elevated (results returned
after discharge). Retic index of 0.8, indicating poor bone
marrow response to her anemia. Anemia was attributed to acute on
chronic kidney disease and anemia of inflammation. Recommend
initiating B12 repletion as an outpatient.
# Acidosis: anion-gap acidosis on admission was attributed to
uremia. Continued to have a non-anion gap hyperchloremic
acidosis during the rest of her hospitalization which was
attributed to renal failure and fluid resuscitation with normal
saline.
CHRONIC ISSUES
=======================
# Anxiety/MDD: Patient reported feeling depressed. Denies SI/HI.
Social work was consulted. Continued escitalopram. Held home
buspar while in house. Decreased Ativan dose to 0.25 mg.
# Gout: allopurinol was changed to 100 mg every other day.
# CAD: no h/o stents. Patient did not tolerate aspirin well in
the past. Currently on Plavix and statin daily. Held plavix on
discharge in anticipation for renal biopsy. Plavix should be
restarted after biopsy.
# DMII: diet controlled. Placed on SSI.
# Sick sinus syndrome s/p pacemaker: EP was consulted due to
orthostatic hypotension. Lower rate of pacemaker was increased
from 60 to 70 BPM.
TRANSITIONAL ISSUES
=========================
- NEW MEDICATIONS: thiamine 100 mg daily, Zofran 4 mg PO q8h prn
nausea, omeprazole 20 mg daily
- CHANGED MEDICATIONS: decreased ativan from ___ mg QD to 0.25
mg q8h prn anxiety or nausea; decreased allopurinol from 100 mg
daily to 100 mg QOD; decreased oxycodone from 5 mg PO to 2.5 mg
PO q8h prn pain
- DISCONTINUED MEDICATIONS: held clopidogrel on discharge for
renal biopsy this week; held tricor due to concern for ___
- Repeat labs (CBC, CMP) performed within ___ days after
discharge. Also will need EKG for QTc monitoring while on
zofran.
- Homocysteine and MMA were elevated (results returned after
discharge). Recommend initiating B12 repletion.
- Continue workup for chronic nausea as outpatient: consider
performing EGD and gastric motility study
- Continue orthostatic hypotension w/u as outpatient which
should include tilt table testing
- Continue PO hydration at home
- Pending labs at discharge: paraneoplastic autoAb panel,
catecholamies, aldosterone
- Recommend f/u with outpatient psychiatrist for depression
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Tricor (fenofibrate nanocrystallized) 145 mg oral daily
2. Atorvastatin 40 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. BusPIRone Dose is Unknown PO DAILY
5. Escitalopram Oxalate 5 mg PO DAILY
6. Allopurinol ___ mg PO DAILY
7. Temazepam Dose is Unknown PO HS:PRN anxiety
8. Lorazepam ___ mg PO DAILY:PRN anxiety
Discharge Medications:
1. Allopurinol ___ mg PO EVERY OTHER DAY
2. Atorvastatin 40 mg PO DAILY
3. Escitalopram Oxalate 5 mg PO DAILY
4. Temazepam 15 mg PO HS:PRN insomnia
5. Acetaminophen 650 mg PO Q6H:PRN pain
RX *acetaminophen 650 mg 1 tablet(s) by mouth every 6 hours as
needed for pain Disp #*28 Tablet Refills:*0
6. BusPIRone 5 mg PO DAILY
7. Outpatient Lab Work
Acute renal failure, anemia
ICD 9 584.9, 285.9
Please obtain CBC and complete metabolic panel on ___. Fax
results to PCP ___ at fax ___ and to Dr. ___
___
8. Thiamine 100 mg PO DAILY
RX *thiamine HCl 100 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
9. Lorazepam 0.25 mg PO Q8H:PRN anxiety/nausea
RX *lorazepam [Ativan] 0.5 mg 0.5 (One half) tablet by mouth
every 8 hours as needed for nausea or anxiety Disp #*21 Tablet
Refills:*0
10. OxycoDONE (Immediate Release) 2.5 mg PO Q6H:PRN pain
11. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
12. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth q8h prn nausea Disp
#*21 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis: acute kidney injury
Secondary diagnosis: metabolic encephalopathy, orthostatic
hypotension, nausea, anemia, acidosis, depression, bradycardia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
It was a great pleasure taking care of you here at ___. You
were admitted for your slurred speech and unstable gait. The
neurologists evaluated you and believed that your symptoms were
most likely due to metabolites from your renal failure, severe
dehydration, and possibly from some of your medications. We
obtained a CT head which was normal. We were unable to perform
an MRI to further look at your brain tissue due to your
pacemaker.You were also admitted because of acute kidney injury.
We also worked up your kidney failure and had our nephrologists
evaluate you. We believe that your kidney failure was due to
severe dehydration, as your kidney function improved with
fluids. However, your creatinine was still elevated at discharge
and you will likely need a kidney biopsy when you leave the
hospital. We were concerned about your orthostatic hypotension,
as low blood pressure can be harmful to your kidneys. We sent
off a number of tests to work up your hypotension and the
majority were pending at the time of your discharge. The
cardiologists increased your pacemaker rate from 60 to 70 beats
per minute, since this can help your low blood pressure. We
performed an ultrasound of your heart which was normal. We also
performed an ultrasound of your carotid arteries in your neck
which did not show stenosis (or narrowing) or the carotid
arteries. Your nausea was also difficult to control and we
provided you with Zofran to take at home as needed.
Please remember to hold plavix when you go home until kidney
biopsy. Talk to your kidney doctor about when to restart plavix
if they decide to not go forward with biopsy. You also have
labs due on next ___. Dr. ___ call you and give
you further instructions next week as well.
Please continue to stay hydrated at home. Like we discussed, we
would also recommend that you try to consolidate your care into
one medical system. Doing this will help your doctors ___
understand your medical history. If you want to establish care
with a primary care doctor at ___ you can call our internal
medicine clinic (called ___ "Healthcare Associates") at
___.
We wish you the best,
Your ___ Team
Followup Instructions:
___
|
19558175-DS-14
| 19,558,175 | 24,829,055 |
DS
| 14 |
2114-11-05 00:00:00
|
2114-11-06 06:33:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Agitation
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ female patient presented to the emergency department
with altered mental status since 6 ___ on ___. Of note she was
alone in the ICU and could not relay a history so the bulk of
this history was obtained via chart review
Ms. ___ presented to the ED with her 2 cousins. Her
family reported that she went camping yesterday with friends.
She took ___ of a tablet of LSD at 2 ___ yesterday. There may
have been co-ingestion of marijuana. Since yesterday at 6 ___ she
has been very agitated and altered. Reportedly she has been
screeming loudly, and expressing concerns that she is going to
die or is already dead. She has used LSD in the past without
this affect. She may have also used weed per family. Per report
she has no history of psychiatric illnesses. The other friends
who did LSD yesterday have not had this response. Her friends
note that she will intermittently have a depressed mood.
ED Course notable for: Upon arrival she was tachycardic to the
150s,agitated and aggressive, requiring security at bedside and
multiple doses of IV Ativan for sedation (14 mg total). She was
intermittently tachypneic to the ___, but remained with a stable
BP, afebrile, and sating >98% on room air. She received 1 L of
NS for tachycardia and dehydration and 700 mg of acyclovir.
Toxicology was consulted and TSH (2.7), urine tox, serum tox
(negative for ASA, ETOH, acetaminophen and tricyclics). CK 582.
Labs were notable for a low bicarb of 19 and an anion gap of 21.
On arrival to the MICU, the patient was sedated and in
restraints. Of note a tampon was removed, which had been in
place for an unknown duration. She was disoriented and speaking
non-sensical sentences, repeatedly saying "You can't cure this"
and "you're lying" in ___. She was hemodynamically stable,
but intermittently tachycardic to the 150s
Past Medical History:
Acne
Social History:
___
Family History:
Unknown.
Physical Exam:
===============
ADMISSION EXAM:
===============
VITALS: Reviewed in metavision
GENERAL: Lying in bed, appears dazed
HEENT: Face symmetric, no scleral icterus, pupils symmetric and
constrict 5-->2 briskly, dried lipstick or blood? on teeth
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Fast rate, regular rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, no clubbing, cyanosis or edema
SKIN: Bruises bilaterally on the anterior shins
NEURO: Could not be performed as patient was not cooperative,
aside from mental status no focal deficits were noted in her
facial and body movement
===============
DISCHARGE EXAM:
===============
VITALS: Reviewed in metavision
GENERAL: Lying in bed, tearful
HEENT: Face symmetric, no scleral icterus, PERRL
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Fast rate, regular rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, no clubbing, cyanosis or edema
SKIN: Bruises bilaterally on the anterior shins
NEURO: Pt can relay events of yesterday without difficulty. No
gross neurologic defects.
Pertinent Results:
===============
ADMISSION LABS:
===============
___ 10:56AM BLOOD WBC-19.2* RBC-4.29 Hgb-13.1 Hct-38.7
MCV-90 MCH-30.5 MCHC-33.9 RDW-13.3 RDWSD-43.3 Plt ___
___ 10:56AM BLOOD Neuts-84.1* Lymphs-8.3* Monos-7.0
Eos-0.0* Baso-0.2 Im ___ AbsNeut-16.16* AbsLymp-1.60
AbsMono-1.35* AbsEos-0.00* AbsBaso-0.04
___ 10:56AM BLOOD Glucose-107* UreaN-13 Creat-0.8 Na-143
K-4.5 Cl-103 HCO3-19* AnGap-21*
___ 10:56AM BLOOD ALT-15 AST-32 CK(CPK)-582* AlkPhos-45
TotBili-0.4
___ 10:56AM BLOOD Albumin-4.4 Calcium-9.7 Phos-3.5 Mg-1.7
___ 10:56AM BLOOD TSH-2.7
___ 10:56AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
=====================
OTHER PERTINENT LABS:
=====================
___ 03:31AM BLOOD TSH-1.2
___ 03:31AM BLOOD ASA-NEG Acetmnp-NEG Tricycl-NEG
===============
DISCHARGE LABS:
===============
___ 02:24AM BLOOD WBC-7.9 RBC-4.11 Hgb-12.6 Hct-38.2 MCV-93
MCH-30.7 MCHC-33.0 RDW-13.8 RDWSD-47.0* Plt ___
___ 02:24AM BLOOD Glucose-103* UreaN-8 Creat-0.6 Na-143
K-3.9 Cl-107 HCO3-23 AnGap-13
___ 02:24AM BLOOD ALT-18 AST-22 LD(LDH)-213 CK(CPK)-378*
AlkPhos-42 TotBili-0.2
___ 02:24AM BLOOD Calcium-8.9 Phos-3.5 Mg-1.9
======
MICRO:
======
___ Blood culture x2 - no growth at time of discharge
========
IMAGING:
========
___ CXR
Bilateral opacities concerning for multifocal pneumonia.
Increased density along the left mediastinum for which a CT
chest should be performed for further evaluation.
___ CT CHEST
Findings consistent with multifocal pneumonia. Confluent
consolidation along the mediastinal aspect of the left lower
lobe may account for apparent mediastinal widening on recent
chest radiograph.
Brief Hospital Course:
Ms. ___ is a ___ woman with acne who presented to
the ___ ED after 24 hours of agitation. Upon arrival she was
tachycardic to the 150s & tachypneic to the ___, agitated and
aggressive, requiring security at bedside and multiple doses of
IV Ativan for sedation (14 mg total). Toxicology was consulted
given concerns for ingestion. The patient was admitted to the
MICU for further stabilization.
# Toxic Metabolic Encephalopathy
# LSD/marijuana Toxicity
On arrival to the MICU, the patient was sedated and in
restraints. Of note a tampon was removed, which had been in
place for an unknown duration. She was disoriented and speaking
non-sensical sentences, repeatedly saying "You can't cure this"
and "you're lying" in ___. She admitted ingestion of LSD and
marijuana prior to presentation (see HPI for full details, other
serum and urine toxicology screen negative). She was started on
a dexmedetomidine drip for sedation to which she responded to
well. The morning of ___, the dexmedetomidine drip was stopped
and the patient's mental status improved. She was going to be
discharged on hospital day 2, but she again acutely
decompensated and again began yelling in ___ that she was
dead or that people were particular. She repeatedly said "the
lie was that I want to commit suicide."
At that time, sSe was restarted on dexmedetomidine drip, and the
Psychiatry service was consulted for management. Psychiatry and
Toxicology agreed that the patient's symptoms were most
consistent with substance-induced psychosis, although it was
unclear if the 'substance' was LSD and/or potentially synthetic
marijuana (K2). The patient was managed supportively with PRN
lorazepam. She briefly required dexmedetomidine infusion to be
restarted. Per the Psychiatry service, she was started on Haldol
2mg BID with good effect. On ___, day of discharge, Ms. ___
appeared significantly improved with regard to her mood,
cognition, and self-awareness. She had had no further episodes
of significant agitation on the day of discharge. After
discussion with the patient and with her mother (HCP), Ms.
___ was discharged with close monitoring (she was going to
stay with her mother), and out-patient Psychiatry follow-up
already arranged in pt's home in ___. The patient and her
family were counseled about need for continual close monitoring
and low threshold to return to the ___ ED if any
decompensation. They all endorsed understanding of this plan, of
the post-discharge instructions, and they all endorsed comfort
with this plan at the time of discharge.
# Elevated CK
Pt was also noted to have an elevated CK soon after admission
(___) which was thought to be due to mild rhabdomyolysis from
violent behavior prior to admission, in the setting of
psychosis. She was hydrated with down-trending CKs, CK was 378
on day of discharge.
# Concern for Multifocal PNA
Pt had a chest x-ray done after admission to look for signs of
infection, and the chest x-ray unexpectedly demonstrated
"multifocal pneumonia and widened mediastinumP per the Radiology
service's impression. Follow-up CT chest with contrast was
performed, which demonstrated "confluent consolidation along the
mediastinal aspect of the left lower lobe may account for
apparent mediastinal widening on recent chest radiograph." Ms.
___ was initially started on ceftriaxone and azithromycin in
response to these radiographic findings; however, as she had no
fever, no leukocytosis, no hypoxia, and no clinical signs
or symptoms of pneumonia, antibiotics were subsequently
stopped. She had no pulmonary complications throughout her
hospitalization.
====================
TRANSITIONAL ISSUES:
====================
- Patient was started on Haldol 2mg BID:PRN on DC home, with
close instructions to return to ___
- Patient will require close psychiatry f/u upon discharge for
intermittently fluctuating mental status
================================================================
# CODE STATUS: Full
# CONTACT: ___, mother, ___ ___ cell)
Medications on Admission:
Isotrentoin
Discharge Medications:
1. Haloperidol 2 mg PO BID:PRN agitation
RX *haloperidol 2 mg 1 tablet(s) by mouth BID:PRN Disp #*10
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY
=======
LSD Toxic Ingestion
Elevated CK
Toxic-Metabolic Encephalopathy
Discharge Condition:
Good
Condition: good
Mental status: awake and alert
Ambulation: independent
Discharge Instructions:
Dear ___,
You were admitted to the hospital because you were very
agitated. We think this was a bad reaction that you had after
taking LSD. We gave you medications to help you calm down until
the LSD had passed through your system. We recommend that you
don't take LSD in the future.
While you were here we noticed that a substance in your blood,
called creatine kinase, was elevated. This was most likely
because you were working your muscles very hard while you were
agitated. We gave you fluids and your levels came down a lot.
Please make sure to stay hydrated and drink lots of fluids once
discharged. Please also make sure to come back to the hospital
if you have any worsening agitation. We would recommend that you
are watched continually by a friend or family member over the
next few days to ensure you are safe.
It was our pleasure taking care of you.
Salud!!!
Your ___ MICU team
Followup Instructions:
___
|
19558203-DS-11
| 19,558,203 | 29,546,678 |
DS
| 11 |
2134-03-24 00:00:00
|
2134-03-25 21:32:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
hydrochlorothiazide
Attending: ___
Chief Complaint:
DYSPNEA ON EXERTION
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ w/ PMH of HTN on lisinopril who presents from her PCP's
office complaining of dyspnea on exertion. Last night she took
two 5 hour long connecting flights from ___ to ___. Upon
arriving in ___ she noticed that she was short of breath
while walking about half a block. She also noticed that when she
attempted to go upstairs in her apartment building she became
exhausted and short of breath, requiring her to rest at every
flight of stairs. She was previously able to walk much greater
distances without any problems as well as climb at least two
flights of stairs without getting short of breath. She denies
any headache, chest pain, palpitations, cough, nausea, vomiting,
or current lower extremity edema. She does not have any prior
history of blood clots.
In the ED initial vitals were: T 98.2 HR 76 BP 144/98 RR 19
O2Sat 96% RA.
Her ED exam is significant for a pleasant, well-appearing woman,
in no apparent distress. Her cardiac exam revealed tachycardia
to ~100s on auscultation but otherwise no murmurs, rubs,
gallops. Her pulmonary exam did not reveal any rales, rhonchi,
or wheezes. Her abdominal exam was unremarkable. She did not
have lower extremity edema but did have some superficial
varicosities.
-EKG: Sinus rhythm with HR of 90 bpm, lateral lead nonspecific
T-wave abnormalities and ST depressions, left anterior
fascicular block. Unclear if changed from prior, pending atrius
records.
-Labs/studies notable for: CHEM7, CBC, coags WNL. BNP 901 (not
clearly negative but diagnostic threshold of >1800 suggested in
patients age >___ for aCHF), Troponin 0.03, D-dimer 5175.
CXR unremarkable
CTPA showing bilateral lobar and segmental PE with early
evidence of R heart strain.
Patient was given: ASA 325mg PO, heparin gtt @ 1100 units/hr.
MASCOT TEAM was consulted, and will not be involved at this
time.
-Vitals on transfer: 98.5 93 170/85 19 95% RA
On the floor, she states that she is now comfortable but
presumes it is due to inactivity. If she were to get up and
walk around she thinks she would likely get SOB. Denies cough,
chest pain, abdominal pain, nausea/vomiting, diarrhea, dysuria.
Past Medical History:
-HTN
-osteoporosis
-uterine prolapse, w/ pessary
-colonic adenoma
-hypercalciuria
Social History:
___
Family History:
Aunt with ___ for unknown reasons
Physical Exam:
ADMISSION PHYSICAL EXAM:
=========================
Tele: NSR 60-70s,
VS: T97.5 (tmax 98.5) BP110/47 (110-120s/4080s) HR76 (40-80)
RR20-26 O2 sat 96-97%RA
Weight:60.9
GENERAL: AOx4, NAD
HEENT: pupils are minimally reactive as she appears to have
cataracts
NECK: Supple with JVP at clavicle
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. S3 gallops. No thrills, lifts.
LUNGS: CTAB, no wheezes, rales, rhonchi
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric
DISCHARGE PHYSICAL EXAM:
========================
VS: 97.7 126/83 91 26 97RA
Wt 60.9
GENERAL: AOx4, gets slightly SOB when speaking
HEENT: pupils are minimally reactive as she appears to have
cataracts
NECK: Supple with JVP at base of neck when sitting up
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No murmurs/rubs/gallops. No thrills,
lifts.
LUNGS: slight crackles noted bilaterally
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric
Pertinent Results:
LABS ON ADMISSION:
==================
___ 12:34PM WBC-5.9 RBC-4.61 HGB-13.5 HCT-41.5 MCV-90
MCH-29.3 MCHC-32.5 RDW-14.0 RDWSD-46.3
___ 12:34PM GLUCOSE-97 UREA N-10 CREAT-0.7 SODIUM-136
POTASSIUM-4.6 CHLORIDE-102 TOTAL CO2-24 ANION GAP-15
___ 12:34PM ___ PTT-32.2 ___
___ 12:34PM proBNP-901*
___ 12:34PM cTropnT-0.03*
___ 12:34PM BLOOD D-Dimer-5175*
STUDIES:
========
EKG: SR @ 90, L axis, TW flattening I, II, III, V4 and TWI
V5-V6
2D-ECHOCARDIOGRAM:
Overall left ventricular systolic function is normal (LVEF>55%).
RV with normal free wall contractility. The ascending aorta is
mildly dilated. Mild (1+) aortic regurgitation is seen.
Physiologic mitral regurgitation is seen (within normal limits).
The tricuspid valve leaflets are mildly thickened. There is no
pericardial effusion.
CTPA:
1. Extensive bilateral pulmonary embolism with probable right
heart strain.
Please correlate clinically.
2. Ectasia of the ascending aorta measuring up to 3.9 cm in
diameter.
MICRO:
======
none
LABS ON DISCHARGE:
==================
___ 05:02AM BLOOD WBC-6.1 RBC-4.24 Hgb-12.4 Hct-39.0 MCV-92
MCH-29.2 MCHC-31.8* RDW-14.1 RDWSD-47.5* Plt ___
___ 05:02AM BLOOD Glucose-80 UreaN-13 Creat-0.7 Na-140
K-3.6 Cl-100 HCO3-27 AnGap-17
Brief Hospital Course:
___ is an ___ w/ HTN presenting with dyspnea on exertion
after two consecutive long-haul flights and a history of
extensive airline travel in the past 6 months. Patient was noted
to have D-dimer 5175, Trop 0.03, proBNP 901, EKG with TW
flattening I, II, III, V4 and TWI V5-V6. CTPA revealed bilateral
lobar and segmental pulmonary emboli. Echocardiogram did not
reveal any evidence of heart strain despite elevation in BNP.
Patient was started on heparin drip overnight, and transitioned
to Apixaban. Her symptoms improved during the hospitalization,
and on ___ she was able to ambulate without shortness of breath
and desaturation.
TRANSITIONAL ISSUES:
=====================
[ ] F/U with Dr. ___ on ___ (appointment already in
place)
[ ] Take apixaban 10 mg twice daily for 7 days (___), then
on ___ transition to 5 mg twice daily for ___ months.
#CODE: presumed Full
#CONTACT: ___ (husband) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 10 mg PO QHS
2. Alendronate Sodium 70 mg PO QSUN
3. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Apixaban 10 mg PO BID Duration: 7 Days
RX *apixaban [Eliquis] 5 mg 2 tablet(s) by mouth twice daily
Disp #*44 Tablet Refills:*0
2. Alendronate Sodium 70 mg PO QSUN
3. Lisinopril 10 mg PO QHS
4. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
==================
pulmonary embolism
Secondary diagnosis:
====================
hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure being a part of your care during your
hospitalization at ___!
Why were you hospitalized?
-Because you developed shortness of breath with minimal
exertion, which is new for you.
What was done for you this hospitalization?
-You had blood tests and a CT ('cat') scan of your chest that
showed you have a clot in the arteries that carry blood to your
lungs (a 'pulmonary embolism')
-You had an ultrasound of your heart that confirmed that the
clot was not making your heart work extra hard
-You were started on an iv medication and then transitioned to a
pill to keep your blood thin and prevent the clot from growing.
What should you do after you go home?
-You should continue to take your new medication called Eliquis
(Apixaban). Take 10 mg twice a day for 7 days (___), then
decrease the dose to 5 mg twice a day (starting ___. You
should take this medication for at least ___ months
-You should follow up with your primary care provider ___
___ as previously scheduled.
Followup Instructions:
___
|
19558325-DS-10
| 19,558,325 | 25,242,454 |
DS
| 10 |
2165-02-22 00:00:00
|
2165-02-22 16:13:00
|
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; Small bowel obstruction
Major Surgical or Invasive Procedure:
None; Conservative management of SBO by ___ decompression
History of Present Illness:
___ transferred from ___ for bowel obstruction. She is
a healthy woman who was in her usual health until approximately
2 days ago when she began to experience crampy abdominal pain
and bloating. She had one episode of emesis and tried pepto
bismol to no avail. She felt "full of gas" and was
unable to pass gas; she had a couple episodes of small hard
stool. She denies fevers but endorses chills and nausea. She
presented to ___ where a CT scan demonstrated a small
bowel obstruction, and she was transferred to ___ for
further management.
Past Medical History:
PMH: hyperlipidemia
PSH: hysterectomy for uterine fibroids, ___
Social History:
___
Family History:
positive for rectal cancer in father
Physical ___: VSS
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, nontender, no rebound or guarding,
normoactive bowel sounds, no palpable masses
DRE: normal tone, no gross or occult blood
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
___ 07:35AM BLOOD WBC-3.3* RBC-3.90* Hgb-12.0 Hct-35.0*
MCV-90 MCH-30.8 MCHC-34.3 RDW-12.4 Plt ___
___ 07:35AM BLOOD Plt ___
___ 07:35AM BLOOD Glucose-102* UreaN-6 Creat-0.5 Na-137
K-3.6 Cl-103 HCO3-27 AnGap-11
___ 07:35AM BLOOD Calcium-8.9 Phos-2.1* Mg-2.1
IMAGING:
___ - CT abd/pelvis (___): diffusely dilated loops of
small bowel consistent with small bowel obstruction; no evidence
of perforation; small amount of free fluid in pelvis
___ - KUB: Diffuse moderate dilatation of loops of small
bowel measuring up to 3.9 cm in a stepladder configuration with
multiple air-fluid levels on the upright radiograph is
compatible small bowel obstruction. Overall appearance is
moderately worse compared with the immediate prior CT. Stool is
seen within the large bowel, which has a normal gas pattern.
There is no free intraperitoneal air. Osseous structures are
unremarkable. An enteric tube ends within the decompressed
stomach.
Brief Hospital Course:
The patient presented to Emergency Department on ___. Pt
was evaluated by Upon arrival to ED patient was complaining of
abdominal pain. Pertinant imaging revealed a small bowel
obstruction. NGT was placed in ED with clear gastric contents
returned, ~400mL, and some relief of symptoms of pain and
distention. The patient was subsequently admitted. NGT
decompression IV hydration were done until patient regained
bowel function in the form fo passing flatus.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored.
GI/GU/FEN: The patient was initially kept NPO with a
___ tube in place for decompression. On ___, the
NGT was removed. Diet was advanced sequentially to a Regular
diet, which was well tolerated. Patient's intake and output were
closely monitored
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
None
Discharge Disposition:
Home
Discharge Diagnosis:
Small bowel obstructioin
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Thank you for choosing ___ for your care. You were evaluated
in the Emergency department for a small bowel obstruction. The
Acute Care Surgery team was consulted and you were admitted for
further managament. With conservative management your
obstruction has since resolved. You are safe to return home for
further recovery.
Please continue the medications that you were taking before
admission unless otherwise specified.
Followup Instructions:
___
|
19558645-DS-21
| 19,558,645 | 27,418,780 |
DS
| 21 |
2159-05-14 00:00:00
|
2159-05-14 20:54:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Sublingual Hematoma
Major Surgical or Invasive Procedure:
Nasotracheal intubation
History of Present Illness:
Mr. ___ is a ___ year old gentleman with a medical
history of AF on Coumadin and recent #17 tooth extraction who
presents with sublinqual hematoma necessitating nasal intubation
at OSH admitted to ___.
Past Medical History:
HTN
Gout
HLD
Osteoarthritis
Diverticulosis
Colonic Polyps
Hypothyroid
A-fib
MGUS - monoclonal gammopathy of unknown significance
___
Mild open angle glaucoma
Social History:
___
Family History:
Noncontributory
Physical Exam:
Admission Physical Exam
Head: atraumatic and normocephalic
Eyes: EOM Intact, PERRL
Ears: right ear normal, left ear normal, no external
deformities
Nose: straight septum, straight nose, non-tender, no epistaxis,
EOE: Mandible has full ROM, left lower
facial ___ edema, inferior border of mandible palpable, no TTP,
ecchymosis spanning length of left inferior border of mandible,
no
evidence of trismus
Neck: normal range of motion, supple, no JVD, and no
lymphadenopathy
IOE: significant b/l edema of tongue, FOM raised and
ecchymotic,
+ TTP. No active bleeding or bring red blood noted in the oral
cavity
CV: A-fib
Resp: CTAB, no wheezes, ronchi, rales
Neuro: AOx3, fully intact neuro exam, no deficits
Discharge Physical Exam:
VS: ___ ___ Temp: 98.8 PO BP: 135/83 HR: 66 RR: 18 O2 sat:
92% O2 delivery: RA
GENERAL: elderly man lying in bed, NAD
HEENT: EOMI, OP clear without evidence of obstruction.
NECK: dark purple ecchymosis on anterior aspect of neck and
platsyma without firmness, tracheal deviation, or stridor
HEART: irregularly irregular, normal rate, no murmurs, gallops,
or rubs.
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles.
ABDOMEN: soft, NTND
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose.
PULSES: 2+ DP pulses bilaterally.
NEURO: Aox3, no focal deficits
SKIN: warm and well perfused, no excoriations or lesions (other
than ecchymosis noted above), no rashes
Pertinent Results:
Admission Labs
---------------
___ 03:16AM BLOOD WBC-11.5* RBC-4.77 Hgb-14.6 Hct-45.5
MCV-95 MCH-30.6 MCHC-32.1 RDW-13.9 RDWSD-49.1* Plt ___
___ 03:16AM BLOOD Plt ___
___ 03:16AM BLOOD ___
___ 05:12AM BLOOD ___
___ 03:16AM BLOOD Glucose-151* UreaN-19 Creat-0.7 Na-142
K-3.7 Cl-103 HCO3-23 AnGap-16
___ 03:16AM BLOOD Calcium-8.1* Phos-2.1* Mg-2.0
___ 03:16AM BLOOD Calcium-8.1* Phos-2.1* Mg-2.0
___ 05:25AM BLOOD ___ pO2-133* pCO2-40 pH-7.38
calTCO2-25 Base XS-0
___ 05:25AM BLOOD Glucose-154* Lactate-1.4 Na-135 K-3.9
Cl-103
URINE CULTURE (Final ___: NO GROWTH.
Discharge Labs:
----------------
___ 07:30AM BLOOD WBC-9.3 RBC-4.40* Hgb-13.7 Hct-41.9
MCV-95 MCH-31.1 MCHC-32.7 RDW-13.9 RDWSD-49.1* Plt ___
___ 07:30AM BLOOD ___ PTT-26.0 ___
___ 07:30AM BLOOD Glucose-99 UreaN-13 Creat-0.6 Na-140
K-3.6 Cl-103 HCO3-23 AnGap-14
___ 07:30AM BLOOD Calcium-8.2* Phos-2.4* Mg-1.8
Imaging:
---------
Chest XRay ___:
IMPRESSION:
1. Endotracheal tube terminates 9 cm above the carina and should
be advanced for optimal positioning.
2. Severe bibasilar atelectasis raises concern for aspiration;
pneumonia
should be considered.
3. Small left pleural effusion.
CTA Neck ___:
IMPRESSION:
1. Left sublingual space hematoma measuring 51 x 30 x 24 mm,
abutting ___ 17 extraction bed with lingual cortex dehiscence.
No evidence for active
extravasation of contrast from the left lingual or facial
arteries.
2. Mild atherosclerosis. Approximately 30% stenosis of the
right ICA by
NASCET criteria and approximately 35-40% stenosis of the left
ICA by NASCET
criteria.
3. 2.7 cm partially calcified right thyroid nodule.
Chest XRay ___:
IMPRESSION:
Compared to chest radiographs since ___ most recently ___.
Moderate bibasilar consolidation, stable and probably
atelectasis on the
right, has increased substantially on the left. Findings raise
possibility of aspiration or developing left lower lobe
pneumonia. Upper lungs clear. Small pleural effusions are
likely. Borderline cardiac enlargement unchanged. No
pneumothorax.
ET tube in standard placement.
Brief Hospital Course:
Summary:
---------
Mr. ___ is a ___ year-old man with atrial fibrillation (on
warfarin), HTN, HLD, and gout, who was initially admitted to the
TSICU after being intubated for
airway protection in the setting of a left sublingual hematoma
following a tooth extraction with INR of 3.5. He was transferred
to medicine for monitoring after anticoagulation was restarted.
ACTIVE ISSUES:
===============================
# Sublingual hematoma / Acute Respiratory Failure (intubation
for airway protection):
The patient presented to OSH with a left sublinqual hematoma
causing difficulty swallowing and shortness of breath. He was
sedated with ketamine and a fiberobtic nasal intubation was
performed. He was subsequently transferred to ___ for
___ evaluation. His CTA showed a left sublingual hematoma 5cm x
3cm following a dental extraction in the setting of
supratherapeutic INR, and initially required fibrooptic
intubation for airway protection. The patient had an INR of 3.5
at the time of the tooth extraction, and was told to hold his
Coumadin for one day prior to the procedure. ___ did not feel
the patient following required additional surgical intervention
at this time. The pt was on low dose phenylephrine for part of
___ but was weaned off easily. On ___ the pt partially self
extubated but was deemed safe for full exubation. The pt was
safely extubated on ___ and continued to saturate well on room
air. He was cleared for resumption of warfarin from their
perspective. Upon discharge, the patient stated that his
hematoma was less firm, and non-tender.
# Atrial fibrillation: CHADS2-VASC2 of 3 (age, HTN).
The patient's cardiologist, Dr. ___ Atrius was contacted and
recommended resumption of warfarin pending clearance by ___,
which occurred on ___. The ___ clinic
was also contacted and recommended resumption of his prior
regimen; 2.5mg warfarin ___ and ___ and 1.25mg all other
days, and will check INR on ___. The patient's cardiologist also
preferred transition to metoprolol while inpatient. He started
metoprolol succinate 25mg PO daily after having rates of 60-80
on fractionated metoprolol 6.25 p6h. He will follow up with ___
___ at ___ on ___.
# HTN: continued home amlodipine 2.5mg, and HCTZ 25. Stopped
atenolol in favor of switching to metoprolol.
# Hypothyroidism: continue home levothyroxine 125 mcg. Please
see transitional issues for incidental thyroid nodule.
CHRONIC/STABLE ISSUES:
===============================
# HLD: continue simvastatin 20mg.
# Glaucoma: Continue latanoprost and Dorzolamide 2%/Timolol 0.5.
# Gout: Continued home allopurinol ___ daily
TRANSITIONAL ISSUES:
#Stopped Meds:
-Atenolol
#New Meds:
-Metoprolol Succinate 25mg PO daily
#Discharge INR: 1.1. He will follow up with ___ at
___. Next INR check should be on
___.
#Discharge HGB: 13.7
INCIDENTAL IMAGING FINDINGS:
#Thyroid Nodule: CTA of the head identified a 2.7 cm partially
calcified right thyroid nodule. Please follow up with
ultrasound.
#Approximately 30% stenosis of the right ICA by NASCET criteria
and approximately 35-40% stenosis of the left ICA by NASCET
criteria. ___ need high potency statin.
#CONTACT: wife ___
#CODE: full, confirmed
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Hydrochlorothiazide 25 mg PO DAILY
2. amLODIPine 2.5 mg PO DAILY
3. Allopurinol ___ mg PO DAILY
4. Simvastatin 20 mg PO QPM
5. Levothyroxine Sodium 125 mcg PO DAILY
6. Atenolol 100 mg PO DAILY
7. Warfarin 2.5 mg PO 2X/WEEK (MO,WE)
8. Warfarin 1.25 mg PO 5X/WEEK (___)
Discharge Medications:
1. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
2. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
3. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
4. Allopurinol ___ mg PO DAILY
5. amLODIPine 2.5 mg PO DAILY
6. Hydrochlorothiazide 25 mg PO DAILY
7. Levothyroxine Sodium 125 mcg PO DAILY
8. Simvastatin 20 mg PO QPM
9. Warfarin 1.25 mg PO 5X/WEEK (___)
10. Warfarin 2.5 mg PO 2X/WEEK (MO,WE)
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
------------------
-Hematoma
-Hypertension
-Atrial Fibrillation
Secondary Diagnosis:
Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure to take care of you at ___.
WHY WERE YOU HERE?
You were admitted to the hospital because you had bleeding in
your neck
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL
- While you were in the hospital you had a breathing tube to
protect your airway from the blood collection (hematoma)
WHAT SHOULD YOU DO WHEN YOU GET HOME?
1) Please follow up at your outpatient appointments.
2) Please take your medications as prescribed. See below for
medications that should be stopped and new medications that have
been started.
3) You will follow up with your ___ clinic on
___
We wish you the best!
Your ___ Care Team
IMPORTANT MEDICATION INFORMATION:
#Stopped Meds:
-Atenolol
#New Meds:
-Metoprolol Succinate 25mg PO daily
#Important Meds:
- 2.5mg warfarin ___ and ___ and 1.25mg warfarin all
other days
Followup Instructions:
___
|
19558897-DS-15
| 19,558,897 | 27,370,333 |
DS
| 15 |
2153-09-06 00:00:00
|
2153-09-06 17:14:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
wrist laceration
Major Surgical or Invasive Procedure:
___- LT wrist exploration, repair median nerve and ulnar
artery, flexor tendon repair
History of Present Illness:
___ year-old RHD male who has depression and h/o
suicide attempt with GSW to the mouth ___ years ago who around
2:30
this morning attempted suicide by cutting his left wrist twice.
He was evaluated at ___ and transferred to ___ for
evaluation. He has left wrist pain and finger numbness. He
states
he is still actively suicidal.
Past Medical History:
He states he has untreated AIDS, but brother at bedside states
he
is not aware of any documentation of this. ( and Negative
antiviral during this amission)
Social History:
___
Family History:
noncontribuatory
Physical Exam:
Discharge Physical Exam
Vitals: Temp 99.1 BP 122/84 HR 88 RR18 PO2 95 RA
Gen: NAD, AxOx3
Card: RRR, no m/r/g
Pulm: CTAB, no respiratory distress
Abd: Soft, non-tender, non-distended, normal bs.
Ext: No edema, warm well-perfused, left arm in a cast
Pertinent Results:
___ 06:23PM HIV Ab-NEG
___ 12:45PM WBC-12.6* RBC-4.34* HGB-13.1* HCT-41.1 MCV-95
MCH-30.2 MCHC-31.9* RDW-13.8 RDWSD-48.1*
___ 12:45PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
tricyclic-NEG
___ 12:59PM GLUCOSE-171* LACTATE-5.5* CREAT-2.2* NA+-142
K+-4.4 CL--109* TCO2-21
Trauma CXR ___
IMPRESSION:
No acute thoracic process. No fracture.
FOREARM (AP & LAT) LEFT; WRIST(3 + VIEWS) LEFT- ___
IMPRESSION:
No acute fracture or dislocation. Soft tissue defect overlying
the distal
left forearm consistent with history of laceration in this
location.
Brief Hospital Course:
Mr. ___ is a ___ year old male who was a transfer from ___
for self inflicted wrist lacerations. He received 1 unit of
packed red blood cells on transit to ___ for hypotension in
the ambulance, however, no further blood transfusions required
throughout this hospitalization He was taken to the operation
with hand surgery on ___ where he underwent a left wrist
exploration, repair of median nerve, ulnar artery and multiple
flexor tendons. He tolerated the procedure well, please see
operative report for additional details. After a brief PACU stay
he was transferred to the floor in stable condition where he
remained afebrile and hemodynamically stable.
Post operatively, He was advanced to a regular diet which he
tolerated. He did go on a " hunger strike" for HD 3 and was
started briefly on IVF to maintain hydration. The hunger strike
ended on HD 4. His pain was well controlled on oral medication,
requiring only oral tylenol. He was started on Aspirin 325 mg
per hand surgery request for a total 30 day course.
On POD 2, he was agitated and he removed his splint. He received
Olanzapine 10 mg IM for his agitation. His arm was re-wrapped.
Due to concern for compliance with the splint, the decision was
made to place a cast for 6 weeks. On POD 4, his arm was placed
in a cast by orthotec.
Throughout his hospitalization he was followed by psychiatry and
had a 1:1 sitter. He received olanzapine to 20mg PO QHS, as well
olanzapine 5mg PO BID:PRN for moderate agitation, Ativan 1mg
q4hr PRN for mild agitation, and olanzapine 10 mg IM for severe
agitation ( he only required one dose during this admission when
his splint was removed). Sertraline 50 mg was started on ___,
with the hope of slowly up titrating to his prior dose of 200 mg
. He was deemed medically cleared and stable for discharge to
inpatient psychiatry to continue his care.
At the time of discharge he was afebrile and hemodynamically
stable, tolerating a regular diet, his pain was well controlled
on oral medication, he was voiding adequately and spontaneously,
and he was deemed stable for discharge to continue his recovery.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
2. Aspirin 325 mg PO DAILY Duration: 30 Days
Please continue for 30 days ( until ___
3. Docusate Sodium 100 mg PO BID
4. LORazepam 1 mg PO Q4H:PRN mild agitation
5. OLANZapine 20 mg PO QHS
6. OLANZapine 10 mg IM DAILY:PRN severe agitation
7. OLANZapine 5 mg PO BID:PRN moderate agitation
8. Sertraline 50 mg PO DAILY
Discharge Disposition:
Extended Care
Discharge Diagnosis:
trauma
self inflicted wrist injuries
ulnar artery laceration
radial artery laceration
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital after self inflicted wrist
lacerations. You had your artery, nerve, and tendons in your
hand repaired by hand surgery. You have now recovered well from
surgery and are ready to be discharged to inpatient psychiatry
to continue your recovery. Please follow these instructions to
ensure a speedy recovery
Please follow up with hand surgery at the appointment listed
below.
You will have a cast on your arm for 6 weeks.
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 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 until your follow-up appointment.
*You may shower, and wrap your cast in a plastic bag to prevent
it from getting wet
Best Wishes,
Your ___ Surgery Team
Followup Instructions:
___
|
19559420-DS-24
| 19,559,420 | 23,412,926 |
DS
| 24 |
2128-04-07 00:00:00
|
2128-04-07 17:06:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Macrobid
Attending: ___
Chief Complaint:
confusion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old man with history of prostate cancer s/p radical
prostatectomy (___), s/p salvage XRT with rising PSA on Lupron,
with radiation cystitis, recurrent UTI and hematuria; also CKD
on HD and hypertension, who presented to the ED night of ___
with hematuria. He was evaluated by Urology, had hand irrigation
of clots and was briefly on CBI with clearing of urine. Foley
was removed. He was discharged morning of ___. He went to HD
following ED discharge and had a full normal run. After
dialysis, wife noted the patient to be confused. He could not
open the car door or figure out how to put his seatbelt on. He
was also noted to be stumbling and thus wife brought him back to
the ED ___ pm. She also noted that he had not voided since HD.
In the ED, initial VS were: 98.5, 123/58, 82, 16, 100%RA. Labs
were notable for normal WBC, H/H 11.4/36, plt 108, BUN/Cr
36/7.6, normal lactate, UA with lg blood/lg leuks. CT head
without any acute intracranial findings. He was given CTX for
presumed UTI. He was re-evaluated by Urology who noted bladder
scan with only 75cc urine, and recommended not to put in foley
and to avoid catheterization unless PVR >400cc. He continued to
be confused in the ED, thus was admitted for workup of
encephalopathy.
On the floor, patient denies being confused. He reports that he
was having trouble in the car last night because it was dark and
he could not see. He denies any lightheadedness, vision changes,
weakness, confusion.
ROS: Per HPI. Denies chest pain, back pain, SOB, abdominal pain,
dysuria, N/V. Denies fevers/chills.
Past Medical History:
Hypertension
History of MI status post angioplasty
CVA in ___
ESRD on HD (___)
Gout
Prostate cancer ___ ___ s/p robotic assisted laparoscopic
prostatectomy and salvage XRT for positive lateral margins, now
on Lupron for rising PSA
Partial nephrectomy for complex renal cyst ___
S/p cystoscopy with clot evacuation and fulguration ___
Arthritis
Depression
Social History:
___
Family History:
Pancreatic cancer. Denies any history of kidney disease or
prostate cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals- 98.3, 158/82, 79, 16, 98%RA
General- Alert, oriented x3, no acute distress.
HEENT- Sclerae anicteric, dry mucous membranes, oropharynx clear
Neck- supple, no JVD, no LAD
Lungs- Clear bilaterally
CV- Regular rhythm, systolic murmur LUSB
Abdomen- soft, NT/ND bowel sounds present, no suprapubic
tenderness
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, ___ and ___ strength ___. Slow to
answer, but appropriate responses. ___ backwards. No
asterixis
DISCHARGE PHYSICAL EXAM:
Vitals: Tm 99.1/Tc 98.0, 172/73 (115-197/66-89), 79 (45-80), 18,
98%RA, 87.4kg
General- Alert, oriented x3, no acute distress.
HEENT- Sclerae anicteric, moist mucous membranes, oropharynx
clear
Neck- supple, no JVD, no LAD
Lungs- Clear bilaterally
CV- Regular rhythm, systolic murmur LUSB
Abdomen- soft, NT/ND bowel sounds present, no suprapubic
tenderness
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. LUE fistula with good thrill/bruit
Neuro- CNs2-12 intact, ___ and ___ strength ___. ___
backwards. Fluent speech, responses appropriate
Pertinent Results:
ADMISSION LABS:
___ 10:50PM BLOOD WBC-7.4 RBC-3.82* Hgb-11.4* Hct-36.1*
MCV-95 MCH-29.8 MCHC-31.6* RDW-15.9* RDWSD-55.2* Plt ___
___ 10:50PM BLOOD Neuts-49.6 ___ Monos-12.1 Eos-2.7
Baso-0.3 Im ___ AbsNeut-3.69 AbsLymp-2.60 AbsMono-0.90*
AbsEos-0.20 AbsBaso-0.02
___ 10:50PM BLOOD Glucose-120* UreaN-36* Creat-7.6*# Na-140
K-4.2 Cl-93* HCO3-32 AnGap-19
DISCHARGE LABS:
___ 06:33AM BLOOD Calcium-9.1 Phos-5.9*# Mg-2.4
___ 06:33AM BLOOD WBC-5.8 RBC-3.43* Hgb-9.9* Hct-32.1*
MCV-94 MCH-28.9 MCHC-30.8* RDW-15.7* RDWSD-54.0* Plt ___
___ 06:33AM BLOOD Glucose-98 UreaN-63* Creat-10.5*# Na-137
K-4.4 Cl-93* HCO3-28 AnGap-20
IMAGING:
CT Head
IMPRESSION:
1. There is no CT evidence for acute territory infarct. No
intracranial hemorrhage.
2. When compared to prior exam there is a new prominent calcific
density at the right MCA bifurcation, most compatible with
atherosclerotic calcification.
3. Given interval development since prior examination of ___,
clinical correlation with patient's symptoms is recommended. If
there no contraindications, MRI MRA brain could be performed for
further evaluation.
RECOMMENDATION(S): Given interval development of prominent
calcification at the expected location of the right MCA
bifurcation since prior examination of ___, clinical
correlation with patient's symptoms is recommended. If there no
contraindications, MRI MRA brain could be performed for further
evaluation for progressive vascular disease.
Brief Hospital Course:
___ year old man with history of prostate cancer s/p
prostatectomy and XRT, on Lupron, c/b radiation cystitis,
recurrent UTI and hematuria; also CKD on HD and hypertension,
who presented with acute encephalopathy after HD.
#Acute encephalopathy: Unclear etiology, likely delirium though
without clear trigger. CT head negative for acute process and
exam non-focal. Occurred after HD so unlikely uremia. Possible
fluid shifts and hypoperfusion post-HD. Improved by time of
admission and further cleared overnight. He was evaluated by ___
for concern of unsteady gait, and was deemed to be stable for
discharge home.
#Hematuria: Recurrent issue due to prostatectomy and radiation
cystitis. He received hand irrigation and brief CBI in the ED.
He was evaluated by Urology who recommended avoiding
catheterization if possible. Hematuria cleared through the
admission. His UA was consistent with hematuria, thus he was not
treated for UTI. He should follow up with ___ clinic.
#Continued on all home meds for other chronic issues that were
stable throughout stay.
TRANSITIONAL ISSUES:
- F/u with ___ clinic regarding hematuria
- f/u MRI recommended on non-urgent basis for interval
development of R MCA calcification on head CT
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Docusate Sodium 100 mg PO BID
2. PhosLo (calcium acetate) 1134 mg oral TID
3. ___ Caps (B complex with C#20-folic acid) 1 mg oral DAILY
4. Acetaminophen 1000 mg PO Q6H:PRN pain
5. Vitamin D ___ UNIT PO QOWEEK
6. Metoprolol Succinate XL 100 mg PO 4X/WEEK (___)
7. Nortriptyline 10 mg PO QHS
8. Simvastatin 20 mg PO QPM
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN pain
2. Docusate Sodium 100 mg PO BID
3. Metoprolol Succinate XL 100 mg PO 4X/WEEK (___)
4. Nortriptyline 10 mg PO QHS
5. Simvastatin 20 mg PO QPM
6. PhosLo (calcium acetate) 1134 mg oral TID
7. ___ Caps (B complex with C#20-folic acid) 1 mg oral DAILY
8. Vitamin D ___ UNIT PO QOWEEK
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
Acute encephalopathy
Hematuria
Hypertension
SECONDARY:
History of prostate cancer
End stage renal disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
It was a pleasure taking care of you at ___
___. You were admitted because of confusion. It is
unclear why this occurred, but you improved throughout the
admission. You were evaluated by Physical Therapy who thought
that you were safe to go home.
You also had blood in your urine. You were evaluated by Urology.
They did not feel that you needed a catheter. The blood in urine
improved while you were here. Please follow up with your
urologist, Dr. ___.
We wish you the best in health,
- your ___ team
Followup Instructions:
___
|
19559427-DS-21
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DS
| 21 |
2180-06-08 00:00:00
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2180-06-08 20:44:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Morphine
Attending: ___.
Chief Complaint:
left foot pain and numbness
Major Surgical or Invasive Procedure:
left femoral endarterectomy with left iliac stent placement
(___)
heart catheterization (___)
History of Present Illness:
___ w PVD, hx of L fem-AK pop bypass and b/l lower extremity
claudication who presents with acute L foot pain in the setting
of ___ months of worsening L calf/foot claudication.
Pt notes that yesterday morning was having severe left calf/foot
claudication walking to work associated with foot numbnesss
around 9am, which lasted approximately ___ minutes - he
reports
the pain was much more severe than his previous symptoms of
claudication, while the numbness was completely new. However
after sitting down at his desk the pain and numbness completely
resolved and he was able to work all day with no issues. His
symptoms recurred at ~9pm last night (~18 hours ago), with acute
onset left foot pain and numbness that remained constant
throughout the night. Also noticed the foot and toes feeling
much
cooler. Was still able to ambulate but this morning noted the
foot felt much stiffer and subsequently presented to the ER.
He currently denies any chest pain, dyspnea, or abdominal pain.
ROS:
(+) per HPI
(-) Denies pain, fevers chills, night sweats, unexplained weight
loss, fatigue/malaise/lethargy, changes in appetite, trouble
with
sleep, pruritis, jaundice, rashes, bleeding, easy bruising,
headache, dizziness, vertigo, syncope, weakness, paresthesias,
nausea, vomiting, hematemesis, bloating, cramping, melena,
BRBPR,
dysphagia, chest pain, shortness of breath, cough, edema,
urinary
frequency, urgency
Past Medical History:
Past Medical History: DM1, CAD, MI ___ s/p 6 stents at OSH, R
carotid stenosis (60-69%, asymptomatic), PAD w b/l lower
extremity claudication, HTN, HLD
Past Surgical History: R common and external iliac stents ___,
L
fem-AK pop bypass w PTFE ___, L CEA
Social History:
___
Family History:
parents have history of CVA
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vitals: T 98.2 HR 78 BP 199/82 RR 18 Sat 100% RA
GEN: A&O, NAD
CV: RRR
PULM: Clear to auscultation b/l
ABD: Soft, nondistended, nontender, no rebound or guarding,
no palpable masses
Ext: b/l extremities non-edematous. L foot cool/pale, w mild
cyanosis of distal ___ toes. No ulcerations, necrosis. Cap
refill delayed ~3 seconds
RLE warm, no ulcerations, no skin changes
PULSES: R p/d/d/d L: p/d(monophasic)/-/-
DISCHARGE PHYSICAL EXAM:
========================
98.0 | 129/64 | HR 82 | RR 20 O2sat 98% on RA
GENERAL: No acute ditress
HEENT: Atraumatic. Sclera anicteric. PERRL. EOMI.
NECK: JVP not visualized.
CARDIAC: Normal rate, regular rhythm. No murmurs, rubs, or
gallops. Carotid pulses brisk and strong with bilateral bruits.
Radial pulses
strong. Pedal pulses diminished and not palpable. No peripheral
edema.
LUNGS: Bilateral basilar inspiratory crackles.
ABDOMEN: Soft, non-tender, non-distended. No palpable
hepatomegaly or splenomegaly.
EXTREMITIES: Mild peripheral edema.
NEURO: CN II-XII intact. No focal deficits.
Pertinent Results:
ADMISSION LABS:
===============
___ 01:56PM BLOOD WBC-10.0 RBC-4.38* Hgb-13.4* Hct-39.2*
MCV-90 MCH-30.6 MCHC-34.2 RDW-12.4 RDWSD-41.0 Plt ___
___ 01:56PM BLOOD Neuts-78.4* Lymphs-12.6* Monos-6.5
Eos-1.7 Baso-0.5 Im ___ AbsNeut-7.80* AbsLymp-1.25
AbsMono-0.65 AbsEos-0.17 AbsBaso-0.05
___ 01:56PM BLOOD ___ PTT-27.9 ___
___ 01:56PM BLOOD Glucose-218* UreaN-25* Creat-1.4* Na-138
K-4.6 Cl-101 HCO3-22 AnGap-15
___ 05:30PM BLOOD CK-MB-3 cTropnT-<0.01
___ 10:10AM BLOOD Calcium-9.3 Phos-3.9 Mg-1.8
RELEVANT INTERVAL LABS:
========================
___ 05:30PM BLOOD CK-MB-3 cTropnT-<0.01
___ 04:03PM BLOOD CK-MB-12* MB Indx-1.1 cTropnT-0.10*
___ 08:44PM BLOOD CK-MB-18* cTropnT-0.15*
___ 02:59AM BLOOD CK-MB-18* cTropnT-0.17*
___ 10:25AM BLOOD CK-MB-18* MB Indx-1.1 cTropnT-0.31*
___ 03:00PM BLOOD CK-MB-23* cTropnT-0.37*
___ 09:25PM BLOOD CK-MB-21* cTropnT-0.46*
___ 04:55AM BLOOD CK-MB-16* cTropnT-0.64*
DISCHARGE LABS:
===============
___ 04:11AM BLOOD WBC-7.2 RBC-3.23* Hgb-10.0* Hct-29.3*
MCV-91 MCH-31.0 MCHC-34.1 RDW-13.2 RDWSD-43.4 Plt ___
___ 04:11AM BLOOD ___ PTT-23.4* ___
___ 04:11AM BLOOD Glucose-191* UreaN-31* Creat-1.3* Na-139
K-3.9 Cl-100 HCO3-26 AnGap-13
___ 04:11AM BLOOD Calcium-8.3* Phos-3.3 Mg-2.0
IMAGING:
========
CAROTID SERIES COMPLETE Study Date of ___ 11:38 AM
60-69% stenosis of the right carotid system.
Less than 40% stenosis of the left carotid system.
CTA AORTA/BIFEM/ILIAC RUNOFF W/W&WO C AND RECONS Study Date of
___ 4:14 ___
1. Complete occlusion of the left common femoral artery, left
common femoral to popliteal graft, and left superficial femoral
artery with reconstitution of the left deep femoral and
popliteal arteries.
2. Left-sided runoff vessels are patent to the level of distal
leg just
proximal to the ankle with multifocal areas of moderate
narrowing. Although no opacification of the arteries are seen
below this level, this is thought to be secondary to slow flow
in the setting of diffuse atherosclerotic disease.
3. Occlusion of the right superficial femoral artery with distal
reconstitution of the popliteal artery. Runoff to the foot is
predominantly via the anterior tibial and peroneal arteries
which are patent with multifocal areas of high-grade narrowing
in the posterior tibial artery.
4. Extensive calcified atherosclerotic disease within the
abdomen and pelvis with a chronic appearing dissection of the
left common iliac artery. Chronic occlusion of the proximal
left internal iliac artery with distal reconstitution of the
branches.
5. Right-sided bladder diverticulum with mild circumferential
bladder wall
thickening can be seen in setting of chronic bladder outlet
obstruction or
cystitis. Recommend correlation with urinalysis.
6. Cholelithiasis.
VENOUS DUP UPPER EXT BILATERAL Study Date of ___ 12:50 ___
Poor bilateral cephalic veins. Moderate quality bilateral
basilic veins
bilaterally with small diameters in the forearm.
CT CHEST W/O CONTRAST Study Date of ___ 4:26 AM
1. No source of hemorrhage identified in the chest.
2. Trace nonhemorrhagic bilateral pleural effusions.
3. 4 mm right upper lobe pulmonary nodule.
4. Fluid distension of the esophagus suggests reflux, and can be
correlated clinically.
5. Findings of prior granulomatous exposure.
CT ABD & PELVIS W/O CONTRAST Study Date of ___ 4:26 AM
1. 4.3 cm left inguinal hematoma near the recent femoral access
site, with
trace fluid tracking along the left pelvic sidewall, resulting
in mass effect on the proximal left common femoral artery. This
noncontrast examination does not allow assessment for active
extravasation. US could be considered if there is any clincial
suspicion for an underlying pseudoaneurysm.
2. No retroperitoneal hematoma.
3. Mild persistent nephrograms suggest renal failure.
TTE (___)
No structural cardiac source of embolism seen. Mild symmetric
left ventricular hypertrophy with normal cavity size and mild
regional systolic dysfunction c/w CAD. No valvular pathology or
pathologic flow identified. Pulmonary artery diastolic
hypertension.
TTE (___)
There is mild symmetric left ventricular hypertrophy with a
normal cavity size. Overall left ventricular systolic function
is moderately depressed secondary to hypokinesis of the inferior
septum, posterior wall, and apex,
and akinesis of the inferior free wall. Quantitative biplane
left ventricular ejection fraction is 37 %.
Normal right ventricular cavity size with normal free wall
motion. The mitral valve leaflets are mildly thickened. There is
moderate mitral annular calcification. There is mild [1+] mitral
regurgitation. Due to
acoustic shadowing, the severity of mitral regurgitation could
be UNDERestimated.
IMPRESSION: regional left ventricular systolic dysfunction most
consistent with multivessel coronary artery disease. Compared
with the prior TTE (images reviewed) of ___ , the left
ventricular ejection fraction is
further reduced secondary to new apical hypokinesis.
CT A/P W/O CONTRAST (___)
1. 4.3 cm left inguinal hematoma near the recent femoral access
site, with
trace fluid tracking along the left pelvic sidewall, resulting
in mass effect on the proximal left common femoral artery. This
noncontrast examination does not allow assessment for active
extravasation. US could be considered if there is any clincial
suspicion for an underlying pseudoaneurysm.
2. No retroperitoneal hematoma.
3. Mild persistent nephrograms suggest renal failure.
CT CHEST W/O CONTRAST (___)
1. No source of hemorrhage identified in the chest.
2. Trace nonhemorrhagic bilateral pleural effusions.
3. 4 mm right upper lobe pulmonary nodule.
4. Fluid distension of the esophagus suggests reflux, and can be
correlated clinically.
5. Findings of prior granulomatous exposure.
STUDIES:
========
Cardiac Cath (___)
The coronary circulation is right dominant.
LM: The Left Main, arising from the left cusp, is a large
caliber vessel. This vessel bifurcates into the
Left Anterior Descending and Left Circumflex systems.
LAD: The Left Anterior Descending artery, which arises from the
LM, is a large caliber vessel. There is a stent in the proximal
segment. There is an 80% stenosis in the proximal and mid
segments.
The Septal Perforator, arising from the proximal segment, is a
small caliber vessel.
The ___ Diagonal, arising from the proximal segment, is a medium
caliber vessel.
The ___ Diagonal, arising from the proximal segment, is a small
caliber vessel.
Cx: The Circumflex artery, which arises from the LM, is a large
caliber vessel.
The ___ Obtuse Marginal, arising from the proximal segment, is a
very small caliber vessel.
The ___ Obtuse Marginal, arising from the mid segment, is a
medium caliber vessel. There is a stent in
the proximal, mid, and distal segments. There is a 90% in-stent
restenosis in the mid segment.
The ___ Inferior lateral of the 2ndOM, arising from the mid
segment, is a small caliber vessel.
The ___ Inferior lateral of the 2ndOM, arising from the mid
segment, is a small caliber vessel.
RCA: The Right Coronary Artery, arising from the right cusp, is
a large caliber vessel. There is a stent in the proximal
segment. There is a 90% in-stent restenosis in the proximal
segment. There are moderate irregularities in the proximal, mid,
and distal segments.
The Acute Marginal, arising from the proximal segment, is a
small caliber vessel.
The Right Posterior Descending Artery, arising from the distal
segment, is a medium caliber vessel.
The Right Posterolateral Artery, arising from the distal
segment, is a medium caliber vessel.
Findings
Multivessel disease with restenosis of the proximal RCA, mid
LAD and OM2 stents.
Brief Hospital Course:
Mr. ___ is a ___ male with a PMH notable for PAD s/p
left femoral-to-above-knee popliteal bypass on ___ and right
common iliac and external iliac artery stenting on ___,
multi-vessel CAD s/p DES x4 to OM1, DES x1 to mLAD, and DES x1
to pRCA on ___, DM1, and CKD who initially presented to the
ED on ___ with left foot numbness and coolness. Vascular
Surgery admitted him to the service, an angiogram on ___
showed left lower extremity CFA occlusion & iliac disease and on
___ he underwent L fem endarterectomy w/ left iliac stent
placement. Please see the operative note for the full details.
On ___, POD#0 he was initially stable, advanced his diet to a
regular diet, he started having some nausea and vomiting and we
checked an EKG which was non-specific however, his troponins
were slowly rising on serial checks. It was at this time that he
was transferred to the CCU on ___ for evidence of
periprocedural type II non-ST elevation myocardial infarction in
the settting of bleeding, hypotension, and acute kidney injury.
#CORONARIES: Multi-vessel CAD s/p DES x4 to OM2, DES x1 to mLAD,
and DES x1 to pRCA on ___ on ___ - has 80% stenosis in
proximal and midLAD, 80% in-stent restenosis in OM2, and 90%
in-stent restenosis in pRCA
#PUMP: EF 37% regional left ventricular systolic dysfunction
most consistent with multivessel
coronary artery disease.
#RHYTHM: Sinus rhythm with 2nd degree Mobitz Type I
ACUTE ISSUES:
=============
#NSTEMI
#Multi-vessel CAD s/p DES x4 to OM2, DES x1 to mLAD, and DES x1
to pRCA on ___
#in-stent restenosis of mLAD, OM2, and pRCA
On ___ patient reported feeling unwell/agitated all day,
intermittently having back pain. Also endorsed sensation of
shortness of breath. An EKG showed ST depressions in the
pre-cordial leads and troponins elevated to 0.10 trended up to
0.64. He was given 325 of ASA. On ___, he was transferred to
the CCU for hypotension to 88/52 for which he received a bolus
of 600 cc IV fluid with improvement.Most likely type II demand
in the setting of hypotension and bleeding. CK-MB has peaked at
23. Cardiac catheterization on ___ showed evidence of in-stent
restenosis in 3 of his DES. Cardiac surgery was consulted for
evaluation for CABG and plans to see him in clinic for continued
evaluation. He was continued on aspirin 81, clopidogrel, and
atorvastatin.
#Acute on chronic CHF (37%)
Prior TTE showed EF 45% on ___ with repeat on ___ of 37%,
decreased in setting of type II NSTEMI. He was treated with
hydralazine for afterload reduction and metoprolol for NHBK. He
was started on losartan and continued on hydralazine for
afterload reduction. He was discharged on Lasix 20mg daily.
#Acute on chronic anemia
Noted to have gradually downtrending H/H from 13.4 on admission
to nadir 7.4 on ___ likely secondary to bleeding from L
femoral endarterectomy procedure and R groin femoral hematoma in
setting of recent cath. He was givne two units of RBCs with
appropriate increase in Hgb and no further evidence of bleeding.
H/H on discharge was ___.
___ on CKD
Baseline Cr 1.3-1.4. Creatinine on admission of 1.4, peak of
2.2, now downtrending most recent 1.3. Cr on discharge 1.3
#b/l ___ claudication s/p L fem-pop bypass in ___
#s/p L fem endarterectomy w/ left iliac stent placement
(___)
Patient originally presented to ED on ___ with left foot
numbness/coolness and underwent a L fem endarterectomy w/ left
iliac stent placement on ___. He was followed by the vascular
surgery team and had wound vac removed on ___. He was
continued on Plavix and will be planned to follow up with Dr.
___ in 1 month as an outpatient with repeat ___ duplex at
that time for surveillance.
CHRONIC ISSUES/RESOLVED
=============
#Type I Diabetes
He was continued on home Lantus and Novolog sliding scale.
___ was consulted for poorly controlled BS and given the
patient's lantus sliding scale. His scales were recommended
lantus per sliding scale and Humalog 5u fixed dose with Humalog
sliding scale. Will need follow up with his endocrinologist
after discharge.
#Hypertension
-Held home antihypertensives during admission and treated with
hydralazine as above. He was discharged on hydralazine and
losartan. He will need to be titrated off hydralazine as
outpatient and should be continued on losartan. Can cosni
#HLD
-Continued home atorvastatin and ezetemibe
TRANSITIONAL ISSUES:
====================
# Discharge weight: 75.7kg
[]Has evidence of in-stent restenosis of 3 of his drug eluting
stents. Should continue outpatient evaluation for CABG with
cardiac surgery with Dr. ___ on ___.
[]Cardiology appointment scheduled with Dr. ___ on ___
[]Decreased metoprolol to 12.5mg daily given bradycardia. Would
uptitrate to 25mg daily as tolerated.
[]Started losartan 100mg daily instead of candesartan/HCTZ given
patient was started on Lasix. Also started hydralazine 25mg TID.
Would continued to titrate off hydralazine as tolerated.
[]Should continue on aspirin/Plavix for now given recent stent
and in-stent re-stenosis. Will need Plavix wash-out prior to
cardiac surgery.
[]Started Lasix 20mg daily. Titrate to keep daily weight the
same.
[]Recheck Cr in ___ days given recently started on losartan and
furosemide.
[]Should follow up with Dr. ___ surgery) in 1
month as an outpatient with repeat lower extremity duplex at
that time for surveillance.
#CODE: Full (confirmed)
#CONTACT/HCP: ___ (wife) ___ ___ (daughter)
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 25 mg PO DAILY
2. Ezetimibe 10 mg PO DAILY
3. Atorvastatin 20 mg PO QPM
4. Clopidogrel 75 mg PO DAILY
5. Diazepam 5 mg PO Q8H:PRN for neck spasm
6. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Other
7. candesartan-hydrochlorothiazid ___ mg oral daily
8. Glargine 9 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Docusate Sodium 100 mg PO BID:PRN Constipation - Second Line
3. Furosemide 20 mg PO DAILY
4. HydrALAZINE 25 mg PO TID
5. Losartan Potassium 100 mg PO DAILY
6. Senna 8.6 mg PO BID:PRN Constipation - First Line
7. Atorvastatin 80 mg PO DAILY
8. Glargine 18 Units Bedtime
Humalog 5 Units Lunch
Humalog 5 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
9. Metoprolol Succinate XL 12.5 mg PO DAILY
10. Clopidogrel 75 mg PO DAILY
11. Diazepam 5 mg PO Q8H:PRN for neck spasm
RX *diazepam 5 mg 1 tab by mouth every eight (8) hours Disp #*9
Tablet Refills:*0
12. Ezetimibe 10 mg PO DAILY
13. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Other
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
==================
peripheral vascular disease
Type II NSTEMI
In-stent restenosis of drug eluting stents
SECONDARY DIAGNOSES:
====================
coronary artery disease
Type I diabetes
chronic kidney disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Dr. ___,
___ see below for more information on your hospitalization.
It was a pleasure taking part in your care here at ___!
WHY WERE YOU ADMITTED TO THE HOSPITAL?
-You had left foot numbness and coolness
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL?
-You underwent vascular surgery where they cleared out plaque
from your left femoral artery and placed a stent in your left
iliac artery to help improve blood flow to your left leg and
foot.
-You had some chest discomfort with evidence of a small heart
attack, and so had a cardiac catherization which showed
blockages in the stents you had placed in ___.
-You were evaluated by cardiac surgery for consideration of
coronary artery bypass graft surgery and should continue to
follow them as an outpatient.
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
- Weigh yourself every morning, seek medical attention if your
weight goes up more than 3 lbs.
- Seek medical attention if you have new or concerning symptoms
or you develop fever/chills, chest pain, trouble breathing at
night or with exertion, swelling in your legs, abdominal
distention, redness/warmth/pus drainage from your surgical site.
We wish you all the best!
- Your ___ Care Team
Followup Instructions:
___
|
19560143-DS-21
| 19,560,143 | 20,039,575 |
DS
| 21 |
2168-02-22 00:00:00
|
2168-02-24 18:45:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bactrim / Toradol / Methadone / shrimp
Attending: ___.
Chief Complaint:
Abnormal ECG, hypotension, dizziness, chest pain.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ woman with a history of DM II,
chronic back pain, adrenal insufficiency, and atypical chest
pain who presented to ___ with chest pain and dizziness
and was found to be hypotensive with Mobitz I heart block.
Patient reports a recent cardiac catheterization at ___ that was
negative for CAD. She has recently experienced severe insomnia.
On day of presentation, she developed SS chest pain in the early
afternoon that was sudden-onset, exacerbated by exertion and
deep breaths, and radiated to arms. There was no clear trigger.
Associated with SOB and dizziness but no f/c. Mild loose stools.
She presented to ___, where troponin was
negative, BP was in the high 60's and rhythm strip showed
dropped QRS complexes in a Mobitz I pattern (per report, there
were Mobitz II patterns, but Cardiology attending Dr. ___
___ all available tracings and saw only Mobitz I or AV
conduction delay).
She was transferred to the ___ ED. Initial vitals were: 9 97.7
66 ___ 95% 4L nc. In the ED, she had two episodes of fecal
incontinence. She was unable to void x 24 hours so a Foley was
placed at OSH. She reported worsening of her chronic low back
pain. Given these symptoms, a stat MRI was ordered to rule out
cord compression, which was negative. Cardiology was consulted
and recommended a CTA to rule out PE. There was no evidence of
PE but bilateral upper lobe opacities and adenopathy. Patient
was given furosemide, morphine, rosouvastatin. Vitals prior to
transfer were: 97.8 66 110/61 14 96% Nasal Cannula.
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:
- Atypical chest pain with negative cath 2 weeks ago
- Severe back pain treated with multiple narcotics
- Seizures
- Anxiety
- PTSD
- PUD
- Kidney stones
- OSA treated with CPAP
- Asthma
- Adrenal insufficiency with orthostatic hypotension
- Depression
- DMII
- Stage III CKD
PAST SURGICAL HISTORY:
- Tubal ligation
- Tonsillectomy and adenoidectomy age ___
- Appendectomy
Social History:
___
Family History:
No known family history of CAD or sudden cardiac death
Physical Exam:
ADMISSION PHYSICAL EXAM:
=========================
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink 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
DISCHARGE PHYSICAL EXAM:
=========================
Unchanged from Admission Examination.
Pertinent Results:
ADMISSION LABS
================
___ 09:35AM BLOOD WBC-6.5 RBC-3.98* Hgb-13.1 Hct-38.9
MCV-98 MCH-32.9*# MCHC-33.6 RDW-13.6 Plt ___
___ 09:35AM BLOOD ___ PTT-32.2 ___
___ 09:35AM BLOOD Glucose-86 UreaN-12 Creat-0.8 Na-142
K-3.7 Cl-108 HCO3-27 AnGap-11
___ 11:25PM BLOOD cTropnT-<0.01
___ 09:35AM BLOOD Calcium-8.4 Phos-2.7 Mg-2.1
___ 09:35AM BLOOD CK-MB-3 cTropnT-<0.01
DISCHARGE LABS
================
___ 05:30AM BLOOD WBC-5.8 RBC-4.03* Hgb-13.2 Hct-39.2
MCV-97 MCH-32.7* MCHC-33.6 RDW-13.3 Plt ___
___ 05:30AM BLOOD Glucose-79 UreaN-18 Creat-0.8 Na-146*
K-3.7 Cl-110* HCO3-25 AnGap-15
STUDIES
==========
ECG (___): Sinus rhythm. Marked P-R interval prolongation.
Generalized low voltage. No previous tracing available for
comparison. Clinical correlation is suggested.
CTA CHEST W/WO CONTRAST (___): IMPRESSION: 1. There are
faint bilateral upper lobe predominant opacities with hilar and
mediastinal adenopathy. These findings may be suggestive of an
multifocal infectious process with associated reactive
lymphadenopathy. Alternatively, the lymphadenopathy may be seen
in Sarcoidosis and the faint bilateral upper
lobe opacities could represent atelectasis. A follow up chest CT
is recommended after treatment to ensure the resolution of
lymphadenopathy.
2. There is also mild interlobular septal thickening suggesting
mild pulmonary edema.
MRI L-SPINE (___): 1. Minimal degenerative disc disease,
particularly at L5-S1, without spinal canal or neural foraminal
narrowing. 2. Vertebral bone marrow signal abnormality with a
stiated pattern, similar to the "___ spine on
radiography, which may be seen in the setting of
chronic renal disease.
Brief Hospital Course:
BRIEF SUMMARY STATEMENT: Ms. ___ is a ___ F w/ DM II, hx
atypical chest pain with negative cath @ ___ ___ per report,
and adrenal insufficiency who presented to ___ with one
day of exertional/pleuritic chest pain, dizziness, and
hypotension then found to be in Mobitz I heart block. Pt. was
without any elevation in her cardiac enzymes. Pt. remained
asymptomatic on this hospitalization. Her heart rhythm was
observed on telemetry. No concerning events were recorded. She
was discharged with close outpatient follow-up with her PCP.
ACTIVE ISSUES
=================
# Mobitz I second degree atrioventricular block: Pt. was
transferred for further evaluation of possible Mobitz II EKG
patterns at ___. Following evaluation of available
tracings, pt. was determined to have evidence of both first
degree atrioventricular block and Mobitz I second degree
atrioventricular block. Given benign nature of both forms of AV
conduction delay, no pacemaker is required at this time. Pt.
was discontinued off diltiazem as she maintained normal BPs
without this medication and was with evidence of AV conduction
delay as mentioned above.
# Chest pain: Pt. presented with pleuritic and exertional chest
pain that improved shortly after admission. Pt. had Trop neg x2
with no ischemic changes on EKG. She also had a recent negative
cath @ ___ ___ per patient. CTA was performed which was
negative for PE. Pt.'s aspirin was continued at 81mg PO daily.
Her CP resolved without intervention.
# Pulmonary edema: Pt. was found to have mild pulm edema on CTA
chest ___ w/ OSH BNP 1134. She has no history of CHF with
___ TTE from ___ showing preserved EF. Admission wt 107.6kg.
Given furosemide 20mg IV x1 on admission. She appeared
euvolemic throughout admission with no clinical signs of heart
failure.
# Diarrhea: Pt. complained of diarrhea on admission. Her CDiff
returned negative. Her diarrhea improved by time of discharge.
CHRONIC ISSUES
===============
# CAD: Hx LAD stenosis 50-60%; unclear if prior stents. No hx
MI. Pt. continued on medical management and reduced dose of
aspirin 81mg PO daily.
# Diabetes mellitus II: Pt. with hx. of DM II. No medications
currently taken at home. She was managed with ISS.
# Adrenal insufficiency: Pt. with hx of recurrent orthostatic
hypotension. Pt. reported intermittent dizziness on admission
which resolved by time of discharge. Her orthostatics were neg
on admission. Continued on home Prednisone 3mg and home
Fludrocortisone Acetate 0.2 mg po daily/
# Asthma: Continued on home Ipratropium
# PTSD / Anxiety / Depression: Resumed on home medications at
time of discharge.
TRANSITIONAL ISSUES
====================
# Hilar / Mediastinal Lymphadenopathy: Follow up chest CT is
recommended after treatment to ensure the resolution of
lymphadenopathy.
# Polypharmacy: Pt. noted to have somnolence on admission likely
___ polypharmacy. Recommend simplifying meds as an outpatient if
possible.
# Code: Full confirmed
# Contact: No official HCP at this time however she would like
her brother, ___, to be her HCP
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aripiprazole 10 mg PO DAILY
2. Calcium Carbonate 500 mg PO BID
3. Vitamin D 800 UNIT PO DAILY
4. melatonin 5 mg oral qHS
5. QUEtiapine Fumarate 50 mg PO BID
6. Acetaminophen 325 mg PO Q6H:PRN pain
7. Aspirin 325 mg PO DAILY
8. Atorvastatin 80 mg PO DAILY
9. Baclofen 10 mg PO QHS:PRN back spasm
10. ClonazePAM 0.5 mg PO TID:PRN anxiety
11. Diltiazem Extended-Release 120 mg PO DAILY
12. Ferrous Sulfate 325 mg PO TID
13. Fludrocortisone Acetate 0.2 mg PO DAILY
14. Fluticasone Propionate 110mcg 2 PUFF IH BID
15. Ipratropium Bromide MDI 2 PUFF IH Q6H
16. Lidocaine 5% Patch 2 PTCH TD Frequency is Unknown
17. Loratadine 10 mg PO DAILY
18. Metoprolol Succinate XL 25 mg PO DAILY
19. Nitroglycerin SL 0.3 mg SL PRN chest pain
20. Omeprazole 40 mg PO BID
21. Ondansetron 8 mg PO Q8H:PRN nausea
22. Polyethylene Glycol 17 g PO DAILY
23. Potassium Chloride 20 mEq PO DAILY
24. PredniSONE 3 mg PO DAILY
25. Pyridostigmine Bromide 30 mg PO Q8H
26. ranolazine 500 mg oral BID
27. Sertraline 100 mg PO DAILY
28. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
29. Cyanocobalamin 500 mcg PO DAILY
Discharge Medications:
1. Aripiprazole 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO DAILY
4. Fludrocortisone Acetate 0.2 mg PO DAILY
5. Lidocaine 5% Patch 1 PTCH TD QAM
6. Metoprolol Succinate XL 25 mg PO DAILY
7. Omeprazole 40 mg PO BID
8. Ondansetron 8 mg PO Q8H:PRN nausea
9. Polyethylene Glycol 17 g PO DAILY
10. PredniSONE 3 mg PO DAILY
11. Calcium Carbonate 500 mg PO BID
12. ClonazePAM 0.5 mg PO TID:PRN anxiety
13. Cyanocobalamin 500 mcg PO DAILY
14. Ferrous Sulfate 325 mg PO TID
15. Loratadine 10 mg PO DAILY
16. melatonin 5 mg oral qHS
17. Nitroglycerin SL 0.3 mg SL PRN chest pain
18. Fluticasone Propionate 110mcg 2 PUFF IH BID
19. Ipratropium Bromide MDI 2 PUFF IH Q6H
20. Potassium Chloride 20 mEq PO DAILY
21. Vitamin D 800 UNIT PO DAILY
22. Pyridostigmine Bromide 30 mg PO Q8H
23. QUEtiapine Fumarate 50 mg PO BID
24. ranolazine 500 mg ORAL BID
25. Sertraline 100 mg PO DAILY
26. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
27. Baclofen 10 mg PO QHS:PRN back spasm
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES
=====================
1. Second Degree Atrioventricular Block: ___ Type I
2. Hilar/Mediastinal Lymphadenopathy
SECONDARY DIAGNOSES
===================
1. Coronary Artery Disease
2. Diabetes Mellitus Type II
3. Chronic Kidney Disease Stage III
4. Adrenal Insufficiency
5. Seizure Disorder
6. Asthma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
It was a pleasure to meet and care for you during your
hospitalization at ___. You
were admitted from an outside hospital with chest pain,
dizziness, and low blood pressure. There was concern for a
heart rhythm that would require a pacemaker. For this concern,
you were transferred to ___.
Here, we determined that you have a heart arrhythmia called
Second Degree Heart Block: Mobitz Type I. This is a benign
arrhythmia without any significant risk. You do not require a
pacemaker at this time. If you develop symptoms that are
concerning to you in the future, please notify your doctors at
that time.
We wish you a speedy recovery.
All the best,
Your ___ Care Team
Followup Instructions:
___
|
19560184-DS-17
| 19,560,184 | 28,665,932 |
DS
| 17 |
2119-03-27 00:00:00
|
2119-03-27 17:52:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: PLASTIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
motorcycle crash with multiple facial injuries
Major Surgical or Invasive Procedure:
Left eyebrow/forehead lac repair.
Left sided facial nerve repair and exploration with plastic
surgery
History of Present Illness:
___ yo M s/p motorcycle accident. Patient was found down without
helmet and significant facial/head injuries. He was reportedly
intubated on the scene for question of hematemesis. GCS 15 on
arrival per records. TDap and cefazolin given at OSH. He was
found to have multiple L sided facial fractures including L
maxillary/orbit fxs, sphenoid fx, trace pneumocephalus,
multifocal areas of hemorrhagic intracranial contusion. He was
transferred to ___ for further evaluation.
Past Medical History:
PMH:
None
.
PSH:
None
Social History:
___
Family History:
Family History: Non-contributory
Physical Exam:
General:
Vitals: 99.6/98.8, 97, 150/80, 18, 96%RA
HEENT: facial lacerations, right scalp laceration currently with
xeroform over it
Cardiac: Normal S1, S2
Respiratory: Breathing comfortably on room air
Abdomen: Soft non-tender, no rebound or guarding
skin: No lesions
Pertinent Results:
___ 07:10AM LACTATE-2.2*
___ 05:45AM GLUCOSE-132* UREA N-9 CREAT-0.9 SODIUM-143
POTASSIUM-4.1 CHLORIDE-107 TOTAL CO2-26 ANION GAP-14
___ 05:45AM CALCIUM-8.7 PHOSPHATE-3.2 MAGNESIUM-1.6
___ 05:45AM WBC-13.6* RBC-4.32* HGB-14.7 HCT-39.4* MCV-91
MCH-34.0* MCHC-37.2* RDW-12.9
___ 05:45AM NEUTS-86.1* LYMPHS-10.3* MONOS-3.3 EOS-0.2
BASOS-0.2
___ 05:45AM PLT COUNT-212
___ 05:45AM ___ PTT-25.8 ___
___ 02:57AM TYPE-ART TEMP-37.0 TIDAL VOL-500 PEEP-5
O2-100 PO2-429* PCO2-44 PH-7.33* TOTAL CO2-24 BASE XS--2
AADO2-238 REQ O2-48 INTUBATED-INTUBATED
___ 12:03AM ___ PH-7.26* COMMENTS-GREEN TOP
___ 12:03AM GLUCOSE-150* LACTATE-3.3* NA+-146* K+-4.0
CL--108 TCO2-22
___ 12:03AM HGB-15.5 calcHCT-47 O2 SAT-84 CARBOXYHB-2 MET
HGB-0
___ 12:03AM freeCa-1.05*
___ 12:00AM UREA N-8 CREAT-0.9
___ 12:00AM estGFR-Using this
___ 12:00AM LIPASE-20
___ 12:00AM ASA-NEG ___ ACETMNPHN-NEG
bnzodzpn-POS barbitrt-NEG tricyclic-NEG
___ 12:00AM URINE HOURS-RANDOM
___ 12:00AM URINE HOURS-RANDOM
___ 12:00AM URINE GR HOLD-HOLD
___ 12:00AM URINE bnzodzpn-POS barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 12:00AM WBC-19.9* RBC-4.63 HGB-15.3 HCT-43.4 MCV-94
MCH-33.0* MCHC-35.2* RDW-13.5
___ 12:00AM PLT COUNT-241
___ 12:00AM ___ PTT-25.6 ___
___ 12:00AM ___ 12:00AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 12:00AM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR
GLUCOSE-300 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 12:00AM URINE RBC-1 WBC-<1 BACTERIA-FEW YEAST-NONE
EPI-0
___ 12:00AM URINE HYALINE-6*
___ 12:00AM URINE MUCOUS-RARE
.
IMAGING:
Radiology Report TRAUMA #3 (PORT CHEST ONLY) Study Date of
___ 11:44 ___
IMPRESSION: Limited examination demonstrating support lines and
tubes in the appropriate position. Probable bilateral
retrocardiac airspace opacities. No large pneumothorax or
effusion.
.
Radiology Report CT HEAD W/O CONTRAST Study Date of ___
1:34 AM
IMPRESSION:
1. Multiple punctate foci of intraparenchymal hemorrhage versus
posttraumatic diffuse axonal injury, without appreciable midline
shift or mass effect.
2. Extensive facial bone fractures, better characterized by
recent CT
maxillofacial.
NOTE ADDED AT ATTENDING REVIEW: There is no evidence of
hemorrhage. The
hyperdensities noted above are noise, rather than small bleeds.
.
Radiology Report CHEST (PORTABLE AP) Study Date of ___
5:42 AM
IMPRESSION:
In comparison with the study of earlier in this date, the
fixation devices remain in place. Continued prominence of the
cardiac silhouette with the left hemidiaphragm now sharply seen
and little if any retrocardiac opacification. No evidence of
appreciable pneumothorax.
.
Radiology Report MR CERVICAL SPINE W/O CONTRAST Study Date of
___ 6:04 ___
IMPRESSION:
1. No evidence for bone marrow edema, ligamentous edema,
prevertebral edema, or posterior paravertebral edema.
2. Mild to moderate multilevel degenerative disease, as detailed
above. At C5-6, a broad-based disc osteophyte complex flattens
the ventral spinal cord, but cord signal remains normal.
.
Radiology Report HAND (PA,LAT & OBLIQUE) LEFT Study Date of
___ 7:42 ___
IMPRESSION:
Probable fracture and ? dislocation proximal fifth metacarpal.
.
Radiology Report CT UP EXT W/O C Study Date of ___ 5:04
___
IMPRESSION:
1. Comminuted intra-articular fracture at the base of the fifth
metacarpal with mild associated ulnar subluxation and impaction
of the base of the fifth metacarpal on the hamate.
2. No additional fracture seen.
Brief Hospital Course:
___ yo M s/p motorcycle accident. Patient was found down without
helmet and significant facial/head injuries. He was reportedly
intubated on the scene for question of hematemesis. GCS 15 on
arrival per records. TDap and cefazolin given at OSH. He was
found to have multiple Left sided facial fractures including
Left maxillary/orbit fxs, sphenoid fx, trace pneumocephalus,
multifocal areas of hemorrhagic intracranial contusion. He was
transferred to ___ for further evaluation.
.
Patient was trasnferred to the ICU in stable condition, after
undergoing initial resuscitation in the trauma bay. CXR at the
time revealed no large pnuemothorax or effusion. MRI C spine
showed no evidence for bone marrow edema, ligamentous edema,
repvertebral edema, or posterior paraverbetral edema. Patient
head CT was negative, with no evidence of hemorrhage, and
extensive facial bone fracures. Plastics came and sutured the
right scalp laceration. Patient continued to do well in the ICU
and was extbuated on ___. Patient foley came out and patient
was stable for transfer to the floor.
.
After transfering to the floor, patient continued to improve. He
was in a C collar at the time and said he had trouble with a
regular diet. However, he denies headaches,
nausea/vomiting/fever/chills. Patient was hypertensive into
180s, thus he was started on Hydrochlorthiazide. Patient was
advised to follow-up with his PCP following discharge to further
address hypertension. He was given a script for 2 months of
HCTZ.
.
On ___, patient's C spine was cleared and collar
discontinued. Patient was noted to have some left hand swelling
and pain with exam so was sent for a left hand xray. There was
a poorly assessed fracture of the ___ MCP so a CT was
recommended. Patient was made NPO for the OR with plastic
surgery for left facial nerve exploration.
.
On ___, Patient went for left hand CT which revealed a
comminuted intra-articular fracture at the base of the fifth
metacarpal with mild associated ulnar subluxation and impaction
of the base of the fifth metacarpal on the hamate.
In addition, patient went to OR with plastic surgery for
exploration of left frontal branch facial nerve and suture of 1
nerve, frontal branch of facial nerve, complex repair of
forehead laceration measuring 8 cm, and complex repair of 1 cm
dorsal nasal laceration. He tolerated the procedure well.
Post-operatively, patient had some episodes of nausea and emesis
overnight which were treated with anti-emetics.
.
On ___, patient was scheduled for ___ for ORIF
vs pinning of ___ MCP base fracture with Dr. ___.
Occupational Therapy made a custom ulnar gutter orthoplast
splint and also felt he should follow up with Cognitive
Neurology s/p a cognitive exam that showed deficits.
.
At time of discharge patient verbalized he was no longer
interested in having surgical repair of his fracture and wanted
to know what other options were reasonable. Dr. ___
___ an ulnar gutter cast with hand follow up in one
week. Cast tech made a custom ulnar gutter cast for left hand
and patient reported it was comfortable and not too tight.
Patient was reminded that if he felt cast was getting to tight
or hand was throbbing, to aggresively elevate left hand.
Patient is to follow up with Dr. ___ ___.
He will apply bacitracin to his nasal wound and left
eyebrow/forehead incision line daily.
Medications on Admission:
None
Discharge Medications:
1. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*40 Tablet Refills:*0
2. Acetaminophen 325-650 mg PO Q6H:PRN pain
3. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 7 Days
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth Every 12 hours Disp #*14 Tablet Refills:*0
4. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*30 Capsule Refills:*0
5. Hydrochlorothiazide 25 mg PO DAILY
RX *hydrochlorothiazide 25 mg 1 tablet(s) by mouth Daily Disp
#*30 Tablet Refills:*1
6. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron HCl 4 mg 1 tablet(s) by mouth Every 8 hours Disp
#*10 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
-Trauma with multiple head and face injuries.
-Left hand ___ MCP base fracture
Discharge Condition:
Patient discharged in stable condition, no changes in mental
status, fully ambulatory.
Discharge Instructions:
Mr. ___, you were admitted to ___
on ___ after undergoing a motocycle accident. You suffered
left sided facial fractres, injuries to your head (including
multifocal areas of hemorragic contusions), trace
pneumocephalus. You also suffered facial injuries including left
maxillary, orbital, roof, frontal sinus, and sphenoid fractures
and also have a left hand ___ metacarpal base fracture that will
need surgical repair. You were cleared by neurosurgery, plastics
surgery performed L facial nerve repair/exploration on ___.
You also suffered Left eyebrow/forehead laceration which
required repair by plastic surgery. Now you are ready for
discharge.
.
-Elevate your forearm/wrist/hand as much as possible and
maintain it in the splint.
-You may shower without the splint but please do not move or use
your left hand in the shower. Dry hand and immediately re-apply
splint after showering.
- If your affected area begins to worsen after discharge home
with an acute increase in swelling or pain, please call Dr.
___ to report this (___)
.
Activities:
* No strenuous activity
* Exercise should be limited to walking; no lifting, straining,
or excessive bending.
.
* Please sleep on several pillows and try to keep your head
elevated to help with drainage.
* Please maintain SOFT diet until your follow up clinic visit
and you can ask your surgeon whether you can advance your diet
at that time.
* Please avoid blowing your nose.
* Sneeze with your mouth open
* Try to avoid sipping liquids through a straw
* No smoking
.
Return to the ER if:
* If you are vomiting and cannot keep in fluids or your
medications.
* If you have shaking chills, fever greater than 101.5 (F)
degrees or 38 (C) degrees, increased redness, swelling or
discharge from incision, chest pain, shortness of breath, or
anything else that is troubling you.
.
Medications:
Continue all home medications. You were hypertensive during your
hospital stay. We started a antihypertensive medication called
hydrochlorthiazide for you. Please follow-up with your primary
care physician for hypertension workup. You will also need to
complete a total 7 day course of Augmentin for antibacterial
coverage for facial fracture. Please take Oxycodone for pain
every four hours as needed. Take Colace and Senna, because one
of the common side effects of narcotics is constipation.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
.
Dressing:
bacitracin applied to incision and abrasion and nasal sites.
Followup Instructions:
___
|
19560275-DS-11
| 19,560,275 | 28,935,968 |
DS
| 11 |
2124-03-16 00:00:00
|
2124-03-16 15:16:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Lipitor
Attending: ___.
Chief Complaint:
Dizziness, lightheadedness, recent falls
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with pAFib, CAD s/p CABG, IDDM, HTN, HLD, and RA who
presented with dizziness.
He reports a 5.5 month history of dizziness upon standing. He
felts unsteady while walking, worse during initial few steps. He
uses a cane at baseline. He does sometimes have a sensation of
vertigo. Denies N/V or HA. He denies any falls until 3 days ago,
at which time he fell out of bed and hit his head on the
nightstand. He reports good PO intake and denies any diarrhea
or vomiting. He takes lasix but has not taken any in the past 3
days after running out of his prescription.
He does not have any numbness, tingling, or leg pain suggestive
of neuropathy. He takes insulin, prescribed for TID, but says
that he sometimes only takes two doses a day. He does not think
he had any low blood sugars, and reports that his fasting sugars
usually run from 110-170.
No fevers. Was noted to be short of breath at neurology clinic
today, but he denies this. He does endorse severe general
fatigue. Also denies orthopnea. Has chronic edema which has not
recently worsened.
In the ED, initial vitals were: 97.0 74 126/67 18 95% RA
- Labs were significant for 11.6 (no prior baseline), Tbili 1.7
(dbili 0.5), BNP 1136 (no prior), serum tox negative
- Imaging revealed: CT head negative for acute intracranial
process, CT C spine slightly limited due to motion but without
acute fracture, RUQ US normal (s/p CCY), CXR with b/l pleural
effusions and pulmonary vascular congestion
- The patient was not given anything
Vitals prior to transfer were: 97.7 68 140/72 20 100% RA
Upon arrival to the floor, initial vitals were 97.6 147/88 75 20
97% RA. He felt well and denied any current dizziness.
Past Medical History:
-CAD s/p CABG
-CHF, EF 55%
-paroxysmal AFib, on warfarin
-IDDM
-HTN
-HLP
-Rheumatoid arthritis on methotrexate and prednisone
-Carotid artery stenosis s/p R CEA
-s/p cholecystectomy
Social History:
___
Family History:
Father died of CAD at age ___.
Physical Exam:
ADMISSION EXAM:
Vitals: 97.6 147/88 75 20 97% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, EOMI
Neck: Supple, JVP difficult to assess given body habitus but
appears elevated
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: RRR, normal S1 and S2, systolic murmur
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, gait deferred, finger to nose and heel
to shin normal.
DISCHARGE EXAM:
VS: 134 kg (135.1 kg on admission), T97.6, BP 149/89, HR 64, RR
18, SAT 100%RA
GEN: Morbidly obese, alert, oriented, no distress
HEENT: JVP hard to assess given neck girth, not sig elevated
HEART: RRR, normal S1, ___ soft systolic murmur LUSB with loss
of S2
LUNGS: Clear, no wheezes, rales, or rhonchi
ABD: Soft, NT ND, normal BS
EXT: ___ pitting edema in both lower legs with chronic venous
stasis changes
Pertinent Results:
ADMISSION LABS:
___ 09:36PM BLOOD WBC-6.6 RBC-4.14* Hgb-11.6* Hct-38.6*
MCV-93 MCH-28.0 MCHC-30.1* RDW-18.4* RDWSD-62.1* Plt ___
___ 09:36PM BLOOD Neuts-71.4* Lymphs-17.5* Monos-8.5
Eos-1.7 Baso-0.6 Im ___ AbsNeut-4.69 AbsLymp-1.15*
AbsMono-0.56 AbsEos-0.11 AbsBaso-0.04
___ 09:36PM BLOOD ___ PTT-42.8* ___
___ 09:36PM BLOOD Glucose-92 UreaN-18 Creat-1.2 Na-141
K-3.9 Cl-107 HCO3-25 AnGap-13
___ 09:36PM BLOOD ALT-21 AST-27 LD(LDH)-249 AlkPhos-84
TotBili-1.7* DirBili-0.5* IndBili-1.2
___ 09:36PM BLOOD proBNP-1136*
___ 09:36PM BLOOD cTropnT-0.04*
___ 09:36PM BLOOD Albumin-3.7 Calcium-9.2 Phos-3.2 Mg-2.1
___ 06:07AM BLOOD VitB12-444 Folate-GREATER TH
___ 09:36PM BLOOD Hapto-231*
___ 04:39AM BLOOD %HbA1c-7.8* eAG-177*
___ 06:07AM BLOOD TSH-2.2
___ 06:07AM BLOOD Cortsol-20.9*
___ 09:36PM BLOOD Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
IMAGING:
___ CT C-SPINE W/O CONTRAST
1. Slightly limited evaluation due to motion artifact along
distal cervical spine starting at level of C5.
2. No definite acute fracture.
3. Mild anterolisthesis of C2 on C3 without prevertebral soft
tissue swelling is most likely degenerative in nature however a
subtle ligamentous injury cannot be excluded. Correlation for
focal tenderness is recommended. MRI is more sensitive in
detecting ligamentous injury.
4. Multi-level degenerative changes.
___ CT HEAD W/O CONTRAST
There is no evidence of infarction, hemorrhage, edema, or mass.
There is
prominence of the ventricles and sulci suggestive of
involutional changes. Periventricular white matter
hypodensities are nonspecific but likely represent sequela of
chronic small vessel ischemic disease.
There is no evidence of fracture. There is mild mucosal
thickening in the
right maxillary sinus. The remaining visualized portion of the
paranasal
sinuses, mastoid air cells, and middle ear cavities are clear.
IMPRESSION:
No acute intracranial process.
___ CHEST (PA & LAT)
Patient is status post median sternotomy and CABG. There is
cardiomegaly. Prominence of the main pulmonary artery raises
concern for pulmonary arterial hypertension. Fluid is seen
along the right major fissure, likely loculated. There are
small bilateral pleural effusions. Right perihilar opacity may
be due to vascular congestion and/or atelectasis, although focal
consolidation is difficult to exclude. No evidence of
pneumothorax is seen.
IMPRESSION:
Bilateral pleural effusions with likely loculated component
along the right major fissure. Pulmonary vascular congestion.
Cardiomegaly.
___ LIVER OR GALLBLADDER US
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 5 mm.
GALLBLADDER: The patient is status post cholecystectomy.
PANCREAS: The head and body of the pancreas are within normal
limits. The tail of the pancreas is not visualized due to the
presence of gas.
KIDNEYS: The right kidney is grossly unremarkable.
RETROPERITONEUM: Visualized portions of the IVC are within
normal limits.
IMPRESSION:
Normal abdominal ultrasound in a patient who is status post
cholecystectomy.
___ CAROTID SERIES US
Duplex evaluation was performed of bilateral carotid arteries.
On the right
there is mild to moderate heterogeneous plaque in the ICA. On
the left there
is mild to moderate heterogeneous plaque seen in the ICA.
On the right systolic/end diastolic velocities of the ICA
proximal, mid and
distal respectively are 127/23, 60/9, 61/16 cm/sec. CCA peak
systolic
velocity is 74 cm/sec. ECA peak systolic velocity is 112 cm/sec.
The ICA/CCA
ratio is 1.7. These findings are consistent with 40-59%
stenosis.
On the left systolic/end diastolic velocities of the ICA
proximal, mid and
distal respectively 113/25, 126/33, 72/20 cm/sec. CCA peak
systolic velocity
72 cm/sec. ECA peak systolic velocity is 119 cm/sec. The ICA/CCA
ratio is 1.7.
These findings are consistent with 40-59% stenosis.
Right antegrade vertebral artery flow.
Left antegrade vertebral artery flow.
Impression:
Right ICA 40-59% stenosis.
Left ICA 40-59% stenosis.
___ TTE
Overall left ventricular systolic function is normal (LVEF>55%).
The aortic valve is not well seen. Mild to moderate (___)
aortic regurgitation is seen. The transaortic valvular velocity
is increased; in the absence of adequate visualization of the
aortic valve it is unclear if this represents aortic stenosis
The mitral valve leaflets are not well seen. Mild (1+) mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Mild to moderate aortic
regurgitation. Probable aortic stenosis of unclear severity.
Mild mitral regurgiation. Preserved global left ventricular
systolic function.
The transaortic valvular velocity is increased; in the absence
of adequate visualization of the aortic valve it is unclear if
this represents aortic stenosis, but given patient's age,
clinical history, and transaortic mean gradient it could be
consistent with moderate aortic stenosis. If clinically
indicated, and patient management would change a cardiac MRI may
be considered.
DISCHARGE LABS:
___ 06:24AM BLOOD WBC-7.6 RBC-4.34* Hgb-11.9* Hct-40.1
MCV-92 MCH-27.4 MCHC-29.7* RDW-18.1* RDWSD-60.4* Plt ___
___ 06:24AM BLOOD ___ PTT-38.4* ___
___ 06:24AM BLOOD Glucose-88 UreaN-30* Creat-1.2 Na-139
K-4.1 Cl-104 HCO3-21* AnGap-18
___ 06:24AM BLOOD Calcium-9.2 Phos-3.9 Mg-2.4
___ 07:03AM BLOOD ___
___ 06:07AM BLOOD ___ PTT-42.3* ___
___ 09:36PM BLOOD ___ PTT-42.8* ___
Brief Hospital Course:
___ with CAD s/p CABG, IDDM, CHF, CKD, HTN, HLP, pAFib, and RA
on methotrexate and prednisone admitted for workup for five
months of dizziness, likely polypharmacy. We discontinued
unnecessary medications to reduce the pill burden for this
chronically ill patient who lives alone and came in with a home
list of more than 20 daily medications. History was concerning
for orthostasis, and he may have been orthostatic at home but
then missed Lasix for 3 days and fluid built up. He had a
systolic murmur which was evaluated with an echo which was poor
quality but showed EF>55%. He was treated for mild heart failure
with doubling of his home Lasix dose.
# DIZZINESS
Suspect polypharmacy. No longer orthostatic. Not toxic metabolic
given no infection and reassuring labs. CT head normal. Ruled
out vitamin B12/folate deficiency, adrenal insufficiency
(patient on chronic prednisone but normal AM cortisol, and
thyroid disease (normal TSH). Exam notable for systolic murmur,
which is new per patient suggestive of AS which could explain
his symptoms. A TTE was performed but was poor quality. It
showed preserved EF >55% with mild/moderate AR and increased
transaortic gradient, which likely represents aortic stenosis
but cannot be confirmed with poor visualization of the valve.
Carotid US looking for vertebrobasilar insufficiency showed mild
stenosis. Medication list was reviewed and many medications were
discontinued given lack of strong indication (see below). ___
evaluated patient and recommended discharge to home with ___.
# POLYPHARMACY
Long list of medications, some without clear cause, likely
contributing to overall dizziness and nonspecific symptoms. It
is not possible or reasonable for this elderly man to manage >20
medications while living on his own. Folate level normal,
stopped folic acid. Stopped bupropion, no history of depression
and states he was started on this for his girlfriend's
immunocompromised illness. Stopped vitamins. Stopped niacin and
coenzyme Q given no indication for routine hyperlipidemia.
Stopped methimazole as TSH is normal 0.91 and patient states he
was just recently started on this for unclear reasons, no
history of thyroid disease. Stopped metformin given mild CKD
already and adequate control with insulin regimen to avoid
hypoglycemia. Reduced Imdur dose.
# DIASTOLIC CHF, MILD, ACUTE
EF >55%. Elevated BNP, missed 3 days of home Lasix, and mild
pulmonary congestion on CXR. TnT 0.04 likely demand, no sign of
acute coronary syndrome. Increased Lasix from home 40 daily to
40 BID, before returning to home dose. Discharge weight of
134kg.
# DM2
HbA1c 7.8%, goal would be <8% given his age and complex
comorbidities. Stopped metformin (recently added, to prevent
hypoglycemia and he has mild CKD stage III Cr 1.2 already). He
continued home regimen of insulin ___ at 60/50/50 units with
meals. After 2 days, he developed hypoglycemia in the AM, and he
reported that at home he only takes his insulin twice a day and
frequently forgets his noon dose. Given the suspicion of dose
stacking, his discharge insulin dose was reduced to insulin
___ 50 units with breakfast and 50 units with dinner.
# Hyperbilirubinemia: Mostly unconjugated. Likely ___
disease. Stable LFTs.
# Rheumatoid arthritis: Continued methotrexate and prednisone.
# CAD s/p CABG: Continued aspirin, statin, metoprolol, Imdur.
Imdur dose was reduced from 90mg to 30mg to prevent orthostasis.
# History of paroxysmal afib. CHA2DS2-VASc score is 6 (CHF, HTN,
age2, diabetes, vascular disease), so warrants lifelong
anticoagulation. Continued warfarin and metoprolol.
# Hyperlipidemia: Cont statin. DC niacin, no indication for
this.
# GERD: Continued pantoprazole.
# CODE STATUS: Full, confirmed
### TRANSITIONAL ISSUES ###
- Stopped unnecessary medications such as bupropion (no
psychiatric history), methimazole (normal TSH and recently
started for unclear reason), metformin (Cr 1.___ontrolled on current insulin regimen), and many vitamins and
supplements
- Reduced Imdur from 90mg to 30mg to reduce orthostatic
hypotension symptoms
- Reduced insulin from 60/50/50 units of 70/30 insulin to 50/50
units before breakfast and dinner. Will need outpatient
titration. Patient often misses noon dose of prior regimen.
- Will need follow up evaluation for aortic stenosis given poor
TTE quality
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PredniSONE 5 mg PO DAILY
2. Methotrexate 10 mg PO 1X/WEEK (___)
3. Methimazole 5 mg PO DAILY
4. Metoprolol Tartrate 12.5 mg PO BID
5. Warfarin 2 mg PO 6X/WEEK (___)
6. Rosuvastatin Calcium 40 mg PO QPM
7. ___ 60 Units Breakfast
___ 50 Units Lunch
___ 50 Units Dinner
8. Furosemide 40 mg PO DAILY
9. Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY
10. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
11. Pantoprazole 40 mg PO Q24H
12. Aspirin 81 mg PO DAILY
13. FoLIC Acid 2 mg PO DAILY
14. Niacin SR 1000 mg PO QHS
15. Ascorbic Acid ___ mg PO DAILY
16. Vitamin E 400 UNIT PO DAILY
17. BuPROPion (Sustained Release) 100 mg PO BID
18. Methimazole 2.5 mg PO QHS
19. coenzyme Q10 400 mg oral DAILY
20. Methotrexate 10 mg PO QTUES
21. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
22. Senna 17.2 mg PO QHS
23. Warfarin 3 mg PO 1X/WEEK (___)
24. MetFORMIN (Glucophage) 500 mg PO DAILY
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
2. Aspirin 81 mg PO DAILY
3. Metoprolol Tartrate 12.5 mg PO BID
4. Pantoprazole 40 mg PO Q24H
5. Rosuvastatin Calcium 40 mg PO QPM
6. Senna 17.2 mg PO QHS
7. Warfarin 2 mg PO 6X/WEEK (___)
8. Methotrexate 10 mg PO 1X/WEEK (___)
10mg ___ AM
9. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
10. Warfarin 3 mg PO 1X/WEEK (___)
11. Furosemide 40 mg PO DAILY
12. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
RX *isosorbide mononitrate 30 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*2
13. PredniSONE 5 mg PO DAILY
14. ___ 50 Units Breakfast
___ 50 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY:
- Dizziness
- Polypharmacy
- Congestive heart failure, acute, diastolic
SECONDARY:
- Diabetes mellitus, on insulin, type II
- Hypertension
- Hyperlipidemia
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 take care of you at ___. You were
admitted to the hospital because of weakness. Most likely, this
was due to side effects from too many medications. We evaluated
your medication list and removed many of the unnecessary
medications to simplify your regimen. You were treated for mild
heart failure with increase in your Lasix dose. You had an
echocardiogram which showed good pumping function but suggested
that you may have narrowing of the aortic valve. You should
follow up with your cardiologist, who will do more testing if
needed.
Please follow up with your PCP and cardiologist and take your
medications as directed on discharge.
Followup Instructions:
___
|
19560412-DS-4
| 19,560,412 | 20,771,544 |
DS
| 4 |
2134-09-04 00:00:00
|
2134-09-04 13:11:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Back pain, nausea, vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ with history of prior
pyelonephritis and renal failure requiring dialysis presenting
with nausea, vomiting, and flank pain.
The patient reports that ___ days ago she developed bilateral
lower back pain and leg pain. The pain is in her bilateral lower
back. No exacerbating or alleviating factors. She also developed
nausea, vomiting, and subjective fevers. She also reports a
headache. She reports urinary frequency but no dysuria or
hematuria. No constipation or diarrhea. No chest pain,
palpitations, shortness of breath, or cough.
In the ED, initial vitals: 10 99.7 132 110/64 16 100% RA
Exam notable for: Positive flank tenderness
Labs notable for: WBC 9.1 H/H 11.6/35.8 plt 141; BMP wnl;
urinalysis grossly positive
Imaging notable for:
- CXR: Normal chest radiograph.
Patient given:
___ 22:32 PO Acetaminophen 1000 mg
___ 22:32 IV Ondansetron 4 mg
___ 22:33 IVF NS 1000 mL
___ 23:15 IVF NS 1000 mL
___ 23:20 IV Ketorolac 15 mg
___ 23:50 IV CefTRIAXone
___ 23:50 IVF NS (1000 mL ordered)
On arrival to the floor, the patient reports that she continues
to have back pain as well as nausea, although both are somewhat
improved. She denies any other complaints at present.
ROS: Pertinent positives and negatives as noted in the HPI.
10-point ROS reviewed and are negative.
Past Medical History:
- History of renal failure at age ___ due to kidney infection,
required 1 month of dialysis
Social History:
___
Family History:
No family history of kidney disease.
Physical Exam:
Discharge exam:
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Moist mucous membranes
CV: Regular, tachycardic
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-TTP
Mild b/l flank pain.
GU: No suprapubic fullness or tenderness to palpation, flank
pain
as above
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
Pertinent Results:
___ 10:51 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 CFU/mL OF TWO COLONIAL
MORPHOLOGIES.
PRESUMPTIVE IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Brief Hospital Course:
#Pyelo:
Pt was admitted on IV CTX. Renal US was done which was
unremarkable. Fevers abated and pain improved. Pt was converted
to PO cipro to complete a 14d course of abx, last day = ___.
Pt discharged to f/u w/ PCP.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth twice
a day Disp #*20 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Pyelonephritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted with an infection of your kidneys. It is now
improving, so you can go home and complete your antibiotics
there.
We wish you the best with your health.
___ Medicine
Followup Instructions:
___
|
19560439-DS-9
| 19,560,439 | 28,815,624 |
DS
| 9 |
2172-03-23 00:00:00
|
2172-03-23 20:35:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Meperidine
Attending: ___
Chief Complaint:
jaundice, abdominal distension
Major Surgical or Invasive Procedure:
ERCP with sphincterotomy
History of Present Illness:
HMED ATTENDING ADMISSION NOTE
.
ADMIT DATE: ___
ADMIT TIME: 0300
.
PCP: no PCP due to lack of health insurance
.
___ yo M with pmhx significant for DM2, HTN, CAD s/p CABG and HLD
with no recent medical care due to lack of insurance is
transferred from ___ with obstructive
jaundice.
.
Patient reports ___ weeks of increasing abdominal distension and
acid reflux symptoms. Also noted yellowing of skin today.
Endorses 12 lbs weight loss x 3 weeks. No fever, chills, nausea
or vomiting. Intermittent diarrhea, no brbpr or melena. Has
been taking ___ pills of 500 mg tylenol per day for "many
years". Never told he had liver problems. No recent etoh,
distant past hx of abuse. Last seen by medical provider ___ years
ago due to lack of insurance. No prescription medications x ___
years.
.
Patient presented to ___ today and was found
to have markedly elevated total bilirubin, alk phos and ast/alt.
He had a negative acetaminophen level. CT scan showed CBD
dilatation and pancreatic fullness. He was started on ___ and
transferred to ___.
.
ED: 98.6 84P 136/71 18 99%RA; 1L D5NS, NAC d/c'ed as
acetaminophen level was negative (repeated at BI). ERCP
consulted and plan for ERCP today.
.
ROS as per HPI, 10 pt ROS otherwise negative
Past Medical History:
DM2
HTN
HLD
CABG ___
Removal of non-cancerous tumor on left lateral neck
Social History:
___
Family History:
adopted - fhx unkown
Physical Exam:
VS: 96.8 116/62 78 18 98RA
Appearance: alert, NAD, jaundiced
Eyes: eomi, perrl, icteric sclera
ENT: OP clear s lesions, mmd, no JVD, neck supple
Cv: +s1, s2 -m/r/g, no peripheral edema, 2+ dp/pt bilaterally
Pulm: clear bilaterally
Abd: soft, mild RUQ ttp, no rebound/guarding, +bs
Msk: ___ strength throughout, no joint swelling, no cyanosis or
clubbing
Neuro: cn ___ grossly intact, no focal deficits
Skin: no rashes, jaundice
Psych: appropriate, pleasant
Heme: no cervical ___
___ Results:
___ 10:12PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-300 KETONE-10 BILIRUBIN-MOD UROBILNGN-NEG PH-5.0
LEUK-NEG
___ 10:12PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 10:12PM ___ PTT-31.6 ___
___ 10:12PM PLT COUNT-312
___ 10:12PM NEUTS-53.2 ___ MONOS-3.3 EOS-1.4
BASOS-1.0
___ 10:12PM WBC-10.8 RBC-3.96* HGB-11.4* HCT-34.3* MCV-87
MCH-28.8 MCHC-33.3 RDW-17.2*
___ 10:12PM URINE GR HOLD-HOLD
___ 10:12PM URINE HOURS-RANDOM
___ 10:12PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 10:12PM ALBUMIN-3.3*
___ 10:12PM LIPASE-74*
___ 10:12PM ALT(SGPT)-428* AST(SGOT)-206* ALK PHOS-1140*
TOT BILI-16.8*
___ 10:12PM estGFR-Using this
___ 10:12PM GLUCOSE-213* UREA N-9 CREAT-0.5 SODIUM-128*
POTASSIUM-3.6 CHLORIDE-95* TOTAL CO2-22 ANION GAP-15
.
CTA PANCREAS: PRELIM READ IMPRESSION: (final read is still
pending at discharge.)
1. Ill-defined hypodensity in the pancreatic head surrounding
the
gastroduodenal artery with irregularity of the artery. The mass
may begin at
the origin of the GDA. A celiac axis node and portacaval lymph
node are mildly
enlarged. No liver lesion is seen. The common bile duct stent is
new from
___, resulting in decreased intrahepatic bile duct
dilation.
2. A 3-4 mm right middle lobe pulmonary nodule. Followup is
recommended in
the setting of pancreatic head mass.
Pathology:
DIAGNOSIS:Common bile duct, brushing:
Negative for malignant cells.
Glandular cells and bile pigment.
Brief Hospital Course:
___ yo M with pmhx significant for DM2, HTN, CAD s/p CABG and HLD
with no recent medical care due to lack of insurance is
transferred from ___ with obstructive
jaundice.
.
#Obstructive jaundice: With CBD dilatation, pancreatic fullness,
aTbili of 16 with weight loss, there was concern for a
pancreatic malignancy. He underwent ERCP with sphincterotomy
and stent placement and had brushings sent which were negative
for malignanvy. He was treated with empiric cipro/flagyl. He
was monitored for post ERCP pancreatitis and his diet was
advanced without difficulty. Hepatobiliary surgery evaluated
the patient also and recommended a CTA pancreas which confirmed
a pancreatic head mass. They recommended EUS as well which will
be scheduled by GI next week. CEA was elevated. CA ___ is
still pending. Hepatitis serologies were sent which show prior
Hep B infection with a negative surface Antigen. Hep C
serologies are still pending at the time of discharge. He will
follow up with Dr. ___. An appointment was made prior to
discharge.
.
#Transaminitis: This was likely due to obstructive jaundice,
cholestatic injury as opposed to acute liver injury. Patient
was started on NAC at OSH however acetaminophen level negative x
2 so it was not continued after transfer. LFTs downtrended.
.
#Hyponatremia: The patient was initially hyponatremic bu it
resolved with IVF. likely hypovolemic due to poor po intake
.
#Anemia: The patient showed no signs of bleeding. Iron studies
were sent showing a normal iron and TIBC level with a ferritin
of 787 ruling out iron deficiency. Likely anemia of chronic
disease.
.
#DM2: The patient had previously been on metformin and glyburide
but had not been taking any of his medications. He was on an
insulin sliding scale while in house but was restarted on
metformin and glyburide at discharge. He will follow up to
establish care with a new PCP near his home.
.
Medications on Admission:
Tylenol prn
No prescription medications
Discharge Medications:
1. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
2. metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
3. glyburide 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
4. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain for 7 days.
Disp:*15 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
pancreatic mass
obstructive jaundice
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for further evaluation of abdominal pain and
jaundice. You underwent and ERCP with sphincterotomy and had a
stent placed. You were monitored for any complications and your
diet was gradually advanced. You had a CTA of your Pancreas.
Surgery evaluated you as well and recommended and endoscopic US.
You will be contacted regarding scheduling for the EUS next
week. You should follow up with surgery as below.
You were also restarted on medications for your diabetes.
You should establish care with a PCP near your home as soon as
possible.
You should not take aspirin, NSAIDS or other blood thinning
medications for another 5 days.
Followup Instructions:
___
|
19560904-DS-16
| 19,560,904 | 21,662,051 |
DS
| 16 |
2131-01-27 00:00:00
|
2131-01-27 20:40:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
hemoptysis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ PMH of Anxiety, PTSD, OCD (compulsion=intense nasal
picking), who presented c/o hemoptysis after ___ visit 2 days ago
where she was diagnosed with PNA and given Levofloxacin, who was
BIBEMS ___ another incident of hemoptysis who was admitted to
medicine for further workup.
As per pt, she was sleeping 2 nights ago when she awoke to
coughing and coughed up a very small volume of BRB and "clots"
which filled ___ cm of a disposable cup. She was extremely
nervous and used her lifeline button, and was transported to
___, where labs/CXR were negative as per pt, so she was
discharged home without any treatment. Later she noted that they
called her back and informed her to take levofloxacin which was
called in to pharmacy for her.
Pt felt ok for the next day but was coughing intermittently,
bringing up clear sputum w/ occasional flecks of blood. She then
had another small volume hemoptysis episode and again was
brought to the ___ but this time at ___.
Notably, pt denied weight loss over past yr, chronic cough, or
risk factors for TB (never homeless/jailed/born in US). She
endorsed a long hx of nose picking as her predominant compulsion
of OCD, and noted that she only picks on the R side. She said it
has gotten so bad that ENT evaluation previously informed her
that she "ruined" that side of her nose causing lots of scar
tissue. However, she denied ever having epistaxis or hemoptysis
in the past. She endorsed stable dysphagia involving solids,
that was unchanged in ___ yrs, and has had negative w/u to date
including (EGD/Barium Swallow).
In ___ initial VS were 97.8 80 107/57 18 99%. Inital
CHEM/CBC/Lactate/UA unremarkable. CXR PA/Lateral, well expanded
and clear, no acute findings. She was given cepastat lozenges,
moxifloxacin and admitted to medicine for further w/u.
On the floor, pt reports feeling comfortable and was tearful.
She reported feeling embarassed that she was hospitalized.
Past Medical History:
Anxiety - Severe, failed multiple long term controller meds
(effexor/celexa/buspar/pamilor etc...). Sees psychiatrist and
therapist every 2 weeks
OCD - Main compulsion = nose picking
Fibromyalgia
TIA?
PTSD
Alopecia
Childhood Lead Poisoning and Seizures
PSH:
Rotator Cuff Repair
Tonsillectomy
Thyroid Biopsy (negative)
ALLERGIES:
Social History:
___
Family History:
No hx of head/neck cancer but has hx of breast/cervical cancer.
Sister had "blood problems with platelets" that resulted in
splenectomy
Physical Exam:
PHYSICAL EXAM:
Vitals: T: 98.1, BP108/43 P70 R18 O2100RA
General: Sitting in bed, comfortable, NAD, occasionally tearful
HEENT: MMM, OP clear, no blood visible. Nares are hyperemic w/
irritated mucosa
CV: RRR, no m/r/g, normal S1/S2
Lungs: CTA b/l, no wheezes/rales/rhonchi, no accessory muscle
use, no increased WOB
Abdomen: Soft, NT, ND, normoactive BS, no rebound/guarding
GU: deferred, no foley
Ext: Warm, well perfused, trace edema
Neuro: AOX3, calm
Skin: Warm, dry, no rashes
Pertinent Results:
___ 07:59AM BLOOD WBC-5.3 RBC-4.04* Hgb-12.8 Hct-39.7
MCV-98 MCH-31.7 MCHC-32.3 RDW-12.1 Plt ___
___ 07:59AM BLOOD Glucose-94 UreaN-10 Creat-0.7 Na-145
K-3.9 Cl-104 HCO3-28 AnGap-17
___ 07:59AM BLOOD CK(CPK)-104
___ 07:59AM BLOOD cTropnT-<0.01
___ 07:59AM BLOOD CK-MB-3
___ 07:59AM BLOOD Lactate-1.0
CXR: Subtle increased opacity projects over the periphery of
the right
midlung. This is nonspecific, could be infectious in the proper
clinical
setting. Recommend repeat after treatment to document
resolution.
Brief Hospital Course:
BRIEF HOSPITAL COURSE:
============================================
___ PMH of Anxiety, PTSD, OCD (compulsion=intense nasal
picking), who presented c/o hemoptysis after ___ visit 2 days ago
where she was diagnosed with PNA and given Levofloxacin, who was
BIBEMS ___ another incident of hemoptysis who was admitted to
medicine for further workup and monitoring and subsequently
discharged after determining that patient likely had small
volume bleed ___ either bronchitis or epistaxis that accumulated
in posterior oropharynx.
ACTIVE ISSUES:
============================================
#Hemoptysis
As per hx, this was pt's first episode of hemoptysis ever. While
most obvious etiology would be epistaxis ___ nasal picking, in
light of her known OCD compulsion, robust Hgb, and small volume
which she reported. Other less likely etiologies include
bronchitis given her hx of non-productive cough. Other less
likely etiologies considered were PE (but no tachycardia),
coagulopathy (normal INR/plt), cancer (no family hx of head/neck
cancer). Given that pt's airway was without compromise,
cough/gag reflex was intact, and pt was able to take PO without
difficulty, her small volume bleed was likely of low risk, and
thus able to be further followed/investigated as an outpatient.
Pt's PCP confirmed that she had an appt the day following
discharge. Dr. ___ spoke with the PCPs coverage to
communicate the plan that patient did not require further
inpatient investigation of hemoptysis. Since her hemoptysis is
small volume, has only ocurred for 48hrs and is not associated
with other systemic illness and likely due to acute bronchitis,
it is reasonable that patient ___ with PCP and only pursue
further testing if it does nto resolve over a week or if the
volume/quantity of bleeding changes or if other symptoms/signs
develop.
Pt was instructed to continue moxifloxacin for possible
pneumonia (although no infiltrate was seen on her CXR done at
___, instructed to avoid nose picking as much as possible, and
to ___ with her PCP the following day. She was instructed to
call her PCPs coverage should she cough up blood again in order
to help triage the situation and prevent another potentially
un-necessary admission. PCPs coverage and patient were in
agreement with this plan. Pt would likely benefit from
outpatient ENT referral given history of repeated nasal trauma.
#Chest Pressure
___ triage nursing note documented chest pressure that pt noted
was chronic. EKG showed TWI in V2, aVL that seemed new as
compared to prior. Pt was continued on ASA81 and B-Blocker.
Cardiac enzymes x1 were negative. Given hx of chest pressure, pt
may benefit from outpatient workup of cardiac disease.
TRANSITIONAL ISSUES:
===========================================
**[]she should have repeat CXR in ___ weeks to document
resolution of subtle R mid lung opacity seen on CXR
1. Pt would benefit from continued outpatient ___ regarding her
psychiatric issues.
2. Pt would likely benefit from outpatient ENT evaluation given
hx of nasal trauma.
3. Pt should attend PCP ___ appt day following discharge to
trend symptoms
4. Pt should continue Levofloxacin as previously prescribed to
complete course for possible bronchitis
5. Pt should call her PCP should another episode of hemoptysis
occur prior to pressing lifealert button in order to better
triage situation.
6. Pt would likely benefit from outpatient w/u of possible
cardiac disease.
# CODE: FULL (confirmed)
# CONTACT: ___ (sister ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Nadolol 40 mg PO QAM
2. Nadolol 20 mg PO QPM
3. Omeprazole 40 mg PO DAILY
4. Patanol (olopatadine) 0.1 % ophthalmic qd
5. ClonazePAM 0.5 mg PO QID anxiety
6. Lorazepam 1 mg PO Q8H:PRN anxiety
7. Sodium Chloride Nasal 2 SPRY NU DAILY:PRN nasal dryness
8. Aspirin 81 mg PO DAILY
Discharge Medications:
1. ClonazePAM 0.5 mg PO QID anxiety
2. Lorazepam 1 mg PO Q8H:PRN anxiety
3. Nadolol 40 mg PO QAM
4. Nadolol 20 mg PO QPM
5. Omeprazole 40 mg PO DAILY
6. Patanol (olopatadine) 0.1 % ophthalmic qd
7. Sodium Chloride Nasal 2 SPRY NU DAILY:PRN nasal dryness
8. Aspirin 81 mg PO DAILY
9. moxifloxacin 400 mg oral q24h Duration: 7 Days
as prescribed by ___ providers for possible
bronchitis
Discharge Disposition:
Home
Discharge Diagnosis:
Hemoptysis
Secondary:
PTSD
OCD
Anxiety
Discharge Condition:
Discharge Condition: Stable
Mental Status: AOx3 (baseline)
Ambulatory Status: Independent (baseline)
Discharge Instructions:
Ms. ___,
It was a pleasure taking care of you while you were hospitalized
at ___. As you know, you were
admitted for concern that you were coughing up blood while you
were at home. Based on the history that you provided and our
exam, we think that you most likely have bronchitis or nose
irritation that had caused the bleeding. Accordingly, we feel
that you are safe for discharge today. Should you notice
bleeding again, you should immediately call your primary care
doctor at ___ before pressing your life alert button as
it may not require re-evaluation in the hospital.
Lastly, you should continue taking the moxifloxacin as
prescribed.
We hope you feel better soon!
Followup Instructions:
___
|
19561018-DS-6
| 19,561,018 | 26,046,850 |
DS
| 6 |
2143-12-04 00:00:00
|
2143-12-04 18:52:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left wrist pain
Major Surgical or Invasive Procedure:
___: Left forearm wound irrigation & debridement, Left
distal radius external fixator placement
History of Present Illness:
___ RHD on aspirin s/p fall down stairs with left wrist pain and
deformity. Headstrike but no LOC. No numbness. Unable to move
fingers due to pain. Taken to ___ were an xray demonstrates an
open distal radius fracture on the left side. Patient given
ancef and tetanus and txf to ___.
Past Medical History:
DM, HTN, HLD, hysterectomy, c-section
Social History:
___
Family History:
Noncontributory
Physical Exam:
On admission:
Vitals:97.8 62 142/78 16 99% RA
Gen: A&Ox3
HEENT: left periorbital swelling and ecchymosis
CV: RRR
Pulm:CTAB
Abd: S/NT
Pelvis stable
Right upper extremity:
- Skin intact
- No deformity, erythema, edema, induration or ecchymosis
- Soft, non-tender arm and forearm
- Full, painless AROM/PROM of shoulder, elbow, wrist, and digits
- EPL/FPL/DIO (index) fire
- SILT axillary/radial/median/ulnar nerve distributions
- 2+ radial pulse
Left upper extremity:
- 1.5cm transverse laceration over ulnar aspect of distal
ventral forearm with surrounding swelling and deformity.
- Patient unable to actively flex or extend digits. Cap refill
<2sec in all digits. Reports pain with passive ROM of the
digits.
- SILT axillary/radial/median/ulnar nerve distributions
- 2+ radial pulse
Right lower extremity:
- Skin intact
- No deformity, erythema, edema, induration or ecchymosis
- Soft, non-tender thigh and leg
- Full, painless AROM/PROM of hip, knee, and ankle
- ___ fire
- SILT SPN/DPN/TN/saphenous/sural distributions
- 1+ ___ pulses, foot warm and well-perfused
Left lower extremity:
- Skin intact
- No deformity, erythema, edema, induration or ecchymosis
- Soft, non-tender thigh and leg
- Full, painless AROM/PROM of hip, knee, and ankle
- ___ fire
- SILT SPN/DPN/TN/saphenous/sural distributions
- 1+ ___ pulses, foot warm and well-perfused
On discharge:
AVSS
Gen: NAD, A&Ox3
CV: RRR
Pulm: CTAB
Abd: Soft, NT/ND
Left upper extremity: Dressing clean/dry/intact. Ex-fix in
place, pin sites clean/dry. Wiggles fingers. SILT M/R/U nerve
distributions. Warm and well-perfused hand
Pertinent Results:
___ 03:42PM WBC-14.4* RBC-4.27 HGB-11.1* HCT-34.9 MCV-82
MCH-26.0 MCHC-31.8* RDW-13.2 RDWSD-39.0
___ 03:42PM PLT COUNT-270
___ 03:42PM ___ PTT-30.5 ___
___ 03:42PM GLUCOSE-176* UREA N-24* CREAT-1.2* SODIUM-140
POTASSIUM-3.9 CHLORIDE-100 TOTAL CO2-27 ANION GAP-17
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have an open left distal radius fracture and was admitted to
the orthopedic surgery service. The patient was taken to the
operating room on ___ for left upper extremity wound
irrigation & debridement and external fixator placement, 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. The patient was given ___ antibiotics
and anticoagulation per routine. The patient received Ancef and
tetanus immunization at the outside hospital prior to transfer
to ___ as per routine protocol for open fracture management.
The patient's home medications were continued throughout this
hospitalization with the exception of oral hypoglycemics which
were held as per routine perioperative protocol. The patient was
maintained on an insulin sliding scale while in-house. The
patient worked with OT who determined that discharge to home was
appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
nonweight bearing in the left upper extremity. 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:
aspirin
atenolol-chlorthialidone 50-25mg daily
januvia 100mg tablet
lantus 100mg'
lisinopril 2.5mg daily
meclezine 25mg dailyu
metformin 500mg daily
niaspan 1000mg daily
novolog 100mg daily
omeprazole 20mg daily
simvastatin 40mg daily
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Docusate Sodium 100 mg PO BID
3. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every three (3) hours
Disp #*90 Tablet Refills:*0
4. Senna 17.2 mg PO DAILY
aspirin
atenolol-chlorthialidone 50-25mg daily
januvia 100mg tablet
lantus 100mg'
lisinopril 2.5mg daily
meclezine 25mg dailyu
metformin 500mg daily
niaspan 1000mg daily
novolog 100mg daily
omeprazole 20mg daily
simvastatin 40mg daily
Discharge Disposition:
Home
Discharge Diagnosis:
Left open distal radius fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Nonweight bearing in your left arm
- Range of motion as tolerated in your left shoulder and elbow
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
WOUND CARE:
- You 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.
- No dressing is needed if wound continues to be non-draining.
- Please keep the pin sites clean and dry.
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 surgeon's team (Dr. ___ in the
Orthopaedic Sports 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 and any new
medications/refills.
Followup Instructions:
___
|
19561246-DS-13
| 19,561,246 | 27,603,878 |
DS
| 13 |
2120-09-22 00:00:00
|
2120-09-25 22:58:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
sulfamethizole
Attending: ___
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
ERCP (___)
Liver biopsy (___)
EGD (___)
History of Present Illness:
Ms. ___ is a ___ lady with idiopathic vs alcoholic
cirrhosis w/ h/o portal vein thrombosis p/w increased vomiting
and ___ transferred to ___ for further evaluation.
Patient has subacute N/V ___ in 2 week period) associated with
chronic lower abdominal pain she attributes to her know ruptured
ovarian cyst. On ___, patient vomited several times
(non-bloody) over the course of the day associated with
lightheadedness prompting her to go to OSH where she had
elevated transaminases compared to baseline so sent to ___ for
possible ERCP.
Does not have F/C, CP, SOB, dysuria, BRBPR, diarrhea, melena,
vaginal bleeding. Abd pain is not worse than usual.
In the ED, initial vitals were: 98.3F, 80, 101/57, 18, 100% RA
Labs were notable for: WBC 14.2, Hgb 9.1. AST/ALT 457/317, AP
21, TBili 1.8. Cr 0.6. UTox +Oxy, UA few bac w/ tr leuk/neg
nitrite. Serum tox negative.
Liver U/S w/ cirrhotic liver w/o ascites and no gallstones. CXR
pending. Transvaginal US w/ ruptured cyst
Hepatology fellow saw pt in ED and recommended infectious
workup.
Currently, feels better.
ROS: as per above
Past Medical History:
1) Anxiety and depression (not formally diagnosed)
2) Cirrhosis - alcohol vs idiopathic
3) Liver abscesses - s/p ertapenem course
4) Portal vein thrombosis - not on anticoagulation
5) History of bacteremia and pneumonia
6) ? latent tuberculosis. Patient tells me that at age ___ she
received treatment for tuberculosis and she has a persistently
positive PPD which may be expected after treatment. The
infection
disease consultant wanted her to have another course of
treatment
when a liver stabilized which has not been done.
7) ?Ovarian infection s/p surgery in ___ ___
Social History:
___
Family History:
Denies family history of GI, liver or biliary issues.
Physical Exam:
============================
ADMISSION PHYSICAL EXAM:
============================
General: Well appearing ___ eastern woman in no distress
HEENT: MMM, sclera anicteric, EOMI, PERRL
Neck: No JVD
CV: Normal S1/S2, RRR, w/o m/r/g
Lungs: CTA b/l w/o w/r/r
Abdomen: Soft, NT, mildly distended w/ umbilical hernia w/o TTP
Ext: Moving all extremities, 2+ distal pulses w/ c/c/e
Neuro: CNII-XII normal, AOX3
Skin: non jaundiced w/o rash
============================
DISCHARGE PHYSICAL EXAM:
============================
VS: T 97.1 BP 116/68 HR 75 RR 18 99% RA
FSBG: 117-316
General: Well appearing woman in no distress, lying in bed
HEENT: MMM, sclera anicteric, EOMI, PERRL
Neck: No JVD, full ROM
CV: Normal S1/S2, RRR, w/o m/r/g
Lungs: CTA b/l w/o w/r/r
Abdomen: Soft, NT, mildly distended w/ umbilical hernia, mild
TTP in LLQ, +BS
Ext: Moving all extremities, 2+ distal pulses w/ c/c/e
Neuro: CNII-XII normal, moves all extremities well, AO X 3
Skin: non jaundiced w/o rash
Pertinent Results:
=====================
ADMISSION LABS:
=====================
___ 12:01AM BLOOD WBC-14.2* RBC-2.92* Hgb-9.1* Hct-27.9*
MCV-96 MCH-31.2 MCHC-32.6 RDW-18.9* RDWSD-66.3* Plt ___
___ 12:01AM BLOOD Neuts-91* Bands-1 Lymphs-8* Monos-0 Eos-0
Baso-0 ___ Myelos-0 AbsNeut-13.06* AbsLymp-1.14*
AbsMono-0.00* AbsEos-0.00* AbsBaso-0.00*
___ 09:30AM BLOOD ___ PTT-38.2* ___
___ 12:01AM BLOOD Glucose-185* UreaN-7 Creat-0.6 Na-133
K-4.1 Cl-107 HCO3-24 AnGap-6*
___ 12:01AM BLOOD ALT-317* AST-457* AlkPhos-214*
TotBili-1.8* DirBili-1.0* IndBili-0.8
___ 06:20AM BLOOD Calcium-7.7* Phos-3.3 Mg-1.7 Iron-101
=====================
PERTINENT RESULTS:
=====================
LABS:
=====================
___ QG6PD-19.3*
___ calTIBC-287 Ferritn-59 TRF-221
___ %HbA1c-4.3* eAG-77*
___ IgM HAV-NEGATIVE
___ HBcAb-NEGATIVE HAV Ab-POSITIVE
___ HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE
___ Smooth-POSITIVE *
___ ___
___ IgG-7060* IgA-220 IgM-120
___ HCV Ab-NEGATIVE
___ QUANTIFERON-TB GOLD Negative
___ ANTI-LIVER-KIDNEY-MICROSOME ANTIBODY Negative
___ ALPHA-1-ANTITRYPSIN Normal
=====================
IMAGING:
=====================
RUQ US (___):
1. Cirrhotic liver.
2. Mild splenomegaly.
3. No ascites. Patent portal vein.
4. Normal gallbladder and biliary tree.
===
CXR (___):
No evidence of pneumonia.
===
Transvaginal Ultrasound (___):
1. 6.1 x 6.8 cm nonvascular complex cystic lesion in the left
adnexa, most likely representing a hemorrhagic cyst, a followup
ultrasound is recommended in 6 weeks (a different point in the
patient's menstrual cycle), to re-evaluate this finding. If
symptoms worsen could image with ultrasound or MRI earlier.
2. Left ovary not confidently seen, with a lesion of this size
and appearance torsion (remotely with hemorrhage) cannot be
excluded.
===
ERCP (___)
Impression: Evidence of a previous sphincterotomy was noted in
the major papilla. Cannulation of the biliary duct was
successful and deep with a sphincterotome using a free-hand
technique. Contrast medium was injected resulting in complete
opacification. The common bile duct, common hepatic duct, right
and left hepatic ducts, biliary radicles and cystic duct were
filled with contrast and well visualized. The course and caliber
of the structures are normal with no evidence of extrinsic
compression, no ductal abnormalities, and no filling defects.
The biliary tree was swept with a balloon starting at the
bifurcation. No stones or sludge were seen. The CBD and CHD were
swept repeatedly and no stones or sludge were seen. The final
occlusion cholangiogram showed no evidence of filling defects in
the CBD. Excellent bile and contrast drainage was seen
endoscopically and fluoroscopically. Otherwise normal ercp to
third part of the duodenum.
===
MRI Pelvis with and without contrast (___): Large left
ovarian hemorrhagic cyst with a few normal ovarian follicles
draped around it, torsion cannot be excluded. In addition, there
is a left sided hematohydrosalpinx.
===
MRI Abdomen with and without contrast (___): Cirrhosis with
mild splenomegaly. There has been interval increased atrophy of
the left lobe of the liver and previously seen cystic lesions in
a branching distribution are no longer visualized on this
examination. There is trace perihepatic free fluid. There is a
10 x 9 mm focus of arterial enhancement within segment 6 of the
lumbar which is smaller in size on subtraction imaging and does
not demonstrate washout (series 9, image 55). The lesion does
not meet criteria for ___, however, ___ MRI imaging in ___
months is recommended. No evidence of hepatic abscesses. Again
noted is complete occlusion of the left portal vein.
===
Liver Biopsy (___):
1. Moderate to severe portal/septal, ___ and lobular
inflammation, comprised of prominent plasma cells, lymphocytes,
neutrophils and eosinophils, with frequent apoptotic hepatocytes
and
hepatocellular drop-out with associated collapse (Grade 3
inflammation).
2. Bile ductular proliferation with associated neutrophils.
3. Mild mixed macro/microvesicular steatosis (involving <10% of
the biopsy) with rare focus suggestive of balloon degeneration.
4. Trichrome and reticulin stains highlight foci of collapse
(involving approximately 30% of the parenchyma), as well as
septal and bridging fibrosis with rare broad fibrous septae (at
least Stage
3). See note.
5. Iron stain is negative for iron deposition; immunostain
results for CMV and HSV will be issued in a revised report.
===
EGD (___): No varices seen but significant amount of food
in stomach and therefore will need to be repeated.
=====================
MICROBIOLOGY:
=====================
Urine culture (___): PRESUMPTIVE GARDNERELLA VAGINALIS.
10,000-100,000 ORGANISMS/ML..
=====================
DISCHARGE LABS:
=====================
___ 05:15AM BLOOD WBC-8.5 RBC-3.17* Hgb-9.4* Hct-29.8*
MCV-94 MCH-29.7 MCHC-31.5* RDW-18.9* RDWSD-65.4* Plt ___
___ 05:15AM BLOOD ___ PTT-36.7* ___
___ 05:15AM BLOOD Glucose-162* UreaN-9 Creat-0.5 Na-131*
K-3.8 Cl-106 HCO3-23 AnGap-6*
___ 05:15AM BLOOD ALT-212* AST-267* LD(LDH)-213
AlkPhos-239* TotBili-1.2
___ 05:15AM BLOOD Albumin-2.5* Calcium-8.0* Phos-2.6*
Mg-1.9
Brief Hospital Course:
Ms. ___ is a ___ y/o woman with a history of cirrhosis
(previously thought to be secondary to alcohol), h/o left portal
vein thrombosis, and history of cholangitis and liver abscess
who presented with abdominal pain and transaminitis. She was
subsequently found to have cirrhosis secondary to autoimmune
etiology and started on prednisone.
===================
ACTIVE ISSUES:
===================
# Autoimmune hepatitis: The patient has a history of cirrhosis
previously thought to be secondary to alcohol, and a history of
cholangitis and liver abscess. She presented from an OSH with
abdominal pain, vomiting, and worsening transaminitis. RUQ
ultrasound showed patent hepatic vasculature. ERCP was negative
for cholangitis or obstruction. MRI abdomen showed stable left
portal vein thrombosis. Infectious workup was negative. The
patient denies alcohol abuse; she reports that she used to drink
___ glasses of wine on ___ nights per week but that she has not
had any alcohol since her cirrhosis diagnosis. Her IgG was found
to be elevated. Given the unclear etiology of her transaminitis,
she underwent liver biopsy on ___ with pathology consistent
with autoimmune hepatitis. Smooth muscle antibody was positive.
She was started on prednisone 40 mg ___ with improvement in
LFTs. Prednisone taper to be determined by Dr. ___ in
outpatient ___. She was started on dapsone for PCP
___ (Bactrim allergy).
# Cirrhosis: The patient has a history of cirrhosis previously
thought to be secondary to alcohol, but found during this
admission to be due to autoimmune hepatitis as described above.
Childs B. No prior HE, ascites, SBP, or varices. EGD during this
admission was limited due to gastric food contents, so will need
to be repeated as an outpatient. MRI abdomen showed stable left
portal vein thrombus; she is not anticoagulated. Patient will be
set up with transplant clinic for further evaluation.
# Hyperglycemia: The patient was found to be hyperglycemic
following steroid initiation. A1C 4.3%. Patient educated on
daily fingersticks and initiated on Lantus 5 units QHS, to be
uptitrated as outpatient as needed.
# Abdominal pain: Patient presented with abdominal pain and
intermittent emesis. She underwent ERCP, which was negative for
cholangitis or obstruction. She underwent US pelvis, MRI
abdomen/pelvis, significant for 6-7cm left adnexal mass,
hemorrhagic cyst vs. endometriosis. She was evaluated by Ob/Gyn
who ruled out torsion. She will ___ with Ob/Gyn as an
outpatient.
# Bacterial vaginosis: Urine culture showed Gardnerella
vaginalis. Treated with 7-days of Flagyl 500 mg BID.
# Hyponatremia: Patient with Na in low 130s throughout
hospitalization.
===================
CHRONIC ISSUES:
===================
# Normocytic anemia: Stable throughout admission.
============================
TRANSITIONAL ISSUES:
============================
- Started on prednisone 40 mg daily on ___ for autoimmune
hepatitis. Duration will be determined by clinical response.
___ with Dr. ___ on ___. Started on PCP ppx with
dapsone.
- Please ___ Quantiferon Gold that was drawn prior to
steroid initiation.
- Patient to check fasting BG while on prednisone given elevated
BG in-house. Started on 5 units Lantus, which should be
uptitrated as tolerated.
- Patient scheduled repeat EGD with Dr. ___ to r/o
esophageal varices. Was given script for repeat labs (CBC,
Chem7, LFTs, coags) to be drawn at that time.
- Given history of left portal vein thrombosis, patient will
need outpatient thrombophilia evaluation.
- Patient was found to be hepatitis B nonimmune. She was given
the first shot in the vaccination series on ___. She will
need to complete the series as an outpatient.
- Flagyl 500 mg BID for BV for 7 days (last dose ___.
# CODE: Full
# CONTACT: ___ (mother who is temporarily in US w/ patient)
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN severe pain
2. Ibuprofen 400 mg PO Q8H:PRN pain
Discharge Medications:
1. Dapsone 100 mg PO DAILY PCP PPX
RX *dapsone 100 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Glargine 5 Units Bedtime
RX *insulin glargine [Lantus Solostar] 100 unit/mL (3 mL) 5
units SC before bedtime Disp #*1 Syringe Refills:*0
3. MetRONIDAZOLE (FLagyl) 500 mg PO BID
RX *metronidazole 500 mg 1 tablet(s) by mouth twice a day Disp
#*5 Tablet Refills:*0
4. PredniSONE 40 mg PO DAILY
RX *prednisone 20 mg 2 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*0
5. FreeStyle Lite Strips (blood sugar diagnostic) 1 strip
miscellaneous DAILY
RX *blood sugar diagnostic [FreeStyle Lite Strips] 1 strip
daily Disp #*50 Strip Refills:*0
6. Lancets,Thin (lancets) 28 gauge miscellaneous DAILY
RX *lancets [FreeStyle Lancets] 28 gauge 1 lancet daily Disp #*1
Each Refills:*0
7. FreeStyle Control (blood glucose control high,low) 1 drop
miscellaneous DAILY
RX *blood glucose control high,low [FreeStyle Control] Please
use only when ___ want to ensure your meter is working properly
prn Disp #*1 Each Refills:*0
8. BD Ultra-Fine Nano Pen Needles (pen needle, diabetic) 32
gauge x ___ miscellaneous DAILY
RX *pen needle, diabetic [BD Ultra-Fine Nano Pen Needles] 32
gauge X ___ Please use daily to administer using insulin pen
daily Disp #*1 Each Refills:*0
9. Outpatient Lab Work
Please draw CBC, Chem7, LFTs, ___ on ___. Please fax to
___ ___ attn. Dr. ___. ICD-10 ___
Discharge Disposition:
Home
Discharge Diagnosis:
=====================
PRIMARY DIAGNOSIS:
=====================
- Autoimmune hepatitis
- Cirrhosis
- Endometriosis
=====================
SECONDARY DIAGNOSIS:
=====================
- Hyponatremia
- Bacterial vaginosis
- Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of ___ during ___ recent admission
to ___. ___ came to us because ___ were having
abdominal pain. We took a biopsy of your liver, and found that
___ have inflammation of your liver caused by your immune system
(autoimmune hepatitis). We gave ___ a steroid called prednisone
to treat this. Because the prednisone can make ___ have high
blood sugars, we have started ___ on a low dose of insulin.
Please check your blood sugar every morning before ___ eat or
take your insulin and keep a record so that your primary doctor
can adjust your medication. Please call your doctor if your
blood sugars are persistently above 200 in the morning. While
___ are on prednisone, ___ will need to be on a new medication
(dapsone) to prevent infections.
___ also had abdominal pain and multiple tests to evaluate the
cause. ___ did not have any blockage or infection in your bile
ducts. We did find that ___ had likely a cyst that ruptured.
Also ___ may have a condition called endometriosis, in which the
tissue that normally grows inside of your uterus is growing
outside of your uterus and causing ___ pain. ___ have an
appointment with a gynecologist to help with this. ___ also had
bacterial vaginosis, which is a common condition where there is
overgrowth of atypical bacteria in the vagina. For this, ___
have two more days of an antibiotic (metronidazole).
___ are scheduled for a repeat endoscopy to rule out enlarged
veins in your esophagus that can result from your liver disease.
___ have this appointment on ___. Please make sure ___ get
lab tests done that same day. We have given ___ a prescription
for these lab tests, which ___ should bring to that appointment.
We wish ___ the ___ of health.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19561246-DS-16
| 19,561,246 | 22,765,175 |
DS
| 16 |
2122-08-25 00:00:00
|
2122-08-26 12:19:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
sulfamethizole
Attending: ___.
Chief Complaint:
Diverticulitis incidentally seen on MRI
Major Surgical or Invasive Procedure:
___ CT guided drainage of abscess
History of Present Illness:
___ yo woman w/ autoimmune hepatitis in remission (on
azathioprine
and prednisone) c/b cirrhosis, endometriosis (Mirena IUD in
place), hx of intra-abdominal adhesions, intra abdominal/hepatic
abscesses, ovarian cyst, L portal vein thrombosis (no longer on
anti-coagulation), and large ventral hernia who was instructed
to
go to ED after routine screening MRI iso fever 1 week ago
revealed diverticulitis.
Pt states that she has chronic abdominal pain secondary to the
above mentioned diagnoses. She was due for a scheduled MRI on
___ for ___ screening and f/u of left portal vein thrombosis.
MRI concerning for diverticulitis w/ phlegmon. Pt states that
prior to MRI she did have abdominal pain, that was at usual
baseline. Had a fever 1 week ago, which resolved w/ Tylenol.
Also
has had some intermittent nausea. She denies diarrhea, continued
fevers, or chills.
In the ED, initial VS were: 99.2 84 124/83 16 100% RA
Exam notable for:
VS-T 99.2, HR 84, BP 124/83, RR 16, O2 100% RA
Gen- well appearing, in NAD
Card- RRR, no m/r/g
Pulm- CTAB
Abd- Large non reproducible midline ventral hernia, tenderness
in
LLQ and RLQ, no rebound or guarding
Ext- no edema
Labs showed: WBC 6.9, ALT: 99 AP: 361 Tbili: 0.8 Alb: 3.2
AST: 109, Lip: 68, Lactate:1.2
Imaging showed:
___ MRI
1. Acute sigmoid diverticulitis with progression of phlegmonous
changes along superior bladder dome, left-sided peritonitis,
extensive adhesions with tethering of small bowel loops, and
sigmo-sigmoid fistula. No obstruction or drainable collection.
2. Cirrhosis. No HCC. Chronic left portal vein thrombosis.
4. 7.9 cm left pelvic peritoneal inclusion cyst.
Patient received: IV cipro and flagyl
___ Surgery was consulted - Recommend admission to
medicine per outpatient GI note and no need for acute surgical
intervention
IV antibiotics: cipro/flagyl
OK for clears from our perspective
Colorectal will follow while in house
Transfer VS were: 98.4 70 112/68 18 98% RA
On arrival to the floor, patient corroborates the story above.
She denies any chest pain or difficulty breathing. She endorses
that her abdominal pain is at its baseline for her. She does
endorse one isolated fever 1 week ago but does not recall how
high it was, she was feeling chills, but is only the one
isolated
episode and she has not had any since then. She denies any
nausea vomiting or diarrhea. She does endorse continued oozing
from the surgical site across her lower abdomen since the
abscess
drainage by Dr. ___ in ___.
Past Medical History:
1) Anxiety and depression (not formally diagnosed)
2) Cirrhosis - alcohol vs idiopathic
3) Liver abscesses - s/p ertapenem course
4) Portal vein thrombosis - not on anticoagulation
5) History of bacteremia and pneumonia
6) ? latent tuberculosis. Patient tells me that at age ___ she
received treatment for tuberculosis and she has a persistently
positive PPD which may be expected after treatment. The
infection
disease consultant wanted her to have another course of
treatment
when a liver stabilized which has not been done.
7) ?Ovarian infection s/p surgery in ___ ___
Social History:
___
Family History:
Denies family history of GI, liver or biliary issues.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
VS: 98.6 PO 105 / 65 71 98
GENERAL: NAD, alert and oriented Ãâ3
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: Large ventral hernia located across the middle of her
abdomen small scar located across her lower abdomen with some
oozing of fluid, mild tenderness to palpation in the left lower
quadrant without any rebound or guarding, normoactive bowel
sounds
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM
=======================
VS: T 98.9F BP 100/67 mmHg P 84 RR 18 O2 98% RA
General: Pleasant woman, lying comfortably in bed, alert,
oriented, no acute distress
CV: Regular rate and rhythm, no murmurs, no rubs, no gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Large reducible ventral midline hernia, minimal TTP in
LLQ and LUQ, JP drain in place, with minimal serosanguinous
output.
bowel sounds present, no rebound or guarding
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
ADMISSION LABS:
==================
___ 12:25AM BLOOD WBC-6.9 RBC-3.85* Hgb-11.4 Hct-36.1
MCV-94 MCH-29.6 MCHC-31.6* RDW-16.6* RDWSD-57.1* Plt ___
___ 12:25AM BLOOD Neuts-54.5 ___ Monos-9.6 Eos-4.4
Baso-0.3 Im ___ AbsNeut-3.73# AbsLymp-2.11 AbsMono-0.66
AbsEos-0.30 AbsBaso-0.02
___ 12:25AM BLOOD ___ PTT-27.7 ___
___ 12:25AM BLOOD Plt ___
___ 12:25AM BLOOD Glucose-100 UreaN-15 Creat-0.8 Na-134*
K-4.8 Cl-102 HCO3-25 AnGap-7*
___ 12:25AM BLOOD ALT-99* AST-109* AlkPhos-361* TotBili-0.8
___ 12:25AM BLOOD Lipase-68*
___ 12:25AM BLOOD Albumin-3.2*
___ 09:35AM BLOOD Calcium-8.6 Phos-3.3 Mg-2.0
___ 12:37AM BLOOD Lactate-1.2
IMAGING
==================
CT ABDOMEN AND PELVIS WITH IV, PO, PR CONTRAST ___:
ABDOMEN:The liver is again noted to be cirrhotic with chronic
left portal vein thrombosis. Scattered splenic calcifications
are consistent with small granulomas. The adrenal glands
pancreas and kidneys are unremarkable.
GASTROINTESTINAL: Small hiatal hernia. No bowel intestinal
obstruction or
ascites. Large ventral hernia containing nonobstructed loops of
bowel is
again seen. Acute on chronic inflammatory changes are present
adjacent to the sigmoid colon. There is a giant sigmoid
diverticulum and inferior to it, there appears to be a contained
perforation which is likely chronic given the lack of
inflammatory soft tissue stranding atthis level. The contained
perforation tracks anteriorly, inferior to the small bowel loops
contained in the large ventral hernia, consistent with a fistula
which opens into the anterior lower abdominal wall. However,
superior to the bladder dome there are increased phlegmonous
changes compared to prior CT, as seen on recent MRI. No colonic
obstruction and no air within the urinary bladder to suggest
colovesical fistula.
PELVIS: Again seen is a left adnexal peritoneal inclusion cyst,
as on recent MR. ___ IUD is again seen.
LYMPH NODES: Prominent retroperitoneal, mesenteric, and inguinal
lymph nodes are presumed reactive, similar to recent prior
studies.
VASCULAR: There is no abdominal aortic aneurysm.
BONES: There is no evidence of worrisome osseous lesions.
SOFT TISSUES: A new rounded hyperdensity in the subcutaneous fat
in the
contact with the skin surface measuring 1.9 x 1.4 cm likely
represents a
sebaceous cyst (302:35), not present on the recent prior study.
Additional similar area inferior to this measuring approximately
13 x 7 mm likely also represents a sebaceous cyst (302:48).
IMPRESSION: Acute on chronic inflammatory changes surrounding
the sigmoid colon with a contained perforation in communication
with the sigmoid colon, likely chronic, better delineated on the
present study compared with the recent prior MRI. There is a
tract that communicates between the contained perforation and
the anterior abdominal wall at the inferior aspect of the large
ventral hernia.
___ CT INTERVENTIONAL PROCEDURE
FINDINGS:
Re-demonstration of a contained perforation adjacent to the
sigmoid colon
secondary to chronic diverticulitis containing fecal material
mixed with
contrast. The fistula tract connects dex the collection to the
left lower
quadrant skin. 10 ___ drainage catheter was placed into the
collection.
Minimal amount of debris was aspirated after flushing with 10 cc
of saline.
IMPRESSION:
Successful CT-guided placement of ___ pigtail catheter
into the
collection. Samples were sent for microbiology evaluation.
___ CT INTERVENTIONAL PROCEDURE
FINDINGS:
Contained perforation adjacent to the sigmoid colon chronic
diverticulitis
containing fecal material with contrast. Fistula tract connects
this
collection to the left lower quadrant skin. Multiple attempts
were made to
pass the wire through the fistula tract however, not successful.
IMPRESSION:
Unsuccessful cannulation of the fistula tract for which
procedure was aborted.
DISCHARGE LABS
===================
___ 07:07AM BLOOD WBC-8.6# RBC-3.41* Hgb-10.4* Hct-32.3*
MCV-95 MCH-30.5 MCHC-32.2 RDW-16.1* RDWSD-55.9* Plt ___
___ 07:07AM BLOOD Glucose-85 UreaN-8 Creat-0.5 Na-136 K-4.2
Cl-103 HCO3-23 AnGap-10
___ 07:07AM BLOOD ALT-74* AST-83* LD(LDH)-160 AlkPhos-286*
TotBili-1.1
___ 07:07AM BLOOD Calcium-8.1* Phos-3.6 Mg-1.8
___ 05:20AM BLOOD IgG-3829*
Brief Hospital Course:
___ yo woman w/ autoimmune hepatitis previously in remission (on
azathioprine and prednisone) c/b cirrhosis, endometriosis
(Mirena IUD in place), hx intra-abdominal adhesions and
abscesses, and large ventral midline hernia who presented to ED
on ___ with diverticulitis found incidentally on routine MRI
likely associated with chronic colocutaneous fistula s/p
___ drainage of intra-abdominal fluid collection.
#Chronic colocutaneous fistula
#Diverticulitis
#Intra-abdominal abscess
Patient presented with acute diverticulitis found incidentally
on routine MRI screening for ___. Her exam was reassuring, with
no WBC elevation, mild TTP in LLQ, no recent fevers aside from
subjective fever 1 week ago lasting 1 day. She was evaluated by
colorectal surgery and did not require acute surgical
intervention. CT with IV, PO, and PR contrast on ___ revealed
acute on chronic inflammatory changes surrounding the sigmoid
colon with a contained perforation in communication with the
sigmoid colon, more conspicuous on present study compared with
recent prior MRI. There is a tract that communicates between the
contained perforation in the lower abdomen to the anterior
inferior abdominal wall at the inferior aspect of the large
ventral hernia and a 6x8 cm abscess fistulized to abd wall, with
pus and air. She was treated with ciprofloxacin and
metronidazole, and was seen by infectious disease who
recommended a course of 7 days following drainage (to be
completed ___. She underwent CT-guided drainage of the
fluid collection and will be discharged home with ___ services
for drain care and ___ follow-up. She will likely require further
surgical intervention in the future after stabilization of her
acute issues.
# Autoimmune hepatitis
# Cirrhosis.
Previously in remission although LFTs mildly elevated in the
setting of missed doses of her immunosuppressant. MELD labs were
trended. She was continued on her home dose of prednisone and
azathioprine. Hepatology followed during her admission.
TRANSITIONAL ISSUES:
========================
# ANTIBIOTIC COURSE. Will complete PO antibiotic course on
___. Please consider ID follow-up as clinically indicated.
# FOLLOW-UP COLONOSCOPY. Will require referral for outpatient
colonoscopy for evaluation of malignancy as well as for
fistulizing inflammatory bowel disease after resolution of
symptoms. Would advise conferral with colorectal surgery and
hepatology for best timing.
# MEDICATION CHANGES. Antibiotics as above
# CODE STATUS: FULL
# CONTACT: Daughter, ___ at ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. PredniSONE 5 mg PO DAILY
2. AzaTHIOprine 125 mg PO DAILY
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H Duration: 4 Days
2. MetroNIDAZOLE 500 mg PO Q8H Duration: 4 Days
3. AzaTHIOprine 125 mg PO DAILY
4. PredniSONE 5 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
==================
Diverticulitis
Intra-abdominal abscess
SECONDAY DIAGNOSIS:
===================
Autoimmune hepatitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
WHY WERE YOU IN THE HOSPITAL?
-You had ___ infection in your colon called diverticulitis that
was seen on your MRI.
-You had ___ abscess in your abdomen that was drained
WHAT HAPPENED WHILE I WAS HERE?
-You received antibiotics by mouth to treat the infection.
-You had a CT scan of your abdomen to evaluate where the fluid
was draining from on your abdomen which showed that you had a
abscess in your abdomen.
-The interventional radiologists were unable to drain your
abscess.
WHAT SHOULD I DO WHEN I GO HOME?
[]Continue to take all your medications as prescribed.
[]Follow up with Dr. ___.
[]Finish your entire course of antibiotics (ciprofloxacin and
flagyl) for 7 days. The last day of antibiotics should be on
___.
It was a pleasure taking care of you,
Your ___ Medicine Team
Followup Instructions:
___
|
19561274-DS-11
| 19,561,274 | 21,375,273 |
DS
| 11 |
2181-03-08 00:00:00
|
2181-03-08 19:07:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Pseudoephedrine / Augmentin / fentanyl / Trilafon / Cortisporin
/ Valtrex
Attending: ___.
Chief Complaint:
R "kidney pain"
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a ___ female with hx of cerebral palsy s/p trach
vent-dependent at night, congenital RLQ kidney c/b
nephrolithiasis requiring ureteroscopy, open pyelolithotomy, as
well as hx of R ureteric reimplant, who presents with R kidney
pain, nausea, and altered mental status off her baseline.
She was complaining of RLQ pain last night similar to prior
UTI/kidney stone events, and so her mother brought her to the
ED.
In the ED, initial vitals: 97.8 94 134/85 16 99% trach mask
- Exam notable for: somnolent but arousable w/ periods of
agitation. RLQ tenderness.
- Labs were notable for: WBC 12, dirty UA
- Imaging:
CT:
1. 2.4 cm obstructing stone in the right extrarenal pelvis, just
proximal to the ureter, with new moderate right hydronephrosis
and perinephric stranding (602b:32).
2. New air in the bladder. Recommend correlation with history of
recent instrumentation.
Renal US:
New, moderate right hydronephrosis with an obstructing stone
measuring at
least 2.3 cm.
- Patient was given: CTX, Ketorolac, Oxycodone liquid x 1
- Consults: She was seen by urology in the ED, who felt that new
hydronephrosis was caused by small stone at UVJ, in contrast to
radiology's call that the 2.4cm stone is obstructing. They
recommended medical management (NSAIDs, fluids, Flomax) with
repeat kidney US in 1 week and outpatient f/u with Dr.
___.
On arrival to the MICU, slightly somnolent but arousable.
Minimally verbal here although she is more verbal at home.
Answering yes/no. Complains of RLQ pain and nausea. 1 episode of
vomiting here.
Past Medical History:
Gyn Hx:
- primary amenorrhea attributed to familial POI/POF
- began HRT in her ___ after extensive w/u per mother
- had 2 ___ throughout her entire life, both nl, last one ___
- remainder of GYN hx reportedly is w/o issue other than POI and
recent abnormal uterine bleeding after ___ yrs of unopposed
estrogen.
- virginal
Med Hx:
- cerebral palsy dx 18mos, stable neurologic deficit, spastic
quadraplegia, wheelchair bound
- developmental delay
- congenital right pelvic kidney
- renal insufficiency (left worse than right pelvic kidney)
- chronic kidney stones s/p multiple procedures
- episode of urosepsis, ARDS (c/b new onset of seizures-per
mother pt had anti-seizure medication for 24 hrs but EEG was
negative and medication was stopped; displaced nephrostomy tube,
transient pulmonary hemorrhage, decubitus ulcer) in ___ t0 ___, admitted to the ICU at ___ for approx 2
mths, then followed by multiple readmissions
- asthma, severe reactive airway disease and restrictive lung
disease; on oxygen 0.5 to 1L during the day, sometime on room
air
- ventilator dependent w/trach at night, hx recurrent PNAs
(equipments needed: tracheostomy - ___ 6.0 ID TTS v-flange
(change once/month); ___ HT 50 SIMV VC 500 mlx12 bpm with
PSV
4cm H20, PEEP 7 and Ti 1.2 sec).
- chronic sinus infections; chronically colonized with
Xanthamonas Mulitphilia which is sensitive only to Bactrim;
prior
infxn w/Pseudomonas aeruginosa and Haemophilus influenza.
- POI/POF that appears to be familial, ? fhx galactosemia but
not
required to be dairy-free. Previously on Vivelle with q4 month
Provera course, last ___ years on unopposed estrogen.
- osteoporosis w/multiple easy fractures. Per Dr. ___
___
visit, "now that she is on prolia, she does not need the HRT
from
the bony perspective. I understand she has not gotten a course
of
MPA for some time, and if GYN f/u, MPA, or US are complicated,
one could consider stopping the HRT."
- kyphoscoliosis s/p spinal fusion
- PTSD from hospitalizations and exams; mood
disorders/depression
with hallucinations
- sensitve to narcotics; 1 mg of IV morphine works well
- per mother: not a candidate for NG or OG tube, multiple
attempts in the past and failed
- pt is full code
- Pt followed closely by Dr. ___ (intensivist at
___), Dr. ___ (urology at ___)
majority
of ___ medical care at ___, pt's mother is trying to
transition pt's care away from children's and into adult health
care providers
___:
- spinal fusion
- right hip osteotomy x2 ___ and ___
- multiple procedures to clear rt kidney stones including an
open
pyelolithotomy; has encrusted numerous stents and a PCN tube as
well. Hx of cystoscopy/ureteroscopy/lithiasis with laser ___
cystoscopy, right retrograde pyelogram, right ureteroscopy,
attempted lithotripsy, right open pyelolithotomy, right
dismembered pyeloplasty ___ cystoscopy, right retrograde
pyelography, exploratory laparotomy, open nephrostomy tube
removal ___.
- trachostomy ___
Social History:
___
Family History:
-breast cancer in both grandmothers in ___
-maternal grandaunt and great grand mother in ___
-no other GYN malignancies or colon cancer
-no bleeding or clotting disorder or hx VTE
-family hx problem of anesthesia: father slow to wake up after
wisdom teeth
Physical Exam:
Admission:
Vitals: T 97.4, BP 113/78, HR 100s, O2 Sat 92% 11L trach mask
GENERAL: NAD, resting in bed
HEENT: sclera non-icteric, non-injected conjunctiva, OP clear
NECK: No LAD
LUNGS: Slightly ronchorous bilaterally, better with continued
resps
CV: RRR no murmurs, rubs, gallops
ABD: Soft, moderately tender RLQ without rebound, neg CVA
tenderness
EXT: warm, well-perfused, no ___ edema
SKIN: warm, well-perfused, peripheral pulses intact
NEURO: Somnolent but arousable, interactive, moving all ext but
will not move ___ on command, CN2-12 grossly intact
ACCESS: PIV
Discharge:
GENERAL: NAD, resting in bed
HEENT: sclera non-icteric, non-injected conjunctiva, OP clear
NECK: No LAD
LUNGS: Slightly ronchorous bilaterally, better with continued
resps
CV: RRR no murmurs, rubs, gallops
ABD: Soft, minimally tender RLQ without rebound, neg CVA
tenderness
EXT: warm, well-perfused, no ___ edema
SKIN: warm, well-perfused, peripheral pulses intact
NEURO: Somnolent but arousable, interactive, moving all ext but
will not move ___ on command, CN2-12 grossly intact
Pertinent Results:
Admission:
___ 12:45PM URINE AMORPH-RARE
___ 12:45PM URINE RBC-1 WBC-40* BACTERIA-NONE YEAST-NONE
EPI-0
___ 12:45PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-LG
___ 12:45PM URINE COLOR-Yellow APPEAR-Cloudy SP ___
___ 12:05AM PLT COUNT-210
___ 12:05AM NEUTS-78.8* LYMPHS-9.6* MONOS-10.6 EOS-0.4*
BASOS-0.3 IM ___ AbsNeut-9.43*# AbsLymp-1.15* AbsMono-1.27*
AbsEos-0.05 AbsBaso-0.03
___ 12:05AM WBC-12.0*# RBC-4.82 HGB-14.7 HCT-48.2*
MCV-100* MCH-30.5 MCHC-30.5* RDW-13.2 RDWSD-49.1*
___ 12:05AM CRP-45.4*
___ 12:05AM HCG-<5
___ 12:05AM CALCIUM-9.6 PHOSPHATE-5.1* MAGNESIUM-2.0
___ 12:05AM GLUCOSE-111* UREA N-14 CREAT-0.5 SODIUM-143
POTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-34* ANION GAP-11
___ 12:15AM LACTATE-0.9
Discharge:
___ 04:03AM BLOOD WBC-11.2* RBC-3.94 Hgb-12.0 Hct-38.9
MCV-99* MCH-30.5 MCHC-30.8* RDW-13.2 RDWSD-47.2* Plt ___
___ 04:03AM BLOOD Plt ___
___ 04:00PM BLOOD Glucose-177* UreaN-9 Creat-0.4 Na-138
K-3.5 Cl-104 HCO3-25 AnGap-13
___ 04:00PM BLOOD Calcium-7.9* Phos-3.2 Mg-2.1
___ 02:30AM BLOOD ___ pO2-56* pCO2-39 pH-7.39
calTCO2-24 Base XS-0
Imaging:
___:
RENAL US:
IMPRESSION:
New, moderate right hydronephrosis with an obstructing stone
measuring at
least 2.3 cm.
___:
CT ABD/PELVIS:
IMPRESSION:
1. A 2.4 cm obstructing stone in the right extrarenal pelvis,
just proximal to the ureter, with new moderate right
hydronephrosis and perinephric stranding.
2. Multiple new tiny stones in the distal right ureter, with no
new
hydroureter, are likely nonobstructive.
3. New air in the bladder. Recommend correlation with history
of recent
instrumentation.
___:
CTU:
IMPRESSION:
1. Congenital right pelvic kidney is redemonstrated. Interval
removal of
right UVJ stones with near complete resolution of right-sided
hydronephrosis.
2. Large 2.5 cm right renal stone is unchanged in size and has
migrated from the ureteropelvic junction to the inferior pole
the right kidney. Otherwise there are multiple unchanged
nonobstructing right renal stones measuring up to 1.2 cm.
BLOOD CULTURES:
Pending from ___ and ___
Brief Hospital Course:
Ms ___ is a ___ female with hx of cerebral palsy s/p trach
(vent-dependent at night), hypothalamic dysfunction, congenital
RLQ kidney c/b nephrolithiasis requiring ureteroscopy, open
pyelolithotomy, as well as hx of R ureteric reimplant, who
presents with R kidney pain, nausea, and altered mental status
off her baseline.
#Nephrolithiasis complicated by hydronephrosis: likely secondary
to kidney stone at ___. Also has 2.4cm stone in R kindey
chronically. Patient was medically managed (toradol, fluids,
Flomax) and the obstructing stone passed. She will need urology
follow-up for definitive management.
#Leukocytosis: Concern for pyelonephritis vs UTI. ___ also be
inflammatory response to obstructing stone. Urine cultures were
negative. She was treated with CTX and vancomycin for presumed
pyelo. She spiked one fever to 101.1 but otherwise remained
afebrile. She was discharged on ciprofloxacin to complete ___nding ___.
#Toxic Metabolic Encephalopathy: Off baseline per mother, more
somnolent and less verbal. Concern for infectious etiology given
suggestive UA and stranding around kidney on CT. Although she
has hypothalamic dysfunction, she did spike a fever on night of
admission. AMS resolved with stone passage and antibiotics.
#Nausea: Likely due to pain. Resolved with stone passage.
#Chronic respiratory failure: S/p trach. On ventilator at night
at home. She was continued on home albuterol, fluticasone,
montelukast. Remained on her home ventilator settings at night.
TRANSITIONAL ISSUES:
- She will require urology followup for definitive management of
recurrent UTIs/stones within 30 days
- She will complete 5-day course of ciprofloxacin for presumed
UTI (END ___
- Blood cultures were pending at the time of discharge from ___
and ___ and should be followed up in the outpatient setting
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Calciferol (ergocalciferol (vitamin D2)) 1600 Units oral
DAILY
2. Fexofenadine 60 mg PO BID
3. Astepro (azelastine) 0.15 % (205.5 mcg) nasal QHS
4. Montelukast 10 mg PO QHS
5. Fluticasone Propionate 110mcg 2 PUFF IH BID
6. Mupirocin Ointment 2% 1 Appl TP BID
7. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN WHEEZE
8. Topiramate (Topamax) 25 mg PO QHS
9. NexIUM (esomeprazole magnesium) 22.3 mg oral BID
10. MedroxyPROGESTERone Acetate 2.5 mg PO QHS X 7 DAYS, GIVE Q4
MONTHS
11. Mupirocin Ointment 2% 1 Appl TP BID
12. Sodium Chloride 3% Inhalation Soln 3 mL NEB Q2H:PRN
SECRETIONS
13. Magnesium Oxide 400 mg PO BID
14. Sodium Chloride Nasal ___ SPRY NU BID
15. Citalopram 3 mg PO BID
16. Ketoconazole Shampoo 1 Appl TP ASDIR
17. Zeasorb AF (miconazole nitrate) 2 % topical DAILY
18. Vaseline (white petrolatum) 1 topical DAILY
19. Clotrimazole 1% Vaginal Cream 1 Appl VG BID:PRN yeast
20. Betamethasone Dipro 0.05% Cream 1 Appl TP BID
21. Vivelle-Dot (estradiol) 0.025 mg/24 hr transdermal ___
and ___
22. LORazepam 0.5 mg PO DAILY
23. LORazepam 0.75 mg PO QHS
24. LORazepam 0.25 mg PO ONCE MR1 anxiety
25. Multivitamins 1 TAB PO DAILY
26. Ferrous Sulfate 18 mg PO DAILY
27. Lidocaine 5% Patch 1 PTCH TD QAM:PRN Pain
28. Lidocaine 5% Patch 1 PTCH TD QAM:PRN Pain
29. Lidocaine 5% Patch 1 PTCH TD QAM:PRN pAIN
30. Patanol (olopatadine) 0.1 % ophthalmic BID:PRN
ITCHING/REDNESS
31. Sodium Chloride Nasal 1 SPRY NU DAILY:PRN SECRETIONS
32. Chloraseptic Throat Spray 5 SPRY PO QID:PRN SORE THROAT
33. Albuterol Inhaler 4 PUFF IH Q2H:PRN WHEEZE
34. ciprofloxacin-dexamethasone 0.3-0.1 % otic BID:PRN
35. Acetaminophen-Caff-Butalbital ___ TAB PO DAILY:PRN Headache
36. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
37. Acetic Acid 2% Otic Solution ___ drops OTIC WITH H2O
EXPOSURE PRN pain
38. Polyethylene Glycol 17 g PO DAILY:PRN CONSTIPATION
39. Ondansetron 4 mg PO Q8H:PRN NAUSEA
40. Neurontin (gabapentin) 250 mg/5 mL oral QHS
41. Codeine Sulfate 30 mg PO Q6H:PRN PAIN
42. Ibuprofen 400 mg PO Q8H:PRN Pain - Moderate
43. Oxymetazoline 2 SPRY NU BID:PRN 3 DAYS
44. OxyCODONE (Immediate Release) 2.5 mg PO BID:PRN Pain -
Severe
45. OxycoDONE Liquid ___ mg PO Q4H:PRN Pain - Severe
46. Denosumab (Prolia) 60 mg SC MONTHLY
47. Clobetasol Propionate 0.05% Gel 1 Appl TP DAILY:PRN ITCHY
SCALP
48. Levofloxacin 500 mg PO Q24H prn URI
49. Azithromycin 500 mg PO Q24H
Discharge Medications:
1. Ciprofloxacin HCl 250 mg PO Q12H Duration: 5 Doses
RX *ciprofloxacin HCl 250 mg 1 tablet(s) by mouth twice a day
Disp #*7 Tablet Refills:*0
2. Acetaminophen-Caff-Butalbital ___ TAB PO DAILY:PRN Headache
3. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
4. Acetic Acid 2% Otic Solution ___ drops OTIC WITH H2O
EXPOSURE PRN pain
5. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN WHEEZE
6. Albuterol Inhaler 4 PUFF IH Q2H:PRN WHEEZE
7. Astepro (azelastine) 0.15 % (205.5 mcg) nasal QHS
8. Betamethasone Dipro 0.05% Cream 1 Appl TP BID
9. Calciferol (ergocalciferol (vitamin D2)) 1600 Units oral
DAILY
10. Chloraseptic Throat Spray 5 SPRY PO QID:PRN SORE THROAT
11. ciprofloxacin-dexamethasone 0.3-0.1 % OTIC BID:PRN
infection
12. Citalopram 3 mg PO BID
13. Clobetasol Propionate 0.05% Gel 1 Appl TP DAILY:PRN ITCHY
SCALP
14. Clotrimazole 1% Vaginal Cream 1 Appl VG BID:PRN yeast
15. Codeine Sulfate 30 mg PO Q6H:PRN PAIN
16. Denosumab (Prolia) 60 mg SC MONTHLY
17. Ferrous Sulfate 18 mg PO DAILY
18. Fexofenadine 60 mg PO BID
19. Fluticasone Propionate 110mcg 2 PUFF IH BID
20. Gabapentin (gabapentin) 250 mg/5 mL ORAL QHS
21. Ibuprofen 400 mg PO Q8H:PRN Pain - Moderate
22. Ketoconazole Shampoo 1 Appl TP ASDIR
23. Lidocaine 5% Patch 1 PTCH TD QAM:PRN Pain
24. Lidocaine 5% Patch 1 PTCH TD QAM:PRN Pain
25. Lidocaine 5% Patch 1 PTCH TD QAM:PRN pAIN
26. LORazepam 0.5 mg PO DAILY
27. LORazepam 0.75 mg PO QHS
28. LORazepam 0.25 mg PO ONCE MR1 anxiety Duration: 1 Dose
29. Magnesium Oxide 400 mg PO BID
30. MedroxyPROGESTERone Acetate 2.5 mg PO QHS X 7 DAYS, GIVE Q4
MONTHS
31. Montelukast 10 mg PO QHS
32. Multivitamins 1 TAB PO DAILY
33. Mupirocin Ointment 2% 1 Appl TP BID
34. Mupirocin Ointment 2% 1 Appl TP BID
35. NexIUM (esomeprazole magnesium) 22.3 mg ORAL BID
36. Ondansetron 4 mg PO Q8H:PRN NAUSEA
37. OxyCODONE (Immediate Release) 2.5 mg PO BID:PRN Pain -
Severe
38. OxycoDONE Liquid ___ mg PO Q4H:PRN Pain - Severe
39. Oxymetazoline 2 SPRY NU BID:PRN 3 DAYS
40. Patanol (olopatadine) 0.1 % ophthalmic BID:PRN
ITCHING/REDNESS
41. Polyethylene Glycol 17 g PO DAILY:PRN CONSTIPATION
42. Sodium Chloride 3% Inhalation Soln 3 mL NEB Q2H:PRN
SECRETIONS
43. Sodium Chloride Nasal ___ SPRY NU BID
44. Sodium Chloride Nasal 1 SPRY NU DAILY:PRN SECRETIONS
45. Topiramate (Topamax) 25 mg PO QHS
46. Vaseline (white petrolatum) 1 topical DAILY
47. Vivelle-Dot (estradiol) 0.025 mg/24 hr TRANSDERMAL ___
AND ___
48. Zeasorb AF (miconazole nitrate) 2 % topical DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Nephrolithiasis
Cystitis
Toxic metabolic encephalopathy
Secondary diagnoses:
Congenital RLQ kidney
Chronic respiratory failure
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 seen at ___ for a kidney stone, which was obstructing
the urine outflow from your kidney. Fortunately, this stone
passed on its own. You were also treated with antibiotics for
infection of your urine due to the stone.
Please follow up with your urologist to discuss options for
preventing further stones and infections. Please also continue
your course of ciprofloxacin as directed.
We wish you the best in your health,
Your ___ team
Followup Instructions:
___
|
19561401-DS-4
| 19,561,401 | 22,696,067 |
DS
| 4 |
2162-05-08 00:00:00
|
2162-05-12 18:21:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Leg ulcers
Major Surgical or Invasive Procedure:
biopsy of skin lesions by Dermatology
History of Present Illness:
Mr. ___ is a ___ year old gentleman with no medical
history because he has not seen a doctor in ___ years presenting
with 6 months of lower extremity ulcer which have worsened with
bleeding/pain over the past 4 days, and caused associated
fever/chills and stomach upset. He first noticed discrete
non-contiguous dry patches of skin in ___ which eventually
became pruritic, erythematous started to ulcerate and
subsequently bleed. Over the past ___ days his pain increased
due to the ulcers oozing, drying and tearing off with clothing.
He denies any numbness, tingling, sharp/electric pain, inability
to walk. He has been using Goldbond medicated lotion with some
relief of symptoms. (Goldbond is Dimethicone 5% & Menthol 0.5%
or 0.15% depending on strength). While that did alleviate his
symptoms, he ulimtately turned to a topical antibiotic in the
past few days. Due to the increased pain, bleeding and chills,
Mr. ___ presented to the ___ for further evaluation.
.
At ___ (per report, no records have been included in the ___
paperwork) he received Vanc & Doxy and was sent to our ___ for
further evaluation.
.
.
-In the ___, initial VS: 100.0 99 139/73 18 99%
-Exam notable for: Multiple ulcerated scabbed over lesions on
lower extremity
-Labs notable for: leukocytosis, anemia, hypokalemia
-The pt underwent: No studies
-The pt received: Percocet
-The pt was seen by: No consultants called
-Vitals prior to transfer: 99.5 124/60 86 20
.
On arrival to the floor Mr. ___ reports the above. He
recalls a "spider bite" from one year prior on his leg that has
fully healed. He also has chronic hand/elbow arthritis
(undiagnosed and untreated) with what appear to be synovial
fluid collections vs. tophi which he attributes to his work as a
___. No recent travel or sick contacts.
.
ROS: Denies headache, vision changes, rhinorrhea, congestion,
sore throat, cough, shortness of breath, chest pain, nausea,
vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria. All other ROS negative.
Past Medical History:
-Arthritis NOS + a nonspecific Gout history
-No follow up
Social History:
___
Family History:
No family history of IBD or RA obtained
Physical Exam:
Admission PE
VS: 98.8 141/98 95 20 95% RA
GENERAL: Well-appearing man in NAD, comfortable, appropriate.
HEENT: Horizontal Strabismus, NC/AT, PERRLA, EOMI, sclerae
anicteric, MMM, OP clear.
NECK: Supple, no thyromegaly, no JVD, no carotid bruits.
HEART: RRR, no MRG, nl S1-S2.
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored.
ABDOMEN: Soft/NT/ND, no masses or HSM, no rebound/guarding.
SKIN/EXTREMITIES:
Upper extremities: Bilateral hand deformities in MCP and PIP
joints c/w swan neck deformities. Bilateral dependent elbow
synovial outpouches vs. elbow tophi.
Lower extremities: Multiple ulcers with surrounding erythema
with either dried blood vs. necrotic tissue on lower
extremities. Serosanguinous draining from some lesions Tender
to palpation. Sensory, motor and pulses all intact.
NEURO: Awake, A&Ox3, CNs II-XII grossly intact, see Extremity
exam.
.
Discharge PE
Tm and Tc: 98.9 BP: 167/105 HR: 66 RR:20 O2 Sats 99 % on RA
I/O 24 1750/NR
.
pain: none per above
GEN: AAOX3, in NAD
HEENT: MMM, orophayrnx clear
NECK: no lad, no obvious thyroid masses
CV: RRR, no rmg
RESP: distant BS at bases
ABD: NTND, no HSM, no rebound
EXTR: WWP, ___ lesions on ble, about 2X2 cm with dried blood
and crust, raised, largest lesion is 4X5 cm on lateral portion
or the right later extremity about half way up the leg-minimal
surrounding erythema, BUE show bilateral synovial outpouchings,
not erythematous and not TTP, lesions minimally TTP and improved
from prior exams
DERM: per above
neuro: MS wnl, horizontal stabismus on the left, otherwise CN
intact, strength and sensation intact
PSYCH: mood and affect wnl
Pertinent Results:
Color Yellow Appear Hazy SpecGr 1.015 pH 6.0 Urobil 8 Bili
Neg
Leuk Neg Bld Neg Nitr Neg Prot Tr Glu Neg Ket Neg
RBC 4 WBC 4 Bact Few Yeast None Epi <1
7:23p Lactate:1.4
.
136 101 11
-------------<82
3.2 26 0.8
estGFR: >75 (click for details)
Ca: 7.9 Mg: 1.9
ALT: 13 AP: 89 Tbili: 0.8 Alb: 3.0
Serum ASA, EtOH, Acetmnphn, Benzo, Barb, Tricyc Negative
.
12.8
13.0>---<266 12.8 266
37.9
N:80.2 L:12.0 M:5.7 E:1.6 Bas:0.5
.
___: 12.8 PTT: 26.3 INR: 1.2
.
MICROBIOLOGY: Blood Cx pending
.
STUDIES:
Hand XR ___
IMPRESSION: Bilateral hand distal erosive osteoarthritis as
above with
bilateral wrist inflammatory arthritis, such as rheumatoid
arthritis as
described above.
.
CXR ___
FINDINGS: There is no acute process. No pneumonia, no pulmonary
edema. No
pleural effusions. Normal size of the cardiac silhouette. There
is loss
structure in the right upper lobe, potentially reflecting
pulmonary emphysema.
CT would be the more sensitive technique to confirm this change.
.
Skin biopsy ___
Procedure date Tissue received Report Date Diagnosed
by
___ ___. ___
DIAGNOSIS:
1. Skin, right lateral shin, biopsy (A):
Ulcer with subjacent superficial to deep dermal/pannicular
neutrophilic infiltrate (see note).
2. Skin, right lateral ankle, biopsy (B):
Edge of ulcer with adjacent reactive epidermal hyperplasia (see
note).
3. Skin, left anterior shin, biopsy (C):
Ulcer incorporating inflamed hair follicle with subjacent
superficial to deep dermal neutrophilic infiltrate (see note).
.
Test Result Reference
Range/Units
CYCLIC CITRULLINATED PEPTIDE >250 H UNITS
(CCP) AB (IGG)
Reference Range
---------------
Negative: <20
Weak Positive: ___
Moderate Positive: 40-59
Strong Positive: >59
Brief Hospital Course:
Mr. ___ is a ___ year old man with no prior medical
history but poor medical follow up who presents with multiple
lower extremity lesions, systemic signs of infection and
symmetric bilateral upper extremity arthritic changes consistent
with undiagnosed rheumatoid arthritis.
.
## Bilateral lower extremity ulcers due to beta strep group A
ecthyma
The differential diagnosis for these lesions was initially broad
and included pyoderma gangrenosa, rheumatoid vasculitis,
ecthyma, lymes disease and recluse spider bite. The patient did
report the lesions being pruritic and secondary infections were
also considered. As part of the work up of these lesions,
dermatology was consulted and they biopsied several of the
lesions. Initially the patient was treated with vancomycin and
zosyn and this coverage was narrowed to augmentin based on the
tissue cultures which came back as growing beta strep group A.
All blood cultures came back negative. The skin biopsies came
back consistent with ecthyma. The patient was placed on topical
mupirocin and dressing changes bid-to be done by home ___.
He was sent home on both topical and systemic oral antibiotics.
His WBC was normal and he was afebrile the day of discharge
.
##Rhematoid arthritis
The patient has a family history of RA and has UE deformities
consistent with long standing and untreated RA. Rheumatology
was consulted for aid in definitive diagnosis and treatment of
his moderate to severe disease. The patient had hand and wrist
XR consistent with RA as well as a positive RF and anti-CCP
antibody. A CXR did not show any obvious pulmonary involvement
of RA but did show some possible signs of emphysema. The
patient was placed on prednisone 50 QD while the biopsies were
pending, as there was a high suspicion for vasculitis. When
these biopsies came back negative, the prednisone dose was
decreased to 10 mg QD. The patient was placed on vitamin D,
calcium and omeprazole in preparation for a long course of
therapy. If the patient ends up being placed on a DMARD, then
these medications could potentially be discontinued. The
patient was also given fexofenadine prn if the patient develops
pruritis again, to prevent secondary infection. The patient had
hepatitis serologies checked, which were negative. Follow up
with a new primary care physician was arranged. His health
insurance would not allow us to directly set him up with a
Rheumatologist at ___, a referral from his PCP would be needed.
.
##HTN
The patient blood pressures were elevated for ___ day above SBP
140 and some days reaching the SBP160-170 range. The patient
was started on HCTZ 12.5 and up titrated to 25 QD. He was sent
home with a prescription for electrolytes to be checked prior to
his follow up with his PCP
.
## Vitamin B-12 Deficiency
Vitamin B-12 level was 201. The patient was placed on
supplementation, his MCV was not elevated nor was his RDW.
.
## Secondary Diabetes Mellitus
The patient blood sugars were elevated on high dose prednisone.
His dose was decreased to 10 mg of PO prednisone and he was not
sent out on any medications. This will need to be monitored by
his PCP
.
##Coagulopathy
This was presumed to be due to poor nutrition (Albumin 3.0).
The patient was given oral vitamin K to correct this.
.
##Anemia, likely of chronic disease
Hgb was the ___ range during this hospitalization. Iron
studies were sent which showed low Fe, low TIBC and high
ferritin consistent with anemia of chronic disease.
.
## Transitional Issues:
-Follow up with PCP ___ ___ weeks with labs and monitor blood
pressure and blood glucose
-Establish follow up with a Rheumatologist and consider starting
DMARD therapy.
Medications on Admission:
None
Discharge Medications:
1. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for Pain, headache.
Disp:*60 Tablet(s)* Refills:*0*
2. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every ___ hours
as needed for pain for 4 days.
Disp:*10 Tablet(s)* Refills:*0*
3. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
4. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO BID (2 times a day).
Disp:*60 Tablet, Chewable(s)* Refills:*0*
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
6. multivitamin,tx-minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
7. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
8. mupirocin 2 % Ointment Sig: One (1) dose Topical three times
a day for 7 days.
Disp:*QS for 7 days * Refills:*0*
9. amoxicillin-pot clavulanate 875-125 mg Tablet Sig: One (1)
Tablet PO Q12H (every 12 hours) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
10. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
11. fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) as needed for pruritis.
Disp:*30 Tablet(s)* Refills:*0*
12. hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
Disp:*60 Capsule(s)* Refills:*0*
13. Outpatient Lab Work
Please draw a CBC and BMP prior to patients appointment with PCP
___ and fax results to her, phone is ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
rheumatoid arthritis
ecthyma
HTN
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to ___ with complaints of leg ulcers. You
were found to have rheumatoid arthritis that has likely been
undiagnosed for a long time. Your ulcer on your legs were
biopsied and showed changes consistent with infection. You were
placed on antibiotics and your legs improved.
.
New medications:
augmentin 875 BID, last dose is ___
calcium carbonate 500 BID
cyanocobalamin 50 mcg QD (vitamin b-12)
fexofenadine 60 BID prn pruritis
HCTZ 25 po QD
mupriocin ointment TID
Multivitamins with mineral
omeprazole 20 po QD
prednisone 10 po QD
vitamin D 400 po QD
Followup Instructions:
___
|
19561674-DS-18
| 19,561,674 | 28,522,807 |
DS
| 18 |
2136-06-30 00:00:00
|
2136-06-30 19:58:00
|
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:
None
attach
Pertinent Results:
ADMISSION LABS:
=============
___ 10:07AM BLOOD WBC-2.9* RBC-4.48* Hgb-14.1 Hct-41.6
MCV-93 MCH-31.5 MCHC-33.9 RDW-12.4 RDWSD-42.2 Plt ___
___ 10:07AM BLOOD Neuts-14.1* Lymphs-58.4* Monos-24.8*
Eos-1.0 Baso-0.7 Im ___ AbsNeut-0.40* AbsLymp-1.67
AbsMono-0.71 AbsEos-0.03* AbsBaso-0.02
___ 05:50PM BLOOD ___ PTT-33.8 ___
___ 10:07AM BLOOD Glucose-100 UreaN-23* Creat-0.8 K-4.4
___ 05:50PM BLOOD Glucose-154* UreaN-23* Creat-0.8 Na-136
K-5.2 Cl-101 HCO3-24 AnGap-11
___ 05:50PM BLOOD ALT-36 AST-21 AlkPhos-33* TotBili-0.6
___ 05:50PM BLOOD VitB12-748
___ 10:07AM BLOOD TSH-<0.01*
___ 10:07AM BLOOD T4-48.8* T3-237* Free T4-5.5*
___ 05:50PM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
___ 05:50PM BLOOD Anti-Tg-LESS THAN Thyrogl-139*
antiTPO-17
___ 07:52AM BLOOD Anti-Tg-PND
___ 05:50PM BLOOD HIV Ab-NEG
___ 05:50PM BLOOD HCV Ab-NEG
PERTINENT LABS:
=============
___ 05:50PM BLOOD Neuts-37.1 ___ Monos-29.6*
Eos-0.7* Baso-1.5* Im ___ AbsNeut-0.50* AbsLymp-0.40*
AbsMono-0.40 AbsEos-0.01* AbsBaso-0.02
___ 06:05AM BLOOD Neuts-56 Bands-6* ___ Monos-12
Eos-1 ___ Metas-2* Myelos-2* AbsNeut-1.18* AbsLymp-0.40*
AbsMono-0.23 AbsEos-0.02* AbsBaso-0.00*
DISCHARGE LABS:
==============
___ 07:52AM BLOOD WBC-3.7* RBC-4.99 Hgb-15.4 Hct-45.7
MCV-92 MCH-30.9 MCHC-33.7 RDW-12.4 RDWSD-40.9 Plt ___
___ 07:52AM BLOOD Neuts-66.0 Lymphs-15.9* Monos-16.7*
Eos-0.0* Baso-0.3 Im ___ AbsNeut-2.46 AbsLymp-0.59*
AbsMono-0.62 AbsEos-0.00* AbsBaso-0.01
___ 12:54PM BLOOD ___ PTT-36.6* ___
___ 07:52AM BLOOD Glucose-230* UreaN-26* Creat-0.9 Na-133*
K-4.5 Cl-96 HCO3-25 AnGap-12
___ 07:52AM BLOOD Calcium-10.0 Phos-5.8* Mg-2.0
IMAGING:
=======
Thyroid Ultrasound ___:
IMPRESSION:
1. Mildly enlarged, heterogeneous thyroid parenchyma with normal
vascularity
on color Doppler imaging may represent sequela of thyroiditis.
2. Stable subcentimeter left and isthmus nodules.
MICROBIOLOGY:
============
Urine cx- No growth
Blood cx- No growth to date
Brief Hospital Course:
SUMMARY STATEMENT:
==================
Mr. ___ is ___ year old male CAD s/p CABG, HLD, aortic
stenosis, sleep apnea, GERD with atrial fibrillation,
intermittent amiodarone use, most recently ___,
andhyperthyroidism in the setting of amiodarone use on
prednisone and methimazole, with mild-moderate thyrotoxicosis
who presented after being found to have marked neutropenia on
routine labs believed to be secondary to methimazole toxicity.
His methimazole was held on arrival and his white count improved
and he was no longer neutropenic on day of discharge. Patient
otherwise underwent an unremarkable work up for hyperthyroidism
(described below) and was started on dexamethasone for type II
amiodarone induced thyrotoxicosis, as described below:
[ ] Follow up outpatient TSH, free T3, and total T3 levels
within one week of discharge
[ ] Patient should complete dexamethasone 4 mg BID course on
___ and continue on daily dexamethasone until his next
endocrinology appointment
[ ] Patient should have follow up CBC with differential at next
outpatient labs
[ ] Patient should have blood smear followed up at next PCP
___ (pending at time of discharge)
[ ] Patient had multiple diagnostic studies for hyperthyroidism
pending at time of discharge that should be followed up by
outpatient endocrinology (TSI, TRAB, anti ___ and anti-TPO
antibodies)
[ ] Patient was cleared (and recommended) to restart amiodarone
as an outpatient from an endocrinology perspective. His
cardiologist was e-mailed and the clinic called regarding this
recommendation from endocrinology.
ACUTE ISSUES:
=============
# Neutropenia
WBC 6.3 as of ___ with most recent down trend to 1.4 and ANC
of 518 on presentation. Regarding etiology, timing was believed
to track
with initiation of methimazole therapy and methimazole was
discontinued on admission. He had an otherwise unremarkable CBC
and his WBC improved with holding of his methimazole. Patient
had two metamyelocytes and two myelocytes on differential at
time of discharge believed to be secondary to marrow
hyper-proliferation after discontinuation of his methimazole.
His WBC at time of discharge was 3.7 with an absolute neutrophil
count of 2.46. His B12, HIV, and hepatitis serologies were
unremarkable.
# Hyperthyroidism
Patient with a history of hyperthyroidism in ___ that was felt
to be secondary to thyroiditis and resolved without treatment.
He
was again noted to be hyperthyroid in ___ and in the
setting of amiodarone administration (which was also utilized in
___ and was believed to have Type 2 Amiodarone induced
thyrotoxicosis that was treated with prednisone and methimazole
at that time. On admission, his FT4 was 5.5 with a TSH<0.01 and
patient underwent serologic work up with TSI, TBII, ___, TPO
pending at time of discharge. His thyroid ultrasound was overall
consistent with thyroiditis and his steroids were transitioned
to dexamethasone, which will be administered for 4 mg BID for
one week and 4 mg daily thereafter.
# Atrial Fibrillation
Patient with long standing history of atrial fibrillation since
___ CABG. Previous amiodarone use in ___ and cardioversion
attempted ___ with subsequent reverting back to atrial
fibrillation. Further cardioversion deferred as outpatient given
hyperthyroidism. Patient was continued on home beta-blocker
without change while admitting, however, re-initiation of
amiodarone was deferred for outpatient cardiologist as above.
CHRONIC ISSUES:
===============
# CAD s/p CABG: IMI/CABG ___ (LIMA-LAD, SVG-R1), EF 50-55%
- continue home rosuvastatin, carvedilol, lisinopril
# Hypertension: Continue home Carvedilol, Lisinopril
# Sleep Apnea: CPAP machine ordered
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PredniSONE 30 mg PO DAILY
Tapered dose - DOWN
2. Lisinopril 40 mg PO DAILY
3. MethIMAzole 20 mg PO DAILY
4. CARVedilol 12.5 mg PO BID
5. Chlorthalidone 25 mg PO DAILY
6. Rosuvastatin Calcium 40 mg PO QPM
7. Rivaroxaban 20 mg PO DAILY
8. Zolpidem Tartrate 5 mg PO QHS
9. Tizanidine 4 mg PO QHS PRN sciatic
Discharge Medications:
1. Dexamethasone 4 mg PO Q12H
RX *dexamethasone [Decadron] 4 mg 1 tablet(s) by mouth twice a
day Disp #*30 Tablet Refills:*0
2. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia
3. CARVedilol 12.5 mg PO BID
4. Chlorthalidone 25 mg PO DAILY
5. Lisinopril 40 mg PO DAILY
6. Rivaroxaban 20 mg PO DAILY
7. Rosuvastatin Calcium 40 mg PO QPM
8. Tizanidine 4 mg PO QHS PRN sciatic
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
=================
-Methimazole induced neutropenia
-Amiodarone induced thyroxicosis
SECONDARY DIAGNOSIS:
=====================
-Coronary Artery Disease
-Atrial Fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
Thank you for choosing to receive your care at ___.
WHY WAS I HERE?
-You were admitted to the hospital with low white blood cell
counts due to a thyroid medication called methimazole
WHAT HAPPENED WHILE I WAS HERE?
-We stopped your methimazole and your white blood cell count
improved.
-We started you on a different medication to help treat your
thyroid dysfunction
WHAT SHOULD I DO WHEN I LEAVE THE HOSPITAL?
-Take your medications as prescribed
-Get your blood work checked as we recommended
It was a pleasure taking care of you. We wish you the best.
-Your ___ Care Team
Followup Instructions:
___
|
19561814-DS-7
| 19,561,814 | 28,995,222 |
DS
| 7 |
2133-05-22 00:00:00
|
2133-05-22 13:58:00
|
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ male with a past medical
history of multiple myeloma and recurrent pneumonia, who
presented with non-resolving pneumonia.
History obtained from patient somewhat unreliable as he appears
mildly confused. However, he was recently seen in ___ clinic on
___. Per ID note he was first diagnosed with pneumonia on ___
when he presented to an oncology visit and endorsed cough and
fatigue. CXR at that time showed bibasilar infiltrates. He was
prescribed levofloxacin at that time. He took around ___ doses
but was unable to tolerate more since the large pill was
difficult to swallow.
Repeat CXR on ___ showed stable infiltrates.
On ___ he presented again for oncology follow up and endorsed
worsening cough and dyspnea on exertion. He was started on
augmentin at that time. CT chest on ___ was notable for
bibasilar consolidations with ground glass opacification and
___ micronodularity as well as a left lower lobe nodule.
He denies any fevers during this time.
In ___ clinic there was concern for possible atypical
mycobacterial infection vs. fungal infection. Sputum cultures
were sent for AFB. There was also concern for possible
aspiration.
He was seen again in oncology follow up on ___ where he was
found to be hypoxic to the ___ on RA. He was sent to the ED for
further workup.
In the ED, he was afebrile and satting between 94-97% on 2L. CTA
was negative for PE but notable for airspace opacities in the
right middle and lower lobes, concerning for
multifocal pneumonia. He received a dose of ceftriaxone and
azithromycin.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
PAST MEDICAL/SURGICAL HISTORY:
- multiple myeloma
- recurring bouts of pneumonia, no other recurring infections
- prior hepatitis A infection (contaminated food when traveling)
- GERD/dysphagia
- hypogammaglobulinemia
- BPH
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: 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
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, AAO X ___ (oriented to ___ and "hospital" but
not to specific hospital, face symmetric, gaze conjugate with
EOMI, speech fluent, moves all limbs, sensation to light touch
grossly intact throughout
PSYCH: pleasant, appropriate affect
Patient examined on day of discharge. AVSS, walked five laps
around unit, with SpO2s from ___ the entire time. Coarse
breath sounds in bases.
Pertinent Results:
___ 03:15PM WBC-4.1 RBC-2.41* HGB-7.4* HCT-23.2* MCV-96
MCH-30.7 MCHC-31.9* RDW-13.3 RDWSD-47.3*
___ 03:15PM NEUTS-67 BANDS-5 LYMPHS-6* MONOS-20* EOS-0*
BASOS-0 ATYPS-2* AbsNeut-2.95 AbsLymp-0.33* AbsMono-0.82*
AbsEos-0.00* AbsBaso-0.00*
___ 03:15PM LACTATE-1.3
___ 03:15PM cTropnT-<0.01
___ 03:15PM GLUCOSE-108* UREA N-13 CREAT-0.8 SODIUM-138
POTASSIUM-4.2 CHLORIDE-102 TOTAL CO2-24 ANION GAP-12
___ 08:17PM URINE RBC-2 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 08:17PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR*
GLUCOSE-NEG KETONE-TR* BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-NEG
___ 08:17PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 03:15PM POIKILOCY-1+* OVALOCYT-1+* RBCM-SLIDE REVI
CTA-Chest
1. No evidence of pulmonary embolism or aortic abnormality.
2. Airspace opacities in the right middle and lower lobes,
concerning for
multifocal pneumonia.
3. Multiple liver lesions, concerning for metastatic disease.
(NOTE: Liver lesions were reported in prior imaging documented
on radiology reads at ___. These images were not
available for our radiologists to review)
Brief Hospital Course:
Mr. ___ is a ___ male with multiple myeloma,
dementia who presents with multiple focal consolidations
concerning for atypical pneumonia and hypoxemia in recent
outpatient visit.
# Pneumonia: Presenting with around three weeks of cough, yellow
sputum, dyspnea on exertion up stairs, and multifocal pulmonary
infiltrates which have failed to resolve with two separate
course of antibiotics. This sounds like a chronic pulmonary
process that has been going on for months. He's been followed by
___ Infectious Diseases (Dr. ___ who has a low suspicion
for bacterial pneumonia. He was initially started on
vancomycin/zosyn, but this was quickly discontinued. We sent one
set of induced respiratory sputum cultures and Coccidiodes,
histoplasma, and blastomycosis testing as well as beta glucan
and galactomannan per prior ID recs. IgG level was not
abnormally low. On day of admission (___), patient was well
appearing and had O2 sats in 94-96 range while at rest and
ambulating. Mr. ___ said he was feeling well and wanted to
go home and would follow up with his outpatient doctors for
further testing.
# Dementia: Though patient denies a formal diagnosis of
dementia, he is followed as an outpatient for memory loss.
Conversations with him was difficult at times as he had
word-finding difficulties and was not sure why he initially came
to the hospital.
# Concern for liver lesions: Incidental liver lesions on CT. No
known solid tumor history. Seen on prior imaging (___ records
were checked) and thought to be cystic. I discussed this was our
radiologists who confirmed that given history of previous cystic
lesions seen on imaging, these were consistent with cysts rather
than malignancy.
# Multiple myeloma. On stable oncologic course. Followed at
At___ by his oncologist Dr. ___.
# HLD: Continued home simvastatin.
# BPH: Continued home prazosin and finasteride
> 30 minutes spent on discharge activities.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Prazosin 10 mg PO QHS
2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
3. fluorouracil 5 % topical 2X/WEEK
4. Simvastatin 40 mg PO QPM
5. Ferrous Sulfate 325 mg PO DAILY
6. Acyclovir 400 mg PO Q12H
7. Pantoprazole 20 mg PO Q24H
8. Aspirin 81 mg PO DAILY
9. Finasteride 5 mg PO DAILY
10. Cyanocobalamin Dose is Unknown PO Frequency is Unknown
11. FoLIC Acid 1 mg PO DAILY
Discharge Medications:
1. Cyanocobalamin 1000 mcg PO DAILY
2. Acyclovir 400 mg PO Q12H
3. Aspirin 81 mg PO DAILY
4. Ferrous Sulfate 325 mg PO DAILY
5. Finasteride 5 mg PO DAILY
6. fluorouracil 5 % topical 2X/WEEK
7. FoLIC Acid 1 mg PO DAILY
8. Pantoprazole 20 mg PO Q24H
9. Prazosin 10 mg PO QHS
10. Simvastatin 40 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
Pulmonary consolidations of unknown etiology
Discharge Condition:
Mental Status: Clear and coherent, though sometimes confused
with memory and word-finding.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___
___ were admitted because your doctors were concerned about your
breathing and getting oxygen to your tissues. They were also
concerned about whether the lung findings ___ have are due to an
infection. We obtained an sputum sample, as well as other blood
tests, to test for these infections. ___ were also found to have
masses on your liver, though they may have been there before.
___ should follow up with your doctor about these findings.
Followup Instructions:
___
|
19561832-DS-10
| 19,561,832 | 28,869,104 |
DS
| 10 |
2122-09-24 00:00:00
|
2122-09-24 13:17:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year-old gentleman with CAD s/p ___ RCA stent ___ and LCx
___, HFrEF (EF 45% in ___, hyperlipidemia and EtOH abuse who
presented to the ___ ED today with generalized weakness and
malaise.
He states that he felt fine over the weekend but that, a few
hours after waking up this morning, he became weak and dizzy
while working his route as a ___. As well, he noted
some mild blurry vision. He reports that he has had episodes
like this before on "days it gets hot" but never as bad as this
most recent episode. He states that he has been drinking
sufficient fluids recently and been urinating a lot. Yesterday
he did not eat very much food due to not having much of an
appetite during the warm weather. He endorses mild SOB on
exertion (he states that he has this from time to time). He has
air conditioning in both his delivery truck and at home. He
denies presyncope prior to this AM.
Admits to diarrhea for a few days last week that resolved as
of 3 days ago. He last drank alcohol last night.
ROS:
(-)Patient denies fevers, chills, night sweats, syncope, cough,
sore throat, chest pressure, palpitations, nausea, vomiting,
dysuria, melena, hematochezia. Denies angina (has never taken
nitroglycerin).
(+)Has occasional claudication bilaterally.
In the ED, initial vitals:
Time Pain Temp HR BP RR Pox Glucose
Triage 12:16 0 96.9 65 73/39 18 100%
Today 12:28 53
Today 12:34 0 75 76/30 16
Today 12:40 88/32
Today 12:53 94/39
Today 13:02 0 83 127/54 16 100% RA
Today 13:02 119
Today 13:14 140 18
Today 13:27 0 97 125/53 14 99% RA
In the ED he received 3L of NS. CXR revealed no acute process.
he was also given ceftriaxone 1g x1.
Past Medical History:
#BLADDER CANCER - inactive, s/p transurethral ressection at ___,
quiescent ___ yrs
#CAD: Inferior STEMI ___: 100% occlusion of RCA s/p
aspiration thrombectomy and Promus DES to ___ RCA; also with
normal LMCA, 60% eccentric mid-distal LAD, 70-80% mid long LCx
lesion; ___ had LCx DES for 80% stenosis
#SYSTOLIC CONGESTIVE HEART FAILURE: no clinical admissions for
such; TTE in ___ with mildly depressed LVEF (45%) secondary to
hypokinesis of the inferior and posterior walls, with focal
basal inferior akinesis.
#HYPERLIPIDEMIA
#HYPERTENSION
#COLONIC ADENOMA: ___ ___ follow up in ___ yrs
#IRON DEFICIENCY ANEMIA
Social History:
___
Family History:
His family history is significant for premature coronary artery
disease. His mother died at ___ of Alzheimer___s and his father
died at age ___ of an MI. His younger brother has undergone a
CABG.
Physical Exam:
On admission:
Vitals: 97.4 BP 155/61 HR 61 RR 18 Sa02 100%
WT 74.1 kg
General- Middle-aged gentleman wearing glasses and seated in
bed, no apparent distress, alert and oriented
HEENT- MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- CTAB no wheezes, rales, rhonchi
CV- RRR, Nl S1, S2, No MRG
Abdomen- soft, NT/ND bowel sounds present, no rebound tenderness
or guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
On discharge:
Vitals- T 98.2, BP 114-155/41-65, P 61-72, RR 18, O2 98-100%RA
General- Middle-aged gentleman in bed and under covers sleeping.
Alert, oriented, no acute distress
HEENT- Hoarse voice, sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- CTAB no wheezes, rales, rhonchi
CV- RRR, Nl S1, S2, No MRG
Abdomen- soft, NT/ND bowel sounds present, no rebound tenderness
or guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
Pertinent Results:
ADMISSION LABS
--------------
___ 12:30PM BLOOD WBC-9.9# RBC-3.54* Hgb-13.4* Hct-40.4
MCV-114*# MCH-37.9*# MCHC-33.2 RDW-13.5 Plt ___
___ 12:30PM BLOOD Neuts-78.4* Lymphs-16.3* Monos-4.1
Eos-0.8 Baso-0.3
___ 01:04PM BLOOD ___ PTT-26.5 ___
___ 12:30PM BLOOD Glucose-127* UreaN-31* Creat-2.1*# Na-138
K-5.2* Cl-101 HCO3-17* AnGap-25*
___ 12:30PM BLOOD ALT-40 AST-77* AlkPhos-74 TotBili-0.2
___ 12:30PM BLOOD Lipase-38
___ 12:30PM BLOOD CK-MB-2
___ 12:30PM BLOOD cTropnT-<0.01
___ 12:30PM BLOOD Albumin-3.9
___ 12:30PM BLOOD ___
___ 12:49PM BLOOD Lactate-6.2*
___ 02:43PM BLOOD Lactate-4.3*
DISCHARGE LABS
--------------
___ 06:50AM BLOOD WBC-5.7 RBC-3.03* Hgb-11.5* Hct-34.3*
MCV-113* MCH-38.0* MCHC-33.5 RDW-13.5 Plt ___
___ 06:50AM BLOOD Glucose-68* UreaN-33* Creat-1.9* Na-146*
K-4.6 Cl-112* HCO3-24 AnGap-15
___ 06:50AM BLOOD ALT-33 AST-47*
___ 06:50AM BLOOD Albumin-3.4* Calcium-7.6* Phos-3.1 Mg-1.6
IMAGING
-------
___ CHEST XRAY:
IMPRESSION:
No acute intrathoracic process
MICRO
-----
___ BLOOD CULTURES X2: PENDING
Brief Hospital Course:
This is a ___ y/o gentleman with a history of CAD s/p ___ RCA
stent ___ and LCx ___, HFrEF (EF 45% in ___, hyperlipidemia
and EtOH abuse who presented to the ED this AM c/o weakness and
malaise, found to be hypotensive and hypoglycemic, currently
normotensive and normal BG, admitted for further workup.
#Hypotension: Upon presentation to the emergency room he had an
initial blood pressure of 73/39 which was likely responsible for
the weakness that he was feeling. He was given 3L of NS in the
ED and his blood pressure and symptoms responded quickly. By
the time he reached the floor he was asymptomatic and he
remained this way until discharge. Given the prompt response to
IVF administration his hypotension is likely ___ to hypovolemia
and exacerbated by his lisinopril. With respect to his
hypovolemia it was most likely ___ to poor PO intake with
possible exacerbating factors being recent warm weather, recent
diarrheal illness at the end of last week, and daily EtOH use
causing diuresis. Upon discharge he was normotensive and
orthostatics were negative.
#Acute Kidney Injury: Upon presentation to the ED his creatinine
was elevated at 2.1. It subsequently was 1.8 and then 1.9 the
following day (the day of discharge). He likely suffered the ___
due to his hypovolemia in the setting of an ACE inhibitor. This
may have caused mild acute tubular necrosis. His urinalysis and
microscopy showed granular and hyaline casts with 30 protein and
no blood to indicate nephritis. We expect that his creatinine
will continue to downtrend. His lisinopril was held over the
course of the admission and should continue to be held upon
discharge pending further follow-up (continuing to trend BUN/Cr)
and management with PCP.
#Elevated Anion Gap/Low HCO3: Initially his anion gap was 18
with albumin 3.9. He was likely suffering from a lactic acidosis
(lactate 6.2) ___ hypovolemia with possible component of acute
renal failure causing retained phosphate/sulfate acids. The
following day (day of discharge) anion gap had improved s/p
fluids to 15 with albumin 3.4, pH unknown, and there was little
concern for significant acidosis given that he is alert and not
tachypneic.
#Alcohol use: On the day of admission his serum tox showed an
EtOH of 133. He stated that his last drink was the evening prior
and that he typically consumes two shots of whiskey and a beer
daily. It is thought that his daily EtOH use may have played a
role in the development of his hypovolemia given EtOH's diuretic
effect. He denies ever having had withdrawal from alcohol and
did not show signs or symptoms of withdrawal during his
admission. He was given thiamine and folate.
Chronic Issues:
#Coronary artery disease: Had acute myocardial infarction in
___ with drug-eluting stent to his proximal right coronary
artery. Subsequently he had a DES to his left circumflex in
___. He did not complain of anginal pains over the course of
the admission. Troponin negative x1 from the ED. He was
continued on his home aspirin, plavix and rosuvastatin. His
metoprolol was held on the day of his admission due to his
hypotensive presentation but was re-started on the day of
discharge.
#Chronic systolic CHF: No history of decompensated CHF.
Currently compensated. EF 45% in ___. His lisinopril was held
because of his creatinine bump and should continue to be held
until his follow-up PCP ___ (when BUN/Cr can be
re-assessed). We restarted his beta-blocker on discharge. His
ACEI was held.
#Hyperlipidemia: Continued home crestor.
#Anemia, macrocytic: Stable. Had Hct of 31.9 in ___, increasing
since then, today 40.4. Colonoscopy in ___ showed colonic
adenoma but no active source of bleeding - f/u in ___ years. MCV
suggestive of EtOH abuse or liver dz. He was discharged with
vitamins.
#Lung nodule: Got screening CT for lung Ca ___ with 2 mm
diameter left apical and right middle lobe lung nodules.
Transitional Issues:
[]requires f/u CT in ___ yr for lung nodules
[]recheck chem7 at next visit to ensure improvement of renal
function to baseline; restart lisinopril when clinically
appropriate
[]He should receive further counselling on his EtOH use
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Clopidogrel 75 mg PO DAILY
2. Lisinopril 30 mg PO DAILY
3. Metoprolol Succinate XL 50 mg PO DAILY
4. Nitroglycerin SL 0.4 mg SL PRN Q5MIN X3 chest pain
5. Rosuvastatin Calcium 40 mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. DiphenhydrAMINE 25 mg PO Q6H:PRN allergy
8. Ferrous GLUCONATE 324 mg PO BID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Rosuvastatin Calcium 40 mg PO DAILY
4. DiphenhydrAMINE 25 mg PO Q6H:PRN allergy
5. Ferrous GLUCONATE 324 mg PO BID
6. Nitroglycerin SL 0.4 mg SL PRN Q5MIN X3 chest pain
7. Metoprolol Succinate XL 50 mg PO DAILY
8. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
#Hypovolemia
#Hypotension
#Acute renal failure due to acute tubular necrosis
#Alcohol use disorder
SECONDARY DIAGNOSES:
#Hypertension
#Coronary artery disease
#Chronic 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. ___,
You were admitted for weakness and low blood pressure that was
likely caused by dehydration. You were given IV fluids and your
blood pressure quickly normalized. We ruled out any trouble
with your heart. Please ensure that you drink enough fluids
(especially on particularly hot days) and eat enough food on a
daily basis. We think that alcohol can cause you to become very
dehydrated. We recommend that you cut back or stop drinking
alcohol entirely as it can cause health problems such as
permanent liver damage.
Additionally, while you were here your kidney function was much
worse than normal. We think this is from being dehydrated while
taking one of your blood pressure medications (lisinopril). You
should STOP taking lisinopril until your primary care doctor
tells you to restart it. They will do blood work at your next
appointment.
You can see your PCP for your regularly scheduled follow-up. It
was a pleasure to be a part of your care!
Your ___ Team
Followup Instructions:
___
|
19561931-DS-11
| 19,561,931 | 21,043,647 |
DS
| 11 |
2155-11-11 00:00:00
|
2155-11-13 11:10:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Zoloft / Xanax / Librium / Amiodarone / Bactrim DS / trazodone /
pravastatin
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ woman with h/o CAD s/p CABG ___, DES to
LAD ___, paroxysmal Afib on Pradaxa, and moderate AS who p/w
chest pain/discomfort waking her up from sleep.
The night prior to admission, Ms ___ was awakened from sleep
by substernal chest pressure and diaphoresis. She took 2
sequential nitroglycerin and the pain resolved. The total
duration of symptoms was approximately 15 minutes. She is on
both aspirin and Pradaxa. Took a full dose aspirin today.
In the ED, initial vitals were 97.7 68 153/44 18 98% RA. Labs
were significant for initial trop of 0.08. CXR without acute
cardiopulmonary process.
On arrival to the floor pt denies any chest discomfort. She
feels tired overall but denies shortness of breath,
palpitations, dizziness/lightheadedness. She has two-pillow
orthopnea which has not changed recently.
At baseline, she gets around with a walker. In the past few
weeks, she has been having more chest discomfort when she walks.
Past Medical History:
- Paroxysmal atrial fibrillation
- CAD s/p CABG in ___ and DES in ___ and ___
- Aortic Stenosis (mod/severe)
- Aortic insufficency (moderate)
- Colonic polyps
- HTN
- Hearing loss
- s/p hysterectomy
- Hypothyroidism
- Dementia
Social History:
___
Family History:
- Mother: CAD
- Father: DM2
- Brother: DM2, ___
Physical Exam:
Admission Physical Exam:
PHYSICAL EXAMINATION:
Vitals: 98.3 158/43 57 18 99%/RA
General: AOx3, hard of hearing, in no distress
HEENT: Anicteric sclerae, moist mucosae. OP clear.
Neck: JVP 8cm. No LAD or thyromegaly.
CV: RRR, ___ systolic murmur at LUSB.
Lungs: CTAB
Abdomen: Soft, nontender, nondistended. NABS.
Extr: Trace pitting edema at ankles.
Discharge Physical Exam:
Vitals: 98.4 150-152/41-48 ___ 100%RA
Weight: 52.9kg
General: AOx3, hard of hearing, in no distress
HEENT: Anicteric sclerae, moist mucosae. OP clear.
Neck: No JVP appreciated at 45 degrees. No LAD or thyromegaly.
CV: RRR, ___ systolic murmur at LUSB.
Lungs: CTAB
Abdomen: Soft, nontender, nondistended. NABS.
Extr: Trace pitting edema at ankles.
Skin: Multiple ecchymoses on forearms and legs
Pertinent Results:
Admission Labs:
___ 11:14AM ___ PTT-41.7* ___
___ 11:14AM PLT COUNT-194
___ 11:14AM NEUTS-65.4 ___ MONOS-10.3 EOS-1.8
BASOS-0.3 IM ___ AbsNeut-4.05 AbsLymp-1.36 AbsMono-0.64
AbsEos-0.11 AbsBaso-0.02
___ 11:14AM WBC-6.2 RBC-3.96 HGB-12.1 HCT-37.1 MCV-94
MCH-30.6 MCHC-32.6 RDW-13.2 RDWSD-45.0
___ 11:14AM CALCIUM-9.3 PHOSPHATE-3.9 MAGNESIUM-2.2
___ 11:14AM cTropnT-0.08*
___ 11:14AM estGFR-Using this
___ 11:14AM GLUCOSE-93 UREA N-25* CREAT-0.9 SODIUM-139
POTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-27 ANION GAP-14
___ 05:30PM CK-MB-11* MB INDX-7.9*
___ 05:30PM cTropnT-0.10*
___ 05:30PM CK(CPK)-139
Discharge Labs:
___ 10:17PM BLOOD WBC-6.2 RBC-4.12 Hgb-12.6 Hct-38.3 MCV-93
MCH-30.6 MCHC-32.9 RDW-13.2 RDWSD-44.7 Plt ___
___ 10:17PM BLOOD Glucose-112* UreaN-30* Creat-0.8 Na-137
K-3.8 Cl-104 HCO3-24 AnGap-13
___ 10:17PM BLOOD cTropnT-0.05*
___ 10:17PM BLOOD Calcium-9.6 Phos-3.6 Mg-2.1
Other Pertinent Results:
ECG Study Date of ___ 5:59:26 ___
Sinus rhythm with A-V conduction delay. Probable left
ventricular hypertrophy with secondary repolarization
abnormalities. No major change from the previous tracing.
Intervals Axes
Rate PR QRS QT QTc (___) P QRS T
58 ___ 36 -36 103
ECG Study Date of ___ 10:34:32 AM
Sinus rhythm with sinus arrhythmia. Probable left ventricular
hypertrophy with secondary repolarization abnormalities.
Compared to the previous tracing the rhythm is now sinus.
Intervals Axes
Rate PR QRS QT QTc (___) P QRS T
64 188 94 420 427 36 -43 88
___: TTE: Performed, results pending.
Brief Hospital Course:
Ms. ___ is a ___ woman with h/o CAD s/p CABG ___, DES to
LAD ___, paroxysmal Afib on Pradaxa, and moderate AS who p/w
chest pain/discomfort waking her up from sleep. She had
troponins 0.08 -> 0.1 ->.07. In ED, initial vitals were T 97.7
HR 68 BP 153/44 RR 18 O2 Sat 98% RA. CXR without acute
cardiopulmonary process. Due to concern for NSTEMI patient was
started on heparin infusion. However, her symptoms subsided,
troponins were downtrending, and after discussion of goals of
care, patient preferred to try medical therapy first given risks
of catheterization. She was restarted on clopidogrel 75mg daily,
which for unclear reasons was stopped after she received a
drug-eluting stent in ___. Dabigatran was also stopped and
replaced with apixaban given more favorable evidence for
apixaban in atrial fibrillation.
ACTIVE ISSUES:
#NSTEMI: Chest pain sounded cardiac in nature, especially
concerning for stent restenosis given she and her son have no
clear recollection of taking clopidogrel after her DES in
___. Troponins 0.08 -> 0.1 ->.07. ECG without ST elevations.
Due to concern for NSTEMI patient was started on heparin
infusion. However, her symptoms subsided, troponins were
downtrending, and after discussion of goals of care, patient
preferred to try medical therapy first given risks of
catheterization.
- Continue aspirin
- Stop pradaxa
- Start apixaban 2.5mg PO BID
- Start plavix
- Holding atorvastatin 80mg daily for now given previous statin
intolerance
#Paroxysmal atrial fibrillation: CHADS2 score is 2. Currently in
sinus rhythm.
- Pradaxa discontinued
- Apixaban started
- Continue sotalol
CHRONIC ISSUES:
#Hypothyroidism: Continue synthroid
#HTN: Continue lisinopril and furosemide
#Depression: Continue venlafaxine
TRANSITIONAL ISSUES:
- TTE results from ___ are pending at discharge. Please
follow up.
- Please ensure patient has followup with Dr. ___ on
___
- Consider stopping premarin if no strong indication given
adverse cardiac effects.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 10 mg PO DAILY
2. Venlafaxine 75 mg PO DAILY
3. Estrogens Conjugated 0.3 mg PO DAILY
4. Acetaminophen 1000 mg PO BID:PRN pain
5. Levothyroxine Sodium 25 mcg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Sotalol 60 mg PO BID
8. Dabigatran Etexilate 75 mg PO BID
9. Furosemide 20 mg PO DAILY
10. Rosuvastatin Calcium 5 mg PO 3X/WEEK (___)
Discharge Medications:
1. Acetaminophen 1000 mg PO BID:PRN pain
2. Aspirin 81 mg PO DAILY
3. Furosemide 20 mg PO DAILY
4. Levothyroxine Sodium 25 mcg PO DAILY
5. Lisinopril 10 mg PO DAILY
6. Sotalol 60 mg PO BID
7. Venlafaxine 75 mg PO DAILY
8. Apixaban 2.5 mg PO BID
RX *apixaban [Eliquis] 2.5 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
9. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
10. Estrogens Conjugated 0.3 mg PO DAILY
11. Rosuvastatin Calcium 5 mg PO 3X/WEEK (___)
12. Isosorbide Mononitrate 10 mg PO BID
RX *isosorbide mononitrate 10 mg 1 tablet(s) by mouth twice a
day Disp #*60 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Non-ST Elevation Myocardial Infarction
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 ___,
___ was a pleasure to take care of you at ___.
You came to us because you had chest pain and sweating that woke
you from your sleep. While you were here, your symptoms
subsided. The lab tests showing injury to your heart improved.
We started you on medical therapy to treat your coronary artery
disease.
Please remember to follow up with the doctors that ___ made an
appointment with. Wishing you a fast recovery.
Sincerely,
Your ___ team.
Followup Instructions:
___
|
19561931-DS-13
| 19,561,931 | 27,078,519 |
DS
| 13 |
2156-05-21 00:00:00
|
2156-05-21 15:46:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Zoloft / Xanax / Librium / Amiodarone / Bactrim DS / trazodone /
pravastatin / bisoprolol / metoprolol / atorvastatin /
isosorbide / Crestor / fenofibrate
Attending: ___
Chief Complaint:
L arm weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ is a ___ yo right handed woman with PMH of CAD sp
CABG, pAF on apixaban and depression who presents after the
acute
onset of left sided clumsiness. The patient reports that her
symptoms started around 8pm last night. She does not recall
exactly what she was doing but suddenly her left arm just didn't
feel right. She doesn't think it was numb or weak. She was able
to go to her room and change into her night gown. She slept well
and in the morning was able to make it to the bathroom around
6:30am but her walking didn't feel right. She went back to bed
and went she woke later she no longer felt comfortably getting
out of bed, so she pushed her life-line.
On neuro ROS: the pt denies headache, loss of vision, blurred
vision, diplopia, oscilopsia, dysarthria, dysphagia,
lightheadedness, vertigo, tinnitus or hearing difficulty. Denies
difficulties producing or comprehending speech. Denies focal
weakness, numbness, paresthesias. No bowel or bladder
incontinence or retention.
On general ROS: 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:
- Paroxysmal atrial fibrillation
- CAD s/p CABG in ___ and DES in ___ and ___
- Aortic Stenosis (mod/severe)
- Aortic insufficency (moderate)
- Colonic polyps
- HTN
- Hearing loss
- s/p hysterectomy
- Hypothyroidism
- Dementia
Social History:
___
Family History:
- Mother: CAD
- Father: DM2
- Brother: DM2, ___
Physical Exam:
ADMISSION PHYSICAL EXAM:
T: 97.6 HR: 80 BP: 183/82 RR: 17 Sat: 97% on RA
GENERAL MEDICAL EXAMINATION:
General appearance: alert, in no apparent distress
HEENT: Sclera are non-injected. Mucous membranes are very dry.
CV: Heart rate is regular
Lungs: Breathing comfortably on RA
Abdomen: soft, non-tender
Extremities: No evidence of deformities. No contractures. No
Edema.
Skin: No visible rashes. Warm and well perfused.
NEUROLOGICAL EXAMINATION:
Mental Status: Alert and oriented to person place and time. Able
to relate history without difficulty. Language is fluent and
appropriate with intact comprehension, reading, repetition and
naming of both high and low frequency objects. Normal prosody.
There were no paraphasic errors. Speech was not dysarthric. Able
to follow both midline and appendicular commands. No neglect,
left/right confusion or finger agnosia.
Cranial Nerves:
I: not tested
II: visual fields full to confrontation
III-IV-VI: pupils equally round, reactive to light. Normal
conjugated, extra-ocular eye movements in all directions of
gaze.
No nystagmus or diplopia.
V: Symmetric perception of LT in V1-3
VII: Face is symmetric at rest and with activation; symmetric
speed and excursion with smile.
VIII: Hearing intact to finger rub bl
IX-X: Palate elevates symmetrically
XI: Shoulder shrug ___ bl
XII: No tongue deviation or fasciculations
Motor: Normal muscle bulk and tone throughout. Left pronator
drift
Strength:
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ 5 4+ 5 4+ 5 4+ 5 5 4+ 4+
R 5 ___ ___ 5 5 5 5 5 5 5
Reflexes:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Toes are down going bilaterally.
Sensory: normal and symmetric perception of pinprick, light
touch, vibration and temperature. Proprioception is intact. No
agraphesthesia or astereognosis. No extinction to DSS.
Coordination: significant dysmetria on finger to nose and
mirroring on the left. RAM were slow and clumsy with irregular
cadence on the left.
Gait: No truncal ataxia when seated.
DISCHARGE PHYSICAL EXAM:
VS: 98.0. 142-157/44-60. 61-75. 18. 100RA
General: AOx3, NAD
CV: RRR
Pulm: CTAB
Neuro: Sensation to L lateral arm intact, dec FE and IO strength
on left, L arm and left ataxia (finger to nose and toe to
finger) out of proportion to weakness, gait unsteady
* sensory changes and strength of left UE symptoms wax and wane
Pertinent Results:
ADMISSION LABS
___ 08:45AM BLOOD WBC-5.0 RBC-4.33 Hgb-12.9 Hct-40.3 MCV-93
MCH-29.8 MCHC-32.0 RDW-13.7 RDWSD-46.5* Plt ___
___ 08:45AM BLOOD Neuts-72.6* Lymphs-15.6* Monos-7.4
Eos-3.2 Baso-1.0 Im ___ AbsNeut-3.63 AbsLymp-0.78*
AbsMono-0.37 AbsEos-0.16 AbsBaso-0.05
___ 08:54AM BLOOD ___ PTT-34.5 ___
___ 08:45AM BLOOD Glucose-95 UreaN-17 Creat-0.7 Na-141
K-5.0 Cl-105 HCO3-27 AnGap-14
___ 08:45AM BLOOD ALT-13 AST-28 AlkPhos-69 TotBili-0.4
___ 08:45AM BLOOD cTropnT-<0.01
___ 04:50AM BLOOD cTropnT-<0.01
___ 08:45AM BLOOD Albumin-3.9 Calcium-9.5 Phos-3.6 Mg-2.3
___ 11:45AM URINE Color-Straw Appear-Clear Sp ___
___ 11:45AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
___ 04:57PM URINE RBC-1 WBC-2 Bacteri-NONE Yeast-NONE Epi-1
PERTINENT INTERIM LABS
___ 04:50AM BLOOD %HbA1c-5.7 eAG-117
___ 04:50AM BLOOD Triglyc-108 HDL-58 CHOL/HD-4.6
LDLcalc-186*
___ 04:50AM BLOOD TSH-3.3
___ 04:50AM BLOOD Albumin-3.9 Calcium-9.3 Phos-3.5 Mg-2.2
Cholest-266*
DISCHARGE LABS
None
IMAGING
___ CXR
No acute cardiopulmonary process.
___ CT Head
No evidence of acute infarction or hemorrhage.
Interval but chronic left basal ganglia infarct.
___ MRI ___
1. Acute to subacute infarct of the right thalamus and right
internal capsule posterior limb without evidence of hemorrhagic
conversion.
2. Chronic left caudate body and corona radiata infarct.
3. Paranasal sinus disease as described.
___ CTA Head and Neck
1. Atherosclerosis involving bilateral cavernous carotid
arteries, the left middle cerebral artery, basilar arteries and
bilateral posterior cerebral arteries causing luminal
irregularity and narrowing as described above. No occlusion or
aneurysm is seen.
2. Atherosclerosis involving the left carotid bifurcation
causing
approximately 50% stenosis by NASCET criteria. Mild
atherosclerosis involving the bifurcation of right carotid
artery without any stenosis by NASCET criteria.
3. Subtle hypodensity in the right thalamus corresponding to the
acute infarct seen on the recent prior MRI. Otherwise,
unremarkable CT of the head.
Brief Hospital Course:
___ is a ___ yo right handed woman with PMH of CAD sp
CABG, pAF on apixaban and depression who presented to ED after
the acute onset of left sided clumsiness. Her exam is notable
for mild left sided weakness, waxing and waning sensory changes
and ataxia out of proportion to her weakness. MRI and CTA head
confirmed acute vs subacute ischemic stroke in the R
thalamus/IC. CTA was negative for aneurysm, thrombosis, or
stenosis. She was admitted for BP optimization, stroke risk
reduction, and neuro monitoring. Her stroke was thought to be
secondary to small vessel ischemic disease from longstanding
hypertension and hyperlipidemia. For HTN, she is on lisinopril,
sotalol and lasix. She cannot tolerate statins which cause her
myalgia. She is not diabetic and is a non smoker. For
secondary stroke prevention she is on aspirin, plavix and
apixaban per her cardiologist's recommendation who feels that
her condition justifies the increased hemorrhagic risk. Her
neuro exam improved throughout hospital stay, but we discussed
she may continue to wax and wane as is typical for lacunar
strokes. She was evaluated by ___ who recommended discharge to
rehabilitation facility to continue ___.
TRANSITIONAL ISSUES:
-***We discovered she was taking a medication in error at
home***. She was taking 180mg (1.5 tablets) of sotalol twice a
day at home. However, her prescription from Dr. ___ is for only
120mg (1 tablet). She was discharged on 120mg sotalol (1 tablet)
from now on.
- CODE STATUS - DNR/DNI
- She will follow-up with Dr. ___ neurologist, who
takes care of her family members, but was not attending on
service while inpatient.
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done -in the ED () Not confirmed () No
2. DVT Prophylaxis administered? (x) Yes - on systemic
anticoagulation () No
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - on ASA and plavix() No
4. LDL documented? (x) Yes (LDL = 186 ) - () 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: severe side effect]
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 - education packet given () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - ___ and OT consulted () No
9. Discharged on statin therapy? () Yes - (x) No [if LDL >100,
reason not given: severe side effect]
10. Discharged on antithrombotic therapy? (x) Yes [Type: (x)
Antiplatelet - asa and plavix (x) Anticoagulation] - apixaban ()
No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? (x) Yes - apixaban() No - () N/A
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Apixaban 2.5 mg PO BID
2. Aspirin 81 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Furosemide 20 mg PO DAILY
5. Lisinopril 10 mg PO DAILY
6. Venlafaxine XR 75 mg PO DAILY
7. Sotalol 120 mg PO BID
8. Travatan Z (travoprost) 0.004 % ophthalmic HS
9. Levothyroxine Sodium 25 mcg PO DAILY
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY
2. Apixaban 2.5 mg PO BID
3. Clopidogrel 75 mg PO DAILY
4. Furosemide 20 mg PO DAILY
5. Sotalol 120 mg PO BID
6. Venlafaxine XR 75 mg PO DAILY
7. Travatan Z (travoprost) 0.004 % ophthalmic HS
8. Levothyroxine Sodium 25 mcg PO DAILY
9. Lisinopril 10 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
acute ischemic stroke
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were hospitalized due to symptoms of left arm weakness
resulting from an ACUTE ISCHEMIC STROKE, a condition where a
blood vessel providing oxygen and nutrients to the brain is
blocked by a clot. The brain is the part of your body that
controls and directs all the other parts of your body, so damage
to the brain from being deprived of its blood supply can result
in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
High blood pressure
High cholesterol
One of your medications have been changed:
****You reported taking 180mg (1.5 tablets) of sotalol twice a
day. However, your prescription from Dr. ___ is for only 120mg
(1 tablet). Please start taking 120mg sotalol (1 tablet) from
now on.
Please followup with Neurology and your primary care physician
as listed below.
Followup Instructions:
___
|
19561931-DS-15
| 19,561,931 | 23,873,802 |
DS
| 15 |
2157-09-23 00:00:00
|
2157-09-23 16:58:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Zoloft / Xanax / Librium / Amiodarone / Bactrim DS / trazodone /
pravastatin / bisoprolol / metoprolol / atorvastatin /
isosorbide / Crestor / fenofibrate
Attending: ___.
Chief Complaint:
Right hip pain
Major Surgical or Invasive Procedure:
Right TFN
History of Present Illness:
___ on eliquis, clopidogrel for afib, prior stroke who
presents with right hip pain after she reportedly slipped out of
bed yesterday. Her aid was in the room next door and heard a
thump and found the patient on the ground. Pt did not complain
of pain yesterday but this morning was having difficulty
ambulating. On arrival pt is unable to provide hx. Hx is
provided by the patient's aid and son.
Past Medical History:
ATRIAL FIBRILLATION on Eliquis and sotalol
COLONIC POLYPS
CORONARY ARTERY DISEASE STATUS post CABG in ___, LAD stenting
in
___, LAD drug-eluting stent ___
HEARING LOSS -bilateral hearing aids
HYPERTENSION
HYPOTHYROIDISM
PELVIC FRACTURE
DEPRESSION
STROKE ___ residual mild left-sided weakness
TOTAL ABDOMINAL HYSTERECTOMY
BILATERAL SALPINGO-OOPHORECTOMY
PRIOR CESAREAN SECTION x2
Social History:
___
Family History:
Mother: ___ ___ years old of MI
Father: ___ ___ years old diabetes, MI
Physical Exam:
No acute distress
Unlabored breathing
Abdomen soft, non-tender, non-distended
Incision clean/dry/intact with no erythema or discharge, minimal
ecchymosis
Splint in place, clean, dry, and intact
Right lower extremity fires ___
Right lower extremity SILT sural, saphenous, superficial
peroneal, deep peroneal and tibial distributions
Right lower extremity dorsalis pedis pulse 2+ with distal digits
warm and well perfused
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have R subtrochanteric femur fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for R TFN, which the patient tolerated
well. For full details of the procedure please see the
separately dictated operative report. The patient was taken from
the OR to the PACU in stable condition and after satisfactory
recovery from anesthesia was transferred to the floor. The
patient was initially given IV fluids and IV pain medications,
and progressed to a regular diet and oral medications by POD#1.
The patient was given ___ antibiotics and
anticoagulation per routine. The patient's home medications were
continued throughout this hospitalization. The patient worked
with ___ who determined that discharge to rehab was appropriate.
The ___ hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
WBAT in the R lower extremity, and will be discharged on home
Eliquis, Plavix, and 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:
aspirin 81mg daily
clopidogrel 75mg daily
diltiazem 90mg tid
levothyroxine 25mcg daily
sotalol 40mg bid
venlafaxine 75mg daily
eliquis bid
Seroquel
Travatan Z 0.004 % eye drops 1 drop ___ at bedtime
Discharge Medications:
1. Acetaminophen 650 mg PO TID
2. Docusate Sodium 100 mg PO BID
3. OxyCODONE (Immediate Release) 2.5 mg PO Q6H:PRN pain
4. Apixaban 2.5 mg PO BID
5. Aspirin 81 mg PO DAILY
6. Clopidogrel 75 mg PO DAILY
7. Diltiazem 90 mg PO TID
8. Sotalol 40 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
R subtrochanteric femur fracture now s/p TFN
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Weight bearing as tolerated in 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 continue home Eliquis, Plavix, and aspirin
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Please remain in your dressing and do not change unless it is
visibly soaked or falling off.
Followup Instructions:
___
|
19561931-DS-9
| 19,561,931 | 24,579,951 |
DS
| 9 |
2155-01-29 00:00:00
|
2155-01-29 18:24:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Zoloft / Xanax / Librium / Amiodarone / Bactrim DS / trazodone /
pravastatin
Attending: ___
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o woman with H/O CAD s/p CABG in ___ and DES in ___,
aortic stenosis and regurgitation, as well as RML bronchiectasis
in ___, hypertension, hyperlipidemia, paroxysmal atrial
fibrillation, and hypothyroidism with new onset of increasing
angina, especially with exertion that got better with rest and
NTG, also associated with some exertional dyspnea. EKG in ED was
reported as stable and troponin-T was negative x2. She was
admitted for unstable angina. She reported no headaches, no
changes in vision.
Past Medical History:
- Paroxysmal atrial fibrillation
- CAD s/p CABG in ___ and DES in ___
- Aortic Stenosis (mod/severe)
- Aortic insufficency (moderate)
- Colonic polyps
- Hypertension
- Hearing loss
- s/p hysterectomy
- Hypothyroidism
- Dementia
- Glaucoma
Social History:
___
Family History:
- Mother: CAD
- Father: Type ___ DM
- Brother: Type ___ DM, ___
Physical Exam:
GENERAL: Elderly Caucasian woman in NAD. Oriented x3. Mood,
affect appropriate.
Discharge Wt 51.7
Discharge VS Temp 98.0 HR 58-68 BP 102 - 181/47-65 RR 18, SaO2
99% on RA
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, slight pallor or cyanosis of the oral mucosa.
NECK: Supple with JVP of 8 cm.
CARDIAC: RR, crescendo decresendo systolic blowing murmur grade
___
LUNGS: No chest wall deformities, scoliosis; slight kyphosis.
Resp were unlabored, no accessory muscle use. CTAB--no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, non-tender, not distended. No HSM or tenderness.
Abd aorta not enlarged by palpation.
EXTREMITIES: 1+ pedal edema extending up to ankles bilaterally.
SKIN: Dry, slightly flaky, No stasis dermatitis, ulcers, scars,
or xanthomas.
PULSES:
Right: Carotid 2+ ___ 1+
Left: Carotid 2+ ___ 1+
Pertinent Results:
___ 10:15PM WBC-5.6 RBC-3.98* HGB-12.0 HCT-36.9 MCV-93
MCH-30.1 MCHC-32.5 RDW-13.6
___ 10:15PM BLOOD Neuts-71.8* ___ Monos-6.9 Eos-2.5
Baso-0.5
___ 06:10AM BLOOD Plt ___
___ 10:15PM BLOOD ___ PTT-30.3 ___
___ 10:15PM GLUCOSE-115* UREA N-24* CREAT-1.0 SODIUM-136
POTASSIUM-4.4 CHLORIDE-99 TOTAL CO2-32 ANION GAP-9
___ 12:05PM BLOOD cTropnT-<0.01
___ 05:30AM BLOOD cTropnT-<0.01
___ 10:15PM BLOOD cTropnT-<0.01
___ 06:10AM BLOOD WBC-7.1 RBC-4.56 Hgb-14.0 Hct-42.8 MCV-94
MCH-30.8 MCHC-32.8 RDW-13.7 Plt ___
___ 06:10AM BLOOD Glucose-87 UreaN-17 Creat-0.7 Na-137
K-4.5 Cl-98 HCO3-30 AnGap-14
___ 06:10AM BLOOD Calcium-9.5 Phos-3.9 Mg-2.4
ECG ___ 9:00:20 ___
Sinus rhythm. Left axis deviation. There is an RSR' pattern in
lead V1 which is probably normal. There is a late transition
which is probably normal. Non-specific ST-T wave changes.
Compared to the previous tracing of ___ sinus rhythm has
replaced an ectopic atrial rhythm and ST-T wave changes are more
pronounced.
CXR ___
The lungs are clear without consolidation, effusion, or
pulmonary vascular congestion. Cardiomediastinal silhouette is
stable. Atherosclerotic calcifications noted at the aortic arch.
Median sternotomy wires and mediastinal clips are again noted.
IMPRESSION: No acute cardiopulmonary process.
Echocardiogram ___
The left atrium and right atrium are normal in cavity size. No
atrial septal defect is seen by 2D or color Doppler. Normal left
ventricular wall thickness, cavity size, and regional/global
systolic function (biplane LVEF = 71 %). Right ventricular
chamber size and free wall motion are normal. There is moderate
to severe aortic valve stenosis (valve area 0.9cm2 using LVOT
VTI 28.1, AV VTI 78.3, LVOT diameter 18mm). The aortic valve
area index is 0.6cm2/m2. Moderate (2+) aortic regurgitation is
seen. The mitral valve leaflets are structurally normal. There
is no mitral valve prolapse. Mild (1+) mitral regurgitation is
seen. The estimated pulmonary artery systolic pressure is
normal. There is no pericardial effusion.
IMPRESSION: Normal left ventricular cavity size and
regional.global systolic function. Moderate to severe calcific
aorta stenosis. Moderate aortic regurgitation.
Brief Hospital Course:
___ with H/O CAD S/P CABG in ___ (SVG-LAD/diag), S/P DES
___ to native LAD after documentation of occlusion of
sequential SVG, paroxysmal atrial fibrillation, hypertension,
hypothyroidism presenting with chest pain. She has been
ambulating more than she usually does, and pain was more sharp
and new. She took 2 NTG and the pain resolved, but she still
went to ED. Troponin-T negative x2 in ED. Dr. ___ primary
cardiologist) then requested she be admitted for further
evaluation with stress test vs. coronary angiogram. In the ED,
she remained stable, with VS of T 98 HR 64 BP 140/58 RR 18 SaO2
98%. The following afternoon she was admitted to the cardiology
floor.
Echocardiogram confirmed moderate-severe aortic stenosis ___
0.9 cm2; index 0.6 cm2/m2) with moderate aortic regurgitation,
with no regional wall motion abnormality and LVEF 71%.
During code status assessment, patient stated that she did not
mind mild discomfort and does not want life prolonging
treatments. In particular, she was not interested in cardiac
catheterization under any circumstances. Her medical regimen was
optimized. She remained well and without chest pain while in
house, was able to ambulate around the ward without dizziness,
shortness of breath, or chest pain.
ACTIVE ISSUES
# Biomarker negative unstable angina, possible LAD restenosis
vs. progression of disease - It was recommended that she
consider starting isosorbide mononitrate as a ___ anti-ischemic
agent as an outpatient and discontinue Premarin given the
cardiovascular and other risks associated with prolonged use of
hormone replacement therapy well after the time of menopause.
Her primary cardiologist reported that she has been trialed on
many statins, but with poor tolerance (myalgias, etc), and once
on isosorbide but with a slight headache. She was continued on
ASA and beta-blocker.
# Paroxysmal atrial fibrillation - Review of her anticoagulation
regimen was deferred to her primary cardiologist.
# Hypertension - Unclear why patient was hypertensive on the
cardiology floor as she had reported receiving her usual
medications in the ED and this was confirmed by review of the ED
orders. SBP was in 180s, and patient was given hydralazine 25
mg. Her BP responded well, with no repeat hypertensive episodes.
Patient remained stable, and this single episode was attributed
to anxiety related to her hospitalization.
# Aortic Stenosis - Echocardiogram showed progression of AS to
moderate-severe (previously moderate) and aortic insufficency to
moderate. Given her reluctance to undergo invasive procedures,
she is currently not a candidate for aortic valve surgery or
TAVR.
Chronic Issues
# Hypothyroidism - continued home levothyroxine
# Glaucoma - continue home travoprost
# Psych - continue atavan prn and venlafaxine
# Hormone replacement therapy - Premarin held given its known
cardiovascular risks and presentation of this patient with known
CAD with unstable angina
Transitional Issues
- HCP = ___, ___
- Consider initiation of low dose isosorbide mononitate for
anginal symptoms
- Recommend continued discussion of anticoagulation for embolic
prevention with atrial fibrillation
- Consider discontinuation of Premerin or transition to topical
agent if needed
for symptomatic relief
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 25 mcg PO DAILY
2. Lorazepam 0.25 mg PO Q8H:PRN anxiety
3. Estrogens Conjugated 0.3 mg PO DAILY
4. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN angina
5. Venlafaxine 75 mg PO DAILY
6. Clopidogrel 75 mg PO DAILY
7. Lisinopril 10 mg PO DAILY
8. Sotalol 60 mg PO BID
Discharge Medications:
1. Clopidogrel 75 mg PO DAILY
2. Levothyroxine Sodium 25 mcg PO DAILY
3. Lisinopril 10 mg PO DAILY
4. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN angina
5. Sotalol 60 mg PO BID
6. Venlafaxine 75 mg PO DAILY
7. Estrogens Conjugated 0.3 mg PO DAILY
8. Lorazepam 0.25 mg PO Q8H:PRN anxiety
9. Aspirin 81 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
- Unstable Angina, biomarker negative
- Moderate - Severe Aortic stenosis
- Moderate Aortic insufficiency
- Hypertension
- Hypothyroidism
- Glaucoma
- Dementia
- Paroxysmal 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. ___,
You came to the hospital because you had chest pain. After
doing some tests we found that you were not having an active
heart attack. We discussed your options (catheterization to see
the vessels and possibly put in a stent for symtpomatic releif,
or medical management only), and you had clearly said that at
this point you prefer medical management and would not like to
do the catheterization.
To optimize your medications, it is important that you follow-up
with your primary cardiologist, Dr ___.
It was a pleasure taking care of you. We wish you all the best.
Sincerely,
Your ___ team
Followup Instructions:
___
|
19562059-DS-5
| 19,562,059 | 24,728,853 |
DS
| 5 |
2114-07-04 00:00:00
|
2114-07-13 10:44:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o F ___ s/p laparoscopic cholecystectomy presents with 1
day of lower abdominal pain. Patient underwent an uncomplicated
larparoscopic cholecystectomy on ___ for symptomatic
cholelithiasis and was discharged home on the same day after a
brief recovery period. She reports she has been feeling well
with
subsiding pain around her incisions though still requiring
oxycodone, however started having acute onset of sharp crampy
abdominal pain mostly in her lower abdomen starting around
midnight. She reports she has not had a bowel movement since
last
___ despite taking colace BID since surgery. Pain is
nonradiating and has stayed about the same. Upon presentation to
the ED, patient was tachycardic in triage to 124 with resolution
to HR in ___ since, normotensive and afebrile. Labs were
remarkable for leukocytosis of 14.3. CXR and KUB showed
pneumoperitoneum and heavy fecal load on KUB. RUQ was normal.
She
was manually disimpacted by the ED staff and received a fleet
enema. She reports current pain to be about the same in
intensity
though is no longer sharp but more dull. Denies any nausea or
vomiting, fevers or chills. Denies any dysuria.
Past Medical History:
PMH: Headaches, lower back pain, neck pain, UTIs
PSH: laparoscopic cholecystectomy ___
Social History:
___
Family History:
Noncontributory
Physical Exam:
Vitals: 98.8 91 (124 in triage) 123/66 18 100% RA
GEN: WDWN, no acute distress, appear comfortable
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, mildly distended, diffusely tender to light palpation
with rebound, surgical incisions with steri-strips dry and
intact, no e/o infection.
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
ADMISSION LABS
==============
___ 08:00AM BLOOD WBC-14.3* RBC-4.72 Hgb-14.2 Hct-40.3
MCV-85 MCH-30.2 MCHC-35.3* RDW-13.7 Plt ___
___ 08:00AM BLOOD Neuts-86.8* Lymphs-9.4* Monos-2.9 Eos-0.7
Baso-0.2
___ 08:00AM BLOOD Glucose-98 UreaN-9 Creat-0.7 Na-138 K-4.2
Cl-102 HCO3-23 AnGap-17
___ 08:00AM BLOOD ALT-46* AST-35 AlkPhos-70 TotBili-0.3
___ 08:00AM BLOOD Lipase-35
___ 08:00AM BLOOD Albumin-4.6
___ 08:40PM BLOOD Calcium-8.9 Phos-2.5* Mg-2.1
___ 10:15PM BLOOD Lactate-2.1*
___ 06:19AM BLOOD Lactate-0.8
DISCHARGE LABS
==============
___ 06:25AM BLOOD WBC-9.1 RBC-4.22 Hgb-13.0 Hct-35.8*
MCV-85 MCH-30.9 MCHC-36.5* RDW-13.1 Plt ___
___ 10:40PM BLOOD Neuts-73.7* ___ Monos-4.6 Eos-1.4
Baso-0.2
___ 05:00AM BLOOD Glucose-95 UreaN-13 Creat-0.8 Na-140
K-4.1 Cl-104 HCO3-26 AnGap-14
___ 05:00AM BLOOD Calcium-9.3 Phos-3.8 Mg-2.1
RELEVANT STUDIES
================
- EKG (___): Sinus tachycardia. Otherwise, within normal
limits. No previous tracing available for comparison.
- LIVER/GB US (___): No fluid in the gallbladder fossa to
suggest postoperative collection. Non-dilated bile ducts.
- CXR (___): Clear lungs. Large amount of pneumoperitoneum.
The patient is reportedly status post recent cholecystectomy ;
amount of air appears larger than would be expected for
cholecystectomy 5 days prior, unclear whether findings may
relate to post surgical change, bowel perforation not excluded.
- KUB (___): Large amount of intraperitoneal free air. Bowel
loops are nondilated.
- CT ABD/PELVIS W/ CONTRAST (___):
1. Large amount of pneumoperitoneum, more than expected given
postop day 5. No source is identified. Trace pelvic free fluid,
but no large amount of free fluid.
2. Bowel loops are of normal caliber without evidence of wall
thickening or obstruction
- CT ABD/PELVIS W/O CONTRAST (___):
1. Linear hyperdense material within the left upper quadrant,
seen and
unchanged from the prior study, may represent of mesenteric
vessel or may be artifactual, this as a source of oral contrast
extravasation is unlikely.
2. Large intraperitoneal free air unchanged from the prior
study.
3. New thickening of the descending colon is a nonspecific
finding and could be seen as a consequence of serosal
inflammation following perforation or in developing inflammation
primary to the colon itself.
Brief Hospital Course:
___ year old female arrived in ED 4 days s/p laparoscopic
cholecystectomy with 1
day of diffuse worsening abdominal pain x24 hours. Labs showed
leukocytosis and abdominal and chest xrays revealed a
disproportionate amount of pneumoperitoneum considering her
surgery was 4 days ago, concerning for a possible duodenal
perforation. Was stable clinically on admission other than
rebound on exam. An interval CT scan was negative. Was kept on
observation with serial exam and IV antibiotics over the
weekend, and steadily improved. Discharged home in stable
condition.
- Being discharged on 2 week course of augmentin, last day
___
- Pt instructed to return to ED if symptoms recur, otherwise she
should follow-up with Dr. ___ in clinic
Medications on Admission:
OCPs
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
take as directed for 2 weeks, last day ___
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth every 12 hours Disp #*28 Tablet Refills:*0
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:
Dear Ms. ___,
It was a pleasure taking care of ___ at ___.
___ came to us after ___ began to experience increased abdominal
pain several days after your gallbladder was removed. We watched
___ closely over the weekend and your symptoms have gotten
better on your own. ___ are now safe to go home, but please
return if these symptoms return.
___ have also been started on antibiotics during this admission,
and ___ should continue to take them for 2 weeks after
discharge, to help your recovery. Please take as prescribed.
Please follow-up with Dr. ___, as detailed below.
Followup Instructions:
___
|
19562282-DS-17
| 19,562,282 | 23,614,783 |
DS
| 17 |
2124-12-10 00:00:00
|
2124-12-11 12:26:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: UROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
- left epididymitis in setting of recent vasectomy
- gross hematuria
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ y/o male without contributory PMH who recently (___)
underwent vasectomy via a single midline incision by Dr. ___
at ___. Per operative report the case was
uncomplicated. He did well but around ___ yesterday developed
acute onset L > R scrotal pain as well as streaks of blood in
urine progressing to gross hematuria.
He was initially evaluated at ___ and then transferred to
the ___ ED. Scrotal ultrasound was not available, so a CT scan
was performed showing bilateral soft tissue stranding consistent
with his recent procedure. He was additionally noted to be
hypokalemic (2.8) with a leukocytosis to ___. He was given K
and vanc/ceftriaxone. Per discussion with the on-call urologist
he was transferred to ___ for further evaluation.
The patient reports a history of testicular torsion in his ___,
does not recall laterality, did not require operative
intervention.
Of note, in addition to the above issues the patient reported a
severe dry cough x 3 days on his initial presentation to the
urgent care facility, raising concern for a coexisting lung
infection. He was started on a three-day course of azithromycin.
At present his pain is somewhat improved, but he attributes this
at least partially to being in bed overnight. He endorses
malaise/fatigue and myalgias but no frank fevers, chills,
sweats, nausea/vomiting, chest pain, or shortness of breath.
Past Medical History:
- asthma
- HTN
- HLD
- vasectomy per HPI
- prior h/o testicular torsion, per HPI
Social History:
___
Family History:
- adopted, no known ___
Physical Exam:
Exam on discharge:
- AAOx4, WDWN male resting comfortably in bed, appearance c/w
stated age
- breathing unlabored on RA
- skin WWP
- abd soft, ND; previous LLQ TTP much improved
- scrotum mildly erythematous; left epididymus tender but
improved from admission; no fluctuance or crepitus
- moving all extremities spontaneously; no edema
Pertinent Results:
___ 02:10AM BLOOD WBC-15.3* RBC-4.91 Hgb-14.5 Hct-42.1
MCV-86 MCH-29.5 MCHC-34.4 RDW-12.8 RDWSD-39.7 Plt ___
___ 07:40AM BLOOD WBC-12.7* RBC-4.40* Hgb-13.3* Hct-38.1*
MCV-87 MCH-30.2 MCHC-34.9 RDW-13.0 RDWSD-40.6 Plt ___
___ 05:50AM BLOOD WBC-11.8* RBC-4.50* Hgb-13.1* Hct-40.3
MCV-90 MCH-29.1 MCHC-32.5 RDW-13.0 RDWSD-42.9 Plt ___
___ 02:10AM BLOOD Glucose-125* UreaN-12 Creat-0.8 Na-137
K-3.0* Cl-97 HCO3-26 AnGap-17
___ 07:40AM BLOOD K-3.2*
___ 01:47PM BLOOD K-3.1*
___ 05:50AM BLOOD Glucose-130* UreaN-11 Creat-0.7 Na-141
K-4.0 Cl-103 HCO3-29 AnGap-13
___ 05:50AM BLOOD Calcium-8.3* Phos-2.1* Mg-2.1
Brief Hospital Course:
Mr. ___ was admitted for observation, pain control, and
antibiotic treatment due to his poor pain control and elevated
temperatures (Tmax in ED 101.0). His chlorthalidone was held due
to his hypokalemia. He was given a single dose of IV ketorolac
and then put on a pain regimen of PO APAP, ibuprofen, and
oxycodone. He was treated with double antibiotic coverage (IV
ceftriaxone/PO ciprofloxacin).
He remained AFHDS overnight and on the morning of HD 2 was
reporting much improved pain control. His hematuria had
improved, though he was unsure to what extent as he had been
provided with a non-translucent cardboard urinal. He had no
further elevated temperatures. His K had normalized to 4.2 after
aggressive IV and PO repletion.
His QTc had been noted to be prolonged at >500 in the ED; this
was rechecked on the morning of HD 2 given the initiation of
ciprofloxacin and had normalized to 444.
He was discharged home in good condition on the morning of HD 2
(___ with oral pain medication and instructions
to complete a two-week course of PO ciprofloxacin. He was to
follow up with Dr. ___ prior to the completion of his
antibiotics in order to discuss a longer course of treatment and
to pursue further workup of his gross hematuria. His home
medications were resumed. He was instructed to follow up with
his PCP within the week for a repeat BMP and QTc check.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. FLUoxetine 40 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing, shortness of
breath
4. Fluticasone Propionate 110mcg 2 PUFF IH BID
5. Famotidine 40 mg PO BID
6. Chlorthalidone 25 mg PO DAILY
7. Carvedilol 25 mg PO BID
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. Ciprofloxacin HCl 500 mg PO Q12H Duration: 2 Weeks
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*28 Tablet Refills:*0
3. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild
4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 5 tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
5. Phenazopyridine 100 mg PO TID:PRN dysuria Duration: 3 Days
RX *phenazopyridine 100 mg 1 tablet(s) by mouth three times a
day Disp #*10 Tablet Refills:*0
6. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing, shortness of
breath
7. Atorvastatin 40 mg PO QPM
8. Carvedilol 25 mg PO BID
9. Chlorthalidone 25 mg PO DAILY
10. Famotidine 40 mg PO BID
11. FLUoxetine 40 mg PO DAILY
12. Fluticasone Propionate 110mcg 2 PUFF IH BID
Discharge Disposition:
Home
Discharge Diagnosis:
- left epididymitis in setting of recent vasectomy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
- Please continue taking your oral antibiotics (ciprofloxacin)
for at least two weeks.
- Please resume activites according to your prior discharge
instructions.
- Please contact Dr. ___ or go to the emergency
room if you experience worsening pain or worsening fever (>
101.0).
- It is important that you undergo a full workup to determine
the cause of your hematuria (blood in urine), in order to rule
out a concerning cause such as a bladder tumor. You can pursue
this with Dr. ___ you see him in clinic.
Followup Instructions:
___
|
19562494-DS-10
| 19,562,494 | 28,770,218 |
DS
| 10 |
2173-03-01 00:00:00
|
2173-03-01 18:31:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Penicillins / dicloxicillin
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
___- OPERATION PERFORMED: Total abdominal colectomy,
ileostomy
and mucous fistula.
History of Present Illness:
___ with HTN, HLD, afib on Coumadin, recently discharged s/p R
inguinal hernia repair, course c/b chest pain & CT findings of
large diaphragmatic hernia, readmitted for abdominal pain with
CT scan significant for colonic distension, with cecum diameter
measuring 9-10cm. She was not having any BMs and not passing
flatus. Her daughters were also concerned that she was confused.
Past Medical History:
PMH:
HTN, HLD, recurrent UTIs, chronic back pain, right shoulder
rotation cuff impingement syndrome, atrial fibrillation, CVA
with
residual left sided weakness
PSH: (unclear due to poor memory, children unclear as well)
possible appendectomy (as a child), left inguinal hernia
repair ___ years ago
Social History:
___
Family History:
diabetes and stroke
Physical Exam:
Physical exam:
Vitals: Stable
General: AAOx3
Cardiac: Normal S1, S2
Respiratory: Breathing comfortably on room air
Abdomen: Tender, mid abdomen, distended, no rebound or guarding.
Tympanic on exam.
Extremity: Pulses palpable
Discharge Physical Exam:
VS: n/a (CMO)
GEN: Disoriented. Somnolent. Arousable to voice. Appears
comfortable.
HEENT: no conjunctival pallor/injection, sclera clear. Moist
mucous membranes.
CHEST: Audible rhonchi
ABDOMEN: Ileostomy with small amount stool. Mucus fistula with
scant amount drainage. Midline incision with staples CDI
EXTREMITIES: Warm, well perfused, pulses palpable, (+) edema
================================================
Pertinent Results:
___ 10:43AM BLOOD ___*
___ 10:15PM BLOOD TSH-1.6
___ 03:59AM BLOOD WBC-17.4* RBC-3.97 Hgb-12.0 Hct-39.0
MCV-98 MCH-30.2 MCHC-30.8* RDW-14.3 RDWSD-51.4* Plt ___
___ 01:53AM BLOOD WBC-15.7* RBC-3.52* Hgb-10.6* Hct-34.4
MCV-98 MCH-30.1 MCHC-30.8* RDW-14.4 RDWSD-51.7* Plt ___
___ 01:38AM BLOOD WBC-17.2*# RBC-3.64* Hgb-11.2 Hct-35.6
MCV-98 MCH-30.8 MCHC-31.5* RDW-14.5 RDWSD-52.1* Plt ___
___ 12:28AM BLOOD WBC-6.4 RBC-4.31 Hgb-13.1 Hct-41.9 MCV-97
MCH-30.4 MCHC-31.3* RDW-14.2 RDWSD-50.4* Plt ___
___ 01:16PM BLOOD WBC-11.8* RBC-4.30 Hgb-13.0 Hct-40.1
MCV-93 MCH-30.2 MCHC-32.4 RDW-14.1 RDWSD-47.5* Plt ___
___ 01:53AM BLOOD Glucose-120* UreaN-24* Creat-0.5 Na-144
K-3.9 Cl-104 HCO3-30 AnGap-14
___ 03:42PM BLOOD Glucose-129* UreaN-22* Creat-0.5 Na-140
K-6.2* Cl-103 HCO3-30 AnGap-13
___:38AM BLOOD Glucose-151* UreaN-24* Creat-0.6 Na-148*
K-3.8 Cl-108 HCO3-30 AnGap-14
___ 03:21AM BLOOD Glucose-163* UreaN-22* Creat-0.6 Na-139
K-4.4 Cl-106 HCO3-23 AnGap-14
___ 10:43AM BLOOD CA12___*
Radiology:
CXR ___: Apparent interval removal of the ET tube --clinical
correlation is requested. Overall similar to the prior study,
but
with new hazy opacity in the left upper zone.
CT abdomen/chest ___: Diffuse colonic dilation with a smooth
tapering at the level of the rectum, findings suggestive of
colonic pseudo-obstruction. Cecum measures 9-10 cm in
diameter. No evidence of ischemia or pneumoperitoneum.
Large diaphragmatic hernia containing stomach, pancreas, colon,
and celiac axis, similar to the prior study. Innumerable
peritoneal and omental soft tissue deposits, the largest in the
left upper quadrant measuring 7.3 x 4.0 x 2.8 cm. Of note, a
2.2
x 1.9 cm deposit is adjacent to the recently placed inguinal
canal plug. These findings are highly suspicious for metastatic
disease, most commonly from ovarian or a GI/gastric primary.
Alternatively, primary omental adenocarcinoma is another
possibility. Further evaluation is recommended. Moderate
non-hemorrhage bilateral pleural effusions with adjacent
Asymmetrically dense left breast tissue
Brief Hospital Course:
Ms. ___ was intially seen in the ED ___. She underwent
CT A/P as part of her initial workup and this was read as
suspicious for pseudoobstruction vs. large bowel obstruction. A
GI consult was placed and she underwent a flexible
sigmoidoscopy, which showed changes more consistent with sigmoid
colon ischemia. Furthermore, there seemed to be an obstruction
of the proximal sigmoid colon.
Her daughter/HCP consented to surgical intervention for ischemic
colitis. She underwent an exploratory laparotomy. Peritoneal
carcinomatosis was discovered upon entry and two large masses
were found to be tethering her colon at the splenic flexure and
in the pelvis. Her hiatal hernia was reduced to allow for
takedown of the splenic flexture and resection of the mass
there. Some of the small bowel was involved with what appeared
to be metastatic disease and was resected. In summary she
underwent a total abdominal colectomy and 10cm SBR (10 cm ileum
removed), as well as creation of a mucous fistula and ileostomy.
The pelvic mass was left behind. She was then transferred from
OR to ICU. She received 2L crystalloid and was started on
levophed for a short while, but quickly was able to be weaned
off pressors.
The patient's daughter/HCP was informed of the findings
immediately postoperatively.
Upon closer inspection and review of her CT a/p, our
radiologists revised their report. They now spotted innumerable
peritoneal and omental soft tissue deposits, the largest in the
left upper quadrant measuring 7.3 x 4.0 x 2.8 cm. Of note, a
2.2 x 1.9 cm deposit was also seen adjacent to the recently
placed inguinal canal plug. They felt, based on this pattern,
that this would most commonly be from an ovarian or a GI/gastric
primary malignancy.
Postoperatively, Ms. ___ did not tolerate spontaneous
ventilation. She had oliguria, responsive to crystalloid
boluses. She was able to successfully extubate on POD1. Her AF
was controlled with metoprolol IV and she continued to receive
resuscitative IVF, including albumin. On POD2 diuresis was begun
for evidence of fluid overload on CXR. She began having
ileostomy function and her abdomen was soft. Her NGT was
removed. Acute pain service was consulted for pain control
guidance and possible epidural placement, however, the patient's
HCP refused. She did not want an invasive procedure for pain
control.
Ms. ___ mental status was not improving. She was
somnolent, unable to articulate her words, and delerius. She
was unable to participate in a bedside swallow evaluation as a
result of this and upon further discussion of GOC with her
family, it was decided that we would forgo dobhoff tube
placement or PEG placement until after the pathology results
returned. Palliative care was involved in this discussion.
On POD5, a family meeting was held. The family made the
decision to shift care to ___. They no longer wanted to wait
for pathology results to come back before shifting to ___
care, since they felt the patient is suffering too much, and,
ultimately, they believe that this is cancer, which their mom
would not have want treated, nor would she want her life
prolonged with a diagnosis of cancer. The family was all in
agreement that their mom would want her care to focus on comfort
at this point.
The patient was then transferred to the floor with supportive
CMO care. Palliative care continued to follow and make
recommendations. Her pain was managed and the patient appeared
comfortable. The patient was discharged to hospice care on POD6.
Discharge instructions were discussed with the family with
verbalized understanding.
Medications on Admission:
- Acetaminophen 650 mg PO TID
- Docusate Sodium 100 mg PO BID
- Enalapril Maleate 40 mg PO DAILY
- Metoprolol Tartrate 37.5 mg PO BID
- OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
- Senna 17.2 mg PO HS
- Simvastatin 40 mg PO QPM
- Vitamin D 1000 UNIT PO DAILY
- Warfarin 2.5 mg PO DAILY16
Discharge Medications:
1. Fentanyl Patch 12 mcg/h TD Q72H
RX *fentanyl 12 mcg/hour 1 patch q72 Disp #*15 Patch Refills:*0
2. Scopolamine Patch 1 PTCH TD ONCE Duration: 72 Hours
RX *scopolamine base [Transderm-Scop] 1.5 mg (delivers 1 mg over
3 days) apply to skin Q3D Disp #*15 Patch Refills:*0
3. Morphine Sulfate (Concentrated Oral Soln) ___ mg SL Q1H:PRN
pain, RR>10
RX *morphine concentrate 100 mg/5 mL (20 mg/mL) ___ mg SL Q1H
Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Metastatic cancer with 3 points of obstruction along the
transverse colon. Two-point of obstruction along the colon.
Discharge Condition:
Level of Consciousness: Lethargic and minimally arousable.
Activity Status: Bedbound.
Mental Status: Delirious.
Discharge Instructions:
You were admitted to ___ with abdominal pain. A flexible
sigmoidoscopy showed colonic obstruction with ischemic bowel and
CT findings were concerning for metastatic cancer with an
obstructing mass. You were taken to the operating room and
underwent total abdominal colectomy, ileostomy and mucous
fistula. Your post-operative course was complicated by delirium,
and your Health Care Proxy family member made the decision that
you would want to be made comfort measures only, given the
prognosis. You are now being discharged to hospice.
Followup Instructions:
___
|
19562494-DS-9
| 19,562,494 | 28,577,213 |
DS
| 9 |
2173-02-20 00:00:00
|
2173-02-20 14:44:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Penicillins
Attending: ___
Chief Complaint:
Right groin pain
Major Surgical or Invasive Procedure:
___: Right inguinal hernia repair
History of Present Illness:
___ hx of CVAs with residual L-sided weakness, afib on Coumadin
(INR 3.2) p/w right groin pain with a bulging mass. She states
that the pain has been intermittent and worsening over the past
week. She developed nonbloody diarrhea this morning. She denies
fever, nausea or vomiting. She has +flatus. Given worsening
pain, she was referred to the ED by her PCP. Surgery was
subsequently
consulted for further evaluation and management of a right
inguinal hernia.
Past Medical History:
PMH:
HTN, HLD, recurrent UTIs, chronic back pain, right shoulder
rotation cuff impingement syndrome, atrial fibrillation, CVA
with
residual left sided weakness
PSH: (unclear due to poor memory, children unclear as well)
possible right appendectomy (as a child), left inguinal hernia
repair ___ years ago
Social History:
___
Family History:
diabetes and stroke
Physical Exam:
Admission Physical Exam:
Vitals: 97.2 70 190/90 16 99%RA
GEN: AOx3, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: right reducible inguinal vs. incisional hernia, hernia
tender on palpation and reduction, abdomen otherwise soft, obese
nondistended, nontender, no rebound or guarding, well head right
paramedian incision and left inguinal hernia incision
Ext: No ___ edema, ___ warm and well perfused
Discharge Physical Exam:
VS: T:97.4, BP: 140/80, HR: 58, RR: 22, O2: 94% RA
GEN: A+Ox3, NAD
HEENT: normocephalic, atraumatic
CV: regular rate, sinus bradycardia
PULM: CTA b/l
ABD: diaphragmatic hernia, otherwise soft, mildly tender to
palpation
GU: Right inguinal hernia repair site with steristrips, skin
well-approximated, no erythema or s/s infection
Ext: no edema, warm, well-perfused b/l
Pertinent Results:
___ 05:54PM ___ PTT-46.9* ___
___ 05:18PM GLUCOSE-105* UREA N-14 CREAT-0.7 SODIUM-141
POTASSIUM-3.1* CHLORIDE-101 TOTAL CO2-28 ANION GAP-15
___ 03:33PM LACTATE-1.7 K+-3.8
___ 03:20PM WBC-6.6 RBC-4.38 HGB-13.5 HCT-41.5 MCV-95
MCH-30.8 MCHC-32.5 RDW-13.9 RDWSD-48.7*
___ 03:20PM NEUTS-73.5* LYMPHS-17.0* MONOS-7.8 EOS-0.9*
BASOS-0.5 IM ___ AbsNeut-4.88 AbsLymp-1.13* AbsMono-0.52
AbsEos-0.06 AbsBaso-0.03
___ 03:20PM PLT COUNT-275
Imaging:
___:
1. Right inguinal hernia containing the inferior pole of the
cecum. No
resultant bowel obstruction.
2. Large hiatal hernia.
Brief Hospital Course:
Ms. ___ is an ___ year-old female who presented to ___ on
___ with complaints of right groin pain and was found to
have a right incarcerated Richter's type direct inguinal
hernia. She was admitted to the Acute Care Surgery team for
further medical management.
She was taken to the Operating Room and underwent a right
inguinal hernia repair.
There were no adverse events in the operating room; please see
the operative note for details. Pt was extubated, taken to the
PACU until stable, then transferred to the ward for observation.
On POD2, the patient was restarted on her home Coumadin and her
INR was monitored. She was noted to be hypertensive and po
metoprolol was ordered and her primary care provider, Dr. ___,
was notified.
On POD4, the patient reported abdominal pain and early satiety
and was noted to have leukocytosis. Imaging revealed a large
left diaphragmatic hernia without evidence of ischemia. It was
discussed with the patient and her family that this hernia would
be repaired electively as an outpatient.
The remainder of the ___ hospital course is summarized by
systems below:
Neuro: The patient was alert and oriented throughout
hospitalization; pain was managed with oral acetaminophen and
oxycodone once tolerating a diet.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI: The patient's the diet was advanced sequentially to a
Regular diet, which was well tolerated. Patient's intake and
output were closely monitored.
ID: The patient's fever curves were closely watched for signs of
infection.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and she
was restarted on her home dose of Coumadin. ___ dyne boots were
used during this stay and was encouraged to get up and ambulate
as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. A follow-up appointment was
scheduled with the Acute Care Surgery clinic.
Medications on Admission:
warfarin 2.5mg', enalapril 20', simvastatin 40', vit D3 1000U'
Discharge Medications:
1. Acetaminophen 650 mg PO TID
RX *acetaminophen 500 mg 2 tablet(s) by mouth every 8 hours Disp
#*50 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth every 12 hours
Disp #*30 Capsule Refills:*0
3. Enalapril Maleate 40 mg PO DAILY
4. Metoprolol Tartrate 37.5 mg PO BID
5. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth every 4
hours as needed for pain Disp #*30 Tablet Refills:*0
6. Senna 17.2 mg PO HS
RX *sennosides [senna] 8.6 mg 1 capsule by mouth every evening
Disp #*30 Capsule Refills:*0
7. Simvastatin 40 mg PO QPM
8. Vitamin D 1000 UNIT PO DAILY
9. Warfarin 2.5 mg PO DAILY16
Please adjust with INR
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right inguinal hernia and diaphragmatic hernia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ on
___ and underwent a right groin hernia repair. You
tolerated this procedure well.
You reported having abdominal pain and a feeling of fullness
after light eating. You were found to have a diaphragmatic
hernia which requires no emergent intervention. Discussion
regarding elective surgery for your hernia repair will take
place at your follow-up appointment in the Acute Care Surgery
clinic.
You have worked with Physical Therapy who recommends your
discharge to a rehabilitation facility. You are tolerating a
regular diet and your pain is better controlled. You are now
medically cleared to be discharged.
Please follow the instructions below to continue your recovery:
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 steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery.
Followup Instructions:
___
|
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