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19562640-DS-9	19,562,640	21,241,092	DS	9	2139-10-27 00:00:00	2139-10-27 14:11:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: minocycline Attending: ___. Chief Complaint: pre-syncope, slurred speech Major Surgical or Invasive Procedure: Interventional radiology port placement and liver biopsy History of Present Illness: ___ PMH of T2DM, HTN, HLD, GCA (c/b aortitis, on prednisone), Bells Palsy, Newly Diagnosed Metastatic Pancreatic Cancer, PE (lovenox), who presented to ED with pre-syncope, slurred speech possibly TIA, as well as new PE As per review of notes, patient was in ___ to get port placement for upcoming palliative chemotherapy, and had slurred speech and felt presyncopal so was transferred urgently to ED, where neurology evaluated her promptly for stroke. Pt explained that she took her lovenox yesterday am, but did not take it morning of her procedure today. She noted that she ate a regular diet until MN then was NPO afterward. She noted that she got a ride to ___ today and was walking without any issue, felt energetic, and robust in her USOH. FSG checked prior to procedure was 140 per her report. She noted that prior to procedure she felt like she was going to pass out and felt that she had sudden slurred speech. Both symptoms occurred abruptly then gradually resolved shortly after arriving in the ED. She notes that she now feels back to her baseline. She denied any difficulties with speech or coordination now. Noted that she ate without issue, has been voiding/stooling normally. Reported that she is without chest pain, SOB, lightheadedness. She is hopeful that she can get her port placed tomorrow. In the ED, initial vitals: 98.0 61 130/34 18 98% RA. Neurology felt that she was speaking fluently, was appropriately oriented, had stable right sided bells palsy findings. CBC wnl, CHEM with Na 132, LFTs AP 221, Serum Tox negative, Lactate 1.2, INR 1.2, TSH 0.11. CTA head/neck performed by ED staff and noted: CT head: No acute intracranial abnormality. CTA: The right vertebral artery is diminutive relative to the left, likely congenital. There is mild atherosclerotic narrowing at the carotid siphon, bilaterally. No high-grade stenosis, aneurysm or dissection. There is a new subsegmental pulmonary embolus (series 3, image 25) extending into multiple left upper lobe subsegmental branches. No evidence of pulmonary infarct. Pulmonary emboli in left lower lobe on the prior examination is not imaged on today's study. As per neurology review of imaging and exam of patient they felt that TIA/Stroke unlikely and that presyncope in setting of dehydration from NPO status for procedure most likely. They rec'd orthostatic testing which was negative. Patient was given 1L of NS, and was started on a heparin gtt, then was admitted for concern of new pulmonary embolism. REVIEW OF SYSTEMS: A complete 10-point review of systems was performed and was negative unless otherwise noted in the HPI. Past Medical History: PAST ONCOLOGIC HISTORY: As per last note by Dr ___: " incidentally found to have a mass in the head of the pancreas during work up for kidney stone. She had a CT urogram in ___ to evaluate L flank pain and hematuria. A small non-obstructing L renal stone was noted, however incidentally was found to have new pancreatic lesions in the head and body (13mm and 18mm, respectively), with upstream PD dilatation, and several suspicious liver lesions concerning for metastatic disease. Subsequent MRCP performed on ___ revealed a 1.9cm complex cyst in the head with dilated PD to 6mm with abrupt cut-off in the body highly concerning for a mass lesion. Previously noted liver abnormalities were felt to be benign. Ms. ___ was seen by Dr. ___ Atrius GI in ___ and EUS was recommended given high concern for possible malignancy. She underwent EUS on ___ which confirmed an approximate 2.2cm pancreatic neck mass with upstream PD dilatation and vascular involvement of the portal vein with mild narrowing. A 1.9cm simple cyst was noted in the head and a 7mm cyst was seen in the left lobe of the liver. FNB of neck mass was consistent with ductal adenocarcinoma" PAST MEDICAL HISTORY: DM2 HTN/HLD Aortic stenosis Mild mitral regurgitation Giant cell arteritis and vasculitis/recent aortitis ___, biopsy negative, treated with Prednisone and followed by Dr. ___, ___ spinal stenosis MGUS Osteopenia Adenomatous colon polyps Bell's palsy Cataracts/macular degeneration GERD Cholelithiasis Hyperthyroidism h/o positive PPD (treated with INH at ___. s/p wisdom teeth extraction Social History: ___ Family History: Father deceased; unclear cause (was living in a small town in ___. Mother died from CVA. No clear history of cancer in her family Physical Exam: ADMISSION Vitals: 99.0 PO 160 / 53 73 18 95 Ra GENERAL: laying in bed, obvious bells palsy of right side of her face, otherwise is very pleasant EYES: PERRLA, has ptosis of right eyelid HEENT: facial droop on right, ptosis and assymetric smile are baseline ___ her bells palsy ___ yrs, speech fluent, OP clear, MMM NECK: supple LUNGS: CTA b/l, no wheezes/rales/rhonchi, normal RR CV: RRR has systolic murmur at sternal border, normal distal perfusion no edema ABD: soft, NT, ND, normoactive BS GENITOURINARY: no foley EXT: warm, dry, thin extremities with poor muscle bulk, no asymmetry, strength ___ bilaterally SKIN: warm, dry NEURO: AOx3, fluent speech with ___ accent, bells palsy as described above, neg pronator drift, normal strength/sensation in limbs ACCESS: PIV Pertinent Results: ADMISSION ___ 07:48AM BLOOD WBC-9.6 RBC-4.71 Hgb-12.3 Hct-37.3 MCV-79* MCH-26.1 MCHC-33.0 RDW-15.9* RDWSD-45.9 Plt ___ ___ 08:44AM BLOOD Neuts-77.0* Lymphs-10.3* Monos-9.8 Eos-1.5 Baso-0.3 Im ___ AbsNeut-7.23* AbsLymp-0.97* AbsMono-0.92* AbsEos-0.14 AbsBaso-0.03 ___ 08:44AM BLOOD Glucose-173* UreaN-28* Creat-0.9 Na-132* K-4.9 Cl-97 HCO3-22 AnGap-13 ___ 08:44AM BLOOD ALT-35 AST-37 CK(CPK)-18* AlkPhos-221* TotBili-0.6 ___ 08:44AM BLOOD cTropnT-0.02* ___ 08:44AM BLOOD Albumin-3.3* Calcium-8.7 Phos-2.8 Mg-2.2 Cholest-252* ___ 08:44AM BLOOD Triglyc-212* HDL-38* CHOL/HD-6.6 LDLcalc-172* ___ 08:44AM BLOOD TSH-0.11* ___ 08:44AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG ___ 08:56AM BLOOD Lactate-1.2 CTA Head & Neck 1. New left upper lobe subsegmental pulmonary embolus. Previously seen pulmonary emboli in the left lung base are not imaged on today's examination. 2. No evidence of hemorrhage, edema, mass effect or infarction. No high-grade stenosis, dissection or aneurysm greater than 3 mm. 3. Pulmonary nodules at the right lung apex are unchanged from chest CT ___. 4. Multiple thyroid nodules measure up to 1.3 cm. 5. Periapical lucencies are noted at left mandibular molars, ___ 19 and ___. DISCHARGE ___ 09:38AM BLOOD WBC-8.1 RBC-4.17 Hgb-10.5* Hct-33.1* MCV-79* MCH-25.2* MCHC-31.7* RDW-16.2* RDWSD-46.7* Plt ___ ___ 07:25AM BLOOD Glucose-285* UreaN-16 Creat-0.8 Na-136 K-4.4 Cl-97 HCO3-21* AnGap-18 Brief Hospital Course: #Slurred Speech #Pre-syncopal Symptoms Patient with slurred speech and presyncopal symptoms of abrupt onset, with gradual relief. Evaluated by neurology in the ED, who felt that this was more likely vasovagal (felt sleepy and blacked out) or presyncopal (in the setting of not eating before procedure.) Ddx includes a TIA but not entirely consistent with this diagnosis as she did not have the acute onset of focal neurologic deficits other than some dysarthria. Reassuringly CT head and CTA head and neck were negative. Orthostatics negative. Overnight and today she was hydrated with IV fluids as she seemed dry (slightly hyponatremic, had been NPO.) Home aspirin was originally held in setting of liver biopsy but resumed on discharge. #Pulmonary Embolism Known to have PE in LLL, but new pulmonary embolism in LUL on CTA Head/Neck from ED, possibly in the setting of withholding her am dose of lovenox today for port placement and liver biopsy today. Dose of lovenox of 80mg daily is appropriate for 1.5mg/kg daily dosing as she is roughly 55kg. She was started on hep gtt overnight and in anticipation of her ___ procedure. She will resume lovenox on discharge. #Newly Diagnosed Metastatic Pancreatic Cancer Patient was scheduled for liver biopsy and port placement on ___. Instead she had those procedures on ___ while inpatient. She had an outpatient appointment with oncology scheduled for ___ instead Dr. ___ came to see her while she was inpatient and discussed with her the treatment plan going forward. The patient has oncology follow up scheduled for next week. #HTN -Initially held home lisinopril, restarted home atenolol #T2DM -Held metformin, ___ #HLD -Continued statin #GCA (c/b aortitis, on prednisone) -Continued prednisone 7.5 mg daily, is on slow taper of 2.5mg decrease every 2 weeks until done # Hyperthyroidism: TSH found to be low. On review with patient, she had not been taking her Methimazole 5mg daily for the past few weeks. She was encouraged to resume this and follow up with her outpatient providers. # Microscopic hematuria: Noted with patient and previously evaluated. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Enoxaparin Sodium 80 mg SC Q24H Start: ___, First Dose: Next Routine Administration Time 2. Atenolol 50 mg PO DAILY 3. Lisinopril 10 mg PO DAILY 4. MetFORMIN (Glucophage) 1000 mg PO DAILY 5. PredniSONE 7.5 mg PO DAILY 6. Simvastatin 40 mg PO QPM 7. Aspirin 81 mg PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild over the counter 2. Methimazole 5 mg PO DAILY previous home medication 3. Aspirin 81 mg PO DAILY 4. Atenolol 50 mg PO DAILY 5. Enoxaparin Sodium 80 mg SC Q24H Start: ___, First Dose: Next Routine Administration Time 6. Lisinopril 10 mg PO DAILY 7. MetFORMIN (Glucophage) 1000 mg PO DAILY 8. PredniSONE 7.5 mg PO DAILY 9. Simvastatin 40 mg PO QPM Discharge Disposition: Home Discharge Diagnosis: Primary: Vasovagal episode vs presyncopal event Pulmonary embolism Metastatic pancreatic cancer Hyperthyroidism Hypertension Secondary: Bells palsy Giant cell arteritis Hypertension Diabetes mellitus type II Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear ___ were admitted to the hospital after having an episode of difficulty speaking before a planned interventional radiology procedure. Head imaging fortunately did not show a stroke. Neurology evaluated ___ and felt that this was not a stroke or other ischemic event but rather a vasovagal episode or a presyncopal event due to not eating and drinking earlier in the day. Fortunately these symptoms did not recur. In addition, the imaging ___ had in the ED did show a new pulmonary embolism. ___ should continue to take your anticoagulant medication called lovenox as previously prescribed. Today ___ were seen by your new oncologist, who discussed the plan for your pancreatic cancer. ___ also went for your interventional radiology procedure for port placement and liver biopsy. Your oncologist arranged follow up for ___ in the coming week. Finally, your thyroid level is low suggesting over active thyroid. please resume your methimazole, as disussed. It was a pleasure taking care of ___! Sincerely, Your ___ team Followup Instructions: ___
19562787-DS-23	19,562,787	28,620,975	DS	23	2188-07-18 00:00:00	2188-07-18 15:47:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Prolixin / Haldol / Ace Inhibitors Attending: ___. Chief Complaint: s/p fall Major Surgical or Invasive Procedure: none History of Present Illness: ___ with a history significant for chronic paranoid schizophrenia,temporal lobe epilepsy, ___ esophagus, hyponatremia, and hematuria s/p mechanical fall yesterday on the street. He came in today because of continued right knee pain, requiring assistance with ambulation. He states he hit his head but did not pass out. He is ambulatory. not on coumadin. . In the ED, VS were 98, 129/70, 97.0, 97% ra. He was triggered when he got here for unequal pulses 70right arm 89/60 Left arm 129/70, decreased radial pulse on his left side compared to his right. Labs were remarkable for hyponatremis (Na 128: although patient has had chronic hyponatremia since at least ___, attributed previously to his carbamazepine). CTA was performed to rule out AAA or dissection, and was negative. However, a left upper lobe lung spiculated lung mass was identified. Patient initially wanted to leave ama, but was talked into staying due to falls and hyponatremia and for workup of new lung mass. Denies chest pain, dyspnea, normal sinus rhythm on monitor. He was given 1L normal saline for hyponatremia, with improvement in sodium level to 129. In addition, Xrays of his chest, hand, knee and CT scan of head were unremarkable. . Currently, in no acute distress. Denies dyspnea, cough, chest pain. Acknowledges the possibility of some recent weight loss, but attributes this to not eating well recently. Denies any fever, shills, night sweats. Denies dysphagia, nausea, vomiting. . ROS: Denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: -Paranoid Schizophrenia -Temporal Lobe epilepsy -___ esophagus -Hematuria -Hyponatremia -BPH -Cervical spine surgery Social History: ___ Family History: His brother was diagnosed with prostate cancer over the past year. Physical Exam: On admission: VS - 97.8, 112/74, 88, 18, 98% RA GENERAL - Thin, undernourished appearing male in NAD, appropriate HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no thyromegaly, no JVD, no carotid bruits LUNGS - CTABL. Difuse scattered wheeze, worse in upper zones. HEART - PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, Right knee warm, with superficial abrasions, tender to palpation, slightly swollen in comparison to left. Left hand swollen, bruised, edematous, warm, superficial abrasions on dorsum. 2+ peripheral pulses (radials, DPs) SKIN - no rashes or lesions LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength ___ throughout, sensation grossly intact throughout, DTRs 2+ and symmetric, cerebellar exam intact, steady gait. . At discharge: Objective: 98, 115/63, 88, 18, 98% RA GENERAL - Thin, undernourished appearing male in NAD, appropriate HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no thyromegaly, no JVD, no carotid bruits LUNGS - CTABL. Difuse scattered wheeze, worse in upper zones. HEART - PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, Right knee warm, with superficial abrasions, tender to palpation, slightly swollen in comparison to left. Left hand swollen, bruised, edematous, warm, superficial abrasions on dorsum. 2+ peripheral pulses (radials, DPs) SKIN - no rashes or lesions LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength ___ throughout, sensation grossly intact throughout, DTRs 2+ and symmetric, cerebellar exam intact, steady gait. Pertinent Results: ___ 06:55AM BLOOD WBC-6.3 RBC-3.58* Hgb-12.1* Hct-34.4* MCV-96 MCH-33.7* MCHC-35.1* RDW-12.4 Plt ___ ___ 09:30AM BLOOD WBC-8.9 RBC-3.70* Hgb-12.7* Hct-35.3* MCV-95 MCH-34.4* MCHC-36.1* RDW-12.5 Plt ___ ___ 06:55AM BLOOD Neuts-49* Bands-0 ___ Monos-14* Eos-2 Baso-0 ___ Myelos-0 ___ 09:30AM BLOOD Neuts-66 Bands-1 ___ Monos-9 Eos-1 Baso-3* Atyps-1* ___ Myelos-0 ___ 06:55AM BLOOD Plt Smr-NORMAL Plt ___ ___ 06:55AM BLOOD ___ ___ 09:30AM BLOOD Plt Smr-NORMAL Plt ___ ___ 09:30AM BLOOD ___ PTT-34.1 ___ ___ 06:55AM BLOOD Glucose-89 UreaN-11 Creat-0.5 Na-138 K-4.1 Cl-104 HCO3-26 AnGap-12 ___ 03:00PM BLOOD Na-129* K-4.1 Cl-96 ___ 09:30AM BLOOD Glucose-108* UreaN-14 Creat-0.8 Na-128* K-4.7 Cl-95* HCO3-26 AnGap-12 ___ 06:55AM BLOOD Plt Smr-NORMAL Plt ___ ___ 06:55AM BLOOD ___ ___ 09:30AM BLOOD Plt Smr-NORMAL Plt ___ ___ 09:30AM BLOOD ___ PTT-34.1 ___ ___ 06:55AM BLOOD Glucose-89 UreaN-11 Creat-0.5 Na-138 K-4.1 Cl-104 HCO3-26 AnGap-12 ___ 03:00PM BLOOD Na-129* K-4.1 Cl-96 ___ 09:30AM BLOOD Glucose-108* UreaN-14 Creat-0.8 Na-128* K-4.7 Cl-95* HCO3-26 AnGap-12 ___ 06:55AM BLOOD ALT-20 AST-18 LD(LDH)-177 AlkPhos-73 TotBili-0.3 ___ 06:55AM BLOOD Albumin-3.4* Calcium-8.6 Phos-3.2 Mg-2.0 ___ 06:55AM BLOOD VitB12-496 Folate-14.7 . ___ CTA Chest with and without reconstruction 3.8 x 2.7 x 1.8 cm left upper lobe lung mass with mild nonenlarged lymph nodes in the aortopulmonary window. These findings are concerning for malignancy. Mild centrilobular emphysema. No aortic pathology or pulmonary embolism. . ___ CT head without contrast No evidence of acute intracranial process. . ___ Right knee Xray 3 views Small joint effusion but no evidence of fracture. . ___ CXR PA and Lateral No evidence of acute cardiopulmonary process. Old healed fractures of the posterior rib as well as the compression fracture of the mid thoracic vertebrae are unchanged since ___. Left upper lobe mass adjacent to aortic knob is better seen in subsequent CT. . ___ Left hand Xrays, 3 views No evidence of fracture. Osteopenia and mild degenerative changes as described above. Brief Hospital Course: ___ with PMH of chronic paranoid schizophrenia, temporal lobe epilepsy, ___ esophagus, hyponatremia, and hematuria s/p mechanical fall yesterday, with new incidental finding of a pulmonary nodule. . # Lung nodule: 3.8 x 2.7 x 1.8 cm left upper lobe lung mass with mild nonenlarged lymph nodes; incidental finding on CTA chest. Patient has a long smoking history, however no cough, dyspnea. He does endorse possible weight loss, no fevers, night sweats, chills. Overall concerning for malignancy, likely of lung epithelial origin. Given PMH of ___ esophagus, differential diagnosis includes esophageal cancer with possible lung metastasis, but this is much less likely that a lung primary in this patient. BOOP might be one other alternative explanation for the etiology of this lesion. He was seen by interventional pulmonology, who have discussed the finding with the patient. They will followup with him to schedule high resolution imaging of his chest, and a subsequent bronchoscopy for biopsy of the lesion. LFTs were performed during this hospitalisation and were unremarkable. . # s/p Fall: Fall appears to have been mechanical, patient tripped on pavement, denies being intoxicated at the time. patient has multiple bruises on left hand, also right knee. Hurt his head but denies any loss of consciousness. CT head, CXR, Xrays of knee and hand all unremarkable for any fractures. His pain was well controlled with tylenol and ibuprofen. . # Hyponatremia: Chronic since at least ___, although has had periods of normal Na readings intermittently. This has previously been attributed to carbamazepine. Chronic siADH due to ephysema is also possible. Head injury likely not causing acute siADH given chronicity of hyponatremia. Pt appeared pre-renal by urine lytes and after some gentle IVF in the ED, his Na returned to normal range on the day of discharge . # Asymmetric BP: Noted in the ED. Repeat blood pressure measurements overnigth were 98/69 in the right arm and 115/63 in the left arm. CTA did not show any aortic or other vascular pathology, however, he will need to followup with his PCP for serial BP measurements . # Chronic paranoid schizophrenia: continued quetiapine, ativan, trazodone. . # Temporal lobe epilepsy: Continued carbamazepine, ativan. . # ___ esophagus: Due for repeat endoscopy in ___, but missed appointment. Denies any heartburn, dysphagia. He should have a repeat EGD as an outpatient. . # Hematuria: Microscopic, chronic. The patient has had no gross hematuria over the past year. He has been followed by Dr. ___ both his hematuria and hyponatremia. His hematuria was believed to be secondary to IgA nephropathy. He will followup with Dr. ___ as an outpatient. . # BPH: The patient has stable symptoms of BPH. PSAs have been normal, last PSA ___ was 0.8. We continued doxazosin. . TRANSITIONAL ISSUES: -Interventional pulmonology will contact the patient early next week to schedule followup for high resolution imaging and bronchoscopy with biopsy. -PCP has been emailed and letter sent regarding new lung nodule, they will follow along and encourage him to participate in care. PCP to also followup regarding his asymmetric blood pressures. -He will followup with Dr. ___: hematuria. -He will need to schedule an EGD to followup regarding his ___ esophagus. Medications on Admission: CARBAMAZEPINE [TEGRETOL XR] - (Prescribed by Other Provider) - 200 mg Tablet Extended Release 12 hr - 1 Tablet(s) by mouth 2 tablets qam and 3 tabs q pm DOXAZOSIN - 8 mg Tablet - 1 Tablet(s) by mouth at bedtime LORAZEPAM [ATIVAN] - (Prescribed by Other Provider) - 1 mg Tablet - 1 Tablet(s) by mouth three times a day QUETIAPINE [SEROQUEL] - (Prescribed by Other Provider) - 100 mg Tablet - 100 mg by mouth in the morning, and 225mg by mouth at bedtime TRAZODONE - (Prescribed by Other Provider) - 50 mg Tablet - one Tablet(s) by mouth at bedtime Discharge Medications: 1. carbamazepine 200 mg Tablet Extended Release 12 hr Sig: Two (2) Tablet Extended Release 12 hr PO QAM (once a day (in the morning)). 2. carbamazepine 200 mg Tablet Extended Release 12 hr Sig: Three (3) Tablet Extended Release 12 hr PO QPM (once a day (in the evening)). 3. doxazosin 4 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 4. quetiapine 100 mg Tablet Sig: One (1) Tablet PO qam. 5. quetiapine 200 mg Tablet Sig: One (1) Tablet PO at bedtime. 6. quetiapine 25 mg Tablet Sig: One (1) Tablet PO at bedtime. 7. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 8. lorazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Discharge Disposition: Home Discharge Diagnosis: Lung nodule, hyponatremia. 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 the ___ ___. You were admitted following a fall. You had Xrays of your knee, hand, chest and a CT scan of your head which did not show any fractures. In the ED, you were also found to have unequal blood pressures in your arms, and we therefore performed a CT scan of your chest. The CT scan did not show any abnormalities in your blood vessels. However, the CT scan showed a nodule in your lung, which is concerning and will require further evaluation. You were seen by interventional pulmonology. They will call you to arrange followup including a more detailed CT scan and a bronchoscopy and biopsy. You were also found to have a low sodium level in the ED, which has now returned to normal. We made no changes to your home medications. Please followup with your doctors, see below. You will needed to followup with interventional pulmonology; they will contact you to arrange an appointment. Please also followup with your primary care practitioner and with Dr. ___, to followup regarding your hematuria. You will also need to have a repeat endoscopy to followup regarding ___ Esophagus. Followup Instructions: ___
19562787-DS-25	19,562,787	28,448,757	DS	25	2189-07-13 00:00:00	2189-07-13 15:02:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Prolixin / Haldol / Ace Inhibitors Attending: ___. Chief Complaint: Failure to thrive Major Surgical or Invasive Procedure: EGD History of Present Illness: This is a ___ gentleman with a past medical history significant for schizophrenia, temporal lobe epilepsy, and SCC of lung who is admitted for failure to thrive. . According to collateral info from patient, sister (Mrs. ___, and OMR notes, it appears as though patient has not been doing well at home. He has missed numerous oncology, XRT, and PET scan appointments. Although he is getting "Meals on Wheels" according to his sister, he continues to lose weight and have poor appetitie. Mr. ___ does not think that he is capable of going to the supermarket himself and admits that he needs more help at home. It is also unclear exactly why he continues to miss appointments. . In the ED, initial vitals were: 98.6 93 89/49 20 94%. Patient complained of chest pain and shortness of breath, and CTA was performed. The CTA was negative for PE, but did show "interval slight increase in size of 7 cm left upper lobe mass with central necrosis and possible surrounding lymphangitic spread." Mr. ___ also complained of pain in his left elbow, from an injury he sustained in ___. He had XRAYs that showed a small fracture. Ortho saw him and put his arm in a sling. In the ED, Mr. ___ received tylenol and aspirin and fluids. On admission, vitals were: 98.8 85 112/56 18 95%. . Upon arrival to the floor, patient denies chest pain, shortness of breath, nausea, vomiting, diarrhea, or other concerning signs or systems. A complete review of systems is negative aside from what is described above. Past Medical History: --Lung cancer, SCC, not currently treated --Paranoid Schizophrenia --Temporal Lobe epilepsy --___ esophagus --Hematuria --Hyponatremia --BPH --Cervical spine surgery Social History: ___ Family History: Brother with prostate cancer. Physical Exam: ADMISSION PHYSICAL EXAM: VS: 97.8, 129/78, 90, 18, 95% on RA GENREAL: Thin, no acute distress, lying in bed with hat on HEENT: Dry mucous membranes NECK: No cervical, submandibular, or supraclavicular LAD CHEST: CTA bilaterally, wheeze that clears with deep inspiration at left lower base CARDIAC: RRR, ___ systolic murmur ABDOMEN: +BS, soft, non-tender, non-distended NEURO: Alert and oriented, responses are slow but appropriate SKIN: Warm and dry Pertinent Results: ___ 06:30PM cTropnT-<0.01 ___ 01:11PM LACTATE-1.6 K+-4.4 ___ 12:57PM GLUCOSE-127* UREA N-15 CREAT-0.6 SODIUM-136 POTASSIUM-6.2* CHLORIDE-97 TOTAL CO2-30 ANION GAP-15 ___ 12:57PM estGFR-Using this ___ 12:57PM ALT(SGPT)-15 AST(SGOT)-41* ALK PHOS-71 TOT BILI-0.2 ___ 12:57PM LIPASE-15 ___ 12:57PM cTropnT-<0.01 ___ 12:57PM ALBUMIN-3.5 CALCIUM-8.8 PHOSPHATE-3.3 MAGNESIUM-2.2 ___ 12:57PM WBC-9.6 RBC-3.42* HGB-11.0* HCT-35.1* MCV-103* MCH-32.1* MCHC-31.3 RDW-14.0 ___ 12:57PM NEUTS-81.2* LYMPHS-9.6* MONOS-5.1 EOS-3.6 BASOS-0.5 ___ 12:57PM PLT COUNT-501* ___ 12:57PM ___ PTT-33.5 ___ . CXR ___: Re- demonstration of left upper lobe mass compatible with known non-small cell lung cancer. No acute cardiopulmonary abnormality otherwise noted. . CTA Chest/abdomen/pelvis ___: 1. No pulmonary embolism or acute aortic pathology. 2. Interval slight increase in size of 7 cm left upper lobe mass with central necrosis and possible surrounding lymphangitic spread. 3. Secretions in the trachea concerning for risk of aspiration without pulmonary findings of aspiration or pneumonia. 4. No evidence of acute intra-abdominal process to explain the patient's symptoms. . Left elbow xray ___: Oblique linear lucency through the olecranon, could reflect a nondisplaced fracture. Clinical correlation to the site of patient's tenderness is suggested. . EGD ___: Mucosa suggestive of ___ esophagus Otherwise, completely normal stomach and duodenum. Otherwise normal EGD to third part of the duodenum . DISCHARGE LABS: ___ 09:30AM BLOOD WBC-7.4 RBC-2.98* Hgb-9.5* Hct-29.3* MCV-98 MCH-31.7 MCHC-32.3 RDW-14.8 Plt ___ ___ 08:55AM BLOOD Glucose-100 UreaN-12 Creat-0.4* Na-129* K-4.5 Cl-95* HCO3-29 AnGap-10 ___ 06:25AM BLOOD ALT-10 AST-10 LD(LDH)-159 AlkPhos-63 Amylase-41 TotBili-0.2 ___ 06:25AM BLOOD Lipase-17 ___ 08:55AM BLOOD Albumin-3.2* Calcium-9.8 Phos-3.8 Mg-2.1 ___ 06:30AM BLOOD ___-___ ___ 06:30AM BLOOD TSH-2.4 Brief Hospital Course: This is a ___ gentleman with a past medical history significant for paranoid schizophrenia, temporal lobe epilepsy, and lung cancer (not treated) who was admitted with FTT, nausea, and vomiting. . # Squamous cell lung cancer: Patient with lung cancer diagnosed ___ which has not been treated yet due to missed and cancelled appointments and imaging. Per most recent imaging (PET in ___, MRI in ___, there is no evidence of metastatic disease. He has been seen by the Thoracic ___ clinic, but has not established care with a primary medical oncologist. CTA in the ED showed 7 cm left upper lobe mass with central necrosis and possible surrounding lymphangitic spread, with possible mediastinal involvement. The tenative plan was for him to have radiation therapy, and he was scheduled for radiation planning on ___. However, patient expressed significant reservations about treating his cancer and refused radiation planning. Palliative care was also consulted. His decision not to treat his cancer was discussed with his family, who felt it was consistent with what his preferences to be. After discussion with his health care proxies, there will be no further lab draws or vital signs and all care will be with palliative intent. The patient will be admitted to a skilled nursing facility and hospice will see the patient in the facility. . # Decision making capacity: Patient with history of paranoid schizophrenia. Initially in discussions, he appeared capable of stating the consequences of declining treatment. However, upon further discussion with patient, his outpatient psychiatry team and social work, concerns were raised around his competency, particularly surrounding his desire to go home despite indications that this would be unsafe. Psychiatry was consulted, and determined that patient lacks decisional capacity and that he could not return home against medical advice. No one in his family or support network is able to provide more than occasional checks on the patient and it was felt that he needs 24 hour care. After much discussion, the patient eventually agreed to sign a healthcare proxy form designating his brother as first proxy and his nephew as second proxy. He has agreed to be discharged to rehabilitation with bridge to hospice and his proxies concur with this plan. . # Nausea, vomiting and abdominal pain: The patient was admitted hypotensive and dehydrated, reported chronic vomiting of unclear duration as well as epigastric abdominal pain. His symptoms were ultimately controlled with scheduled Zofran and PPIs. GI was consulted given known history of ___ esophagus and patient's complaints of dysphagia. EGD showed continued ___ esophagus, but normal stomach and duodenum. MRI of the brain was ordered to assess for brain mets causing symptoms (as last MRI 9 months ago), but patient refused this test. . # Failure to thrive: Patient with multiple falls over the past month. He lives alone with no services, and reported that he has had difficulty preparing food recently secondary to weakness. He has limited social supports. He reported that while he was at home during the recent blizzard he was unable to get out because of the snow and had no food so he didn't eat. Per ___ evaluation, he was not judged to be safe to return home due to fall risk and difficulty with ADLs. Patient's outpatient psychiatry team also reported concerns about the patient's increasing weakness and his paranoid schizophrenia limiting his ability to live safely at home. . # ORTHOSTATIC HYPOTENSION: He was found to be orthostatic during this admission. This was felt to be due to volume depletion and his medications. He consistantly refused IV fluids for multiple days but agreed on at least one evening when he developed hyponatremia. Given his palliative goals of care, no further vital signs or lab draws will be obtained. . # HYPONATREMIA: He developed hyponatremia during his hospital stay with accompanying orthostasis. This was felt to be due to volume depletion. He only intermittantly agreed to IV fluids. Given his palliative goals of care, no further vital signs or lab draws will be obtained. . # LEFT ELBOW FRACTURE: Patient found to have non-displaced olecranon fracture secondary to recent fall. He was evaluated by orthopedics, who recommended a sling. However, he was not compliant with this recommendation. He can follow up with ___ clinic as an outpatient if needed for acute changes but he is not scheduled for follow up due to his palliative goals of care. . # PARANOID SCHIZOPHRENIA: Continued carbamazepine, seroquel. # BPH: Continued terazosin # INSOMNIA: Continued trazadone. # CODE STATUS: DNR/DNI . Contact Information for Health Care Proxies: brother ___ ___ ___ home, ___ work. nephew ___ cell ___, work ___, home ___. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Carbamazepine 400 mg PO QAM 2. Carbamazepine 600 mg PO QPM 3. Lorazepam 1 mg PO Q8H:PRN Anxiety Please hold for oversedation or RR <10. 4. Quetiapine Fumarate 100 mg PO QAM 5. Quetiapine Fumarate 225 mg PO QPM 6. traZODONE 50 mg PO HS:PRN Insomnia Please hold for oversedation or RR <10. 7. Doxazosin 8 mg PO HS Discharge Medications: 1. Carbamazepine 400 mg PO QAM 2. Carbamazepine 600 mg PO QPM 3. Doxazosin 8 mg PO HS 4. Lorazepam 1 mg PO TID 5. Quetiapine Fumarate 100 mg PO QAM 6. Quetiapine Fumarate 225 mg PO QPM 7. traZODONE 50 mg PO HS 8. Pantoprazole 40 mg PO Q24H 9. Sucralfate 1 gm PO QID 10. Ondansetron 4 mg PO BID Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary diagnosis: Nausea with vomiting Lung cancer Secondary diagnosis: Hyponatremia Orthostatic hypotension ___ esophagus Chronic psychosis Malnutrition Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: It was a pleasure taking care of you at ___. You were admitted to the hospital with nausea and vomiting. You underwent EGD which showed your known ___ esophagus. Your symptoms were controlled with scheduled ondansetron and pantoprazole. . You also were severely dehydrated and malnourished. This is likely due to your lung cancer. You were evaluated by physical therapy who recommended skilled nursing placement. You were evaluated by the psychiatry team who felt that you did not have capacity to make decisions. You appointed your brother and your nephew as your health care proxies. You and your health care proxies have agreed that you should go to a skilled nursing facility with hospice care. Your health care proxies have decided that you should not have further vital signs or laboratory tests because the goals of your care are palliative. The contact information for your health care proxies follows: Your brother ___ ___ home, ___ work. Your nephew ___ cell ___, work ___, home ___. Followup Instructions: ___
19562831-DS-6	19,562,831	23,689,495	DS	6	2138-07-08 00:00:00	2138-07-08 21:12:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: Penicillins / ___ Original Attending: ___. Chief Complaint: Slurred speech Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ w/ hx of HTN, COPD/asthma, glaucoma, OA, and B12 deficiency who presents per PCP recommendation for ___ w/u for multiple small subacute strokes found on MRI and 4 days of slurred speech and left facial droop. Reports recent difficulty hearing in right ear, thought may have had an ear infection. Called on call physician, who advised swimmer's ear drops. Started using ear drops ___. Went to have hair done on ___, where beautician remarked that her speech sound somewhat slurred. ___ went to family dinner for relative's birthday at restaurant. Noted she was not feeling herself, and again family commented that her speech sounded slurred. Felt nervous about not feeling well and speech, so called on call physician who advised presenting to OSH ED. Reported she was kept for high BP. OSH CT obtained and discharged home on ___ evening. Presented to PCP ___ morning for follow-up and scheduling MRI per OSH recommendations. Went down to pharmacy to get prescription for ativan due to anxiety w/ imaging. Then went upstairs to get Holter monitor. Got home at 5PM, and was called by her daughter who was told to go to ED due to stroke on MRI. Was started on statin, antihypertensives, and low dose aspirin when discharged from OSH. Feels speech has improved since ___ and denies noting new symptoms. Past Medical History: Glaucoma Osteoarthritis (back, bilateral knees) Osteoporosis Asthma/COPD HTN B12 deficiency Social History: ___ Family History: No known family hx of stroke Physical Exam: ADMISSION PHYSICAL EXAM ====================== Note contains an addendum. See bottom. Note Date: ___ Time: 0027 Note Type: Initial note Note Title: Neurology Stroke Note Electronically signed by ___, MD on ___ at 8:43 am Affiliation: ___ Electronically cosigned by ___, MD on ___ at 10:31 pm NEUROLOGY STROKE CONSULT NOTE Time/Date the patient was last known well: ___ ___ ___ Stroke Scale Score: 2 t-PA administered: [] Yes - Time given: __ [X] No - Reason t-PA was not given or considered: outside of window Thrombectomy performed: [] Yes [X] No - Reason not performed or considered: no LVO on CTA NIHSS performed within 6 hours of presentation at: 12:15 AM ___ NIHSS Total: 2 1a. Level of Consciousness: 0 1b. LOC Question: 0 1c. LOC Commands: 0 2. Best gaze: 0 3. Visual fields: 0 4. Facial palsy: 1 5a. Motor arm, left: 0 5b. Motor arm, right: 0 6a. Motor leg, left: 0 6b. Motor leg, right: 0 7. Limb Ataxia: 0 8. Sensory: 0 9. Language: 0 10. Dysarthria: 1 11. Extinction and Neglect: 0 REASON FOR CONSULTATION: 4ds slurred speech and facial asymmetry HPI: Ms. ___ is a ___ w/ hx of HTN, COPD/asthma, glaucoma, OA, and B12 deficiency who presents per PCP recommendation for ___ w/u for multiple small subacute strokes found on MRI and 4 days of slurred speech and left facial droop. Reports recent difficulty hearing in right ear, thought may have had an ear infection. Called on call physician, who advised swimmer's ear drops. Started using ear drops ___. Went to have hair done on ___, where ___ remarked that her speech sound somewhat slurred. ___ went to family dinner for relative's birthday at restaurant. Noted she was not feeling herself, and again family commented that her speech sounded slurred. Felt nervous about not feeling well and speech, so called on call physician who advised presenting to OSH ED. Reported she was kept for high BP. OSH CT obtained and discharged home on ___ evening. Presented to PCP ___ morning for follow-up and scheduling MRI per OSH recommendations. Went down to pharmacy to get prescription for ativan due to anxiety w/ imaging. Then went upstairs to get Holter monitor. Got home at 5PM, and was called by her daughter who was told to go to ED due to stroke on MRI. Was started on statin, antihypertensives, and low dose aspirin when discharged from OSH. Feels speech has improved since ___ and denies noting new symptoms. ROS: On neurological review of systems, has chronic blurry vision ___ glaucoma. The patient denies headache, confusion, difficulties producing or comprehending speech, loss of vision, diplopia, dysphagia, lightheadedness, vertigo, or tinnitus. Denies focal weakness, numbness, parasthesiae. No bowel or bladder incontinence or retention. Denies difficulty with gait. On general review of systems, has had occasional diarrhea since ___. The patient denies recent fever, chills, night sweats, or recent weight changes. Denies cough, shortness of breath, chest pain or tightness, palpitations. Denies nausea, vomiting, constipation or abdominal pain. Denies dysuria, or recent change in bowel or bladder habits. Denies arthralgias, myalgias, or rash. Problems (Last Verified - None on file): Glaucoma Osteoarthritis (back, bilateral knees) Osteoporosis Asthma/COPD HTN B12 deficiency Surgical History (Last Verified - None on file): None HOME MEDICATIONS: Medications Printed/Routed on ___ Vitamin D 50,000U Qweekly ASA 81mg QD Allergies (Last Verified ___ by ___ Original Penicillins Social History (Last Verified - None on file): Lives with brother and granddaughter. Retired from driving ___ bus. Active tobacco use (reports quit few days ago) 1 PPD for ___ yrs. Occasionally EtOH use ___ drinks/wk). Denies marijuana or illicit substance use. - Modified Rankin Scale: [X] 0: No symptoms [] 1: No significant disability - able to carry out all usual activities despite some symptoms [] 2: Slight disability: able to look after own affairs without assistance but unable to carry out all previous activities [] 3: Moderate disability: requires some help but able to walk unassisted [] 4: Moderately severe disability: unable to attend to own bodily needs without assistance and unable to walk unassisted [] 5: Severe disability: requires constant nursing care and attention, bedridden, incontinent [] 6: Dead Family History (Last Verified - None on file): No known family hx of stroke PHYSICAL EXAMINATION: Vitals: HR 92 BP 180/100 RR 16 SpO2 98% on RA General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, poor dentition, MMM, no lesions noted in oropharynx. Neck: Supple, no nuchal rigidity. Pulmonary: Normal work of breathing. Cardiac: NR, RR, warm, well-perfused. Abdomen: Soft, non-distended. Extremities: No ___ edema. Skin: No rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive, able to name ___ backward without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Able to name both high and low frequency objects. Able to read without difficulty. Speech mildly dysarthric but easily intelligible. Able to follow both midline and appendicular commands. Able to register 3 objects and recall ___ at 5 minutes, an additional ___ w/ choices. There was no evidence of apraxia or neglect. -Cranial Nerves: II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without nystagmus. Normal saccades. VFF to confrontation. Visual acuity ___ bilaterally. Fundoscopic exam revealed no papilledema, exudates, or hemorrhages. V: Facial sensation intact to light touch. VII: L NLFF, symmetric activation. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii bilaterally. XII: Tongue protrudes in midline . -Motor: Normal bulk and tone throughout. No pronator drift. No adventitious movements, such as tremor or asterixis noted. [___] L 5 5 5 5 5 5 5 5 5 5 5 5 R 5 5 5 5 5 5 5 5 5 5 5 5 -Sensory: No deficits to light touch, pinprick, temperature, vibration, or proprioception throughout. No extinction to DSS. Romberg absent. -Reflexes: [Bic] [Tri] [___] [Pat] [Ach] L 2 2 2 2 1 R 2 2 2 2 1 Plantar response was flexor bilaterally. -Coordination: No intention tremor. Normal finger-tap bilaterally. No dysmetria on FNF or HKS bilaterally. -Gait: Good initiation. Narrow-based, normal stride and arm swing. Able to walk in tandem without difficulty. DISCHARGE PHYSICAL EXAM ======================== Unchanged from above Pertinent Results: LABS ====== ___ 08:33PM BLOOD WBC-9.8 RBC-4.04 Hgb-12.8 Hct-38.7 MCV-96 MCH-31.7 MCHC-33.1 RDW-14.4 RDWSD-50.8* Plt ___ ___ 08:33PM BLOOD Glucose-96 UreaN-10 Creat-0.8 Na-140 K-4.2 Cl-104 HCO3-22 AnGap-14 ___ 08:33PM BLOOD ALT-12 AST-15 CK(CPK)-98 AlkPhos-100 TotBili-0.3 ___ 08:33PM BLOOD cTropnT-<0.01 ___ 08:33PM BLOOD Albumin-4.2 Calcium-9.7 Phos-3.4 Mg-1.9 Cholest-186 ___ 08:30PM BLOOD %HbA1c-5.7 eAG-117 ___ 08:33PM BLOOD Triglyc-115 HDL-52 CHOL/HD-3.6 LDLcalc-111 ___ 08:33PM BLOOD TSH-2.1 IMAGING ======== TTE IMPRESSION: No definite structural cardiac source of embolism identified. Mild symmetric left ventricular hypertrophy with normal cavity size and regional/global biventricular systolic function. CTA IMPRESSION: 1. No large vascular territory infarct or hemorrhage. Hypodensities in the white matter are noted which can reflect chronic small vessel disease, although hypodensities in the frontal lobe on the right could correspond to subcortical infarcts given the reported findings on outside imaging, not available for direct comparison. 2. Patent circle of ___ without definite evidence of stenosis,occlusion,or aneurysm. 3. Patent bilateral cervical carotid and vertebral arteries without definite evidence of stenosis, occlusion, or dissection. 4. Partially calcified nodule in the left parotid tail measures 16 mm. Consider tissue sampling and ENT consultation. 5. 19 mm right thyroid nodule for which ultrasound is recommended. RECOMMENDATION(S): Thyroid nodule. Ultrasound follow up recommended. ___ College of Radiology guidelines recommend further evaluation for incidental thyroid nodules of 1.0 cm or larger in patients under age ___ or 1.5 cm in patients age ___ or ___, or with suspicious findings. Suspicious findings include: Abnormal lymph nodes (those displaying enlargement, calcification, cystic components and/or increased enhancement) or invasion of local tissues by the thyroid nodule. ___, et al, "Managing Incidental Thyroid Nodules Detected on Imaging: White Paper of the ACR Incidental Findings Committee". J ___ ___ ___ 12:143-150. Left parotid nodule - tissue sampling and ENT consultation is suggested. Brief Hospital Course: Ms. ___ is a ___ yo woman w/ pmhx of HTN, COPD/asthma, glaucoma, OA, and B12 deficiency who presents per PCP recommendation for ___ w/u for frontal R.MCA distribution infarcts. Transitional Issues ==================== [ ] Pt will need to follow-up with a stroke neurologist in the atrius system, requires referral from PCP [ ] Pt discharge on Ziopatch, please follow-up results [ ] Pt w/ incidental thyroid nodule noted on imaging, ultrasound recommended [ ] Parotid nodule, consider ENT evaluation per radiology Pt initially developed dysarthria and facial asymmetry on ___. She presented to an OSH for initial evaluation and was set-up w/ outpatient MRI and Holter monitor. Additionally she was started on ASA 81mg, atorvastatin 40mg and amlodipine for blood pressure control. The pt saw her PCP who obtained an MRI, which was notable for small scattered areas of infarct in the right frontal lobe (MCA distribution). At this time the patient was referred to the emergency room for expedited workup. Here she has had a CTA, which demonstrated b/l L>R carotid siphon atherosclerotic disease, as well as minimal atherosclerotic plaque of the aortic arch. A TTE was unremarkable, demonstrating only a mild LVH. The etiology of her stroke is thought to be embolic, though it is not entirely clear if this was an artery-artery embolus (ie. from the carotid siphon) given it falls in one vascular territory, or if it was a cardiac embolus that only went to one artery before dispersing. This admission the patient was loaded w/ Plavix 300mg and should continue DAPT with aspirin 81mg and Plavix 75mg for 21 days through ___. She was discharged w/ a 2 week Ziopatch. AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic Attack 1. Dysphagia screening before any PO intake? (X) Yes, confirmed done - () Not confirmed () No. If no, reason why: 2. DVT Prophylaxis administered? (X) Yes - () No. If no, why not (I.e. bleeding risk, hemorrhage, etc.) 3. Antithrombotic therapy administered by end of hospital day 2? (X) Yes - () No. If not, why not? (I.e. bleeding risk, hemorrhage, etc.) 4. LDL documented? (X) Yes (LDL = 111) - () No 5. Intensive statin therapy administered? (simvastatin 80mg, simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, rosuvastatin 20mg or 40mg, for LDL > 70) (x) Yes - () No [if LDL >70, reason not given: [ ] Statin medication allergy [ ] Other reasons documented by physician/advanced practice nurse/physician ___ (physician/APN/PA) or pharmacist [ ] LDL-c less than 70 mg/dL 6. Smoking cessation counseling given? () Yes - (x) No [reason (x) non-smoker - () unable to participate] 7. Stroke education (personal modifiable risk factors, how to activate EMS for stroke, stroke warning signs and symptoms, prescribed medications, need for followup) given in written form? (x) Yes - () No 8. Assessment for rehabilitation or rehab services considered? () Yes - (x) No. If no, why not? patient at baseline functional status 9. Discharged on statin therapy? (x) Yes - () No [if LDL >70, reason not given: [ ] Statin medication allergy [ ] Other reasons documented by physician/advanced practice nurse/physician ___ (physician/APN/PA) or pharmacist [ ] LDL-c less than 70 mg/dL 10. Discharged on antithrombotic therapy? (x) Yes [Type: (x) Antiplatelet - () Anticoagulation] - () No 11. Discharged on oral anticoagulation for patients with atrial fibrillation/flutter? () Yes - (x) No - If no, why not (I.e. bleeding risk, etc.) () N/A Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Vitamin D 1000 UNIT PO DAILY 2. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 3. Montelukast 10 mg PO DAILY 4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 5. Atorvastatin 40 mg PO QPM 6. Aspirin EC 81 mg PO DAILY 7. amLODIPine 5 mg PO DAILY Discharge Medications: 1. Clopidogrel 75 mg PO DAILY Please continue for 21 days through ___ RX clopidogrel 75 mg 1 tablet(s) by mouth once a day Disp #19 Tablet Refills:0 2. amLODIPine 5 mg PO DAILY 3. Aspirin EC 81 mg PO DAILY 4. Atorvastatin 40 mg PO QPM RX atorvastatin 40 mg 1 tablet(s) by mouth QPM Disp #30 Tablet Refills:3 5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 7. Montelukast 10 mg PO DAILY 8. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: Acute Ischemic Stroke Secondary Diagnoses ===================== Hyperlipidemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear ___, You were hospitalized with slurred speech and a facial droop due to ACUTE ISCHEMIC STROKE, a condition where a blood vessel providing oxygen and nutrients to the brain is blocked by a clot. The brain is the part of your body that controls and directs all the other parts of your body, so damage to the brain from being deprived of its blood supply can result in a variety of symptoms. Stroke can have many different causes, so we assessed you for medical conditions that might raise your risk of having stroke. In order to prevent future strokes, we plan to modify those risk factors. Your risk factors are: high cholesterol. We will monitor you for an abnormal heart rhythm with a heart monitor or ziopatch for 2 weeks. We are changing your medications as follows: - Continue Aspirin 81mg with Plavix 75mg for a total of 21 days through ___ - You were just started on atorvastatin which you should continue 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: ___
19563488-DS-13	19,563,488	24,870,266	DS	13	2154-06-09 00:00:00	2154-06-20 19:48:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Ascites, Hyponatremia Major Surgical or Invasive Procedure: Paracentesis x3 History of Present Illness: Mr. ___ is a ___ year old man with HCV (genotype 1) and alcoholic cirrhosis complicated by ascities and varicies who is referred in by ___ clinic for hyponatremia and anemia found on recent labs as well as increasing ascities. Regarding patient;s relevant history, he as diagnosed with cirrhosis in ___ in the setting of ascities. He established care with the ___ Hepatology team in ___ with subsequent work up including RUQ U/S ___ that showed coarse liver texture and large volume ascities, and EGD in ___ that showed non-bleeding grade II varices. Due to his ascities despite ___ of increased lasix 40mg/spironolactone 100mg, patient was actually unable to complete a fibroscan. ___ clinic 3 days ago on ___ where he reported continued ascities despite compliance with low sodium diet and fluid restriction. He was originally scheduled for diagnostic/therapeutic large volume paracentesis on ___ but the patient now referred in from ___ clinic for increased abdominal distention and fatigue. Upon arrival to ___, initial VS 98.2 74 97/63 22 100%. Labs notable for Chem 7 with Na 135 otherwise wnl, CBC with H/H 9.8/31.4 lower than recent baseline, coags with INR 1.4, LFTs with ALT 34 AST 81, AP 64 TB 1.6 Alb 2.9, Lipase 106, Lactate of 1.2. RUQ U/S with patent vasculature notable for large volume ascities and coarse/nodular liver. A diagnostic (only 20cc taken off) paracentesis was conducted with 194 WBCs, 10 PMNs. VS prior to transfer 98.4 67 99/66 18 98%RA Upon arrival to the floor, patient is ___ 107/63 81 20 100% RA. Patient is well appearing without specific complaints other than stable abdominal distention. ROS: per HPI, denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: Alcoholic and hepatitis C cirrhosis complicated by esophageal varices and ascities Hypothyroidism Aortic aneurysm Hernia History of rheumatic fever at age of ___ History of lung nodule History of elevated AFP with an MRI in ___ negative for any lesions. Last ultrasound in ___ without any lesions. Social History: ___ Family History: Father with colon cancer at the age of ___ Mother with thyroid disease No liver diseases in the family Physical Exam: ADMISSION PHYSICAL EXAM VS: 98.0 107/63 81 20 100%RA General: Well appearing elderly man, sitting in bed, NAD HEENT: NC/AT, slight temporal wasting, MMM, oropharynx clear Neck: Supple CV: RRR, +S1/S2, no m/r/g Lungs: CTAB Abdomen: Distended and moderately tense without tenderness to palpation, no rebound/guarding. Unable to appreciate hepatosplenomegaly due to distension. DISCHARGE PHYSICAL EXAM VS: Tm 98.32 77 103/59 18 100% General: Well-appearing elderly man, sitting in bed, NAD HEENT: NC/AT, slight temporal wasting, MMM, oropharynx clear Neck: Supple CV: RRR, +S1/S2, no m/r/g Lungs: CTAB Abdomen: Distended and soft without tenderness to palpation, no rebound/gaurding. Unable to appreciate hepatosplenomegaly due to distention, reducible umbilical hernia (ascities) GU: large rightsided hernia with reducible bowel in scrotum Ext: WWP, 1+ edema, DP 2+ Neuro: CN II-XII, motor, and sensation grossly intact. Gait normal Skin: Dry Pertinent Results: ADMISSION LABS: ___ 11:10AM BLOOD WBC-6.1 RBC-3.66* Hgb-9.8* Hct-31.4* MCV-86 MCH-26.7* MCHC-31.1 RDW-17.0* Plt ___ ___ 11:10AM BLOOD Neuts-59.1 Lymphs-15.7* Monos-9.2 Eos-15.4* Baso-0.6 ___ 11:10AM BLOOD ___ PTT-35.9 ___ ___ 11:10AM BLOOD Glucose-96 UreaN-18 Creat-1.0 Na-125* K-4.4 Cl-94* HCO3-22 AnGap-13 ___ 11:10AM BLOOD ALT-34 AST-81* AlkPhos-64 TotBili-1.6* ___ 11:10AM BLOOD Albumin-2.9* ___ 04:50PM BLOOD calTIBC-455 Ferritn-19* TRF-350 ___ 11:10AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 11:12AM BLOOD Lactate-1.2 ___ 04:56PM URINE Color-Yellow Appear-Clear Sp ___ ___ 04:56PM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-2* pH-5.5 Leuks-NEG ___ 04:56PM URINE RBC-4* WBC-1 Bacteri-NONE Yeast-NONE Epi-0 ___ 04:56PM URINE CastHy-19* ___ 04:56PM URINE Mucous-MOD ___ 04:56PM URINE Hours-RANDOM Creat-329 Na-10 K-98 Cl-10 ___ 04:56PM URINE Osmolal-800 ___ 01:07PM ASCITES WBC-194* ___ Polys-10* Bands-1* Lymphs-32* Monos-0 Eos-1* Mesothe-8* Macroph-48* ___ 01:07PM ASCITES TotPro-0.8 Glucose-110 PERTINENT LABS ___ 05:40AM BLOOD WBC-2.9# RBC-2.76 Hgb-7.4* Hct-23.0# MCV-83 MCH-27.0 MCHC-32.4 RDW-17.0 Plt Ct-90* ___ 12:50PM BLOOD Neuts-65.4 Lymphs-13.4* Monos-12.3* Eos-8.2* Baso-0.8 ___ 05:40AM BLOOD ___ PTT-42.8* ___ ___ 05:40AM BLOOD Glucose-84 UreaN-19 Creat-0.9 Na-125* K-3.9 Cl-95* HCO3-23 AnGap-11 ___ 12:50PM BLOOD ALT-32 AST-65* AlkPhos-61 TotBili-1.7* DISCHARGE LABS ___ 05:52AM BLOOD WBC-3.7* RBC-2.83* Hgb-7.7* Hct-23.9* MCV-85 MCH-27.2 MCHC-32.1 RDW-17.5* Plt Ct-90* ___ 05:52AM BLOOD ___ PTT-46.6* ___ ___ 05:52AM BLOOD Glucose-97 UreaN-15 Creat-1.0 Na-125* K-4.3 Cl-94* HCO3-24 AnGap-11 ___ 05:52AM BLOOD ALT-28 AST-55* AlkPhos-51 TotBili-1.3 ___ 05:52AM BLOOD Calcium-8.9 Phos-2.4* Mg-2.0 IMAGING/ REPORTS Cardiovascular ReportECGStudy Date of ___ 11:03:44 AM Slight baseline artifact. Sinus rhythm with a single premature atrial contraction. Left axis deviation with left anterior fascicular block with an intraventricular conduction delay. Isolated Q wave in lead aVL. There are QS complexes in leads V1-V2 with poor anterior R wave progression in lead V4 consistent with prior anteroseptal myocardial infarction. Possible left atrial abnormality. T wave inversion in lead aVL with non-specific repolarization abnormalities in leads I and V6. Lateral repolarization abnormalities are non-specific, but ongoing ischemic process cannot be excluded. Clinical correlation is suggested. No previous tracing available for comparison. IntervalsAxes ___ ___ ___ OR GALLBLADDER US 1. Patent portal and hepatic veins. 2. Coarsened liver echogenicity as well as nodular hepatic contour or in keeping with known diagnosis of cirrhosis. 3. Large volume ascites. 4. Though not as clearly visualized, there is persistent splenomegaly. ___ (PA & LAT) FINDINGS: Frontal and lateral chest radiographs demonstrate a normal cardiomediastinal silhouette and hyperinflated lung volumes. There is no focal opacity, pneumothorax, or pleural effusion. Pes excavatum is noted. IMPRESSION: No acute cardiopulmonary process. ___ FLUID Peritoneal fluid: NEGATIVE FOR MALIGNANT CELLS. Mesothelial cells, histiocytes, lymphocytes and blood. ___ DIAG/THERA Uneventful therapeutic paracentesis yielding 2.6 L of serosanguineous ascitic fluid. MICRO ___ 12:20 pm BLOOD CULTURE FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 1:07 pm PERITONEAL FLUID PERITONEAL FLUID. FINAL REPORT ___ 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 (Final ___: NO GROWTH. ___ 4:56 pm URINE Source: ___. *FINAL REPORT ___ URINE CULTURE (Final ___: <10,000 organisms/ml. Brief Hospital Course: ___ with HCV (genotype 1) and alcoholic cirrhosis complicated by ascites and varices referred from ___ clinic for hyponatremia, anemia and increasing ascites. Patient underwent diagnostic paracentesis that was negative. He underwent 3 separate paracentesis during his hospital stay to remove ascities. His abdominal distension improved significantly prior to discharge. He was instructed to eat a low sodium diet (less than 2 grams) and restrict his fluid intake to 1.5L per day. In terms of his anemia he was found to have iron deficiency. Given IV infusion of iron and started on oral supplements. Patient has a history of polyps and should be evaluated with a colonoscopy as an outpatient. # Hyponatremia: Patient presented with Na 125 from baseline ___. He was clinically stable without suggesting more a subacute process. Most likely etiology is hypovolemic/increased ADH hyponatremia in the setting of cirrhosis and worsening of his liver disease. . Patients infectious work up was negative for SBP, CXR with no evidence of pneumonia and a non concerning UA. Portal vein thrombosis was ruled out by doppler. SIADH and adrenal insufficiency were ruled out as urine electrolytes were not concerning and AM cortisol was normal. His lasix was stopped as he was not tolerating it well and likely leading to worsening hyponatremia. # Ascites: Patient with progressively worsening ascites in the setting of not being able to tolerate increased diuretic doses (muscle cramping) and hyponatremia. In ED, Diagnostic paracentesis without evidence of SBP. Patient underwent a therapeutic paracentesis that removed 3.5L and subsequently underwent a second therapeutic that removed 2.5L. His home dose of nadalol was held during hospital stay and was restarted. His lasix was held secondary to hyponatremia. Patient continued spironolactone at 50mg daily. Patient likely has diuretic refractoy ascities and decision was made to have weekly paracentesis to control ascities and consider TIPS in the future. Patient was stable upon discharge. # Anemia: Patient subacute Hb drop from baseline ___ Hb low-11s now down to ___ Most recent ___ EGD with non-bleeding grade II varices for which patient is on nadolol. Guaiac in ED negative. The patient was asymptomatic. Patient had iron studies that were concerning for iron deficiency and was given IV ferric gluconate followed by PO iron supplementation. Hemolysis was ruled out. The patient will likely need an outpatient colonoscopy. # HCV/Alcoholic Cirrhosis: Complicated by varices (on nadalol), ascites (on spironolactone/lasix), but denies any history of hepatic encephalopathy. Patient was started on lactulose TID as well as rifaximin however the patient refused as in the past it has caused constipation. Patient underwent paracentesis as above. Lasix was held due to hyponatremia and spironolactone was continued. Patient was stable on discharge. # Eosinophilia: Patient presented with noted eosinophilia on CBC. CBC with WBC 6.1, 15.45 Eos (AEC 939). AM cortisol was normal. Outpatient follow up is recommended. # Hypothyroidism: Stable, Continued on home levothyroxine TRANSLATIONAL ISSUES - Weekly paracentesis to control ascities and consideration of TIPs in the future - Started on lactuose and rifaximin however patient complained of constipation with rifaximin and refused. Patient was not encephalopathic during stay. Reassess need for medications as outpatient. -Colonoscopy as outpatient, he was found to have iron deficiency anemia and has a history of polyps. Started on oral iron supplementation. - Patient had eosinophilia noted on CBC that requires further work up as an outpatient. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Fluticasone Propionate NASAL 1 SPRY NU BID 2. Levothyroxine Sodium 125 mcg PO DAILY 3. Nadolol 10 mg PO DAILY 4. Omeprazole 20 mg PO DAILY 5. Spironolactone 50 mg PO DAILY 6. Furosemide 20 mg PO DAILY Discharge Medications: 1. Levothyroxine Sodium 125 mcg PO DAILY 2. Omeprazole 20 mg PO DAILY 3. Spironolactone 50 mg PO DAILY 4. Docusate Sodium 100 mg PO BID RX docusate sodium [Colace] 100 mg 1 capsule(s) by mouth daily Disp #30 Capsule Refills:0 5. Ferrous Sulfate 325 mg PO DAILY RX ferrous sulfate [Iron (ferrous sulfate)] 325 mg (65 mg iron) 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 6. Lactulose 15 mL PO TID RX lactulose 10 gram/15 mL (15 mL) 1 cup by mouth three times a day Refills:*0 7. Fluticasone Propionate NASAL 1 SPRY NU BID 8. Nadolol 10 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS Alcoholic Cirrhosis SECONDARY DIAGNOSIS Hyponatremia Anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure taking care of you during you stay at ___ ___. You were hospitalized for increased abdominal distension. This was due to your cirrhosis which has caused fluid to accumulate. For this you underwent paracentesis to remove the fluid. You were also found to have a low sodium and low blood counts. These are thought to be secondary to your liver disease. We encourage you to eat a diet with less than 2 grams of sodium and limit your self to 1.5L of fluid daily. You will also require weekly paracentesis to have the fluid from your abdomen drained. For your anemia you will need to talk to your doctor about ___ colonoscopy. Please continue to take your medications as prescribed and follow up with your doctors as ___. Sincerely, Your ___ Team Followup Instructions: ___
19563547-DS-11	19,563,547	20,095,262	DS	11	2179-09-11 00:00:00	2179-09-15 01:31:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Vicodin / Erythromycin Base / Lipitor / Penicillins Attending: ___. Chief Complaint: rectal pain Major Surgical or Invasive Procedure: none History of Present Illness: Pt accompanied by dtrs who state they have been trying to bring him in to ED for eval for several weeks. Pt reports rectal pain similar to prior since presentation but acutely worsening over the past several weeks to the point that it is happening almost every hour even up to several times. Feels like a dull pain but also like spasms. Pain can be present when lying down but is particularly worse when he is having bowel movements or attempting to urinate or defectate. has not had pain or burning but states that he has a lot of urinary hesitancy and urgency and feels difficulty getting urine out. States that he has not had constipation and has uptitrated his bowel regimen dramatically lately and stool caliber is "like mud" not firm and no bloody bowel movements. Occassionally has pain radiating into the testincles but no back or leg pain. Once last week he felt short lived (several seconds) central chest pain and lightheadedness after straining to have bowel movement. Denies however that he is straining more than usual. No fevers or nausea vomiting. Feels lower abd cramping at times and a lot of gas in the abdomen but has had no issues passing gas. No diarrhea. He is having regular bowel movements several times daily. Currently no chest pain or SOB. Pt without headaches. Normal appetite. No fevers. Currently no dysuria. He has had to go up dramatically on his oxycodone use over the past few weeks. ED COUSRE: T 96.6 HR 94 BP 145/98 --> 111/58 RR 20 100% RA. Labs with WBC 8, Hct 32.9, Plts 185. PMNS 75%. Na 130 otherwise chem reassuring except glucose 287. Pt was given total of 8mg IV morphine, ___ gpo oxycontin and 5mg po oxycodone. On arrival to the floor he states he has no pain currently. Denies having had back pain or leg weakness. Past Medical History: ONCOLOGIC HISTORY: ___ initially presented in ___ with hematochezia and rectal pain, and physical exam finding of a rectal mass. On ___, he underwent pelvic MRI which identified a tumor at the anorectal junction involving much of the anus and left lower rectum invading along the left anorectal wall. Multiple mesorectal lymph nodes were enlarged. On ___ he underwent colonoscopy under anesthesia. Biopsy of the mass revealed poorly-differentiated carcinoma consistent with large cell neuroendocrine carcinoma, staining positive for cytokeratin, synaptophysin and chromogranin and weakly positive for CDX2. Findings were consistent with poorly-differentiated large cell neuroendocrine carcinoma. CT torso ___ identified multiple liver lesions consistent with metastases. On ___, Mr. ___ initiated palliative chemotherapy with carboplatin/etoposide. -___ C1D1 ___ -___ C2D1 ___ -___: CT Torso: good PR -___ C3D1 ___ -___ C4D1 ___ -___ C5D1 ___ -___: CT Torso with continued good PR -___: C6D1 ___ -___: C7D1 ___ -___: CT Torso increased size of multiple liver mets - ___ C8D1 ___ Past Medical History: 1. Basilar artery syndrome, status post TIA ___. 2. Type 2 diabetes mellitus, diet controlled. 3. Hypercholesterolemia. 4. Hypertension. 5. Obstructive sleep apnea. 6. Chronic low back pain. Social History: ___ Family History: Family History: The patient's mother died at ___ years with ulcerative colitis. His father died at ___ years with Alzheimer's disease. His maternal grandfather was treated for head and neck cancer at ___ years and died at ___ years. A paternal grandfather died of cardiovascular disease. He has one brother who has hypertension and a history of alcohol excess. He has two daughters, one of whom is adopted, without health concerns. Physical Exam: ADMISSION PHYSICAL EXAM: VITAL SIGNS: 98.6 ___ 18 94% RA General: NAD HEENT: MMM, no OP lesions, no cervical, supraclavicular, or axillary adenopathy, no thyromegaly CV: RR, NL S1S2 no S3S4 MRG PULM: CTAB GI: BS+, soft, NTND, no masses or hepatosplenomegaly GU: bladder scan only 50cc. Rectal exam external normal, no blood or masses, finger inserted into rectal vault w/ significant pain but no masses felt however due to pain did not attempt to pass further inside rectum DISCHAGE: PHYSICAL EXAM: VITAL SIGNS: 98.6 118/60 18 95% RA General: NAD HEENT: MMM, no OP lesions, no cervical, supraclavicular, or axillary adenopathy, no thyromegaly CV: RR, NL S1S2 no S3S4 MRG PULM: CTAB GI: BS+, soft, NTND, no masses or hepatosplenomegaly perineal area exam: no fistula or fissure seen on external examination. the patient declined DRE. Pertinent Results: LABS: ============ ___ 06:45PM URINE HOURS-RANDOM ___ 06:45PM URINE HOURS-RANDOM ___ 06:45PM URINE UHOLD-HOLD ___ 06:45PM URINE GR HOLD-HOLD ___ 06:45PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 06:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG ___ 06:45PM URINE RBC-1 WBC-<1 BACTERIA-FEW YEAST-NONE EPI-<1 ___ 03:25PM GLUCOSE-287* UREA N-10 CREAT-0.9 SODIUM-130* POTASSIUM-3.8 CHLORIDE-92* TOTAL CO2-25 ANION GAP-17 ___ 03:25PM estGFR-Using this ___ 03:25PM CALCIUM-9.7 PHOSPHATE-3.8 MAGNESIUM-1.6 ___ 03:25PM WBC-8.0# RBC-3.09* HGB-11.3* HCT-32.9* MCV-107* MCH-36.6* MCHC-34.3 RDW-16.1* RDWSD-61.8* ___ 03:25PM NEUTS-74.4* LYMPHS-16.0* MONOS-7.8 EOS-0.6* BASOS-0.4 IM ___ AbsNeut-5.95# AbsLymp-1.28 AbsMono-0.62 AbsEos-0.05 AbsBaso-0.03 ___ 03:25PM PLT COUNT-185 ___ 07:30AM BLOOD WBC-8.5 RBC-2.68* Hgb-9.7* Hct-28.1* MCV-105* MCH-36.2* MCHC-34.5 RDW-15.6* RDWSD-59.7* Plt ___ ___ 09:00AM BLOOD Neuts-86.3* Lymphs-5.6* Monos-7.0 Eos-0.2* Baso-0.3 Im ___ AbsNeut-9.56# AbsLymp-0.62 AbsMono-0.78 AbsEos-0.02* AbsBaso-0.03 ___ 07:30AM BLOOD Plt ___ ___ 07:30AM BLOOD Glucose-196* UreaN-6 Creat-0.7 Na-132* K-3.8 Cl-96 HCO3-25 AnGap-15 ___ 07:30AM BLOOD Calcium-8.7 Phos-3.4 Mg-1.8 IMAGING =============== ___ Imaging MR RECTAL ___ & W/O CONTR 1. Heterogeneously enhancing anorectal mass representing known neuroendocrine carcinoma shows increased size and increased perirectal tumor involvement compared to the prior MRI, though without significant change compared to the recent CT. 2. Multiple metastatic pelvic lymph nodes are grossly stable compared to the recent CT scan. A left obturator lymph node or tumor deposit/EMVI is in close proximity to the sciatic nerve with some spiculation and tethering of adjacent structures. 3. No perirectal abscess or other acute abnormality identified to suggest the cause of rectal pain. ___BD & PELVIS W & W/O 1. No acute process in the abdomen or pelvis. 2. Large colonic fecal loading. 3. Right lung base focal area of consolidation and ___ opacity consistent with aspiration or early pneumonia. 4. Small volume of nonspecific free fluid within the abdomen and pelvis. 5. Interval increase in size of hepatic metastases and peripherally enhancing rectal mass. EKG: Normal sinus rhythm. Normal ECG. No previous tracing available for comparison. Brief Hospital Course: This is a ___ with history of rectal neuroendocrine carcinoma metastatic to LN who was admitted with rectal pain urgency and frequency. # Rectal pain: On admission an MRI of the rectum showed increased size local spread of his rectal tumor along the neurovascular innervation. There was also evidence of proximity to the sciatic nerve with some spiculation and tethering of adjacent structures which likely explains his pain. The patient was evaluated by the pain services, and his opiate medication were adjusted oxycodone (OxyCODONE ___ mg PO/NG Q4H:PRN for pain) and (oxycontin 40 mg PO Q8H). Due to involvement of the neurovascular bundle the patient was started on radiation therapy (session 1= ___ for palliation. He will receive a total of 5 sessions the last being on ___. # Fever: The patient was noted to have fever which was attributed to a possible episode of colitis which was empirically treated for 5 days with ciprofloxacin and flagyl. # Abdominal pain: During hospitalization, he complained of severe Abdominal pain and bloating and a CT abdomen showed no acute process but revealed large stool burden. He was aggressively treated with Mirolax, lactulose, senna and Colace. After passing a multiple large bowel movements, his pain significantly improved. We continued the patient on bowel preparation. # Hyponatremia: the patient was noted to have low serum sodium to 130 on arrival which was also noted 2 month ago. Therefore, his hyponatremia is not acute. SIADH is a possibility. Also a paraneoplastic phenomenon is also likely. At the time of discharge the cause of his hyponatremia was not clear. # Prediabetes: was noted to have serum glucose to 200's on several occasions. His HbA1C was noted to be 6.1 on ___ consistent with being Prediabetic. He was placed on a sliding scale. TRANSTITIONAL ISSUES: - The patient was noted to have increase size of liver mets noted on a ___ from ___. We recommend further discussion regarding the choice of chemotherapeutic agent and palliative options. - the patient was started on XRT sessions directed to his rectal tumor. His ___ and last session will be as an outpatient on ___. - the patient was discharged on Mirolax, lactulose, senna and Colace - the patient's opiates medication were adjusted oxycodone (OxyCODONE ___ mg PO/NG Q4H:PRN for pain) and (oxycontin 40 mg PO Q8H). - The patient had a small right lung base focal area of consolidation and ___ opacity consistent with aspiration or early pneumonia. We recommend further respiratory symptom monitoring and a repeat CXR in 12 weeks. - The patient was noted to have elevated blood glucose (200s-300s). his last A1C check was in ___. We recommend rechecking A1C at follow up. - due to the patient diagnosis and aiming at decreasing the burden of medication burden, we would recommend further simplification of his med list. CODE: full. DTRs/HCP: ___ ___. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 40 mg PO QPM 2. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB 3. FoLIC Acid 1 mg PO DAILY 4. Ondansetron 8 mg PO Q8H:PRN nausea 5. OxyCODONE SR (OxyconTIN) 30 mg PO Q12H 6. OxyCODONE SR (OxyconTIN) 20 mg PO DAILY 7. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN pain 8. Prochlorperazine 10 mg PO Q6H:PRN nausea 9. Aspirin 325 mg PO DAILY 10. Senna 8.6 mg PO BID 11. Docusate Sodium 200 mg PO BID 12. Polyethylene Glycol 17 g PO DAILY 13. Tamsulosin 0.4 mg PO QHS Discharge Medications: 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB 2. Aspirin 325 mg PO DAILY 3. Docusate Sodium 200 mg PO BID 4. FoLIC Acid 1 mg PO DAILY 5. Ondansetron 8 mg PO Q8H:PRN nausea 6. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN pain RX oxycodone 10 mg 1 tablet(s) by mouth every four (4) hours Disp #42 Tablet Refills:0 7. OxyCODONE SR (OxyconTIN) 40 mg PO Q8H RX oxycodone 40 mg 1 tablet(s) by mouth every eight (8) hours Disp #21 Tablet Refills:0 8. Polyethylene Glycol 17 g PO BID constipation RX polyethylene glycol 3350 17 gram 1 powder(s) by mouth twice a day Disp #30 Packet Refills:0 9. Prochlorperazine 10 mg PO Q6H:PRN nausea 10. Senna 17.2 mg PO BID RX sennosides 8.6 mg 2 tablets by mouth twice a day Disp #28 Tablet Refills:0 11. Lactulose 30 mL PO DAILY:PRN constipation RX lactulose 20 gram/30 mL 30 ml by mouth daily Refills:0 12. Atorvastatin 40 mg PO QPM 13. Tamsulosin 0.4 mg PO QHS Discharge Disposition: Home Discharge Diagnosis: rectal neuroendocrine carcinoma metastatic to LN infecous colitis opiate induced constipation hyponatremia hyperglycemia chronic anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear ___ was a pleasure taking care of you at the ___. You were admitted because of pain in the rectum. You underwent an MRI which showed that your rectal tumor was incasing nearby nerves after local spread. As a result you were seen by the pain specialist and radiation oncologist. Your pain medication were adjusted, and we started you on radiation therapy localized to the rectum and pelvis. On you presentation to the hospital you also had fever which is likely from an infection of your colon called (colitits). We treated you with antibiotics and you responded well. You also complained of severe constipation which resulted in sever abdominal pain. This was relieved with laxative. You completed a total of 5 session of radiation during you hospitalization and were discharged without complications. Please continued to take you medication as prescribed and follow up with your appointments as listed below. Please make sure to attend you final radiation session tomorrow ___ at 2:15PM. It was a pleasure taking care of you at the ___. We wish you all the best. Your ___ team Followup Instructions: ___
19563570-DS-25	19,563,570	27,325,833	DS	25	2133-06-18 00:00:00	2133-06-20 23:02:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Bactrim Attending: ___. Chief Complaint: Lethargy Major Surgical or Invasive Procedure: Foley placement History of Present Illness: ___ year old male with history of DM, CAD, HTN, urologic obstruction now requiring self-caths x2 weekly now presenting with ___ days general malaise/weakness and cough. He endorses pain all over, but cannot not localize pain or be more specific about complaints, cough, weakness. Denies nausea or diarrhea. No fevers. Per telephone conversation with his daughter, the family (patient's daughter and wife) have had URI for the past 2 weeks. The patient began experiencing fatigue,cough and body aches since ___. They noticed he he ate minimal amounts of food and stopped drinking all together. Also, he has been more stubborn and confused at home, not taking his medications or taking his FSG as he usually does. Family concerned because he was making false statements (eg,"I dont take any medications and havent been for years now.") In the ED, initial VS: 97.0 74 112/48 24 99%. Labs were notable for K 5.9 and Cr3.3 (baseline 1.2 in ___. u/a was grossly positive. Patient received ceftriazone and zofran. CXR without focal consolidation. REVIEW OF SYSTEMS: (+) as per HPI (-) fever, chills, night sweats, headache, vision changes, rhinorrhea, sore throat, shortness of breath, chest pain, abdominal pain, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: - Fournier's gangrene s/p debridement w/ suprapubic catheter placement ___ - infrarenal AAA - Urethral abscess & stricture - CAD s/p PCI for stable angina felt as left arm pain - embolization of left hypogastric artery and debridement of gluteal abscess - moderate Aortic Stenosis -vascular disease with bilateral iliac stents and aortic stent -chronic kidney disease, proteinuria since ___ -obesity -COPD -Arthritis -Diabetes -PUD -Macular degeneration -Pulmonary nodule -___ - coil embolization of Rt hypogastric artery Social History: ___ Family History: Colon cancer in father FH of HTN, stroke, HLD, DM, CAD Physical Exam: ADMISSION PHYSICAL EXAM: VS: 98.5 100/50 92 18 96RA; Weight 207lbs FSG 300 GENERAL: lethargic, moaning in bed, oriented to person, place, and partially to time. HEENT: NC/AT, PERRLA, EOMI, dry MM NECK - supple, no JVD LUNGS - rhonchi bilaterally, no focal crackles or wheezing HEART - RRR, ___ SEM at right sternal border, nl S1-S2 ABDOMEN - soft/NT/ND, no masses, no rebound/guarding, NO CVA tenderness EXTREMITIES - WWP, no edema; 2+ peripheral pulses (radials, DPs) NEURO - awake, A&Ox3 (partially to time), CNs II-XII grossly intact, muscle strength ___ throughout, gait not assessed RECTAL: declined (repeatedly) DISCHARGE PHYSICAL EXAM: VS: 98.3 160/70 80 20 95RA GENERAL: NAD, alert, oriented x3. HEENT: NC/AT, PERRLA, EOMI, mmm NECK - supple, no JVD LUNGS - CTAB HEART - RRR,Right sternal border ___ SEM, ABDOMEN - soft/NT/ND, no masses, no rebound/guarding, NO CVA tenderness EXTREMITIES - WWP, no edema; 2+ peripheral pulses (radials, DPs) NEURO - awake, A&Ox3 (partially to time), CNs II-XII grossly intact, muscle strength ___ throughout, gait not assessed RECTAL: declined Pertinent Results: ADMISSION LABS: ___ 01:45PM BLOOD WBC-6.7 RBC-3.86* Hgb-12.4* Hct-36.2* MCV-94 MCH-32.1* MCHC-34.2 RDW-15.0 Plt ___ ___ 01:45PM BLOOD Neuts-76.8* Lymphs-14.4* Monos-7.2 Eos-1.1 Baso-0.5 ___ 01:45PM BLOOD Plt ___ ___ 01:45PM BLOOD Glucose-140* UreaN-109* Creat-3.3# Na-138 K-5.9 Cl-113* HCO3-13* AnGap-18 ___ 01:45PM BLOOD ALT-14 AST-13 AlkPhos-75 TotBili-0.3 ___ 06:06AM BLOOD Calcium-7.9* Phos-3.8 Mg-2.4 ___ 10:54AM BLOOD Type-ART Temp-36.9 pO2-142* pCO2-31* pH-7.23* calTCO2-14* Base XS--13 Lactate-0.8 K-6.2* Cl-126* INTERVAL LABS ___ 06:06AM BLOOD Glucose-114* UreaN-81* Creat-2.3* Na-144 K-6.3* Cl-123* HCO3-12* AnGap-15 ___ 03:00PM BLOOD UreaN-71* Creat-2.3* Na-149* K-5.6* Cl-120* HCO3-18* AnGap-17 ___ 07:39AM BLOOD Glucose-129* UreaN-51* Creat-1.8* Na-154* K-4.3 Cl-120* HCO3-24 AnGap-14 ___ 01:20PM BLOOD UreaN-47* Creat-1.8* Na-145 K-4.7 Cl-113* HCO3-22 AnGap-15 ___ 06:06AM BLOOD C3-130 C4-61* DISCHARGE LABS: ___ 08:15AM BLOOD WBC-6.7 RBC-3.59* Hgb-11.1* Hct-33.5* MCV-93 MCH-31.0 MCHC-33.2 RDW-14.2 Plt ___ ___ 08:15AM BLOOD Calcium-8.2* Phos-2.1* Mg-1.5* ___ 08:15AM BLOOD Glucose-136* UreaN-34* Creat-1.7* Na-146* K-4.6 Cl-113* HCO3-22 AnGap-16 URINE: ___ 02:30PM URINE Color-Straw Appear-Clear Sp ___ Blood-SM Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-LG RBC-2 WBC-66* Bacteri-FEW Yeast-NONE Epi-<1 TransE-<1 Mucous-RARE Eos-POSITIVE Other Urine Chemistry: UreaN:669 Creat:67 Na:39 K:9 Cl:43 ___ UA sg 1.020, pH 5.5, large ___, nitrite neg, protein 1+, blood small. Urine Sediment Microscopy: numerous white cells/hpf, no cellular casts, few granular and occasional muddy brown cast. ___ bacteria per hpf, 1 epi cell per hpf URINE CULTURE (Final ___: SKIN AND/OR GENITAL CONTAMINATION. Other MICRO: DFA INFLUENZA SWAB: Negative for influenza A and B. Blood CULTURE: no growth for 48hours IMAGING: CXR ___: PA LATERAL: PA and lateral chest radiographs were obtained. The lungs are well expanded. Bibasilar linear opacities are attributable to vascular markings. There is no definite consolidation, effusion, or pneumothorax. Cardiac and mediastinal contours are normal. On the lateral view, a relatively dense well circumscribed 1 cm nodule is again seen, unchanged from ___. IMPRESSION: 1. No acute cardiopulmonary process. 2. Well-circumscribed nodule either within the anterior left lung or anterior mediastinum. The nodule is stable since ___ but should be assessed with CT, if this exam has not been performed elsewhere. GU US: ___: Please note the complete GU examination was not performed as the patient has been Foley catheterized limiting assessment of bladder and prostate. The right kidney measures 11.6 cm. Left kidney measures 11.9 cm. There is no hydronephrosis, stone or mass seen bilaterally. The bladder is decompressed and not well assessed. Brief Hospital Course: ___ with PMH CAD, HTN, DM, CKD, and ureteral strictures requiring intermittent self-catheterization, admitted with URI symptoms and poor PO intake found to have ___, hyperkalemia and non anion gap metabolic acidosis. He reports not having performed straight catheterization on regular schedule and had a UA consistent with infection. ACTIVE ISSUES: # Acute renal failure on Chronic Kidney Disease: History of CKD (baseline Cr 1.3-1.4). He presented with Cr 3.3, K 6.3 and non-anion gap metabolic acidosis. FeNa was 1.39%, urine Na 39, FeUrea 30.23%. His acute kidney injury was multifactorial from pre-renal azotemia (caused by poor po intake and relieved with fluid bolus) and post-renal obstruction (hx of strictures and urinary retention requiring foley placement during inpatient stay). Interestingly, as described by the renal consulting service, the urinary obstruction lead to a distal RTA type IV where the back flow of obstruction caused pressure in the collecting ducts and eventually compromised secretion of H and K and thus leading to non-anion gap metabolic acidosis. Notably, his renal function improved with IV fluids, and foley catheter to relieve obstruction. US showed no dilatation of the renal pelvis or ureters. He was able to void on his own after foley was removed. At discharge Cr 1.7 and K4.7 and both were trending downward. He was instructed to perform clean technique self-cath 4x weekly rather than twice. He will follow-up with urology and nephrology. # Hyperkalemia: K to 6.3 in the setting of ARF. No peaked T waves on EKG. No cardiac complaints. ___ ___ with urinary obstruction and RTA4. The hyperkalemia resolved with kayexalate, IV insulin + dextrose, lasix, calcium gluconate, and foley to relieve urinary obstruction. #Non anion Gap Metabolic ___ urinary obstruction phenomenon that leads to dysfuction of the collecting duct, causing retention of H and K alone. Was treated with sodium bicarb. # UTI Patient did not complain of dysuria etc, but his UA showed pyuria concerning for UTI vs prostatitis. Pt would not agree to rectal exam thus differentiation difficult. UTI was considered more likely because of self-caths and urinary retention. Urine culture was mixed flora only. He was treated with IV ceftriaxone and switched to 10 day cipro 500mg po. Patient was also instructed on sterile technique for performing self-catheterizations. # URI Patient presented with cough, body aches and fatigue concerning for URI. Additionally, his wife was getting over a serious URI. Influenza antigen tests were negative for influenza A and B. At time of discharge his symptoms had resolved, so no further intervention needed. # Altered mental status On presentation the patient was lethargic, and family reported he had altered mental status including confusion and refusal to eat. This was likely delerium secondary to UTI, ___ and uremia. With resolution of acute problems the patient's mental status returned to baseline. # Pulmonary nodule. Patient had a CXR that showed a nodule in anterior mediastinum / anterior left lung. This is stable compared to CXR since ___, but outpatient CT recommended to better evaluate. INACTIVE ISSUES: # DMII: History of well controlled sugars on glyburide. Last Hgb A1c 5.9% on ___ Given danger of hypoglycemia, his home glyburide was stopped and his sugars were controlled with an insulin sliding scale. He was discharged on glyburde 1.25mg po BID (half his previous home regimen). # HTN: Patients lisinopril was held in the setting ___ and hyperkalemia. His HTN is generally well controlled, so he was restarted on home regimen of lisinopril on discharge. # CAD: stable. No symptoms concerning for ACS. Ekg was unremarkable. He continued beta blocker, statin and aspirin. Given ___, his lisinopril was held during admission, but restarted on discharge. # HLD: stable, continued simvastatin TRANSITIONAL ISSUES: -PCP to follow sugars and Cr and can restore glyburide home dose if kidney function has restored - Self-catheterization should be performed 4x a week instead of just 2x a week - Follow up with out patient urologist concerning ureteral stricture and obstruction - Complete 10 day course of ciprofloxacin 500 mg Q12 for UTI - Chest CT recommended to follow up on pulmonary nodule if it has not been performed previously Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 10 mg PO DAILY hold for SBP < 100 2. Metoprolol Tartrate 12.5 mg PO BID hold for HR < 60 or SBP < 100 3. Aspirin 81 mg PO DAILY 4. GlyBURIDE 2.5 mg PO BID 5. Nitroglycerin SL 0.3 mg SL PRN chest pain 6. Simvastatin 20 mg PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Metoprolol Tartrate 12.5 mg PO BID hold for HR < 60 or SBP < 100 3. Simvastatin 20 mg PO DAILY 4. Lisinopril 10 mg PO DAILY hold for SBP < 100 5. Nitroglycerin SL 0.3 mg SL PRN chest pain 6. Ciprofloxacin HCl 500 mg PO Q12H RX ciprofloxacin 500 mg 1 tablet(s) by mouth twice a day Disp #20 Tablet Refills:0 7. GlyBURIDE 1.25 mg PO BID RX glyburide 1.25 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:0 Discharge Disposition: Home Discharge Diagnosis: Acute renal failure Urinary obstruction Dehydration Hyperkalemia Hypernatremia Urinary tract infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure taking care of you while you were admitted to ___. You were admitted with a urinary tract infection, acute kidney failure and severely elevated potassium levels. This was most likely caused by poor oral intake and urinary tract obstruction. You were treated with intravenous fluids and medications which you tolerated well. You also had a foley catheter to drain your bladder for 24 hours. Your potassium level has returned to normal. Your kidney function is now recovering. When you return home, it is very important that you continue eating and drinking. You will take an oral antibiotic to continue to treat the urinary tract infection. You will also need to continue to self-catheterize with clean technique, but you will now need to self-catheterize every other day until you see your urologist. Your glyburide dose has been decreased and it is important that you take only 1.25mg twice a day and continue to monitor your blood sugars at home. Please call your PCP if you notice that your fingerstick levels are too low (less than 70) or too hight (greater than 220). If you start to have fevers/chills, confusion, or decreased amount of urine, please seek medical attention. Followup Instructions: ___
19563570-DS-28	19,563,570	20,685,956	DS	28	2137-11-10 00:00:00	2137-11-13 09:28:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Bactrim Attending: ___. Chief Complaint: Abnormal outpatient labs Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ with h/o aortic stenosis (s/p tissue AVR + CABG x 3V (___), CAD, T II DM, Fournier gangrene, scrotal abscess (s/p exploration and I&D), PUD, diabetic neuropathy, AAA (bilat iliac artery aneurysms, s/p eprcut endovasc AAA repair ___, COPD, urethral stricture, CKD, HTN, CHF, diabetic nephropathy who presents for anemia and ___. Patient was recently hospitalized from ___ for a GI bleed. He was evaluated by GI, and taken for an endoscopy and colonoscopy. It was felt that his bleed was most likely an upper GI bleed ___ erosions seen on upper endoscopy. He was discharged on a PPI with planned followup. During that admission a stool H. pylori was negative, as were serologies. He was also noted to have ___ on CKD, which was felt to be obstructive. A foley was placed with some difficulty by urology ___ a stricture, with plan to leave foley in place for at least 2 weeks prior to urology follow up. The patient presented for post-discharge labs. At that time he was found to have a Hgb of 6.6 from 8.0 at time of discharge on ___. He was also found to have a Cr increase from 1.8 to 2.4, and a K of 6.1. He was therefore referred to the ED. He reports that he has felt well since his last admission, with no lightheadedness or dizziness. His stool was dark, but has gotten lighter, with no bright red blood. He believes his foley has been draining. In the ED, initial vitals were: 97.8, 84, 154/73, 18, 97% RA - Exam was notable for guaiac positive brown stools - Labs notable for: CBC: WBC 9.9, Hgb 6.8, Hct 23.3, Plt 200 A repeat CBC was done, showing Hgb drop to 6.4. Lytes: 139 / 106 / 44 -------------- 6.1 \ 22 \ 2.4 Repeat lytes: 136 / 104 / 46 ----------------- 296 6.4 \ 22 \ 2.5 Repeat K :5.6 Ca: 7.9 Mg: 1.9 P: 3.6 ___: 12.4 PTT: 30.4 INR: 1.1 Lactate:1.5 Ferritn: 171 ALT: 18 AST: 14 %HbA1c: 5.9 U/a with lg leuks, prot 100, gluc 150, WBC >160, Bact mod - Imaging was notable for a renal ultrasound, with results pending. - Renal was consulted, and recommended 500cc NS + 80mg IV lasix to assist with excretion of K, with goal to keep euvolemic; keep foley in place; renal ultrasound. - Patient was given: ___ 21:56 IV Insulin Regular 10 units ___ 21:56 IV Dextrose 50% 25 gm ___ 21:56 IV Calcium Gluconate ___ 22:40 IV Pantoprazole 40 mg ___ 23:01 IV Furosemide 80 mg ___ 00:05 IVF NS 500 mL - Vitals prior to transfer: 98.5, 72, 128/62, 20, 96% RA Upon arrival to the floor, patient reports that he feels fine. Denies any lightheadedness or dizziness, and states that his stool was dark when he was discharged, but is now brown. REVIEW OF SYSTEMS: (+) Per HPI (-) 10 point ROS reviewed and negative unless stated above in HPI Past Medical History: History of PUD requiring ICU admission and several units of pRBCs in ___ AS s/p tissue AVR CAD s/p 3v CABG x 3V (done at the time of his AVR) AAA s/p ___ EVAR Venous insufficiency s/p vein harvesting DM2 HTN CKD (baseline Cr 1.5) CHF HTN HFpEF, per chart review COPD Macular degeneration periurethral abscess in ___ Diffuse ureteral stricture disease with history of urinary retention Social History: ___ Family History: FH of HTN, stroke, HLD, DM, CAD Colon cancer in father Physical Exam: =========================== ADMISSION PHYSICAL =========================== General: Alert, oriented, no acute distress HEENT: Sclerae anicteric, MMM, oropharynx clear CV: Regular rate and rhythm. Normal S1+S2, no murmurs, rubs, gallops. Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: Foley in place draining light clear urine Ext: Warm, well perfused, 2+ pulses, ___ edema to knees =========================== DISCHARGE PHYSICAL =========================== Vital Signs: 98.4 139/76 77 20 95%RA I/O: ___ General: Alert, no acute distress, laying completely flat CV: Regular rate and rhythm. Normal S1+S2, no murmurs, rubs, gallops. Lungs: Clear to auscultation bilaterally Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: Foley in place draining light clear urine Ext: Warm, well perfused, 2+ pulses, ___ edema to knees Pertinent Results: ===================================== ADMISSION LABS ===================================== ___ 10:50AM BLOOD WBC-9.9 RBC-2.28* Hgb-6.8* Hct-23.3* MCV-102# MCH-29.8 MCHC-29.2 RDW-18.2* RDWSD-61.6* Plt ___ ___ 08:44PM BLOOD Neuts-75.1* Lymphs-11.4* Monos-7.9 Eos-3.2 Baso-0.5 NRBC-0.6* Im ___ AbsNeut-6.27* AbsLymp-0.95* AbsMono-0.66 AbsEos-0.27 AbsBaso-0.04 ___ 08:44PM BLOOD ___ PTT-30.4 ___ ___ 10:50AM BLOOD UreaN-44* Creat-2.4* Na-139 K-6.1* Cl-106 HCO3-22 AnGap-17 ___ 10:50AM BLOOD ALT-18 AST-14 ___ 06:00AM BLOOD TotBili-1.4 DirBili-0.3 IndBili-1.1 ___ 08:44PM BLOOD Calcium-7.9* Phos-3.6 Mg-1.9 ___ 10:50AM BLOOD Ferritn-171 ___ 06:00AM BLOOD Hapto-298* ___ 10:50AM BLOOD %HbA1c-5.9 eAG-123 ___ 08:56PM BLOOD Lactate-1.5 K-6.5* ___ 11:04PM BLOOD K-5.6* ___ 06:00AM BLOOD Ret Aut-8.5* Abs Ret-0.21* ___ 09:05PM URINE Color-Straw Appear-Cloudy Sp ___ ___ 09:05PM URINE Blood-SM Nitrite-NEG Protein-100 Glucose-150 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG ___ 09:05PM URINE RBC-25* WBC->182* Bacteri-MOD Yeast-NONE Epi-0 ___ 09:05PM URINE Hours-RANDOM Creat-53 Na-96 K-21 ___ 09:05PM URINE Osmolal-489 ___ 09:05PM URINE Uhold-HOLD ===================================== DISCHARGE LABS ===================================== ___ 06:05AM BLOOD WBC-7.8 RBC-2.74* Hgb-8.5* Hct-27.0* MCV-99* MCH-31.0 MCHC-31.5* RDW-18.6* RDWSD-62.5* Plt ___ ___ 06:05AM BLOOD Glucose-172* UreaN-38* Creat-2.2* Na-142 K-5.1 Cl-103 HCO3-24 AnGap-20 ___ 06:05AM BLOOD Calcium-8.4 Phos-3.9 Mg-2.5 ===================================== PROCEDURES/STUDIES/IMAGING ===================================== ___ Renal Ultrasound No evidence of hydronephrosis, nephrolithiasis, or perinephric fluid collection. ===================================== MICRO ===================================== __________________________________________________________ ___ 9:05 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: STAPH AUREUS COAG +. >100,000 CFU/mL. 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. GRAM POSITIVE BACTERIA. >100,000 CFU/mL. Alpha hemolytic colonies consistent with alpha streptococcus or Lactobacillus sp. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + \| GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S NITROFURANTOIN-------- <=16 S OXACILLIN-------------<=0.25 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S __________________________________________________________ ___ 8:44 pm BLOOD CULTURE Blood Culture, Routine (Pending): Brief Hospital Course: ___ year old man with a complicated cardiovascular history (s/p AVR and CABG in ___, percutaneous endovascular repaired AAA rupture ___ who was recently admitted with GI bleeding and now re-presents with a new symptomatic Hgb drop discovered on routine follow up labs as an outpatient, as well as ___, with concern for ongoing slow GI bleed. #Symptomatic anemia #Slow GI bleed Likely continuation of slow GI bleed from erosions seen on recent EGD. He has not been taking NSAIDs since discharge and H pylori stool and antibody negative. He responded appropriately to blood transfusion x 1 and his counts remained stable for 24 hours after the transfusion. We felt that he may simply need more time to heal the erosion with PPI vs. there is a more distal slow upper GIB. Plan is to have patient follow up as an outpatient with GI to consider capsule endoscopy to rule out small bowel bleed. He remained hemodynamicaly stable while in house. He had a borderline reticulocyte index and may require more time before his hgb/hct return to normal. There was no evidence of hemolysis or iron deficiency. #Acute on Chronic Kidney disease: #Hyperkalemia Cr on admission 2.4 from 1.8 on prior admission. This was associated with hyperkalemia to 6.4. Though to be pre-renal azotemia from self reported poor PO fluid intake and anemia. Renal u/s not concerning for obstruction. Cr improved with IVF and blood transfusion. Patient received 1 dose of 80mg IV Lasix with 1L NS for treatment of hyperkalemia which resolved (6.4 on admission, 5.1 on discharge). Hyperkalemia thought to be from ___ in the setting of K absorption from GI tract in setting of GI bleed and also from K-load from the blood transfusion. #Urethral stricture Had ___ placed at last hospitalization with plans to follow up as an outpatient. He has a history of stricture. Foley drained well in house. # DM - Very labile in the past, with very gentle sliding scale used during last admission. His home glipizide was restarted at discharge. # Hypertension Lisinopril held in the setting of ___, to be restated as an outpatient. # CAD Aspirin was continued throughout, his beta blocker was initially held but once he proved stable hemodynamics it was restarted without issues, and his statin was continued. # CODE: full # CONTACT: Name of health care proxy: ___ Relationship: daughter Phone number: ___ TRANSITIONAL ISSUES Cr on discharge 2.2 (baseline 1.8). K 5.1 Hgb 8.5 []please restart lisinopril upon resolution of ___. Consider starting at 5mg instead of 10mg due to recurrent hyperkalemia []please check Chem10 and CBC on ___ []patient discharged with Foley catheter after development of obstructive uropathy during last hospitalization. It was kept in place due to a ureteral stricture which made it difficult to place. Plan is to have it removed at outpatient urology follow up. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Simvastatin 40 mg PO QPM 3. GlipiZIDE 5 mg PO BID 4. Metoprolol Tartrate 25 mg PO BID 5. Ocuvite (vit C-vit E-lutein-min-om-3) 150-30-5-150 mg-unit-mg-mg oral BID 6. Pantoprazole 40 mg PO Q12H Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. GlipiZIDE 5 mg PO BID 3. Metoprolol Tartrate 25 mg PO BID 4. Ocuvite (vit C-vit E-lutein-min-om-3) 150-30-5-150 mg-unit-mg-mg oral BID 5. Pantoprazole 40 mg PO Q12H 6. Simvastatin 40 mg PO QPM 7.Outpatient Lab Work Chem10 and CBC on ___ Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS Anemia Acute Kidney Injury Hyperkalemia GI bleed Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure taking care of you during your hospital stay. You came to the hospital for abnormal labs at your routine follow appointment. Your labs showed you were anemic and had kidney injury. We think this was because you were dehydrated and had some left over bleeding from your prior hospitalization. We gave you some blood and fluid through an IV and your kidney function and anemia improved. Please go to your primary care physician ___ ___ to have them recheck your labs. Your follow up appointments and medications are detailed below. We wish you the ___! Your ___ Care team Followup Instructions: ___
19563715-DS-17	19,563,715	29,011,013	DS	17	2144-03-25 00:00:00	2144-03-25 12:49:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: HPI(4): Ms. ___ is a ___ woman who was in her normal state ___ until she "turned yellow" three weeks ago. She broke her hip about a year ago and hap a hip replacement; at that time, she "lost her taste" for cigarettes (had previously smoked a PPD her entire life). Otherwise, she has been feeling well -- no abdominal pain, good appetite, no weight loss, no fevers or chills. She has to walk with a walker because of her claudication, but otherwise has been in her normal state of health -- cooking for her extended family and generally enjoying life. Then three weeks ago, her family noticed that she had started to turn yellow, which progressed, having her present to BID-M. In the ED there, a CT scan was obtained which showed 1. Biliary obstruction with moderately dilated intrahepatic and extrahepatic bile ducts. Hyperdense gallbladder. Rule out gallbladder/bile duct malignancy. MRCP recommended for further evaluation. 2. Right colon bowel wall thickening, ? Colitis. Tumor not excluded. Clinical correlation and correlation with colonoscopy if indicated. Therefore, she was transferred to ___ ED. Here, AVSS, CBC normal, BMP normal, INR 1.5, T Bili 30.2, ALP 379, ALT 79, AST 92, Alb 2.7, Ca 8.9, Phos 3.1, Mg 1.9. The ERCP team was consulted, planning on taking patient to ERCP and then admission to medicine. ROS: Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative. PAST MEDICAL/SURGICAL HISTORY: 1. PAD 2. Hip replacement SOCIAL HISTORY: ___ FAMILY HISTORY: Sister died of brain cancer. ALLERGIES/ADR: See webOMR PREADMISSION MEDICATIONS: confirmed with patient on admission. --------------- --------------- --------------- --------------- Active Medication list as of ___: Medications - Prescription CARVEDILOL - carvedilol 25 mg tablet. 1 tablet(s) by mouth twice a day - (Prescribed by Other Provider) NIFEDIPINE - nifedipine ER 60 mg tablet,extended release 24 hr. 1 tablet(s) by mouth once a day - (Prescribed by Other Provider) PHYSICAL THERAPY - physical therapy . evaluate and treat for gait abnormality, ICD-9 781.2 SIMVASTATIN - simvastatin 20 mg tablet. 1 tablet(s) by mouth once a day - (Prescribed by Other Provider) Medications - OTC ASPIRIN - aspirin 325 mg tablet,delayed release. 1 tablet(s) by mouth once a day - (Prescribed by Other Provider) MULTIVITAMIN [DAILY MULTI-VITAMIN] - Daily Multi-Vitamin tablet. 1 tablet(s) by mouth once a day - (Prescribed by Other Provider) OMEGA 3-DHA-EPA-FISH OIL [FISH OIL] - Dosage uncertain - (Prescribed by Other Provider) --------------- --------------- --------------- --------------- EXAM(8) VITALS: Afebrile and vital signs stable (see eFlowsheet) GENERAL: Alert and in no apparent distress EYES: Conjunctival icterus, PERRL ENT: OP clear, MMM, sublingual jaundice 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: S/NT/ND, full, nonpainful gallbladder felt while hooking at end-expiration GU: No suprapubic fullness or tenderness to palpation MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: Jaundice 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 Major Surgical or Invasive Procedure: ERCP with spnincterotomy ___ History of Present Illness: . Past Medical History: . Social History: ___ Family History: . Physical Exam: . Pertinent Results: ___ 08:50AM BLOOD CA ___ -PND ___ 06:20AM BLOOD Albumin-2.7* Calcium-8.9 Phos-3.1 Mg-1.9 ___ 05:50AM BLOOD Calcium-9.3 Phos-3.6 Mg-1.7 ___ 06:20AM BLOOD ALT-79* AST-92* AlkPhos-379* TotBili-30.2* ___ 05:50AM BLOOD ALT-81* AST-74* AlkPhos-416* TotBili-32.0* ___ 06:20AM BLOOD Glucose-82 UreaN-13 Creat-0.6 Na-140 K-3.9 Cl-107 HCO3-21* AnGap-12 ___ 05:50AM BLOOD Glucose-97 UreaN-11 Creat-0.6 Na-144 K-3.4* Cl-105 HCO3-23 AnGap-16 ___ 06:20AM BLOOD ___ PTT-33.2 ___ ___ 06:20AM BLOOD Plt ___ ___ 05:50AM BLOOD ___ PTT-37.7* ___ ___ 06:20AM BLOOD Neuts-74.1* Lymphs-15.1* Monos-7.1 Eos-2.3 Baso-0.6 Im ___ AbsNeut-5.92 AbsLymp-1.21 AbsMono-0.57 AbsEos-0.18 AbsBaso-0.05 ___ 06:20AM BLOOD WBC-8.0 RBC-3.88* Hgb-12.5 Hct-36.3 MCV-94 MCH-32.2* MCHC-34.4 RDW-23.5* RDWSD-77.3* Plt ___ ___ 05:50AM BLOOD WBC-8.2 RBC-4.18 Hgb-13.4 Hct-41.9 MCV-100* MCH-32.1* MCHC-32.0 RDW-24.5* RDWSD-88.5* Plt ___ Dopplers of the bilateral lower extremities on ___ IMPRESSION: 1. No evidence of deep venous thrombosis in the right or left lower extremity veins. 2. Small right ___ cyst. Brief Hospital Course: SUMMARY/ASSESSMENT: Ms. ___ is a ___ woman who presents with painless jaundice and Courvoisier's sign, and a CT that shows biliary obstruction with gallbladder fullness, most consistent with malignancy -- pancreatic CA versus cholangiocarcinoma. The ERCP team was consulted and did the ERCP on ___. They found that she has a 2cm mid-CBD stricture, and CBD dilation to 1.5cm above the stricture. Sphincterotomy was preformed, brushings obtained, and a ___ 8cm plastic stent was deployed across the stricture. She tolerated the procedure well, had IVF overnight, and tolerated a regular diet the next day without any pain or nausea. Her bilirubin should decrease over the next week, but jaundice will persist in the interim. ERCP team recommended that she have CA ___ and pancreatic protocol CT which were done, but results of this were pending at the time of discharge. She will follow-up with the result of these as well as the brushings in multidisciplinary pancreas clinic upon discharge. For her INR that was 1.5 and increased to 1.7 after the procedure, this was likely from nutritional deficiency as well as possible hepatic insufficiency. She has no bleeding noted. She received Vitamin K 10mg PO x1 and can have INR rechecked as an outpatient. Her ASA was initially held on admission, but restated upon discharge from the hospital. I spent > 30 min in discharge planning and coordination of care. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. CARVedilol 25 mg PO BID 2. NIFEdipine (Extended Release) 60 mg PO DAILY 3. Aspirin 325 mg PO DAILY 4. Multivitamins 1 TAB PO DAILY 5. Simvastatin 20 mg PO QPM 6. Fish Oil (Omega 3) 1000 mg PO BID Discharge Medications: 1. Aspirin 325 mg PO DAILY 2. CARVedilol 25 mg PO BID 3. Fish Oil (Omega 3) 1000 mg PO BID 4. Multivitamins 1 TAB PO DAILY 5. NIFEdipine (Extended Release) 60 mg PO DAILY 6. Simvastatin 20 mg PO QPM Discharge Disposition: Home Discharge Diagnosis: Stricture of the common bile duct Hyperbilirubinemia/jaundice 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 because of a blockage in your bile duct that caused jaundice, or yellowing of the skin. You had an ERCP which is a procedure that was able to open the area. You had additional tests to try and understand what caused the blockage, since a mass is one of the possibilities. You will be seen in follow-up with specialty docty Followup Instructions: ___
19563762-DS-4	19,563,762	28,654,332	DS	4	2169-10-31 00:00:00	2169-11-02 17:02:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: sepsis Major Surgical or Invasive Procedure: central line placement endotracheal intubation History of Present Illness: ___ w/unknown PMHx found down at home for an unknown period of time this evening. She was last seen well 4 days ago. This evening she was found by her friend and landlord in her apartment; noted to be incontinent of urine, cold, and without any verbal response. She was taken to ___ where she was intubated for airway protection (received etomidate, succinylcholine, and fentanyl), but her initial ABG was 7.47/41/48/29.8, lactate 2.0. Head CT there was negative for acute bleed; showed generalized atrophy as well as ill-defined hypodensities that could be age-indeterminate lucunar type infarcts. She was noted to be hypotensive and hypothermic. OSH labs: Chem7 Na 148, K 2.2, Cl 94, CO2 28, Cr 2.9 WBC 9.8, Hgb 15.9, Hct 48.7 (manual diff 56 neuts, 30 bands), Plt 98 AST 76, ALT 40, Alk phos 80 Troponin I 0.03 UA: negative ketones, neg nitrites, + leuk esterase, many bacteria CK 1249 She received Zosyn and was volume resuscitated with 5L NS, started on Levophed, and was transferred to ___ for further management. In the ED, initial vitals VS 91.7 (rectal), 97, 135/95, 18, 97% intubated (vent settings ). Exam was notable for coarse lung sounds and also had loose guaiac positive dark brown/black watery stools. Labs notable for Na 152, K 2.3, Cl 128, HCO3 17. ABG was 7.15/46/102/17, lactate 1.8. Cr was 1.9. WBC 9.6, Hct 46.5 and Plt 93, INR 1.1. CK 854, MB 37, MBI 4.3. Serum tox screen was negative. CXR prelim read concerning for PNA. CT abdomen without contrast was performed which showed R sided pleural effusion and possible infection versus atelectasis of L lung base; possible bowel wall thickening versus decompressed bowel of descending colon also seen. EKG showed NSR 97, TWI V3-V6, no ischemic ST changes otherwise. The patient received an additional 1L NS bolus in the ED. Blood cultures pending. She received CK repletion and an additional dose of Vanc/Zosyn prior to transfer to MICU. Patient with R IJ central line placed at OSH for access. On arrival to the MICU, initial VS 96.7, 95, 108/63, 19, 94% intubated. Past Medical History: COPD chronic alcohol abuse osteoarthritis Social History: ___ Family History: unknown Physical Exam: ADMISSION PHYSICAL EXAM: Vitals- 96.7, 95, 108/63, 19, 94% intubated GENERAL: sedated, intubated, responsive to voice, not following any commands HEENT: MMM, NCAT, pupils reactive symmetrically NECK: supple, JVP not elevated, no LAD LUNGS: rhonchorous lung sounds bilaterally, no end-expiratory wheezes CV: RRR, nml S1 and S2, no m/r/g ABD: soft, mildly distended, pt not grimacing with deep palpation EXT: warm, extremities diffusely mottled, palpable pulses distally of BLE SKIN: per above NEURO: sedated, intubated DISCHARGE PHYSICAL EXAM: Vitals: 98.6; 144/84; 97; 20; 97/RA General: No acute distress. HEENT: PERRL, dry cracked lips. Cardiac: RRR, no murmurs, rubs, gallops but distant heart sounds Respiratory: Coarse breath sounds. Poor air movement Abdominal: Soft, nontender, nondistended. Normal active bowel sounds Extremities: Warm, well-perfused. Neuro: Knows she is in hospital in ___. Does not know month or year. Moving all extremities. Pertinent Results: ADMISSION LABS: ============================ ___ 01:05AM UREA N-74* CREAT-1.9* ___ 01:05AM estGFR-Using this ___ 01:05AM CK(CPK)-854* ___ 01:05AM CK-MB-37* MB INDX-4.3 ___ 01:05AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 01:05AM WBC-9.6 RBC-4.33 HGB-14.6 HCT-46.5 MCV-107* MCH-33.8* MCHC-31.5 RDW-16.0* ___ 01:05AM ___ PTT-31.7 ___ ___ 01:05AM PLT SMR-LOW PLT COUNT-93* ___ 01:05AM ___ ___ 01:19AM TYPE-ART PO2-102 PCO2-46* PH-7.15* TOTAL CO2-17* BASE XS--12 ___ 01:19AM GLUCOSE-92 LACTATE-1.8 NA+-152* K+-2.3* CL--128* ___ 01:19AM HGB-14.7 calcHCT-44 O2 SAT-93 CARBOXYHB-1 MET HGB-0 ___ 01:19AM freeCa-0.80* ___ 04:47AM URINE HOURS-RANDOM ___ 04:47AM URINE HOURS-RANDOM ___ 04:47AM URINE GR HOLD-HOLD ___ 04:47AM URINE UHOLD-HOLD ___ 04:47AM URINE COLOR-YELLOW APPEAR-Hazy SP ___ ___ 04:47AM URINE BLOOD-MOD NITRITE-POS PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-LG ___ 04:47AM URINE RBC-3* WBC-55* BACTERIA-MANY YEAST-NONE EPI-4 ___ 04:47AM URINE HYALINE-32* ___ 04:47AM URINE MUCOUS-OCC ___ 05:55AM GLUCOSE-106* UREA N-72* CREAT-2.1* SODIUM-158* POTASSIUM-3.4 CHLORIDE-125* TOTAL CO2-21* ANION GAP-15 ___ 05:55AM ALT(SGPT)-60* AST(SGOT)-146* ALK PHOS-118* TOT BILI-0.6 ___ 05:55AM ALBUMIN-2.1* CALCIUM-6.2* PHOSPHATE-5.4* MAGNESIUM-1.7 ___ 05:55AM HBsAg-NEGATIVE HBs Ab-NEGATIVE IgM HBc-NEGATIVE ___ 05:55AM HCV Ab-NEGATIVE ___ 05:55AM WBC-8.2 RBC-3.91* HGB-13.0 HCT-42.8 MCV-110* MCH-33.3* MCHC-30.4* RDW-15.6* ___ 05:55AM NEUTS-80* BANDS-3 LYMPHS-7* MONOS-6 EOS-1 BASOS-0 ATYPS-1* METAS-1* MYELOS-1* ___ 05:55AM I-HOS-AVAILABLE ___ 05:55AM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-NORMAL MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-NORMAL ___ 05:55AM ___ PTT-31.6 ___ ___ 05:55AM PLT SMR-LOW PLT COUNT-107* ___ 06:01AM ___ PO2-62* PCO2-96* PH-6.96* TOTAL CO2-23 BASE XS--13 ___ 06:01AM LACTATE-2.8* ___ 07:20AM TYPE-ART TEMP-37.2 RATES-32/ TIDAL VOL-380 PEEP-8 O2-100 PO2-81* PCO2-45 PH-7.08* TOTAL CO2-14* BASE XS--16 AADO2-581 REQ O2-96 INTUBATED-INTUBATED VENT-CONTROLLED ___ 07:20AM LACTATE-2.4* ___ 07:20AM O2 SAT-87 ___ 07:20AM freeCa-0.79* ___ 10:16AM ___ PO2-65* PCO2-59* PH-7.05* TOTAL CO2-17* BASE XS--15 ___ 10:16AM O2 SAT-79 ___ 10:13AM TYPE-ART PO2-89 PCO2-47* PH-7.07* TOTAL CO2-14* BASE XS--16 ___ 10:13AM LACTATE-3.2* ___ 11:31AM URINE HOURS-RANDOM UREA N-363 CREAT-55 SODIUM-33 POTASSIUM-18 CHLORIDE-37 ___ 02:32PM CALCIUM-5.6* PHOSPHATE-4.2 MAGNESIUM-1.4* ___ 02:32PM GLUCOSE-168* UREA N-66* CREAT-2.0* SODIUM-147* POTASSIUM-2.9* CHLORIDE-118* TOTAL CO2-13* ANION GAP-19 ___ 02:32PM OSMOLAL-316* ___ 02:32PM AMMONIA-59 ___ 02:32PM WBC-6.0 RBC-3.91* HGB-12.6 HCT-42.9 MCV-110* MCH-32.2* MCHC-29.4* RDW-15.8* ___ 02:32PM PLT COUNT-65* ___ 02:48PM TYPE-ART PO2-100 PCO2-50* PH-7.08* TOTAL CO2-16* BASE XS--15 ___ 02:48PM LACTATE-4.5* ___ 07:58PM TYPE-ART TEMP-36.1 O2-50 PO2-78* PCO2-39 PH-7.28* TOTAL CO2-19* BASE XS--7 INTUBATED-INTUBATED ___ 07:58PM LACTATE-2.3* ___ 07:58PM freeCa-1.08* ___ 07:45PM GLUCOSE-169* UREA N-65* CREAT-2.1* SODIUM-143 POTASSIUM-3.6 CHLORIDE-115* TOTAL CO2-20* ANION GAP-12 ___ 07:45PM CALCIUM-6.8* PHOSPHATE-3.3 MAGNESIUM-1.3* ___ 06:07PM TYPE-ART RATES-22/ TIDAL VOL-500 PEEP-8 O2-50 PO2-89 PCO2-42 PH-7.23* TOTAL CO2-18* BASE XS--9 ___ 06:07PM LACTATE-2.2* K+-3.1* DISCHARGE LABS =============================== ___ 05:42AM BLOOD WBC-6.0 RBC-2.15* Hgb-7.1* Hct-21.8* MCV-102* MCH-33.2* MCHC-32.7 RDW-16.6* Plt ___ ___ 05:42AM BLOOD Plt ___ ___ 05:42AM BLOOD Glucose-73 UreaN-9 Creat-0.9 Na-146* K-3.4 Cl-116* HCO3-23 AnGap-10 ___ 05:42AM BLOOD Calcium-8.3* Phos-3.6 Mg-1.7 MICROBIOLOGY ============================== ___ BLOOD CULTURE negative ___ 6:00 am MRSA SCREEN Source: Nasal swab. FINAL REPORT ___ MRSA SCREEN (Final ___: No MRSA isolated. ___ 11:31 am URINE Site: NOT SPECIFIED Source: Catheter. FINAL REPORT ___ URINE CULTURE (Final ___: ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML.. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI \| AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R ___ 9:30 am STOOL CONSISTENCY: WATERY FINAL REPORT ___ C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. (Reference Range-Negative). ___ 10:00 am BLOOD CULTURE pending ___ 10:00 am URINE FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. ___ 10:00 am SPUTUM FINAL REPORT ___ GRAM STAIN (Final ___: >25 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final ___: Further incubation required to determine the presence or absence of commensal respiratory flora. GRAM NEGATIVE ROD(S). SPARSE GROWTH. SUGGESTING PSEUDOMONAS. ___ 10:00 am BLOOD CULTURE pending ___ 12:45 pm BRONCHOALVEOLAR LAVAGE BRONCHIAL LAVAGE. GRAM STAIN (Final ___: 3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Preliminary): NO GROWTH, <1000 CFU/ml. ___ 12:26 pm SPUTUM GRAM STAIN (Final ___: >25 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Preliminary): NO GROWTH ___ 10:11 pm STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. FINAL REPORT ___ C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. (Reference Range-Negative). ___ 1:20 pm URINE Site: CATHETER CHM S# ___ UCU ADDED ___. **FINAL REPORT ___ URINE CULTURE (Final ___: YEAST. 10,000-100,000 ORGANISMS/ML.. OF TWO COLONIAL MORPHOLOGIES. IMAGING: =============================== ___ EEG IMPRESSION: This is an abnormal continuous video EEG study due to the presence of a diffuse slowing of the background with frequent bursts of generalized slowing and frequent suppressive bursts. These findings indicate a moderate-severe diffuse encephalopathy which implies widespread cerebral dysfunction but is non-specific as to etiology. No epileptiform activity was seen. ___ EKG Sinus rhythm. Borderline low voltage. Diffuse ST segment changes. Consider ischemia versus toxic metabolic process. No previous tracing available for comparison. ___ CXR IMPRESSION: 1. Peribronchial opacification in the right lower lung extending to the chest wall, concerning for aspiration. 2. Left lower lobe collapse, which could also be possibly due to aspiration. 3. Left pleural effusion. 4. ET tube and right IJ central line are in adequate position. 5. NG tube terminates with the side port at the level of the GE junction. The tube could be advanced 5-10 cm for more optimal positioning. ___ CT ABDOMEN/PELVIS W/O CONTRAST IMPRESSION: 1. Somewhat limited exam due to noncontrast technique. 2. Left lower lobe atelectasis/collapse. 3. Bilateral pleural effusions. 4. Bowel wall thickening in the descending colon without adjacent fat stranding, consistent with a non-specific colitis. 5. Pericholecystic fluid, recommend continued attention on followup. 6. Mild to moderate ascites throughout the abdomen. ___ CXR FINDINGS: In comparison with the earlier study of this date, there has been placement of a left IJ catheter that extends to the lower portion of the SVC. Other monitoring and support devices are unchanged. Little change in the left basilar opacity consistent with volume loss in the left lower lobe and layering pleural effusion. Right lung remains essentially clear. ___ CXR In comparison with the study of ___, there has been placement of a Dobbhoff tube that extends to the distal stomach. There is poor definition of the right hemidiaphragm with some vague opacification above that. This could reflect layering pleural effusion with volume loss in the right lower lung. No evidence of vascular congestion. ___ CXR IMPRESSION: In comparison with the study of ___, the lungs are now clear. Right PICC line extends to the lower SVC. Brief Hospital Course: ___ with unknown PMHx presenting from OSH after being found unresponsive with LLL PNA/collapse, toxic metabolic encephalopathy, septic shock and oliguric renal failure leading to a MICU stay, and transferred to the floor. ACUTE ISSUES =========================== # Septic shock - Patient had imaging findings concerning for PNA and with significant bandemia per OSH labs; Less likely sources were sacral ulcer and UTI ___ E coli). Initially on pressors, norepinephrine and vasopressin, and broad spectrum antibiotics (vanc/cefepime/levo/flagyl). Bronchoscopy with bronchoalveolar lavage was performed and grew out Pseudomonas and MSSA, both sensitive to Zosyn. She completed a 14 day course of Zosyn, with the last day being ___. # Hypoxemic Respiratory failure: Intubated primarily for airway protection at OSH, but initial ABG suggestive of hypoxemic respiratory failure. Likely due to LLL pneumonia diagnosed on bronch. Treated as above, initially required paralysis w/ rocuronium in addition to fent/versed, extubated ___. # Pseudomonas and MSSA pneumonia: Concerning for possible aspiration pneumonia given that she was found down by EMS. Bronchoscopy with bronchoalveolar lavage was performed and grew out Pseudomonas and MSSA, both sensitive to Zosyn. She completed a 14 day course of Zosyn, with the last day being ___. Patient completed a 14 -day course of Zosyn on ___. # Urinary urgency - U/A on ___ was positive while patient was still on Zosyn. She was started on empiric treatment with vancomycin until urine cultures returned as yeast, likely a contaminant. Her vancomycin was then discontinued. # Toxic metabolic encephalopathy: Patient likely became intoxicated, aspirated, and became septic. Since she lived alone, she went several days before her neighbor checked up on her. CT head was negative for acute bleed although OSH CT read noted possibility of prior lacunar infarcts. Serum tox showed no evidence of any ingestion, although ingestion of other alcohol (ethylene glycol/methanol) still possible. EKG showed no evidence of any arrhythmia and ACS unlikely with normal troponin. EEG was negative for seizure. Mental status improved after sedation weaned. Delirious in ICU after extubation. After transfer to the floor, patient's mental status improved after she was taken off restraints and her foley and rectoseal tubes were removed. She was continued on thiamine, folate, and multivitamins. # Nutrition: A dobhoff tube was placed for tube feeds. On the floor, patient pulled out her dobhoff tube several times. She was placed on TPN for a few days until she passed her video swallowing test. Nutrition recommended thin liquids and pureed solids. Shortly after patient resumed PO intake, she started having more bowel movements daily. C. diff was negative. - Encourage patient's PO intake as she does not naturally eat or drink much. ___ need to supplement nutrition. Patient is currently on thin liquids and pureed solids. # Oliguric ___ requiring CVVH: Cr of 1.9 at admission was improved from 2.9 at OSH. Increased creatinine likely due to ATN from septic shock. CVVH was initiated for acidemia (pH as low as 7.05 on ABG) through temporary femoral line. At time of call out from the ICU, she was making about 20cc/hr urine. Her femoral line was discontinued and she was monitored for renal recovery. On the floor, she did not require any more dialysis, she remained hemodynamically stable, and her kidney function continued to improve. Creatinine on discharge was 0.9. # Transaminitis: Mild. ALT 60, AST 146 on admission. Resolved the day after admission and was most likely due to alcohol abuse given AST/ALT ratio. # Thrombocytopenia: Resolved. Most likely related to sepsis on top of chronic alcohol use. DIC unlikely as coags were normal. No evidence of schistocytes on smear. Since platelets dropped to 27 on ___, ordered HIT wkup. HIT AB+ with equivocal optical density. 4T score: 3 (low prob). Presented to OSH ___ withplatelets 98. Got three doses of SQH total here (___). Serotonin-release assay was negative for HIT, and plts uptrended to normal. Patient was restarted on heparin with no drop in platelet counts. # Anemia: Likely GI source since stools all guaiac positive in the unit. Hemolysis labs were negative. In the unit, her hemaglobin dropped acutely from 14.6 on admission to 8.8 in two days. Unclear if due to dilutional effect from fluids. Patient's hemaglobin stabilized during the rest of admission, with discharge hemaglobin being 7.1. - Recheck hemoglobin on ___ as it was 7.1 on discharge. Transfuse if necessary. TRANSITIONAL ISSUES ============================= - Recheck hemoglobin on ___ as it was 7.1 on discharge. Transfuse if necessary. - Encourage patient's PO intake as she does not naturally eat or drink much. ___ need to supplement nutrition. Patient is currently on thin liquids and pureed solids. - Recheck chemistry as patient's Na on ___ was 146, likely due to poor PO intake and diarrhea. - Code status: DNR/can intubate - Contact: ___ ___ (H), ___ (C) Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Fluoxetine 20 mg PO DAILY 2. Gabapentin 600 mg PO TID 3. Losartan Potassium 25 mg PO DAILY 4. meloxicam 15 mg oral daily 5. Methadone 20 mg PO BID 6. Methadone 10 mg PO QHS 7. Pravastatin 20 mg PO DAILY 8. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB 9. ClonazePAM 0.5 mg PO Q8H:PRN anxiety Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary diagnosis: Septic shock Hypoxemic respiratory failure Pseudomonas and MSSA pneumonia Toxic metabolic encephalopathy Oliguric ___ Secondary diagnoses: Failure to thrive Thrombocytopenia Anemia Transaminitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Ms. ___, Thank you for letting us participate in your care at ___ ___. You were transferred to the Intensive Care Unit from an outside hospital because you were found unconscious. You were intubated in the ICU because you were not breathing well on your own. It turned out that you had a bad pneumonia, which you completed antibiotics for. Your kidney function also decreased, but they returned to normal during your stay here. Our nutrition team followed you while you were here and made sure you were able to get the nutrients you needed when you couldn't eat. It is very important that you keep eating and drinking water so that your blood pressure does not get too low again and your kidneys do not get injured again. We wish you a speedy recovery! Your ___ team Followup Instructions: ___
19564403-DS-11	19,564,403	27,550,027	DS	11	2139-12-19 00:00:00	2139-12-19 22:08:00	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 a ___ year-old male with no significant past medical history who presented to ___ ED on ___ with chest pain after drinking two cups coffee and smoking on ___. The pain was crampy and radiated to his left arm. The episode was associated with diaphoresis. He does not report alleviating nor exacerbating factors. Subsequently, the pain decreased in severity but did not remit. The patient decided to come to the ED due to concerns about his heart. Past Medical History: None Social History: ___ Family History: Denies family history of heart disease. Physical Exam: ============================ ADMISSION PHYSICAL EXAMINATION ============================ ___: T: 98.0 BP: 145/94 L Lying HR: 73 O2 sat: 99% FSBG: L arm General: Alert, oriented, no acute distress HEENT: Sclerae anicteric, MMM, oropharynx clear, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: Warm, dry, no rashes or notable lesions. Neuro: grossly intact ============================= DISCHARGE PHYSICAL EXAMINATION ============================= ___: T:98.4 BP: 146/103 L Lying HR: 73 O2 sat: 99% FSBG: L arm General: Alert, oriented, no acute distress HEENT: Sclerae anicteric, MMM, oropharynx clear, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: Warm, dry, no rashes or notable lesions. Neuro: grossly intact Pertinent Results: =============== ADMISSION LABS =============== ___ 10:50PM BLOOD WBC-8.7 RBC-5.35 Hgb-15.6 Hct-44.9 MCV-84 MCH-29.2 MCHC-34.7 RDW-11.9 RDWSD-35.4 Plt ___ ___ 10:50PM BLOOD Glucose-86 UreaN-15 Creat-1.0 Na-142 K-3.6 Cl-101 HCO3-29 AnGap-12 ___ 10:50PM BLOOD cTropnT-<0.01 ___ 10:50PM BLOOD Triglyc-105 HDL-39* CHOL/HD-4.2 LDLcalc-104 ___ 10:50PM BLOOD TSH-2.3 ___ 06:09AM BLOOD Cortsol-4.5 ___ 10:50PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 12:45AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG =============== DISCHARGE LABS =============== ___ 03:55PM BLOOD WBC-6.5 RBC-5.31 Hgb-15.2 Hct-44.0 MCV-83 MCH-28.6 MCHC-34.5 RDW-12.0 RDWSD-36.2 Plt ___ ___ 03:55PM BLOOD Glucose-91 UreaN-12 Creat-1.0 Na-143 K-4.0 Cl-102 HCO3-30 AnGap-11 ___ 05:45AM BLOOD %HbA1c-5.3 eAG-105 ======== IMAGING ======== CXR - ___ No focal consolidation or pleural effusion seen. Mild prominence along the right mediastinum along/adjacent to the course of the ascending aorta, underlying lymphadenopathy or dilatation of the ascending aorta not excluded. Findings would be further assessed on chest CT. CTA CHEST - ___ 1. No evidence of pulmonary embolism or aortic abnormality. 2. Findings suggestive of small airways disease. RENAL U/S AND ARTERY DOPPLER - ___ Normal renal ultrasound. No renal artery stenosis Brief Hospital Course: SUMMARY: =================== ___ is a ___ male with no significant past medical history who presented to the ___ ED on ___ with 1 week of intermittent chest pain, found to have elevated blood pressure concerning for hypertensive emergency. He was admitted for further work-up and management; his hospital course is detailed below. ACTIVE ISSUES: # Chest pain # Hypertensive emergency Patient presents with acute onset, recurrent episodes of chest pain that radiates to his left arm and associated with diaphoresis for the past week. In the ED, the patient was found to have blood pressure of 181/116. ECG was notable for incomplete RBBB. Trops negative X3. CTA chest was negative for PE, dissection, or coarctation. Renal U/S with doppler showed normal cortical echogenicity and corticomedullary differentiation with no evidence of renal artery stenosis. TSH, morning cortisol, lipid profile and A1C were within normal limits. Serum metanephrines pending at discharge. The patient endorses consumption of energy drinks, coffee and soda several times a day. Toxicology screen negative for alcohol and cocaine. In the ED, the patient was given labetalol and nitroglycerin that decreased his BP significantly. The patient was started on Lisinopril 10 mg once daily and hydrochlorothiazide 12.5 mg once daily. He was advised to follow-up with nephrology for work up of possible secondary hypertension as well as a primary care physician for assessment of blood pressure and a serum chemistry check given initiation of the above medications. # Right bundle branch block: ECG was notable for incomplete RBBB on ___ in the setting of hypertensive emergency as noted above. CHRONIC ISSUES: ===================== # Headache Frequent, morning headaches x ___ years. Unrelated to episodes of hypertension and chest pain. Concern for sleep apnea vs paroxysmal headaches from frequent NSAID use. Transitional issues: ===================== [] Serum metanephrines pending at discharge [] Cardiac echo not performed during this admission, will need to be scheduled as outpatient [] Pt instructed to call a primary care doctor and schedule an appointment for this week. After discharge, patient scheduled himself to see ___, NP. Discharge paperwork to be sent to his office for review prior to this appointment [] Pt instructed to call a the ___ clinic to schedule an appointment for further work up of high blood pressure. The number is ___. [] Pt instructed to ask his primary care doctor to schedule an outpatient SLEEP STUDY Medications on Admission: None Discharge Medications: 1. Hydrochlorothiazide 12.5 mg PO DAILY RX hydrochlorothiazide 12.5 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:3 2. Lisinopril 10 mg PO DAILY RX lisinopril 10 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:3 Discharge Disposition: Home Discharge Diagnosis: PRIMARY: - Chest pain - Hypertensive emergency SECONDARY: - Right bundle branch block - Headaches Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear ___, It was a pleasure to care for you at the ___ ___. Why did you come to the hospital? -You had high blood pressure that caused you chest pain. What did you receive in the hospital? -You were given medications to decrease your blood pressure which also helped your chest pain. -You were started on two blood pressure medications called Lisinopril and hydrochlorothiazide. What should you do once you leave the hospital? -You should continue to take your blood pressure medication as instructed (Lisinopril 10 mg once daily and hydrochlorothiazide 12.5 mg once daily). -You should start seeing a primary care physician (PCP) to follow-up on high blood pressure. If you are interested in seeing a doctor here at the ___, please call Health Care Associates (HCA) at ___ to schedule an appointment. -You should follow-up with a kidney doctor. If no one contacts you in ___ business days please call ___ to schedule an appointment. -Please limit your intake of caffeinated beverages such as energy drinks, soda and coffee -Please speak with your primary care doctor about life style changes such as weight loss, exercise and eating a healthy diet, as we believe this will help improve your blood pressure. We wish you the best! Your ___ Care Team Followup Instructions: ___
19564521-DS-10	19,564,521	25,458,869	DS	10	2167-04-10 00:00:00	2167-04-10 20:33:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: This is a ___ year old woman who was recently diagnosed with invasive cancer in her right breast ER/PR + HER2 +, with recently identified mets to liver and thoracic spine, C3D8 from docetaxel, trastuzumab and pertuzumab w/ Neulasta. She is presenting with recurrent low grade fevers to 100.8 over the weekend w/ associated new DOE and some pleuritic chest pressure, as recently as yesterday. She also notes LH on standing as well as diarrhea, but notes that this is consistent with her prior diarrhea after her chemo cycles. She has not had any other localizing infectious symptoms. Past Medical History: stage IV breast CA, mets to thoracic spine and liver depression goiter Social History: ___ Family History: paternal aunt breast CA brother/father in good health mother uterine CA paternal GM colon CA Physical Exam: Admission exam: t98 110/72 hr 110 rr16 98% ra comfortable eomi, perrl no ___ neck supple chest clear tachy regular abd benign ext w/wp without edema neuro: non-focal skin: no rash Discharge exam: Vitals: 98.2 96/50 95 14 98% RA (orthostatic by HR and symptoms) GENERAL: NAD, awake and alert HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva, patent nares, MMM, good dentition NECK: nontender and supple, no LAD, no JVD CARDIAC: RRR, nl S1 S2, no MRG LUNG: CTAB, no rales wheezes or rhonchi, no accessory muscle use ABDOMEN: +BS, soft, non-tender, non-distended, no rebound or guarding, no HSM EXT: warm and well-perfused, no cyanosis, clubbing or edema PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII tested and intact, strength ___ throughout, sensation grossly normal, gait intact SKIN: warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: Admission labs: ___ 04:10PM URINE HOURS-RANDOM ___ 03:36PM LACTATE-1.9 ___ 03:15PM GLUCOSE-101* UREA N-4* CREAT-0.7 SODIUM-141 POTASSIUM-3.7 CHLORIDE-99 TOTAL CO2-30 ANION GAP-16 ___ 03:15PM WBC-17.8# RBC-4.00 HGB-12.7 HCT-37.7 MCV-94 MCH-31.9 MCHC-33.8 RDW-15.0 ___ 03:15PM NEUTS-63 BANDS-8* LYMPHS-7* MONOS-6 EOS-0 BASOS-0 ___ METAS-5* MYELOS-6* PROMYELO-5* ___ 02:15PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-OCCASIONAL ___ 04:10PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG ___ 04:10PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 04:10PM URINE GR HOLD-HOLD ___ 04:10PM URINE UCG-NEGATIVE ___ 04:10PM URINE HOURS-RANDOM ___ 04:10PM URINE HOURS-RANDOM Discharge labs: ___ 07:25AM BLOOD WBC-23.7* RBC-3.48* Hgb-10.6* Hct-32.9* MCV-94 MCH-30.6 MCHC-32.4 RDW-15.1 Plt ___ ___ 07:25AM BLOOD Glucose-72 UreaN-6 Creat-0.6 Na-142 K-3.8 Cl-106 HCO3-27 AnGap-13 ___ 07:25AM BLOOD Calcium-8.9 Phos-3.8 Mg-1.9 Studies: CT-PE ___: IMPRESSION: 1. No pulmonary embolism or acute aortic pathology. 2. New tiny minimally-complex pericardial effusion. 3. Worsening osseous metastatic disease involving the majority of the thoracic spine. There is no evidence of a fracture or spinal canal narrowing at this point. 4. Hepatic metastases appear decreased in size and number, though assessment is suboptimal on this arterial phase exam. TTE ___: IMPRESSION: Very small pericardial effusion. Normal biventricular cavity size and global/regional systolic function. No pathologic valvular abnormalities. Bone scan ___: IMPRESSION: Osseous metastatic disease involving the right sacrum, which has become positive since ___. Lesions at T10 and L2 only appreciated on SPECT/CT performed today. Note that most of the thoracic spine was not included on the SPECT/CT. Brief Hospital Course: This is a ___ year old woman who was recently diagnosed with invasive cancer in her right breast ER/PR + HER2 +, with recently identified mets to liver and thoracic spine, C3D8 from docetaxel, trastuzumab and pertuzumab w/ Neulasta, presenting with DOE, pleuritic chest pressure, and low grade fevers. # DOE/pleuritic chest pressure: Unclear etiology but acute in onset. No e/o cardiopulmonary abnormality on exam, EKG, CT/PE, or TTE. Pleuritic chest pain could be ___ sternal marrow stimulation from Neulasta or pleurisy. She was not severely anemic. DOE could have been ___ hypovolemia and deconditioning in the setting of advanced cancer. Her DOE resolved soon after admission with volume resuscitation. She was ambulated without dyspnea or hypoxia. She will follow up with medical oncology as an outpatient. # Hypovolemia: Likely ___ diarrhea from chemo. She was orthostatic on admission, which resolved with IVF. # Low grade fevers: No obvious etiology, but was afebrile upon admission. Only localizing symptom was diarrhea, and this was most likely ___ chemo (has occurred with prior cycles), and also had resolved by the time she was admitted. Leukocytosis likely ___ Neulasta. Her UA was neg, no PNA on CT. Could also consider tumor response to chemo as an etiology. # Metastatic breast cancer: Stage IV, Triple+, mets to liver and spine. C3D8 from docetaxel, trastuzumab and pertuzumab w/ Neulasta. Liver mets imrproved on CTA. It was unclear at discharge if new thoracic lesions on CT and pelvis lesions on bone scan were pre-existing and only now flairing from chemo response (which would argue for better prognosis). The plan is for q3 cycles of chemo going forward. She will follow up with medical oncology as an outpatient. Transition issues: - She will follow up with medical oncology as an outpatient. Medications on Admission: 1. Dexamethasone 8 mg PO Q12H 2. Lorazepam 0.5-1 mg PO Q6H:PRN nausea, insomnia 3. Ondansetron 8 mg PO Q12H 4. Neulasta (pegfilgrastim) 6 mg/0.6mL subcutaneous once 5. Prochlorperazine 10 mg PO Q6H:PRN nausea Discharge Medications: 1. Dexamethasone 8 mg PO Q12H 2. Lorazepam 0.5-1 mg PO Q6H:PRN nausea, insomnia 3. Neulasta (pegfilgrastim) 6 mg/0.6mL subcutaneous once 4. Ondansetron 8 mg PO Q12H 5. Prochlorperazine 10 mg PO Q6H:PRN nausea Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: metastatic breast cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a pleasure taking care of you during your hospitalization at ___. You were admitted due to shortness of breath and low-grade fevers. You were also having diarrhea which resolved. You had a CT scan which was negative for blood clot in your lungs. You got a scan of your heart which showed that it was functioning normally. You will be discharged home without changes to your medications to follow up with Dr. ___ Dr. ___. Followup Instructions: ___
19564630-DS-20	19,564,630	22,397,205	DS	20	2139-09-29 00:00:00	2139-10-01 11:51:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: rash, fever Major Surgical or Invasive Procedure: none History of Present Illness: OUTPATIENT ATTENDING: Dr. ___ ___ COMPLAINT: Fever, Rash HISTORY OF PRESENT ILLNESS: Ms. ___ is a ___ year old woman with hx of stage I breast cancer, ER+/PR-, ___ s/p 2 cycles of Cyclophosphamide/Taxotere with neulasta (day 11 today) who presents with fever and rash. Her rash started 4 days ago and she saw dermatology yesterday ___ who recommended supportive treatment with hydroxyzine and triamcinolone cream. She has been taking these since her appointment yesterday. She came to the ER today after a fever of 101.5 at home. She also noted that the rash worsened today to involve her face. She has had a dry cough and sore throat which started yesterday. She denies mouth sores or mouth pain. In the emergency department, initial vitals: 101.9 110 102/68 16 99% RA. She was noted to have a WBC of 25.6. Other labs were wnl. LFTs were wnl. She notes that after her first cycle of TC she developed a slight rash at the IV site which lasted for about a week. Currently, she feels itchy but is not uncomfortable. She denies nausea, vomiting, diarrhea or constipation. She is in no pain. Review of systems: (+) Per HPI (-) Denies recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: PAST ONCOLOGIC HISTORY: -- ___: noted pruritus of the lower inner quadrant of the left breast and felt a mass -- ___: diagnostic mamogram showed highly suspicious mass in the upper inner left breast. An ultrasound confirmed the presence of a 15 mm x 10 mm x 10 mm lesion in that area that was highly suspicious and she underwent core needle biopsy, which confirmed the diagnosis of adenocarcinoma grade 3 infiltrating ductal type, ER positive, PR negative, HER-2 negative. -- ___: breast MRI showed the known biopsy-proven lesion in the upper inner left breast was noted measuring 2.1 cm and area of enhancement was also observed in the lower inner left breast biopsy of which was performed ___ and was negative for malignancy. -- ___: left sided total mastectomy with final pathology: pT1cN0Mx ER+/PR-/Her 2 non-amplified, +LVI. -- Oncytopye DX was 37 -- ___: cycle 1 TC -- ___: cycle 2 TC PAST MEDICAL HISTORY: cataracts glaucoma osteoporosis vertigo s/p hysterectomy s/p c-section x 2 Social History: ___ Family History: Negative for breast and ovarian cancer. Her father has had nasal cancer. Physical Exam: ADMISSION PHYSICAL EXAM: ============================= VS: T99.5 BP 90/54 HR 97 RR 20 98% RA GENERAL: alert and oriented, NAD HEENT: No scleral icterus. Sclerae are non-injected, no eye pain with movement. PERRLA/EOMI. MMM. OP with very small white patch on her left buccal mucosa. Neck Supple, No LAD. CARDIAC: RR. Normal S1, S2. No m/r/g. LUNGS: CTA B, good air movement bilaterally. ABDOMEN: NABS. Soft, NT, ND. No HSM GU: Rash extends to vagina but does not involve internal mucous membranes. EXTREMITIES: No c/c/e, 2+ dorsalis pedis/ posterior tibial pulses. NEURO: A&Ox3. Appropriate. CN ___ grossly intact. Preserved sensation throughout. ___ strength throughout. ___ reflexes, equal ___. Gait assessment deferred SKIN: Diffuse erythematous morbiliform rash with urticarial patches over arms and legs and confluent areas of the back, chest and abdomen. Face with diffise morbiliform rash. Eyelids are slightly swollen. DISCHARGE PHYSICAL EXAM: ============================ VS: Tm 99.1 Tc 98.3 BP 98/70 (98-116/60-70) 84 16 99% RA I/O: 1254/1425+, 1 BM GENERAL: Pleasant Asian woman, alert and oriented, NAD. HEENT: No scleral icterus. Sclerae are non-injected, no eye pain with movement. PERRLA/EOMI. MMM. OP with very small white patch on her right tongue without pain. No evidence of mucositis. NECK: Supple, possible node vs submandibular gland noted in right neck CARDIAC: RRR. Normal S1, S2. No m/r/g. LUNGS: CTAB, good air movement bilaterally. ABDOMEN: NABS. Soft, NT, ND. No HSM GU: Deferred EXTREMITIES: No c/c/e, 2+ dorsalis pedis/ posterior tibial pulses. NEURO: A&Ox3. Appropriate. CN ___ grossly intact. Preserved sensation throughout. ___ strength throughout. ___ reflexes, equal ___. Gait assessment deferred SKIN: Diffuse erythematous urticarial/targetoid patches over arms and legs and confluent areas of the back, chest and abdomen. Face with diffuse morbiliform rash. Eyelids are slightly swollen. All lesions signficantly improved from ___. Pertinent Results: PERTINENT LABS: ================================= ___ 02:30PM BLOOD WBC-36.3# RBC-3.73 Hgb-12.2 Hct-34.8* MCV-93 MCH-32.8* MCHC-35.1* RDW-14.3 Plt ___ ___ 05:45PM BLOOD WBC-25.6* RBC-3.81* Hgb-12.4 Hct-35.9* MCV-94 MCH-32.5* MCHC-34.5 RDW-13.7 Plt ___ ___ 07:50AM BLOOD WBC-24.0* RBC-2.97* Hgb-9.4* Hct-27.6* MCV-93 MCH-31.6 MCHC-34.0 RDW-14.3 Plt ___ ___ 05:00AM BLOOD WBC-26.1* RBC-2.90* Hgb-9.1* Hct-27.1* MCV-94 MCH-31.6 MCHC-33.7 RDW-14.3 Plt ___ ___ 07:40AM BLOOD WBC-15.8* RBC-2.90* Hgb-9.1* Hct-27.0* MCV-93 MCH-31.2 MCHC-33.6 RDW-14.1 Plt ___ ___ 07:45AM BLOOD WBC-11.0 RBC-3.10* Hgb-9.5* Hct-29.1* MCV-94 MCH-30.7 MCHC-32.7 RDW-14.2 Plt ___ ___ 05:45PM BLOOD Neuts-91.6* Lymphs-6.1* Monos-2.0 Eos-0.1 Baso-0.2 ___ 05:00AM BLOOD ___ PTT-43.6* ___ ___ 02:30PM BLOOD ___ ___ 05:45PM BLOOD Glucose-103* UreaN-7 Creat-0.7 Na-133 K-3.5 Cl-98 HCO3-24 AnGap-15 ___ 07:45AM BLOOD Glucose-110* UreaN-6 Creat-0.5 Na-141 K-4.0 Cl-109* HCO3-24 AnGap-12 ___ 05:45PM BLOOD ALT-18 AST-29 AlkPhos-84 TotBili-0.3 ___ 05:00AM BLOOD ALT-11 AST-16 LD(LDH)-298* AlkPhos-53 TotBili-0.4 ___ 07:45AM BLOOD Calcium-8.2* Phos-3.0 Mg-2.2 ___ 07:40AM BLOOD Albumin-2.8* Calcium-7.9* Phos-2.3* Mg-2.2 MICROBIOLOGY: ======================== ___ 08:45PM URINE Color-Straw Appear-Clear Sp ___ ___ 08:45PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ 08:45PM URINE RBC-<1 WBC-1 Bacteri-NONE Yeast-NONE Epi-0 urine culture ___ - < 10,000 organisms ___ blood cultures x 2 - negative ___ and ___ blood cultures x 2 - no growth to date ___ C. diff assay - negative IMAGING: ======================== ___ CXR IMPRESSION: No acute cardiopulmonary process. ___ CXR IMPRESSION: As compared to the previous radiograph, no relevant change is seen. No pneumonia, no pulmonary edema, no pleural effusions. Normal size of the cardiac silhouette. Minimal tortuosity of the thoracic aorta. Clips projecting over the mediastinum and the left axillary region. The study and the report were reviewed by the staff radiologist. ___ CXR IMPRESSION: As compared to the previous radiograph, no relevant change is seen. The lung volumes are normal. Normal size of the cardiac silhouette. Mild tortuosity of the thoracic aorta. Clips projecting over the mediastinum and the left axillary region. No evidence of pneumonia. No pleural effusions. No pulmonary edema. Brief Hospital Course: Ms. ___ is a ___ year old woman with a history of stage I breast cancer receiving adjuvant TC who presents with a morbiliform/urticarial drug erruption which started 7 days after recieving cyclophosphamide and taxotere and was associated with fever to 101.5 and leukocytosis # Drug Eruption: Most likely drug reaction from Taxotere, cytoxan or the antiemetics she recieved. There was some concern for ___'s syndrome secondary to neulasta given fever and leukocytosis, but these resolved without intervention, making ___'s syndrome less likely. Dermatology was consulted and they also believed this was consistent with drug reaction. Biopsy was offered to Ms. ___, but she declined multiple times. She was provided topical therapy and symptomatic relief with cetirizine, hydroxyzine, clobetasol and hydrocortisone creams. Her lesions were resolving by the time of discharge. She will most likely need a new chemotherapy regimen such as AC versus allergy testing prior to subsequent doses of TC. # Systemic Inflammatory Response: Fever to 101.5 and WBC to 36. She was initially started on Vancomycin and Cefepime over concern for systemic infection, but infectious work-up was negative. Therefore antibiotics were discontinued and she remained afebrile for 24 hours after this. # Breast Cancer: Will likely need new chemotherapy regimen (AC) vs. allergy testing prior to next dose. Her primary oncologist was informed of her drug reaction and will make this determination in follow-up # Glaucoma: Continued home eye drops # Sore Throat: Presented with sore throat, and some evidence of thrush. Treated with topical lidocaine and oral nystatin with good effect. TRANSITIONAL ISSUES: ======================== - likely needs alternative chemotherapy regimen (possibly AC) versus allergy testing - should stop taking clobetasol and desonide by ___ if not sooner Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID:PRN rash 2. HydrOXYzine 25 mg PO HS:PRN itching 3. Cetirizine 10 mg oral daily 4. Latanoprost 0.005% Ophth. Soln. 1 DROP RIGHT EYE HS 5. Pilocarpine 1% 1 DROP RIGHT EYE Q8H 6. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP RIGHT EYE BID Discharge Medications: 1. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP RIGHT EYE BID 2. Latanoprost 0.005% Ophth. Soln. 1 DROP RIGHT EYE HS 3. Pilocarpine 1% 1 DROP RIGHT EYE Q8H 4. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID RX clobetasol 0.05 % apply to skin, NOT FACE twice a day Refills:0 5. Hydrocortisone Cream 2.5% 1 Appl TP DAILY RX hydrocortisone 2.5 % apply to rash on face daily Refills:0 Discharge Disposition: Home Discharge Diagnosis: Drug reaction to likely taxotere causing diffuse eruptions, fever and leukocytosis 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 participating in your care while you were inpatient at ___. You came in with a rash all over your body that we think was caused by your chemotherapy medication. You also had a fever, but did not have any other evidence of infection. We therefore think that your fever was also due to your reaction to the medication. We are very pleased that your rash is doing better. You should continue to take the creams that we have prescribed and apply them. Please do not use the creams after ___. You will follow-up with the breast care oncology group on ___ to discuss further care. We wish you the best, Your ___ team Followup Instructions: ___
19564979-DS-5	19,564,979	24,793,520	DS	5	2152-03-19 00:00:00	2152-03-22 16:51:00	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 swelling Major Surgical or Invasive Procedure: None History of Present Illness: ___ male with HTN, HLD, BPH, arthritis presenting with swelling of left lower leg. Pt noted left leg discomfort one week ago when he returned from a trip to ___. He was the passenger in a car ride for approximately 3.5 hours. Pain began at the left knee and traveled downwards. He states that over the last week, pain and swelling have improved. Area of erythema has remained approximately the same. He reports ___ pain that does not affect his ambulation; takes prn ibuprofen. He was seen at ___'s office for routine follow-up. PCP noticed his left leg swelling and ordered ultrasound which was ambiguous for ruptured popliteal cyst vs thrombosed vein. D-dimer was elevated to 2520. He was referred to ED for further evaluation. Pt denies hx of recent surgery, trauma or injury. Denies family or personal history of cancer. He does not have any hx of malignancies. Denies chest pain or SOB. Denies fevers. . In the ED, initial VS: 97.6 112 145/82 17 100% ra. ___ performed at ___ was reviewed with radiologist here who felt that DVT was unlikely; felt that ruptured popliteal cyst vs ruptured plantaris were likely. MRI w/o contrast was performed that showed fluid tracking down gastrocnemius, most likely ___ infection such as cellulitis. He received 1g IV cefazolin prior to transfer to floor. . REVIEW OF SYSTEMS: Denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria. Past Medical History: Anemia, Macrocytic Prostatic Hypertrophy CAROTID BRUIT s/p CEA ___ ARTHRITIS - GOUTY HYPERTENSION, ESSENTIAL HYPERCHOLESTEROLEMIA Overweight Social History: ___ Family History: Father: stomach cancer Mother: CVA Physical ___: VS - 98.1 147/90 89 18 99%RA GENERAL - Alert, interactive, well-appearing in NAD HEENT - PERRL, EOMI, sclerae anicteric, MMM, OP clear NECK - Supple, no thyromegaly, no JVD HEART - PMI non-displaced, RRR, nl S1-S2, no MRG LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use ABDOMEN - NABS, soft/NT/ND, no masses or HSM EXTREMITIES - left leg from knee to ankle with swelling and mild diffuse erythema, only minimally tender to palpation, not significantly warmer to palpation as compared to RLE, no palpable cords, 2+ ___ peripheral pulses b/l, sensation intact SKIN - several cuts on both hands due to dry skin with dried blood LYMPH - no cervical LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength ___ throughout, steady gait Pertinent Results: ADMISSION LABS: ___ 05:15PM WBC-5.4 RBC-3.73* HGB-12.4* HCT-32.9* MCV-88 MCH-33.3* MCHC-37.7* RDW-12.1 ___ 05:15PM NEUTS-65.3 ___ MONOS-6.2 EOS-5.5* BASOS-0.7 ___ 05:15PM PLT COUNT-320 ___ 05:15PM GLUCOSE-89 UREA N-14 CREAT-0.9 SODIUM-134 POTASSIUM-3.8 CHLORIDE-97 TOTAL CO2-26 ANION GAP-15 . MRI Calf IMPRESSION: 1. Two non-hemorrhagic collections centered between the subcutaneous fat and calf musculature seen medially and laterally in the calf -- though no contrast was administered, these most likely represent fluid collections. The most likely etiology is sequella of a ruptured ___ cyst, although the distribution is somewhat atypical. 2. No evidence of plantaris rupture. 3. There is mild subcutaneous edema and minimal skin thickening, which is nonspecific. A component of cellulitis is not entirely excluded, but cellulitis is not favored to represent the primary process. Clinical correlation is requested. 4. Please note that this study was not optimized for assessment of the vessels or for assessment of the internal structures of the knee. Prominent venous varicosities noted. Brief Hospital Course: ___ male with HTN, HLD, BPH, arthritis presenting with swelling of left lower leg. . # Left leg swelling: Mr. ___ MRI showed a fluid collection most likely caused by a ruptured ___ cyst. He did not have a DVT on the MRI or prior US. Cellulitis was considered and he did receive one dose of antibiotics in the ED. However these were not continued on admission. He was discharged with ibuprofen for pain and swelling and instructions to elevate his foot to help reduce the swelling. . CHRONIC ISSUES: . # HTN: Well controlled on current regimen. Continuedt atenolol, lisinopril, HCTZ . # Anemia: Has chronic anemia. He was near his baseline and further work up was not performed. Medications on Admission: Atenolol 25 mg Oral Tablet Take 1 tablet daily Lisinopril 40 mg Oral Tablet TAKE ONE TABLET DAILY Hydrochlorothiazide 25 mg Oral Tablet TAKE ONE TABLET DAILY Simvastatin 10 mg Oral Tablet TAKE 1 tablet every evening DOCOSAHEXANOIC ACID/EPA (FISH OIL ORAL) MULTIVITAMIN ORAL ASPIRIN 81 MG TAB 1 tablet daily. . Discharge Medications: 1. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. docosahexanoic acid-epa Oral 6. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. 7. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Ruptured Popliteal Cyst Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr ___, Thank ___ for coming to the ___ ___. ___ were admitted because of the swelling in your leg. The MRI did not show a blood clot in your leg. We believe the most likely cause of the swelling is a ruptured cyst in your leg. ___ can take ibuprofen for pain and swelling. ___ can also elevate your leg to reduce the swelling. It is possible but less likely that this is an infection. We do not think that ___ need to take antibiotics now but if ___ have fevers, worsening pain or redness ___ should call your doctor or call the hospital at ___ and ask for Dr. ___ Dr ___ should make sure to call to set up an appointment with your primary doctor in the next week. There have been no changes to any of your medications during this admission. Followup Instructions: ___
19565020-DS-15	19,565,020	28,427,129	DS	15	2135-02-15 00:00:00	2135-02-15 14:27:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: chest pain Major Surgical or Invasive Procedure: Cardiac catheterization with bare metal stent to the right coronary artery History of Present Illness: Mr. ___ is ___ year old man with heavy smoking history and chronic pancreatitis but no other cardiac risk factors who was admitted to the CCU with a STEMI. Patient reported left arm pain over the past week. ___ he was evaluated in the emergency department for left arm pain, CT abdomen completed and was unremarkable and EKG reassuring. Patient carries a diagnosis of chronic pancreatitis. Given negatve work up and normal EKG patient was diagnosed with chronic pancreatitis/"gas pain" and discharged home. Left arm pain continued intermittent and waxing at first and without other associated symptoms and denying chest pain, chest pressure, shortness of breath, or DOE. He notes the pain became more constant on ___ night into morning of admission. He reports the pain worsened, he developed heart burn sensation, shortness of breath and dyspnea on exertion ___ night into the morning. Morning of admission he returned to ___ with worsening, constant left arm pain and heart burn symptoms. EKG in the ED revealed ST segment elevations in leads II, III and aVF (III>II) with also lateral V5, V6 ST segment elevations. Patient was taken for emergent cardiac catherization. Cath revealed occlusion of RCA which was stented. In the cath lab, patient was Plavix loaded with 600mg, he had already received 325mg PO Aspirin, Heparin and Integrillin drips were started for continued left arm pain. Cath also revealed proximal LAD disease and high Diag vs Ramus disease. He remained hemodynamically stable and course was uncomplicated. right groin was closed with angioseal. On arrival to the CCU, patient appeared comfortable and in NAD. He had residual left arm pain and symptoms of heart burn and so patient was started on nitro drip. Hemodynamically stable with SBPs in 130s and Hrs in ___. On review of systems, he denied any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denied recent fevers, chills or rigors. He denied exertional buttock or calf pain. All of the other review of systems were negative. Cardiac review of systems was notable for current absence of chest pain, no recent history of dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: - Depression - ?Chronic Pancreatitis ___ GI) Social History: ___ Family History: - Sister has MS and all of his relatives died at an advanced age. - No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. - Father: MI at ___ (___) Physical Exam: Admission Exam: VS:Afebrile, HR 70, BPs 125/80, RR 12 94% 2LNC W:88.5KG H ___ GENERAL: NAD. Oriented x3. Mood, affect appropriate. Comfortable HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with low JVP CARDIAC: PMI located in ___ intercostal space, midclavicular line. RR, S1, S2 clear and of good quality. No m/r/g. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi, moving air well and symmetrically ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. No femoral bruits. 2+ pulses bilateral ___. right femoral groin C/D/I no hematoma, bleed or bruit NEURO: AOx3, non-focal Discharge Exam: VS: TM/TC: 98.2/98.2 HR: 63-654 RR: ___ BP: 100-107/54-60 O2 sat 100% RA WEight 89.3 GENERAL: NAD. Oriented x3. Mood, affect appropriate. Comfortable HEENT: Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. NECK: Supple with low JVP CARDIAC: RR, S1, S2 clear and of good quality. No m/r/g. No S3 or S4. LUNGS: CTAB, no crackles, wheezes or rhonchi, moving air well and symmetrically ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. No femoral bruits. 2+ pulses bilateral ___. right femoral groin C/D/I no hematoma, bleed or bruit NEURO: AOx3, non-focal Pertinent Results: Admission Labs: ___ 11:45AM BLOOD WBC-10.7 RBC-5.33 Hgb-15.9 Hct-48.7 MCV-91 MCH-29.8 MCHC-32.6 RDW-13.3 Plt ___ ___ 11:45AM BLOOD Neuts-77.8* Lymphs-13.7* Monos-5.7 Eos-2.0 Baso-0.8 ___ 11:45AM BLOOD ___ PTT-31.4 ___ ___ 11:45AM BLOOD Glucose-136* UreaN-18 Creat-1.1 Na-135 K-4.1 Cl-101 HCO3-25 AnGap-13 ___ 11:45AM BLOOD ALT-25 AST-23 AlkPhos-76 TotBili-0.3 Cardiac Biomarkers: ___ 11:45AM BLOOD cTropnT-<0.01 ___ 06:30AM BLOOD cTropnT-0.07* ___ 03:46PM BLOOD CK-MB-44* MB Indx-7.7* cTropnT-0.96* ___ 04:22AM BLOOD CK-MB-13* cTropnT-0.42* Lipids and HbA1c: ___ 04:22AM BLOOD Triglyc-63 HDL-44 CHOL/HD-3.5 LDLcalc-98 ___ 04:22AM BLOOD %HbA1c-5.7 eAG-117 Discharge Labs: ___ 07:23AM BLOOD WBC-10.9 RBC-4.45* Hgb-13.6* Hct-41.0 MCV-92 MCH-30.5 MCHC-33.1 RDW-13.5 Plt ___ ___ 07:23AM BLOOD Glucose-94 UreaN-19 Creat-1.0 Na-139 K-4.1 Cl-105 HCO3-25 AnGap-13 ___ 04:22AM BLOOD ALT-25 AST-44* LD(LDH)-227 AlkPhos-68 TotBili-0.8 ECG Study Date of ___ 6:35:18 AM Normal sinus rhythm with inferolateral ST segment elevation consistent with acute myocardial infarction. Abnormal tracing. Compared to the previous tracing the ST segment abnormalities are new. Intervals Axes Rate PR QRS QT/QTc P QRS T 81 132 94 ___ 73 ECG Study Date of ___ 8:14:12 AM Normal sinus rhythm. Inferior Q waves which are new in comparison to the preceding tracing. Inferior and anterior ST segment elevation which is less marked. Compared to the previous tracing abnormal tracing. Intervals Axes Rate PR QRS QT/QTc P QRS T 82 150 92 354/392 59 6 39 ECG Study Date of ___ 3:52:14 ___ Normal sinus rhythm. Inferior myocardial infarction with persistent ST segment elevation in the inferior and anterior leads. Anterolateral myocardial infarction with anterolateral ST segment elevation. Compared to the previous tracing inferior Q waves are more marked. Anterolateral Q waves are newly noted in the anterolateral and inferior ST segment elevations are more marked. Abnormal tracing. Intervals Axes Rate PR QRS QT/QTc P QRS T 72 ___ 31 -52 57 STUDIES: - Cardiac Cath Study Date of ___ - COMMENTS: 1. Selective coronary angiography of this co-dominant system demonstrated single vessel coronary artery disease. The LMCA was without angiographically apparent flow-limiting stenosis. The LAD had a 30% proximal and 40% mid-vessel stenosis. The LCx was without angiographically apparent flow-limiting stenosis. The RCA had a 95% mid-vessel and 40% distal stenosis. 2. Limited resting hemodynamics revealed severe systemic arterial hypertension with transient bradycardia and hypotension resolved with 0.5mg atropine. Left-sided filling pressure was mildly elevated with LVEDP of 24 mmHg. FINAL DIAGNOSIS: 1. One vessel coronary artery disease. 2. Systemic arterial hypertension. 3. Elevated left-sided filling pressures with LVEDP of 24 mmHg. - Portable TTE (Complete) Done ___ at 12:24:25 ___ FINAL - The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is mildly depressed (LVEF = 45 %) secondary to akinesis of the inferior free wall, hypokinesis of the inferior septum, and hypokinesis of the apex (with a small area of focal apical dyskinesis). The other walls of the left ventricle are hyperdynamic. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The left ventricular inflow pattern suggests impaired relaxation. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: inferior and apical contractile dysfunction - CHEST (PORTABLE AP) Study Date of ___ 6:27 AM - FINDINGS: No focal consolidation, pleural effusion, pneumothorax, or pulmonary edema is seen on this single view. The aorta is tortuous. There is no mediastinal widening. Heart size is normal. IMPRESSION: No radiographic evidence for acute cardiopulmonary process. Brief Hospital Course: Mr. ___ is a ___ year old gentleman with history of long term tobacco use who was admitted with acute inferior STEMI s/p PCI BMS to mid-RCA. # Inferior STEMI: Presenting symptoms of severe left arm pain as well as abdominal pain. Culprit lesion was 95% mid-RCA lesion s/p BMS PCI with resolution of ST segment elevations inferiorly post intervention. He remained hemodynamically stable and without conduction abnormalities on EKG and telemetry. Left arm pain persisted initially to milder degree in the CCU with mild STE in V3-V5 (worsened from post-intervention ECG); nitro drip was initiated for about 24 hours and then weaned off, but ECG changes were then attributed to aneurysm vs reperfusion. TTE showed mildly depressed EF 45%, with akinesis of the inferior free wall, hypokinesis of the inferior septum, and hypokinesis of the apex. He was started on aspirin and plavix, atorvastatin 80mg daily, metoprolol succinate 50mg daily, lisinopril 2.5mg daily. He was counseled on smoking cessation. He will follow up in 1 week with his primary care physician and in 3 weeks with cardiology. He should have repeat TTE in 1 month as outpatient. INACTIVE ISSUES: # Question Hx Chronic Pancreatitis: Chronic, stable without abdominal pain. Held pancreatic enzymes during this hospitalization. TRANSITIONAL ISSUES: - uptitrate beta blocker and ACE inhibitor as tolerated - repeat TTE in 1 month - smoking cessation counseling Medications on Admission: Lipase-protease-amylase [Zenpep] 15,000 unit-51,000 unit-82,000 unit Capsule, Delayed Release(E.C.) 2 Capsule(s) by mouth daily with meals , 1 tablet with each snack Oxycodone 5 mg Tablet ___ Tablet(s) by mouth every ___ hours as needed for pain Stomach pill Dosage uncertain Tramadol 50 mg Tablet 1 (One) Tablet(s) by mouth once a day Discharge Medications: 1. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet Sublingual as directed as needed for chest pain: Take 1 tab, wait 5 minutes, then take 1 more tab if chest pain not relieved. Call ___ if you still have chest pain after 2 tabs. . Disp:25 tablets Refills:0 5. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:15 Tablet(s) Refills:2 6. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. Disp:30 Tablet Extended Release 24 hr(s) Refills:2 7. Zenpep Oral 8. tramadol 50 mg Tablet Sig: One (1) Tablet PO once a day as needed for pain. 9. oxycodone 5 mg Tablet Sig: ___ Tablets PO every ___ hours as needed for pain. Discharge Disposition: Home Discharge Diagnosis: ST-elevation myocardial infarction Tobacco Abuse Acute Systolic Dysfunction Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a privilege to provide care for you here at ___. You were admitted because you had a heart attack. You were treated with a cardiac catheterization and a bare metal stent was placed in the right coronary artery. We have started medicines which will help your heart recover from the heart attack. Your condition has improved and you can be discharged home. The following changes were made to your medications: 1. START Aspirin 325 mg daily and Clopidogrel (Plavix) 75 mg daily to prevent the stent from clotting off and causing another heart attack. Do not stop taking aspirin and clopidogrel or miss any doses unless Dr. ___ you it is OK. 2. START taking lisinopril to lower your blood pressure and help your heart recover from the heart attack. 3. START taking metoprolol to slow your heart rate and help your heart recover fromt the heart attack. 4. START taking atorvastatin (Lipitor) to lower your cholesterol. 5. START nitroglycerin tablets if you have chest pain Please keep your follow-up appointments as scheduled below. Please do your utmost to stop smoking, as it is very harmful to your health. Your primary care doctor can discuss options with you to help you stop smoking successfully. Followup Instructions: ___
19565063-DS-22	19,565,063	25,026,254	DS	22	2132-10-21 00:00:00	2132-10-21 15:10:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: ACE Inhibitors / dicloxacillin / ivp dye Attending: ___ ___ Complaint: Dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: Mrs ___ is a ___ w/ T2DM, HTN, DL, CKDIII, hypothyroidism, prior PE ___ and recently diagnosed pancreatic cancer metastatic to liver who presents w/ 2 weeks of increasing sob, and significantly worse past 48hrs. No fevers, no cough, no CP, no PND, no orthopnea, no ___. SOB was only with exertion, not with rest. Of note, she has diminished appetite for weeks. In ED, a portable bedside TTE revealed R heart strain. She was started on a heparin gtt. Past Medical History: PULMONARY EMBOLISM [415.19B] ___ In setting of knee surgery; B/L large segmental defects on V/Q scan. Given PE in setting of provoked event with reversible cause per Heme consult patient was anticoagulated for 3 months only. Kidney Disease, Chronic, Stage III (Moderate, EGFR ___ ml/min) (Cr = 1.4 - ___ HYPERCHOLESTEROLEMIA DM - TYPE 2 UNCNTRLD W RENAL COMPLIC- last HgbA1C = 7.1 ___ HYPERTENSION - ESSENTIAL - Baseline BPs: Date: BP: ___ 122/78 ___ 128/76 ___ 120/76 ___ 114/72 ___ 128/78 Vitamin D Deficiency Obesity DM (Diabetes Mellitus) Type II Uncontrolled, Neurologic Manifestation OSTEOARTHRITIS, LOCALIZED PRIMARY - L wrist ANEMIA, UNSPEC HYPOTHYROIDISM LOW BACK PAIN SICKLE-CELL TRAIT Social History: ___ Family History: No other hx of pancreatic or breast cancer Father died of MI Mother died of DM 1 brother died age ___ ?thrombosis 1 sister alive ___ ___ mother) Physical Exam: ADMISSION EXAM: ================== General: NAD VITAL SIGNS: ___ ___ 24 100% RA 44.7 kg HEENT: MMM, no OP lesions, no cervical or supraclavicular adenopathy CV: RR, NL S1S2 no S3S4 No MRG PULM: CTAB, No C/W/R ABD: BS+, soft, NTND, no palpable masses or HSM LIMBS: WWP, no ___, no tremors SKIN: No rashes on the extremities NEURO: Grossly normal DISCHARGE EXAM: ================= Pertinent Results: ADMISSION LABS: ================= ___ 06:40AM BLOOD WBC-12.7* RBC-2.90* Hgb-8.2* Hct-24.3* MCV-84 MCH-28.4 MCHC-33.7 RDW-14.6 Plt ___ ___ 06:45PM BLOOD ALT-66* AST-148* AlkPhos-243* TotBili-0.6 ___ 06:40AM BLOOD Glucose-134* UreaN-34* Creat-1.5* Na-134 K-3.1* Cl-94* HCO3-26 AnGap-17 IMAGING: ================= CXR: No acute intrathoracic process. CT ABD & PELVIS W/O CONTRAST: WET READ: 1. Limited evaluation due to lack of IV contrast. Approximately 2.7 x 2.7 cm lesion in the tail of the pancreas likely reflecting the known pancreatic cancer. Multiple metastatic liver lesions and mild retroperitoneal lymphadenopathy. 2. Partially visualized parenchymal and subpleural pulmonary nodules measuring up to 4 mm bilaterally. Dedicated CT chest is recommended if not previously obtained. DISCHARGE LABS: ================ Brief Hospital Course: Mrs ___ is a ___ w/ T2DM, HTN, DL, CKDIII, hypothyroidism, prior PE ___ and recently diagnosed pancreatic cancer metastatic to liver who presents w/ 2 weeks of increasing sob, and significantly worse past 48hrs, which has since improved while in house. ACTIVE ISSUES: # Dyspnea: No fevers, no cough, no CP, no PND, no orthopnea, no ___. SOB was only with exertion, not with rest. Of note, she has diminished appetite for weeks. In setting of pancreatic cancer, and h/o of PE, concerning for PE. EKG/Trop non-ischemic. Per ED there was RHS on bedside TTE suggesting PE, which is highly likely in setting of pancreatic ca. V/Q scan negative for PE. Anemia could explain dyspnea - as Hgb down from 13 to 8.2 - 8.6 today. TTE ruled out CHF as etiology for dyspnea (EF 70%). No antibiotics given. Dyspnea resolved without intervention. # Pancreatic Ca. -- on gemcitabine/abraxane - did not receive chemotherapy while in house. CHRONIC, INACTIVE ISSUES #T2DM: stable -- ISS #Hypothyroidism -- cont Synthroid TRANSITIONAL ISSUES - Chemotherapy Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. OxycoDONE (Immediate Release) 5 mg PO Q8H:PRN pain 2. GlipiZIDE 2.5 mg PO DAILY:PRN hyperglycemia 3. Levothyroxine Sodium 112 mcg PO DAILY Discharge Medications: 1. Levothyroxine Sodium 112 mcg PO DAILY 2. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain 3. Acetaminophen ___ mg PO Q8H:PRN pain 4. GlipiZIDE 2.5 mg PO DAILY:PRN hyperglycemia Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: 1* dianosis: dyspnea 2* diagnoses: pancreatic cancer, HTN, DM-II, HLD, h/o PE (___) Discharge Condition: Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Mental Status: Clear and coherent. Discharge Instructions: Dear Ms. ___, You were admitted to ___ for shortness of breath. You had a chest X ___ that was clear, as well as a scan that was negative for blood clot in your lungs. You had a test of your heart (echo), which showed normal heart function. It was a pleasure caring for you! We wish you well. - Your team at ___ Followup Instructions: ___
19565063-DS-23	19,565,063	20,909,425	DS	23	2132-11-24 00:00:00	2132-11-26 07:20:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: ACE Inhibitors / dicloxacillin / ivp dye Attending: ___ Chief Complaint: fever Major Surgical or Invasive Procedure: None History of Present Illness: ___ w/ T2DM, HTN, DL, CKDIII, ypothyroidism, recently diagnosed pancreatic cancer metastatic to liver on chemo (last received day 8 chemo gem/abraxane on ___ presenting with fever. Fever to 100.6F today at home. Feeling fatigued. Family reports dry cough. +multiple family members with productive cough recently. Also reports cramping over epigastrum. Denies c/n/v, rhinorrhea, nasal congestion, chest pain, shortness of breath, diarrhea, urinary symptoms. - In the ED, initial VS were 2 101.9 113 126/64 18 100%. - Exam was notable for CTAB, mild ttp over epigastrum, no CVA tenderness. - Labs were notable for lactate 1.1, Cr 1.4 (prior ), hct 23.2, plt 125. - Imaging was notable for CXR which showed no acute process. EKG showed sinus 114, NA, No ischemia - Patient was given 500cc IV NS, tylenol and IV ceftraixone. - Patient was admitted to OMED for further mx. - VS prior to ED 99.5 114 117/77 18 100% RA. On arrival to the floor, the patient was VSS. She had no uri symptoms, cough, runny nose, dysuria, pain with eating, altered mental status. She had no rashes, skin breaks. Past Medical History: presented to internal medicine in ___ complaining of unintentional weight loss. Further work up included a CT chest, abdomen, and pelvis at ___ that was concerning for a mass in the pancreas as well as liver mets on ___. Both CEA and ___ were elevated. She underwent She was started on oxycodone prn for ___ intermittent abd pain that she has not been taking. She reports for the last 2 weeks, she has not gone to work and spends most of the time in bed. Denies fevers, night sweats, chills, headache, dizziness, nausea, vomiting, chest pain, shortness of breath, diarrhea, constipation, bruising or bleeding, skin changes, and joint pains. Not eating much but fasting AM sugar was 290s. No interest in food. Presents today with son ___, daughter ___ and ___ boyfriend ___, niece ___ (who is a SW). Chemo: ___ - start of C2, dose reduced to 50% due to neutropenia and elevated LFTs ___ - ANC 1000, received day 8 chemo gem/abraxane PAST MEDICAL HISTORY: PULMONARY EMBOLISM [415.19B] ___ In setting of knee surgery; B/L large segmental defects on V/Q scan. Given PE in setting of provoked event with reversible cause per Heme consult patient was anticoagulated for 3 months only. Kidney Disease, Chronic, Stage III (Moderate, EGFR ___ ml/min) (Cr = 1.4 - ___ HYPERCHOLESTEROLEMIA HTN Vitamin D Deficiency Obesity DM (Diabetes Mellitus) Type II Uncontrolled, Neurologic Manifestation OSTEOARTHRITIS, LOCALIZED PRIMARY - L wrist ANEMIA, UNSPEC HYPOTHYROIDISM LOW BACK PAIN SICKLE-CELL TRAIT Social History: ___ Family History: No other hx of pancreatic or breast cancer Father died of MI Mother died of DM 1 brother died age ___ ?thrombosis 1 sister alive ___ ___ mother) Physical Exam: ADMISSION EXAM:VITAL SIGNS: 99.2 120/64 96 24 100 ra HEENT: MMM, no OP lesions, no cervical, supraclavicular, or axillary adenopathy, no thyromegaly CV: RR, NL S1S2 no S3S4 MRG PULM: CTAB ABD: BS+, soft, tender in LUQ, no masses or hepatosplenomegaly LIMBS: No edema, clubbing, tremors, or asterixis; no inguinal adenopathy SKIN: No rashes or skin breakdown NEURO: Cranial nerves II-XII are within normal limits excluding visual acuity which was not assessed, no nystagmus; strength is ___ of the proximal and distal upper and lower extremities, AOX3 DISCHARGE EXAM: VITAL SIGNS: Tm Tm 98.8 Tc 98.8 94 18 130/70 100RA BG 61 ___ General: NAD HEENT: MMM, no OP lesions, no cervical, supraclavicular, or axillary adenopathy, no thyromegaly CV: RR, NL S1S2 no S3S4 MRG PULM: CTAB ABD: BS+, soft, no TTP, no masses or hepatosplenomegaly LIMBS: No edema, clubbing, tremors, or asterixis; no inguinal adenopathy SKIN: No rashes or skin breakdown NEURO: Cranial nerves II-XII are within normal limits excluding visual acuity which was not assessed, no nystagmus; strength is ___ of the proximal and distal upper and lower extremities, AOX3 Pertinent Results: ADMISSION LABS: ___ 07:45PM BLOOD WBC-6.8# RBC-2.68* Hgb-7.6* Hct-23.2* MCV-87 MCH-28.2 MCHC-32.6 RDW-20.2* Plt ___ ___ 07:45PM BLOOD Neuts-93.1* Lymphs-4.0* Monos-1.2* Eos-1.5 Baso-0.2 ___ 07:45PM BLOOD Glucose-53* UreaN-28* Creat-1.4* Na-138 K-3.4 Cl-99 HCO3-26 AnGap-16 ___ 07:45PM BLOOD ALT-33 AST-55* AlkPhos-276* TotBili-0.4 ___ 07:45PM BLOOD Albumin-3.6 ___ 07:51PM BLOOD Lactate-1.1 ___ 12:00AM URINE Color-Straw Appear-Clear Sp ___ ___ 12:00AM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG ___ 12:00AM URINE RBC-1 WBC-<1 Bacteri-NONE Yeast-NONE Epi-<1 MICROBIOLOGY: ___ 12:00 am URINE URINE CULTURE (Preliminary): ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML. ___ BLOOD CULTURE X2: NO GROWTH TO DATE DISCHARGE LABS: ___ 06:35AM BLOOD WBC-3.7* RBC-2.58* Hgb-7.6* Hct-22.0* MCV-85 MCH-29.5 MCHC-34.6 RDW-18.8* Plt Ct-89* ___ 06:35AM BLOOD Neuts-83.1* Lymphs-11.8* Monos-1.8* Eos-2.9 Baso-0.4 ___ 06:35AM BLOOD Glucose-111* UreaN-22* Creat-1.2* Na-142 K-4.4 Cl-106 HCO3-26 AnGap-14 ___ 06:35AM BLOOD Calcium-8.7 Phos-2.9 Mg-1.7 STUDIES: ___ CXR: IMPRESSION: No acute cardiopulmonary process. ___ CT ABDOMEN: PRESSION: 1. Similar appearance of 2.7 cm pancreatic tail mass, widespread liver metastatic lesions, multiple pulmonary nodules, retroperitoneal lymphadenopathy, and bilateral renal lesions. As previously recommended, MRI would be helpful to further characterize renal lesions. 2. Right upper lobe ___ opacities were not previously imaged and are nonspecific but consistent with infection. 3. Trace pericardial effusion. Brief Hospital Course: ___ w/ recently diagnosed metastatic pancreatic cancer getting gem/abraxane C2D10 today presenting w/ fevers. # Fevers: Attributed to pneumonia, given CT abdomen showed ___ opacities in right upper lung. She initially received IV ceftriaxone and azithromycin, but was discharged on PO levoquin for community-acquired pneumonia. CXR was clear interestingly. Other infectious work-up included urinanalysis, which was normal (urine culture did grow ___ enterococci, however, she had no dysuria and was not treated). She was also flu negative. On presentation, she reported left-sided abdominal pain (reason for which CT abdomen was ordered), however, she had no abdominal tenderness on exam and CT (non-contrast) did not show any gross abnormalities. PE was entertained as source of fever given borderline tachycardia, however, she had no hypoxia and no further fevers once treated with antibiotics. Lastly, one cannot exclude fever from gemcitabine vs hepatic metastases. # Left lower quadrant/flank pain: Of unclear etiology. UA was unremarkable. CT (although without contrast) did not show any gross abnormalities. She has no known bony metastases, however, it does bother her more at night. She was started on lidocaine patch overnight, which helped her pain greatly. # Acute on chronic anemia: H/H decreased overnight from 23.2->18.7. No active signs of bleeding. She may have been hemoconcentrated on admission. Possible sources include BM toxicity ___ chemo vs GI loss vs hemolysis. Reticulocyte index = 0.2%. Stool guiaic was negative. Hemolysis labs were WNL. She responded to one unit pRBC transfusion. # Pancreatic Cancer: Last dose of chemo on ___. Patient with scheduled follow-up with oncologist. # CKD: Cr 1.4 on admission, at baseline. # Hypothyroid: She continued Levothyroxine Sodium 112 mcg PO DAILY # Diabetes: Glipizide was held, but restarted on discharge. # Anxiety: She continued home at___ prn and social work was consulted for assistance with coping. TRANSITIONAL ISSUES: - Patient will complete course of Levaquin 750mg PO on ___ ___ - Patient will follow up with ___ Oncology, ___ MD, ___ - Patient endorsed much anxiety recently and may benefit from trial of SSRI - Patient was seen by SW, and was referred to resources for elderly services Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Levothyroxine Sodium 112 mcg PO DAILY 2. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain 3. Acetaminophen ___ mg PO Q8H:PRN pain 4. GlipiZIDE 2.5 mg PO DAILY:PRN hyperglycemia 5. Lorazepam 0.5 mg PO Q6H:PRN anxiety Discharge Medications: 1. Lidocaine 5% Patch 1 PTCH TD QPM RX lidocaine [Lidoderm] 5 % (700 mg/patch) Apply to affected area QPM Disp #30 Patch Refills:0 2. Levothyroxine Sodium 112 mcg PO DAILY 3. Lorazepam 0.5 mg PO Q6H:PRN anxiety 4. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain 5. Acetaminophen ___ mg PO Q8H:PRN pain 6. GlipiZIDE 2.5 mg PO DAILY:PRN hyperglycemia 7. Levofloxacin 750 mg PO Q48H RX levofloxacin 750 mg 1 tablet(s) by mouth Q48H Disp #1 Tablet Refills:0 Discharge Disposition: Home Discharge Diagnosis: Primary diagnoses: community-acquired pneumonia, acute on chronic anemia, back pain Secondary diagnoses: anxiety, pancreatic cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms ___, It was a pleasure taking care of you at the ___ ___. You were admitted for fever and concern for infection. Imaging showed a possible pneumonia, so we treated you for this with initially intravenous antibiotics then antibiotics by mouth. We found no other source of your infection. You were also anemic so we gave you one blood transfusion. You have one more antibiotic pill (levofloxacin or levaquin) to take on ___ and your course will be completed. We also gave you a prescription for a lidocaine patch, which helped your left-sided back pain. Please follow-up at the appointments that have been scheduled for you below. On behalf of your ___ team, We wish you all the best Followup Instructions: ___
19565113-DS-20	19,565,113	20,930,294	DS	20	2145-12-22 00:00:00	2145-12-24 09:47:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: interferon beta-1b Attending: ___. Chief Complaint: Weakness and Confusion Major Surgical or Invasive Procedure: None History of Present Illness: ___ w/ PMHx MS, HLD, HTN, DM2 who presents after being found by ___ daugher confused and weak on the morning prior to presentation. ___ daugther reports that she was rosy-cheeked, warm and sweaty and was not acting like herself. The daughter reports that she was also very slow to answer questions. Bother the patient and the daughter reports that she was extreemly weak and required complete assitance with ___ daughter picking ___ up out of bed and onto and off of the toilet. The daughter reports that she had ___ flu shot and ___ tetnus shot yesterday but no new medications at all. She denies any recent sick contacts. On arrival to the ED, initial VS were 100.1 112 153/83 16 98% ra but temp quickly uptrended to 103.5. ___ daughter felt that she had returned back to ___ baseline mental status but continues to be weak. Labs notable for hct 32.9, Na 132, and UA with sm leuk and mod blood. CXR without infiltrate. Given 1L NS and ceftriaxone IV 1g and admitted to medicine for further management of likley UTI. On arrival to the floor, the patient says she is comfortable and feels at ___ mental baseline, which ___ daughter confirms. She still feels a little more weak in the legs. Review of Systems: (+) fever, chills, weakness (-) 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: Optic Neuritis Multiple sclerosis Hypercholesterolemia Hypertension, essential, benign DM (diabetes mellitus), type 2 Osteopenia Social History: ___ Family History: Mother with CAD/PVD, died of MI in ___ ___. Brother with colon cancer at age ___, type II DM. Sister also with DM typeII Physical Exam: ADMISSION EXAM: Vitals- T99.9, BP 103/64, HR 96, RR 20, O2 sat 98%RA Gen: middle aged woman lying in bed smiling, pleasant, slow to respond HEENT: PERRL, eyes disconjugate at times with left eye exotropia, slightly dry MM, oropharynx clear Neck: Supple, no JVD. No thyromegaly. Resp: Clear to auscultation bilaterally, no wheezes, rales or rhonchi Heart: Regular rhythm without murmurs, rubs, or gallops. Abdomen: Bowel sounds normal, soft, without tenderness or organomegaly. Extremities: no edema. DP pulses palpable. Neuro: A&Ox3, CNs intact, strength ___ in upper extremities, ___ in lower extremities with increased tone. Vitals- T 99.1, BP 134/84, HR 88 RR 20, O2 sat 99%RA Gen: middle aged woman lying in bed, NAD HEENT: left eye exotropia, MMM, oropharynx clear Resp: Clear to auscultation bilaterally, no wheezes, rales or rhonchi Heart: Regular rhythm without murmurs, rubs, or gallops. Abdomen: Bowel sounds normal, nontender, mildly distended Extremities: no edema Neuro: A&Ox3 strength ___ in upper extremities, ___ in ___ Pertinent Results: DISCHARGE LABS: ___ 08:15AM BLOOD WBC-4.6 RBC-3.21* Hgb-9.8* Hct-27.3* MCV-85 MCH-30.5 MCHC-35.8* RDW-12.6 Plt ___ ___ 08:15AM BLOOD ___ PTT-31.4 ___ ___ 08:15AM BLOOD Glucose-127* UreaN-16 Creat-1.0 Na-136 K-4.4 Cl-100 HCO3-25 AnGap-15 ___ 01:10PM BLOOD ALT-19 AST-26 AlkPhos-70 TotBili-0.3 ___ 08:15AM BLOOD Calcium-8.9 Phos-3.1 Mg-1.8 ___ 06:45PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 06:52PM BLOOD Lactate-1.5 ___ 02:30AM URINE Blood-SM Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG ___ 02:30AM URINE RBC-<1 WBC-27* Bacteri-FEW Yeast-NONE Epi-3 ___ 9:30 pm URINE *FINAL REPORT ___ URINE CULTURE (Final ___: Culture workup discontinued. Further incubation showed contamination with mixed skin/genital flora. Clinical significance of isolate(s) uncertain. Interpret with caution. ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. CXR: FINDINGS: PA and lateral views of the chest provided demonstrate no focal consolidation, effusion, or pneumothorax. Cardiomediastinal silhouette is normal. The imaged osseous structures are intact. Irregularity involving the right distal clavicle could represent an old injury. Brief Hospital Course: ___ w/ PMHx MS, HLD, HTN, DM2 who presents with weakness, confusion and fevers found to have a likely UTI. # UTI: positive UA and longstanding issues with urine retention due to MS. ___ urine culture showed predominant E coli, but also other flora. This was from a catheterized sample, so it is likely that she has colonization of the GU tract from urinary stasis. She will be discharged on Cipro to complete a 7 day course of ABX. She may benefit from follow-up with a urologist to determine the best treatment of ___ urinary retention and whether she would benefit from intermittent straight cath. # Constipation: The patient normally has a BM once per week. She has gone 10 days now without a bowel movement. A rectal exam did not show fecal impaction. She was given Miralax, colace, and a dulcolax suppository here. She should have a robust bowel regiment at rehab. # MS: - continue baclofen, copaxone, and trospium - reposition to prevent bed sores # Diabetes mellitus type II: on glimepiride and metformin # Code: Full (discussed with patient), also is ___ and would not want any blood products # Emergency Contact: daughter ___ ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. Polyethylene Glycol 17 g PO DAILY 2. Baclofen 20 mg PO BID 3. glimepiride 1 mg Oral QAM 4. Atenolol 100 mg PO DAILY 5. Simvastatin 40 mg PO HS 6. modafinil 100 mg Oral daily 7. Lisinopril 5 mg PO DAILY 8. MetFORMIN (Glucophage) 1000 mg PO BID 9. trospium 20 mg Oral BID 10. Copaxone (glatiramer) 20 mg/mL Subcutaneous daily 11. Cyanocobalamin 250 mcg PO DAILY 12. Multivitamins 1 TAB PO DAILY 13. Fish Oil (Omega 3) 1000 mg PO DAILY 14. cod liver oil 1,250-135 unit Oral daily Discharge Medications: 1. Atenolol 100 mg PO DAILY 2. Baclofen 20 mg PO BID 3. Copaxone (glatiramer) 20 mg/mL Subcutaneous daily 4. Cyanocobalamin 250 mcg PO DAILY 5. Lisinopril 5 mg PO DAILY 6. MetFORMIN (Glucophage) 1000 mg PO BID 7. modafinil 100 mg Oral daily 8. Multivitamins 1 TAB PO DAILY 9. Polyethylene Glycol 17 g PO DAILY 10. Simvastatin 40 mg PO HS 11. cod liver oil 1,250-135 unit Oral daily 12. Fish Oil (Omega 3) 1000 mg PO DAILY 13. glimepiride 1 mg Oral QAM 14. trospium 20 mg Oral BID 15. Ciprofloxacin HCl 500 mg PO Q12H Duration: 3 Days RX ciprofloxacin 500 mg 1 tablet(s) by mouth every 12 hours Disp #6 Tablet Refills:0 16. Docusate Sodium 100 mg PO BID Discharge Disposition: Extended Care Facility: ___ for Rehabilitation and Sub-Acute Care) Discharge Diagnosis: Urinary Tract Infection Multiple Sclerosis Deconditioning Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted to the hospital with weakness and confusion and you were found to have a urinary infection. We treated the urinary infection with antibiotics and you got better. We found that you were slightly weaker while here, so you will be discharged to a rehab before you can go home. Please take all medications as prescribed and make all of your follow-up appointments. Followup Instructions: ___
19565358-DS-3	19,565,358	22,811,968	DS	3	2201-08-08 00:00:00	2201-08-15 14:32:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Amlodipine Attending: ___. Chief Complaint: Hyperkalemia Major Surgical or Invasive Procedure: None History of Present Illness: ___ with PMH diastolic CHF, DM on insulin, HTN, HLD, who was referred to the ED by his PCP after he was found to have hyperkalemia on routine labs. He visited his PCP because he had been feeling "unwell" since ___ and possibly prior to that. He noticed low blood sugars and low blood pressures which is new for him. He also endorses diarrhea that he descirbes as explosive, usually three loose stools with associated cramping. He otherwise denies abdominal pain. He also lost 20 pounds in that time frame. He denies fevers, chills, night sweats, cough, hematochezia, or melena. On his PCP visit on ___ his K was noted to be 6.3 with lipase of 741 and was referred to the ED, where he was found to have a K of 6.8 - Imaging: ___ 1545 EKG with peaked T waves, appeared improved on repeat. Patient was given: insulin and dextrose X 2, 500cc NS, 1g IV ceftriaxone, and 1g calcium gluconate Past Medical History: DIABETES ___ DIASTOLIC DYSFUNCTION Preserved EF but echo evidence of diastolic dysfunction HYPERLIPIDEMIA HYPERTENSION HYPOTHYROIDISM OBESITY BMI: 41.6 SLEEP APNEA Severe. AHI 102/hr. Oxygen nadir as low as 70%. VENOUS STASIS Social History: ___ Family History: Sister rheumatic heart disease Mother breast CA ___ aunt and cousin w/ breast CA Physical Exam: ADMISSION PHYSICAL Vital Signs: 97.7 111/60 76 20 95 RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL, neck supple, JVP difficult to assess given body habitus CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended GU: No foley Ext: Warm, well perfused, extensive venous stasis changes. R dressing c/d/i apart from some minor serosanguinous drainage Neuro: CNII-XII grossly intact Access: peripherals ===================== DISCHARGE PHYSICAL Pertinent Results: ADMISSION LABS ___ 02:34PM BLOOD WBC-11.6* RBC-4.30* Hgb-11.9* Hct-37.9* MCV-88 MCH-27.7 MCHC-31.4* RDW-15.4 RDWSD-49.8* Plt ___ ___ 02:34PM BLOOD Neuts-66.8 Lymphs-16.0* Monos-10.9 Eos-5.1 Baso-0.5 Im ___ AbsNeut-7.76* AbsLymp-1.86 AbsMono-1.26* AbsEos-0.59* AbsBaso-0.06 ___ 02:34PM BLOOD UreaN-71* Creat-2.5* Na-135 K-6.3* Cl-99 HCO3-24 AnGap-18 ___ 02:34PM BLOOD ALT-11 AST-9 AlkPhos-82 TotBili-0.2 ___ 02:34PM BLOOD Lipase-741* ___ 03:55PM BLOOD proBNP-741* ___ 02:34PM BLOOD CRP-26.5* DISCHARGE LABS ___ 10:43AM BLOOD WBC-9.5 RBC-4.03* Hgb-11.0* Hct-34.3* MCV-85 MCH-27.3 MCHC-32.1 RDW-14.8 RDWSD-46.2 Plt ___ ___ 10:43AM BLOOD Glucose-343* UreaN-55* Creat-1.9* Na-130* K-5.3* Cl-92* HCO3-25 AnGap-18 ___ 10:43AM BLOOD Calcium-8.7 Phos-4.2 Mg-2.0 OTHER PERTINENT LABS ___ 02:34PM BLOOD %HbA1c-7.8* eAG-177* ___ 06:53AM BLOOD Cortsol-24.2* ___ 02:34PM BLOOD TSH-3.9 ___ 02:34PM BLOOD T4-6.8 T3-97 calcTBG-1.03 TUptake-0.97 T4Index-6.6 Free T4-1.0 ======================= MICROBIOLOGY ___ 4:22 pm URINE *FINAL REPORT ___ URINE CULTURE (Final ___: ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE IDENTIFICATION. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI \| AMPICILLIN------------ <=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 ============================================= IMAGING ---------------- CT ABDOMEN AND PELVIS W/O CONTRAST (___): 1. Essentially normal CT appearance of the pancreas (noncontrast). A slightly bulky configuration to the pancreatic tail is noted as described above. In the setting of the provided history, could obtain laboratory values to exclude autoimmune pancreatitis. However, given that this appearance is unchanged since the CT of ___, the finding is of doubtful significance and is likely configurational. 2. Stable splenomegaly. 3. Indeterminate bilateral enlargement of otherwise morphologically normal pelvic lymph nodes. Significance is uncertain, particularly given the concomitant finding of splenomegaly. However, it is noted that those lymph nodes included in the CT chest of ___ are also stable. 4. Stable bibasilar pulmonary nodules consistent with granulomas. RECOMMENDATION(S): Please consider laboratory evaluation to exclude autoimmune pancreatitis and evaluate indeterminate-significance splenomegaly and pelvic lymph node enlargement, also stable to the extent that comparison can be made with a prior chest CT. Brief Hospital Course: Mr. ___ presented to the ED (___) after referral from his PCP due to hyperkalemia. He had a K of 6.8 and peaked T waves on EKG. This was felt to be secondary to his spironolactone and lisinopril, which were held. He was given insulin and dextrose, calcium gluconate, and he was admitted for hyperkalemia. On the floor (___), his was given a low potassium diet and treated with IV fluids and Lasix, however the Lasix was held after a mild rise in Cr. He was given kayexalate and his K decreased to 5.1. Patient was also complaining of intermittent urinary retention over the last 2 weeks and he was also found to have a leukocytosis of 11.8 and his urine culture grew E. coli. He was treated with ciprofloxacin and his leukocytosis resolved upon discharge (to 9.5). Mr. ___ also presented with a 2 month history of diarrhea, which he did not experience during his stay. He underwent a CT abdomen scan, which showed no hydronephrosis and was overall stable from his CTA in ___. Mr. ___ was instructed to follow up for a Chem 7 within 48 hours, to call to schedule an appointment with nephrology, and to adopt a low potassium diet. TRANSITIONAL ISSUES ======================= -K was 5.3 and Cr 1.9 on discharge, ordered chem 7 within 48 hours of discharge. Will need to be followed-up. -Will need follow up with Nephrology (Dr. ___ clinic ___ to follow up hyperkalemia and ___ on CKD. Patient will schedule. -Pt should follow up with cardiology as an outpatient given new medication changes below -Blood sugars were 200-300 during admission on 35 glargine in AM, 50 glargine in ___, sliding scale humalog. His liraglutide and metformin were held initially but restarted on discharge. He should have follow up with endocrinology -Patient should continue to take a low-potassium diet until potassium normalizes and remains normal -Stopped medications: lisinopril, spironolactone -New medications: Ciprofloxacin, 7 day course for UTI ending ___ -Labs pending at discharge: Renin, ___, IgG1234, Ova and Parasites culture -Instructed to make an appointment with your primary care physician within one week of leaving the hospital. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 10 mg PO DAILY 2. Ketoconazole 2% 1 Appl TP DAILY 3. Carvedilol 25 mg PO BID 4. MetFORMIN (Glucophage) 850 mg PO TID 5. Fluticasone Propionate NASAL 2 SPRY NU DAILY 6. Atorvastatin 20 mg PO QPM 7. liraglutide 0.6 mg/0.1 mL (18 mg/3 mL) subcutaneous DAILY 8. Glargine 35 Units Breakfast Glargine 50 Units Bedtime Insulin SC Sliding Scale using Novolog Insulin 9. Spironolactone 25 mg PO DAILY 10. Multivitamins 1 TAB PO DAILY 11. Omeprazole 20 mg PO DAILY 12. Aspirin 81 mg PO DAILY 13. Furosemide 40 mg PO DAILY Discharge Medications: 1. Ciprofloxacin HCl 500 mg PO Q12H RX ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every 12 hours Disp #11 Tablet Refills:0 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 20 mg PO QPM 4. Carvedilol 25 mg PO BID 5. Fluticasone Propionate NASAL 2 SPRY NU DAILY 6. Furosemide 40 mg PO DAILY 7. Glargine 35 Units Breakfast Glargine 50 Units Bedtime Insulin SC Sliding Scale using Novolog Insulin 8. Ketoconazole 2% 1 Appl TP DAILY 9. liraglutide 0.6 mg/0.1 mL (18 mg/3 mL) subcutaneous DAILY 10. MetFORMIN (Glucophage) 850 mg PO TID 11. Multivitamins 1 TAB PO DAILY 12. Omeprazole 20 mg PO DAILY 13. HELD- Lisinopril 10 mg PO DAILY This medication was held. Do not restart Lisinopril until your potassium normalizes and your doctor tells you to restart 14. HELD- Spironolactone 25 mg PO DAILY This medication was held. Do not restart Spironolactone until your potassium normalizes and your doctor tells you to restart 15.Outpatient Lab Work Please draw Chem 10 drawn before ___ and faxed to Dr. ___ office at ___. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis Hyperkalemia Urinary tract infection Secondary Diagnosis Diabetes ___ on CKD Hypertension chronic diastolic congestive heart failure Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear ___, You were admitted to the hospital because the potassium level in your blood was found to be high. This was felt to be due to the lisinopril and spironolactone that you were taking. These medications were stopped and you were given insulin, sugar, and diuretics to decrease the potassium but it remained high. The kidney team was consulted and they recommended some tests to determine why your potassium remained high. These tests were done and were still not back when you were discharged. You were also given a medication that binds potassium in your intestine (kayexalate) and this helped to decrease your potassium. You should follow up with the kidney doctors as ___ outpatient to follow up on these labs. You may need an additional medication to treat the underlying cause of your high potassium. During your hospitalization, it was also found that you had worsening kidney function, which improved back to baseline at discharge. It was also found that you had a bladder infection and you were treated with an antibiotic (ciprofloxacin), which you should continue taking after discharge and take your last dose on ___. In addition your blood sugars were high during your hospitalization. You should continue taking liraglutide, metformin, glargine 35 units in the morning, 50 units at bedtime, and follow up with endocrinology after discharge to determine if your medications need to be changed. It was a pleasure taking care of you. We wish you the best! -Your ___ Care Team TRANSITIONAL ISSUES ==================== -You should NOT take spironolactone and lisinopril at home until you follow up with the kidney doctors -___ should continue taking ciprofloxacin through ___ -You should continue to take a low-potassium diet until told otherwise by your doctor ___ low potassium diet sheet attached) -You will need labs drawn within 48 hours, which you have a prescription for. -You will need to follow up with Nephrology (Dr. ___ ___ clinic ___ to follow up hyperkalemia. Please call them on ___ to schedule this. -You will need to follow up with your cardiologist given the medication changes -Your blood sugars were high during your hospitalization. You should follow up with endocrinology (though patient says he does not want endocrine follow up) -Stopped medications: lisinopril, spironolactone -New medications: Ciprofloxacin ___nd ___ -Labs pending at discharge: Renin, ___, IgG1234, Ova and Parasites culture Followup Instructions: ___
19565388-DS-21	19,565,388	26,400,452	DS	21	2136-10-19 00:00:00	2136-10-19 14:44:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: pain right hip inabilty to ambulate Major Surgical or Invasive Procedure: right hip hemiarthroplasty History of Present Illness: ___ w/PMH of dementia, DM, HTN, HLD presented with right fully displaced femoral neck fracture s/p slip and fall day prior on ___. Ambulates with walker and sustained fall after slipping on wet floor, landed backwards and experienced immediate right knee pain, denies head strike or LOC. Was unable to ambulate s/p fall.on wet floor landed backwards. Past Medical History: 1. Diabetes, Type 2 2. Dementia 3. Hypertension 4. Hyperlipidemia Social History: ___ Family History: Two grandsons with diabetes. No known family h/o hypertension or CAD. Physical Exam: HEENT: Normocephalic, atraumatic, Extraocular muscles intact Oropharynx within normal limits Chest: Clear to auscultation Cardiovascular: Regular Rate and Rhythm, Normal first and second heart sounds Abdominal: Soft, Nontender GU/Flank: No costovertebral angle tenderness, no midline C/T/L spine tenderness Extr/Back: No cyanosis, clubbing or edema, 2+ DP pulse bilaterally, minimal point tenderness lateral patella, pain with posterior drawer but no laxity, pain with MCL stress but no laxity of MCL/LCL, full ROM hip and ankle on right without pain, no hip or ankle tenderness Skin: No rash, Warm and dry Neuro: Speech fluent Psych: Normal mood, Normal mentation ___: No petechiae RLE skin clean and intact Minimally shortened and externally rotated Tenderness at lateral hip and distal femur; no erythema, edema, induration or ecchymosis Thighs and legs are soft No pain with passive motion at knee and ankle; ROM at hip not assessed based on review of images; Saph Sural DPN SPN MPN LPN ___ FHL ___ TA PP Fire 1+ ___ and DP pulses Contralateral extremity examined with good range of motion, SILT, motors intact and no pain ___ Pertinent Results: ___ 05:07AM BLOOD WBC-9.9 RBC-3.20* Hgb-8.3* Hct-26.5* MCV-83 MCH-25.8* MCHC-31.2 RDW-16.0* Plt ___ ___ 05:15AM BLOOD Hct-28.6* ___ 05:12AM BLOOD WBC-7.0 RBC-3.27* Hgb-8.2* Hct-26.9* MCV-82 MCH-25.1* MCHC-30.6* RDW-15.9* Plt ___ ___ 11:26AM BLOOD WBC-8.6 RBC-4.02* Hgb-10.2* Hct-33.1* MCV-82 MCH-25.3* MCHC-30.7* RDW-15.7* Plt ___ ___ 10:45AM BLOOD WBC-7.6 RBC-4.72 Hgb-11.9* Hct-38.5 MCV-82 MCH-25.2* MCHC-30.9* RDW-15.8* Plt ___ ___ 05:07AM BLOOD Plt ___ ___ 11:26AM BLOOD Plt ___ ___ 04:45AM BLOOD Plt ___ ___ 04:45AM BLOOD ___ PTT-32.2 ___ ___ 10:45AM BLOOD Plt ___ ___ 10:45AM BLOOD ___ PTT-32.8 ___ ___ 05:07AM BLOOD Glucose-136* UreaN-41* Creat-1.5* Na-137 K-4.9 Cl-106 HCO3-23 AnGap-13 ___ 05:15AM BLOOD Glucose-153* UreaN-34* Creat-1.5* Na-135 K-4.2 Cl-103 HCO3-23 AnGap-13 ___ 05:12AM BLOOD Glucose-194* UreaN-31* Creat-1.4* Na-135 K-4.3 Cl-103 HCO3-22 AnGap-14 ___ 11:26AM BLOOD Glucose-196* UreaN-29* Creat-1.3* Na-140 K-3.9 Cl-104 HCO3-24 AnGap-16 ___ 04:45AM BLOOD Glucose-125* UreaN-34* Creat-1.3* Na-139 K-4.2 Cl-105 HCO3-25 AnGap-13 ___ 05:12AM BLOOD Calcium-8.0* Phos-2.3* Mg-1.8 ___ 11:26AM BLOOD Calcium-8.9 Phos-2.7 Mg-1.8 Brief Hospital Course: She was admitted to the ortho service and on ___ was taken to the or and underwent a right hip hemiarthroplasty without complications. Post op she did well she was treated for uti with cipro for seven days. She was seen by pt and was able to tx to chair with max assist . Rehab screened her and she was excepted. On ___ her foley was dc, she did not void over 8 hrs she was bolused still no void foley replaced and she was bolused with 500 at time of dc foley again was dc and she was dtv Medications on Admission: docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO BID (2 times a day) as needed for Constipation. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). trazodone 50 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)) as needed for Insomnia. multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily). cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for doses. alendronate 70 mg Tablet Sig: One (1) Tablet PO QMON (every ___. donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). glipizide 10 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO BID (2 times a day). levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). pioglitazone 15 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). sertraline 50 mg Tablet Sig: 0.5 Tablet PO QAM (once a day (in the morning)). calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). verapamil 180 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO Q24H (every 24 hours). ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). vitamin E 400 unit Capsule Sig: One (1) Capsule PO DAILY (Daily). magnesium oxide 140 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 2. oxycodone 5 mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for Pain. 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO BID (2 times a day) as needed for Constipation. 5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. trazodone 50 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)) as needed for Insomnia. 7. multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 8. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 6 doses. 10. alendronate 70 mg Tablet Sig: One (1) Tablet PO QMON (every ___. 11. donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 12. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. glipizide 10 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO BID (2 times a day). 14. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. pioglitazone 15 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 16. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 17. sertraline 50 mg Tablet Sig: 0.5 Tablet PO QAM (once a day (in the morning)). 18. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 19. verapamil 180 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO Q24H (every 24 hours). 20. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 21. vitamin E 400 unit Capsule Sig: One (1) Capsule PO DAILY (Daily). 22. magnesium oxide 140 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 23. enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous QPM (once a day (in the evening)) for 2 weeks. Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: right hip fracture Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: may be wbat on right leg anterior hip precautions keep wound clean and dry take dc meds as ordered Physical Therapy: Activity: Activity: Out of bed w/ assist Activity: Ambulate twice daily if patient able Right lower extremity: Full weight bearing Left lower extremity: Full weight bearing Encourage turning, deep breathing and coughing qhour when awake. Treatment Frequency: Site: R hip Description: surgical incision covered with DSD Care: Assess daily for s&s of infection. Change dsg daily and prn. ___ leave OTA if no drainage. Followup Instructions: ___
19565522-DS-3	19,565,522	29,459,581	DS	3	2158-04-06 00:00:00	2158-04-06 14:35:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROSURGERY Allergies: Vicodin Attending: ___. Chief Complaint: S/P Fall Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ (aka EU Critical ___ is a ___ year old male who sustained a fall of approximately 20 feet while helping a friend move today. He had no loss of consciousness. He arose after the fall and drove himself home. His only symptoms were head pain. Later that evening, he had his fiancee drove him to the nearest ED for evaluation. At the outside hospital, a non-contrast head CT revealed a left parieto-occipital epidural hematoma. It was later read as a subdural hematoma by the outside hospital radiologist. The patient was loaded with Keppra at that time. The patient was then transferred to ___ for neurosurgery evaluation. Mr. ___ was also evaluated by the ACS/Trauma service for other traumatic injuries. They cleared the patient's cervical collar and found no other intra-abdominal or intra-thoracic injuries(based on OSH cervical, torso CT). Past Medical History: Depression, anxiety, PTSD, low back pain. Social History: ___ Family History: Non-contributory Physical Exam: On the day of admission: O: HR 59, BP 136/72 RR 14 O2 sat 97% on room air. Gen: WD/WN, comfortable, NAD. HEENT: PERRL, EOM intact. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, to mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. XI: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power ___ throughout. No pronator drift Sensation: Intact to light touch. On the day of discharge the patient was alert and oriented to person place and time. The patient was neurologically intact and moving all extremities with full strength. The patient was ambulating independently, and tolerating a regular diet. Hematoma dime sized under toungue on left. Pertinent Results: CT HEAD W/O CONTRAST ___ Impression: 1. Stable left parieto-occipital extra-axial hematoma. Possible minimal widening of the left occipitomastoid and left side of the lambdoid suture compared to the contralateral side; questionable fracture in OR in close proximity to the suture line. 2. Possible small subdural hematoma along the left anterior falx. 3. A small 1.5 x1 0.6 cm slightly round, extra-axial for lesion, in the left parasagittal anterior frontal location series 3, image 51; series 601 be, image 63 -Can represent a dural based lesion. Limited assessment as noncontrast study. Consider evaluation with MRI of the head without and with IV contrast if not contraindicated or post-contrast CT for better assessment . Brief Hospital Course: Mr. ___ was admitted to the Neurosurgery service at ___ for management of his left-sided epidural hematoma. The patient was started on Keppra for seizure prophylaxis and his blood pressure controlled with a goal SBP of < 140. The patient was admitted to the step-down unit for close neurologic monitoring. Since he was neurologically intact overnight, a repeat CT scan of the head was deferred until the am of ___ which was found to be stable. On ___, The patient was neurologically intact but sleepy. A physical therapy consult was initiated. On ___, the patient is alert and oriented to person, place and time. The patient is neurologically intact, and moving all his extremities with full strength. The patient is ambulating independently to the bathroom, and tolerating a regular diet. The patients pupils are equal round and reactive to light bilaterally. Hematoma present under tounge on left side. The patient was noted to have a possible mass on ___ and will follow up with a MRI with and without contrast for further evaluation in 4 weeks as recommended by Dr ___. Medications on Admission: PCN 500mg PO q 8 hours (recent tooth extraction), gabapentin 400mg QID, Ativan 1mg BID, Seroquel 200mg daily Discharge Medications: 1. Gabapentin 600 mg PO QID 2. QUEtiapine extended-release 200 mg PO DAILY 3. Docusate Sodium 100 mg PO BID RX docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #30 Capsule Refills:0 4. LeVETiracetam 500 mg PO BID RX levetiracetam 500 mg 1 tablet(s) by mouth twice a day Disp #30 Tablet Refills:1 5. Penicillin V Potassium 500 mg PO Q8H Duration: 5 Days 6. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain RX oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #45 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Left parieto-occipital epidural hematoma Discharge Condition: On the day of discharge the patient was alert and oriented to person place and time. The patient was neurologically intact and moving all extremities with full strength. The patient was ambulating independently, and tolerating a regular diet. small hematoma under tongue on left side Discharge Instructions: Take your pain medicine as prescribed. Exercise should be limited to walking; no lifting, straining, or excessive bending. Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, or Ibuprofen etc. You have been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. There is a small hematoma the size of a dime under your tongue on the left side. This will resolve overtime. If this should appear infected - please follow up with your primary care physcian. Your head Ct in addition to your left parieto-occipital extra-axial hematoma there was a small 1.5 x1 0.6 cm slightly round, extra-axial for mass, in the left anterior frontal region of your brain. When you return to the office you will have a MRI Brain with and without contrast to further evaluate this mass. Followup Instructions: ___
19565640-DS-18	19,565,640	26,587,548	DS	18	2189-03-27 00:00:00	2189-03-27 12:42:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: right sided chest pain and shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: ___ year old male well known to our service who had underwent CABG x3 on ___ with Dr. ___ with history of preoperative atrial fibrillation but post operative was noted for rapid ventricular rate with associated hypotension treated with amiodarone and digoxin. His atrial fibrillation was rate controlled and he was discharged to rehab on post operative day 6. He continued to do well and was seen in clinic ___ progressing post op. He was continuing to do well until ___ when he presented to his cardiologist office for follow up and underwent echocardiogram that revealed pericardial effusion. He was admitted to ___ for pericardial drainage but it was unreachable. He was transferred to ___ for further management and echocardiogram revealed tamponade physiology and was taken to the operating room for pericardial window. He tolerated the procedure and was started on NSAID due to concern for pericarditis. The chest tube remained for few days and was removed the day of discharge. He was doing well and seen in clinic ___ with plan for echocardiogram with his cardiologist which was planned for the following week. He recently saw Dr ___ states at that visit he was told to stop the NSAID. He presented to ___ ___ with right sided chest pain that started that am that he felt was musculoskeletal but then he became short of breath. At ___ they obtained CT scan of the chest which revealed pericardial effusion, they were unable to obtain echocardiogram and he was transferred to ___ for further evaluation. ED attempted echo with poor windows, cardiology consulted for echocardiogram to r/o tamponade and further assessment of effusion. Past Medical History: Chronic Obstructive Pulmonary Disease Congestive Heart Failure, chronic systolic Coronary Artery Disease Diabetes Mellitus Type II Hyperlipidemia Hypertension Mitral Regurgitation Obesity pericardial effusion Past Surgical History: Nasal artery ligation s/p CABG ___ Social History: ___ Family History: None relevant Physical Exam: Physical Exam: Pulse: 120 Aflutter Resp: 24 O2 sat: 96% 2 L NC B/P ___ Height: ___ Weight: 236 lbs per pt report General: Laying on stretcher at 30 degrees unable to complete sentences when talking no use of accessory muscles Skin: Dry Sternal incision healed except small pinpoint area at base unable to express any fluid - erythema distal ___ incision Old chest tube site with scant serous drainage HEENT: PERRLA Neck: Supple Full ROM Chest: Lungs clear decreased right bases no rhonchi or wheezes Heart: Irregular Abdomen: Soft non-distended non-tender bowel sounds + Obese umbilical hernia Extremities: Warm Edema +2 feet and +1 lower calf Neuro: Alert and oriented x3 no focal deficits Pulses: DP Right: p Left:p ___ Right: p Left:p Radial Right: p Left:p Discharge Physical Exam Temp: 97.4 (Tm 97.9), BP: 119/78 (97-137/58-96), HR: 80 (71-89), RR: 18 (___), O2 sat: 98% (96-99), O2 delivery: Ra, Wt: 231.7 lb/105.1 kg Physical Examination: General: NAD [x] Neurological: A/O x3 [x] non-focal [x] Cardiovascular: RRR [] Irregular [x] Murmur [] Rub [] Respiratory: CTA [x] No resp distress [x] GI/Abdomen: Bowel sounds present [x] Soft [x] ND [x] NT [x] Extremities: Right Upper extremity Warm [x] Edema Left Upper extremity Warm [x] Edema Right Lower extremity Warm [x] Edema +2 Left Lower extremity Warm [x] Edema +2 Pulses: DP Right: 1+ Left: 1+ ___ Right: 1+ Left: 1+ Radial Right: 1+ Left: 1+ Skin/Wounds: Dry [x] intact [x] Sternal:Sternum stable [x] Prevena [] 2 open areas mid sternum with packing and dry dressing, mild erythema although improving Lower extremity: Right [] Left [] CDI [] Upper extremity: Right [] Left [] CDI [] Pertinent Results: ___ 04:56AM BLOOD WBC-9.4 RBC-3.17* Hgb-10.2* Hct-31.4* MCV-99* MCH-32.2* MCHC-32.5 RDW-15.9* RDWSD-57.9* Plt ___ ___ 04:42AM BLOOD WBC-9.6 ___ 04:42AM BLOOD ___ ___ 04:42AM BLOOD UreaN-22* Creat-0.8 K-4.0 ___ 04:42AM BLOOD Mg-2.1 ___ 03:49AM BLOOD ALT-12 AST-30 LD(LDH)-344* AlkPhos-81 TotBili-1.1 CT chest non contrast ___ Status post CABG surgery with unremarkable appearance of midline sternotomy with a very small fluid collection in the inferior retrosternal space, unchanged compared to ___, likely a postsurgical seroma. Small bilateral pleural effusions, left greater than right. No evidence of pneumonia or pulmonary edema. Minimally decreased size of the pericardial effusion, particularly along the left pericardium ___ TTE The estimated right atrial pressure is >15mmHg. Normal right ventricular cavity size with normal free wall motion. The aortic valve leaflets (3) are mildly thickened. The mitral valve leaflets appear structurally normal. There is trivial mitral regurgitation. There is a moderate circumferential pericardial effusion. Tamponade physiology is difficult to assess due to the poor image quality and irregular rhythm (?atrial fibrillation). The effusion is echo dense, c/w blood, inflammation or other cellular elements. Brief Hospital Course: Patient was admitted on ___ and placed on vanco and cefazolin for sternal erythema. He was diuresed. A transesophageal echocardiogram was done and interpreted by cardiology as stable moderate pericardial effusion. He remained in rate controlled afib/flutter, continued on warfarin in light of stable pericardial effusion. Repeat TTE ___ showed continued stable effusion. Infectious disease was consulted and a PICC line was placed to treat MSSA positive blood cultures x 4. His sternal wound was opened and debrided by Dr. ___ required sternal packing to mid and lower pole wound openings. His WBC has remained stable. Vanco was discontinued and he was continued on Cefazolin Q8 until ___. CT from ___ re read here->? potential fluid collection deep to sternum, which remains not completely approximated- repeat CT scan ___ shoed no significant fluid collections per ___. He was discharged to home on HD ___ with with intravenous antibiotics, infectious disease follow-up and continued dressing changes. He will follow-up in the cardiac surgery office next week for his wound check. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amiodarone 200 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 80 mg PO QPM 4. Metoprolol Tartrate 50 mg PO BID 5. Tiotropium Bromide 1 CAP IH DAILY 6. Warfarin 2 mg PO 5X/WEEK (___) 7. GlipiZIDE XL 5 mg PO DAILY 8. MetFORMIN (Glucophage) 500 mg PO BID Discharge Medications: 1. Acetaminophen 325-650 mg PO Q4H:PRN Pain - Mild/Fever 2. CeFAZolin 2 g IV Q8H Duration: 9 Days RX cefazolin in dextrose (iso-os) 2 gram/50 mL 2 gm IV every 8 hours Disp #27 Intravenous Bag Refills:0 3. Docusate Sodium 100 mg PO BID 4. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild 5. Omeprazole 40 mg PO DAILY RX omeprazole 40 mg one capsule(s) by mouth daily Disp #30 Capsule Refills:2 6. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line flush 7. TraMADol 50 mg PO Q4H:PRN Pain - Moderate RX tramadol 50 mg one tablet(s) by mouth every four hours Disp #40 Tablet Refills:0 8. Warfarin 4 mg PO ONCE Duration: 1 Dose RX warfarin 4 mg one tablet(s) by mouth daily Disp #30 Tablet Refills:2 9. ___ MD to order daily dose PO DAILY16 goal INR ___. Amiodarone 200 mg PO DAILY RX amiodarone 200 mg one tablet(s) by mouth daily Disp #30 Tablet Refills:2 11. Aspirin 81 mg PO DAILY 12. Atorvastatin 80 mg PO QPM RX atorvastatin 80 mg one tablet(s) by mouth daily Disp #30 Tablet Refills:2 13. Furosemide 80 mg PO BID RX furosemide 80 mg one tablet(s) by mouth two times daily Disp #60 Tablet Refills:2 14. GlipiZIDE XL 5 mg PO DAILY RX glipizide 5 mg one tablet(s) by mouth daily Disp #30 Tablet Refills:2 15. MetFORMIN (Glucophage) 500 mg PO BID RX metformin 500 mg one tablet(s) by mouth two times daily Disp #60 Tablet Refills:2 16. Metoprolol Tartrate 50 mg PO BID RX metoprolol tartrate 50 mg one tablet(s) by mouth two times daily Disp #60 Tablet Refills:2 17. Tiotropium Bromide 1 CAP IH DAILY RX tiotropium bromide [Spiriva with HandiHaler] 18 mcg one cap inh daily Disp #30 Capsule Refills:2 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: pericardial effusion and sternal wound infection Discharge Condition: Alert and oriented x3, non-focal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - opened and packed 1+ Edema BLE Discharge Instructions: Please shower daily -wash incisions gently with mild soap, no baths or swimming, look at your incisions daily Please - NO lotion, cream, powder or ointment to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics Clearance to drive will be discussed at follow up appointment with surgeon No lifting more than 10 pounds for 10 weeks Please call cardiac surgery office with any questions or concerns ___. Answering service will contact on call person during off hours* Followup Instructions: ___
19565687-DS-12	19,565,687	26,312,709	DS	12	2178-09-13 00:00:00	2178-09-14 14:37:00	Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Hypoxia Major Surgical or Invasive Procedure: None History of Present Illness: ___ Female with diastolic CHF, dementia (oriented to self and place only), wheelchair bound, Afib with pacer and warfarin, presents from skilled nursing facility with 3 days productive cough, hypoxia to low 90's. She has had no fevers, no chest pain, abd pain/nausea/vom. She has urinary incontinence and diarrhea at baseline. In the ED, initial vitals were T97.0 83 151/64 36 99% NRB, found to be 95% on room air. No leukocytosis, BNP 8000 unknown baseline, INR 2.4. CXR c/e pulm edema, no focal infiltrate. EKG showed a paced rhythm. She was given ceftriaxone, vanc, azithro. On arrival to the floor, the patient did not know why she was brought to the hospital. She was still having cough, but no SOB, no chest pain. Her son was in the room, stated that his concern was the cough and the mental status changes- poor memory, poor recall since abrupt onset in ___. He states that she has had diarrhea for the past few weeks. ROS: per HPI, denies fever, chills, night sweats, headache, vision changes, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: Diastolic CHF GERD HTN Social History: ___ Family History: Patient's mother died at age ___ and had osteoarthritis. Patient's father died of ? stomach CA at age ___. She has 7 siblings, none of whom have arthtitis, autoimmune disease or vasculitis. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals- 97.9 BP 137/94 HR 70 RR 22 O2 97% General- Alert, oriented to self and BID, coughing sputum, no acute distress HEENT- Sclera anicteric, MMM, oropharynx clear Neck- supple, JVP not appreciated Lungs- Bibasilar wheezes, rales, ronchi CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen- soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU- no foley, incontinent of urine Ext- warm, bilateral pitting edema lower legs Neuro- CNs2-12 intact, motor function grossly normal DISCHARGE PHYSICAL EXAM: VS: 98.1 159/85 75 20 97%RA 8hr I/O: ___ General- Alert, oriented to self and hospital, awake, NAD HEENT- Sclera anicteric, MMM, oropharynx clear Neck- supple, no JVD Lungs- Trace crackles at bilateral bases but otherwise CTAB CV- Irregular rate, +S1/S2, III/VI SEM at RUSB. No appreciable r/g. Abdomen- soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU- foley present Ext- warm, well perfused, trace edema bilateral lower legs Neuro- Stable L-sided facil droop, otherwise CNs2-12 intact, motor function grossly normal Pertinent Results: ADMISSION LABS: ___ 10:00AM BLOOD WBC-8.7 RBC-4.78 Hgb-15.0 Hct-44.7 MCV-94 MCH-31.3 MCHC-33.5 RDW-15.2 Plt ___ ___ 10:00AM BLOOD Neuts-71.2* ___ Monos-4.9 Eos-1.1 Baso-2.2* ___ 10:00AM BLOOD Glucose-134* UreaN-22* Creat-1.1 Na-138 K-4.5 Cl-105 HCO3-21* AnGap-17 ___ 10:00AM BLOOD proBNP-8693* ___ 10:00AM BLOOD cTropnT-0.01 PERTINENT LABS: ___ 07:40AM BLOOD Calcium-10.8* Phos-3.1 Mg-2.1 ___ 07:40AM BLOOD WBC-5.8 RBC-4.68 Hgb-14.5 Hct-43.5 MCV-93 MCH-30.9 MCHC-33.2 RDW-15.2 Plt ___ ___ 07:35AM BLOOD Glucose-111* UreaN-22* Creat-1.1 Na-139 K-4.1 Cl-104 HCO3-27 AnGap-12 ___ 07:35AM BLOOD Calcium-11.3* Phos-3.1 Mg-2.0 ___ 06:28AM BLOOD WBC-10.4 RBC-5.13 Hgb-15.9 Hct-46.9 MCV-91 MCH-31.0 MCHC-33.9 RDW-14.8 Plt ___ ___ 06:28AM BLOOD Glucose-108* UreaN-35* Creat-1.4* Na-138 K-4.4 Cl-99 HCO3-25 AnGap-18 ___ 06:28AM BLOOD Mg-2.1 ___ 05:05AM BLOOD WBC-11.3* RBC-5.11 Hgb-15.9 Hct-47.3 MCV-93 MCH-31.0 MCHC-33.5 RDW-14.6 Plt ___ ___ 05:05AM BLOOD Glucose-117* UreaN-43* Creat-1.6* Na-138 K-4.2 Cl-99 HCO3-30 AnGap-13 ___ 04:38PM BLOOD VitB12-781 ___ 04:38PM BLOOD TSH-1.8 ___ 04:38PM BLOOD PTH-298* ___ 04:38PM BLOOD 25VitD-35 ___ 05:45AM BLOOD WBC-10.1 RBC-5.01 Hgb-15.4 Hct-46.5 MCV-93 MCH-30.8 MCHC-33.2 RDW-14.5 Plt ___ ___ 05:45AM BLOOD Glucose-115* UreaN-44* Creat-1.4* Na-141 K-4.0 Cl-102 HCO3-26 AnGap-17 ___ 05:45AM BLOOD Mg-2.4 ___ 02:22PM BLOOD Type-ART pO2-72* pCO2-36 pH-7.49* calTCO2-28 Base XS-4 Intubat-NOT INTUBA ___ 02:22PM BLOOD Glucose-89 Lactate-1.5 Na-140 K-3.9 Cl-103 ___ 02:22PM BLOOD freeCa-1.34* DISCHARGE LABS: ___ 04:20AM BLOOD WBC-9.7 RBC-4.86 Hgb-15.1 Hct-45.8 MCV-94 MCH-31.1 MCHC-33.0 RDW-14.7 Plt ___ ___ 04:20AM BLOOD Plt ___ ___ 04:20AM BLOOD Glucose-99 UreaN-38* Creat-1.3* Na-138 K-4.4 Cl-101 HCO3-26 AnGap-15 ___ 04:20AM BLOOD Mg-2.2 ANTICOAGULATION: ___ 10:00AM BLOOD ___ PTT-47.2* ___ ___ 07:40AM BLOOD ___ PTT-50.3* ___ ___ 07:35AM BLOOD ___ PTT-47.2* ___ ___ 06:59AM BLOOD ___ PTT-52.2* ___ ___ 06:40AM BLOOD ___ PTT-49.4* ___ ___ 06:28AM BLOOD ___ PTT-51.5* ___ ___ 05:05AM BLOOD ___ PTT-48.0* ___ ___ 05:45AM BLOOD ___ PTT-44.9* ___ ___ 05:45AM BLOOD ___ PTT-44.9* ___ ___ 06:05AM BLOOD ___ PTT-44.4* ___ REPORTS: ___ Imaging ABDOMEN (SUPINE & ERECT FINDINGS: Three frontal abdominal images demonstrate dilation of the transverse colon measuring up to 7.7 cm, concerning for colonic ileus. There is no evidence of free air under the right hemidiaphragm. The visualized osseous structures demonstrate dextroscoliosis and severe degenerative changes throughout the lumbar spine. There is a pin located in the left femoral head. IMPRESSION: Dilation of the transverse colon up to 7.7 cm, concerning for colonic ileus. ___ Imaging CT HEAD W/O CONTRAST IMPRESSION: 1. Encephalomalacia within the left parietal occipital region and right cerebellum unchanged since prior examination. 2. No evidence of acute hemorrhage, edema, mass effect, or infarction. 3. Redemonstration of near complete opacification of bilateral maxillary sinuses with inspissated secretions. Cannot exclude fungal colonization. ___ Imaging CHEST (PORTABLE AP) FINDINGS: In comparison with the study of ___, there is little overall change in the appearance of the heart and lungs and dual-channel pacer device. ___ Imaging VIDEO OROPHARYNGEAL SWA FINDINGS: Swallowing video fluoroscopy was performed in conjunction with the speech and swallow division. Multiple fluoroscopic images were obtained while the patient ingested various consistencies of barium. Penetration was seen with thin liquids. There was no aspiration. A hyperdensity seen anterior to C3-4 does not deform the esophagus anteriorly. IMPRESSION: Penetration with thin liquids. No aspiration. For further details, please see the speech pathology note in the ___ medical record ___ Imaging CT HEAD W/O CONTRAST FINDINGS: There is a 2.5 x 1.9 cm hypodensity in the left parieto-occipital region (301:20) which is compatible with a focus of encephalomalacia secondary to old infarct. Otherwise, there is no new hemorrhage, edema, mass, mass effect, or large territorial infarction. Prominent ventricles and sulci are compatible with age-related atrophy. Severe periventricular white matter changes as well as lacunar infarcts in the right lenticular nucleus are compatible with sequelae of chronic small vessel ischemic disease. There is preservation of gray-white matter differentiation in the non-affected parts of the brain. The basal cisterns are patent. No fracture is identified. The maxillary sinuses are nearly completely opacified with inspissated secretions and calcifications with associated bony sclerosis of the medial and lateral walls, all suggesting chronic inflammation. The remaining paranasal sinuses, mastoid air cells and middle ear cavities are clear. Atherosclerotic calcifications of the vertebral arteries and the carotid siphons are present. There is no facial or extracranial soft tissue abnormality. IMPRESSION: 1. Focus of encephalomalacia in the left parieto-occipital region is likely secondary to old watershed infarct. 2. Severe sequelae of chronic microvascular disease. 3. Near-complete opacification of the bilateral maxillary sinuses with inspissated calcified secretions ("sinoliths") and associated bony sclerosis suggest chronic sinusitis; superimposed fungal colonization cannot be excluded with this appearance. NOTE ADDED IN ATTENDING REVIEW: There is also a chronic encephalomalacic focus in the inferomedial aspect of the right cerebellar hemisphere (304:8), likely reflecting an old right ___ territorial infarct. Given the findings above, this may relate to previous embolic episode(s), but should be correlated with more detailed history. ___ ImagingCHEST (PA & LAT) FINDINGS: In comparison with the study of ___, there is little change. Continued mild enlargement of the cardiac silhouette and any elevated pulmonary venous pressure is minimal. No evidence of acute focal pneumonia. Dual-channel pacer device is in place. ___ CardiovascularECHO Findings LEFT ATRIUM: Elongated LA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. A catheter or pacing wire is seen in the RA and extending into the RV. LEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Suboptimal technical quality, a focal LV wall motion abnormality cannot be fully excluded. Overall normal LVEF (>55%). Diastolic function could not be assessed. No resting LVOT gradient. RIGHT VENTRICLE: RV not well seen. AORTA: Focal calcifications in aortic root. AORTIC VALVE: ?# aortic valve leaflets. Severely thickened/deformed aortic valve leaflets. Critical AS (area <0.8cm2). No AR. MITRAL VALVE: Moderately thickened mitral valve leaflets. No MVP. Moderate mitral annular calcification. Moderate thickening of mitral valve chordae. Calcified tips of papillary muscles. Mild to moderate (___) MR. [Due to acoustic shadowing, the severity of MR may be significantly UNDERestimated.] TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Moderate PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS. Physiologic PR. PERICARDIUM: There is an anterior space which most likely represents a fat pad, though a loculated anterior pericardial effusion cannot be excluded. GENERAL COMMENTS: The rhythm appears to be atrial fibrillation. Frequent ventricular premature beats. Echocardiographic results were reviewed by telephone with the houseofficer caring for the patient. Conclusions The left atrium is elongated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF 55-60%). Diastolic function could not be assessed. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are severely thickened/deformed. There is critical aortic valve stenosis (valve area 0.6 cm2). No aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. There is no mitral valve prolapse. There is moderate thickening of the mitral valve chordae. Mild to moderate (___) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is moderate pulmonary artery systolic hypertension. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: Mild symmetric left ventricular hypertrophy with normal global systolic function. Critical aortic stenosis. Mild to moderate mitral regurgitation. Moderate pulmonary hypertension. ___ ImagingCHEST (PORTABLE AP) FINDINGS: The heart is mildly enlarged. A left sided pacemaker is seen in adequate position with its leads terminating in the right atrium and right ventricle, expected locations. There is calcification of the aortic knob. There are increased interstitial pulmonary markings which may relate to chronic lung findings or mild pulmonary edema. There is no definite focal consolidation, pleural effusion or pneumothorax. IMPRESSION: Increased interstitial pulmonary markings may relate to chronic lung findings or mild pulmonary edema. ___ CardiovascularECG Demand ventricular pacing with underlying atrial fibrillation. No previous tracing available for comparison. MICROBIOLOGY: ___ BLOOD CULTURE - PENDING ___ URINE CULTURE-FINAL {YEAST} INPATIENT URINE CULTURE (Final ___: YEAST. 10,000-100,000 ORGANISMS/ML.. ___ Blood Culture, Routine-FINAL INPATIENT NO GROWTH. ___ Blood Culture, Routine-FINAL INPATIENT NO GROWTH. ___ Blood Culture, Routine-FINAL INPATIENT NO GROWTH. ___ C. difficile DNA amplification assay-FINAL INPATIENT C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. (Reference Range-Negative). ___ Blood Culture, Routine-FINAL INPATIENT NO GROWTH. ___ Legionella Urinary Antigen -FINAL INPATIENT NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. (Reference Range-Negative). Performed by Immunochromogenic assay. A negative result does not rule out infection due to other L. pneumophila serogroups or other Legionella species. Furthermore, in infected patients the excretion of antigen in urine may vary. ___ URINE CULTURE-FINAL {BETA STREPTOCOCCUS GROUP B, ESCHERICHIA COLI} INPATIENT URINE CULTURE (Final ___: Culture workup discontinued. Further incubation showed contamination with mixed skin/genital flora. Clinical significance of isolate(s) uncertain. Interpret with caution. BETA STREPTOCOCCUS GROUP B. 10,000-100,000 ORGANISMS/ML.. ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI \| AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R ___ Blood Culture, Routine-FINAL {MICROCOCCUS/STOMATOCOCCUS SPECIES}; Aerobic Bottle Gram Stain-FINAL EMERGENCY WARD Blood Culture, Routine (Final ___: MICROCOCCUS/STOMATOCOCCUS SPECIES. PRESUMPTIVE IDENTIFICATION. Isolated from only one set in the previous five days. Aerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN CLUSTERS. Reported to and read back by ___ AT 2:20PM ON ___. ___ BLOOD CULTURE Blood Culture, Routine-FINAL NO GROWTH. Brief Hospital Course: DIASTOLIC CONGESTIVE HEART FAILURE: The patient presented with cough and hypoxia. Transthoracic echocardiogram on ___ ___ showed severe diastolic dysfunction, dilated right ventricle, 2+ mitral regurgitation, 2+ tricuspid regurgitation, and critical aortic stenosis with a valve area of 0.6cm2. Clinically, the patient was found to have significant pulmonary venous congestion and peripheral edema. For this, she was diuresed initially with an intravenous furosemide bolus followed by a furosemide drip, which was then transitioned to oral torsemide. Diuresis was held for two days in the setting of altered mental status given possibility of overdiuresis and poor forward flow. On the day prior to discharge, she was started on a maintenance dose of Torsemide 20mg. At the time of discharge, the patient appeared euvolemic and was without any oxygen requirement. Her discharge weight was 187lb (84.8kg). AORTIC STENOSIS: The patient had a history of aortic stenosis, and was found on ___ transthoracic echocardiogram to have critical aortic stenosis with a valve area of 0.6cm2Patient presenting with critical AS with valve area 0.6cm. The interventional cardiologists saw the patient for consideration of transcatheter aortic valve replacement versus palliative balloon angioplasty. It was decided that given the patient's first presentation of volume overload as well as waxing and waning mental status, that a trial of additional medical management should be pursued prior to an interventional approach. Throughout this admission, her volume status was closely monitored closely without complications. POSITIVE BLOOD CULTURE: On admission, the patient had 1 out of 2 blood cultures that grew gram positive cocci in clusters, that eventually speciated as Micrococcus. The patient was initially treated with Vancomycin. The Infectious Disease team was consulted and thought that the positive culture was a contiminant, as micrococcus are usually pathogenic in only immunocompromised hosts. As such, all antibiotics were discontinued. At the time of discharge, surveillance blood cultures remained no growth. ASPIRATION: During this admission, the patient was noticed to have poor management of her secretions. Chest X-ray was negative for focal consolidations or pneumonia. The Speech and Swallow team saw the patient and conducted a video swallow study that showed that she is not silently aspirating, and recommended that she be on liquids. ALTERED MENTAL STATUS: Per the patient's son, the patient had an acute mental status change on ___. During this hospitalization, the patient was noted to have worsening and waxing-waning mental status change. The differential for this included decreased forward flow in the setting of diuresis and critical aortic stenosis versus delerium versus. Given the family's concern, a non-contrast head CT was conducted on ___ and showing old lacunar infarcts, prior ___ infarct, but no new lesions. The neurology team saw the patient, and thought that her altered mental was consistent with metabolic encephalopathy. Another repeat head CT on ___ was no significantly changed from prior and did not show any new intracranial proess. A geriatrics consult was placed, and ranitidine was discontinued and she was started on cinacalcet for hypercalcemia (see below). An palliative care consult was also placed to discuss the patient's goals of care, and a consensus was reached to provide comfort-directed care. ASYMPTOMATIC BACTERURIA: The patient has several months of asymptomatic bacteremia. During this admission, urine legionella antigen was negative and urine cultures grew group B streptococcus (likely vaginal contaminant) and E.coli. She was without urinary symptoms at this time. The infectious disease team was consulted and did not recommend starting antibiotics for her asymptomatic bacteruria. ATRIAL FIBRILLATION: The patient has known atrial fibrillation. Her home atenolol was converted to metoprolol tartrate 25mg BID, and her heart rate remained well-controlled in the 60-70s. She was also continued on her home dose of coumadin (2.5mg daily), which was decreased to 1mg daily in the setting of supratherapeutic INR to 3.3. Otherwise, her INR remained therapeutic at ___. At the time of discharge, her INR was 2.8. She will need an INR check on ___. HYPERCALCEMIA: The patient's calcium in the setting of normal albumin increased from 10.8-11.3. Vitamin D level was normal but PTH level was elevated to 298, suggesting primary hyperparathyrodism. The patient was started on cincalcet for this, and should remain on this at discharge. GASTROESOPHAGEL REFLUX DISEASE: The patient was continued on his home omeprazole. INSOMNIA: The patient was continued on his home trazodone. TRANSITIONAL ISSUES - Patient needs to have daily weights and I/Os check - ___ MD if weight increases by more than 3 lb - Patient needs electrolyte check on ___ - Patient need weekly electrolyte and INR checks (beginning on ___ - The patient remained DNR/DNI throughout this admission Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Milk of Magnesia 30 mL PO DAILY:PRN constipation 2. Multivitamins 1 TAB PO DAILY 3. Omeprazole 40 mg PO DAILY 4. Acetaminophen 650 mg PO Q8H 5. Furosemide 40 mg PO 4X/WEEK (___) 6. Furosemide 60 mg PO 3X/WEEK (___) 7. TraZODone 25 mg PO HS 8. Warfarin 2.5 mg PO DAILY16 9. Artificial Tears ___ DROP BOTH EYES PRN dry eyes 10. Atenolol 37.5 mg PO DAILY Discharge Medications: 1. Potassium Chloride 20 mEq PO DAILY Duration: 24 Hours Hold for K > 4 2. Acetaminophen 650 mg PO Q8H 3. Artificial Tears ___ DROP BOTH EYES PRN dry eyes 4. Milk of Magnesia 30 mL PO DAILY:PRN constipation 5. Multivitamins 1 TAB PO DAILY 6. TraZODone 25 mg PO HS 7. Warfarin 1 mg PO DAILY16 8. Cinacalcet 30 mg PO BID 9. Torsemide 20 mg PO DAILY 10. Omeprazole 40 mg PO DAILY 11. Docusate Sodium 100 mg PO BID 12. Metoprolol Tartrate 25 mg PO BID 13. Guaifenesin ___ mL PO Q6H:PRN coughing 14. Senna 2 TAB PO HS Discharge Disposition: Extended Care Facility: ___ ___ Diagnosis: Primary Diagnosis: Acute-on-chronic Diastolic Heart Failure Secondary Diagnoses: Critical aortic stenosis Discharge Condition: Mental Status: Confused - always. 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 take care of you during this hospitalization. You were admitted to ___ for cough. You were found to have significant excess fluid in your lungs and your body because of "heart failure," decreased pumping of your heart. You were treated with intravenous medicines to help you get rid of this excess fluid. Your discharge weight was 187lb (84.8kg). You were also found to have severe narrowing of your aortic valve, which likely contributed to the accumulation of fluid. You were seen by Dr. ___ who felt that opening your valve would expose you to more risk than benefit. There was a concern for infection when you first came into the hospital, for which you were started on antibiotics. The Infectious Disease specialists were consulted, and they thought that this was not a true infection. The antibiotics were stopped and you had no further signs of infection. There was a concern that your mental status was changed. You had two head CT scans that did not show any new changes. The neurology team saw you and thought that ___ mental status change was due to being in the hospital and your illness. You have also had many small strokes over a long period of time, contributing to your confusion. You medications and follow-up appointments are summarized below. Followup Instructions: ___
19565999-DS-5	19,565,999	23,094,195	DS	5	2185-10-13 00:00:00	2185-10-13 15:11:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: lactose / donepezil / cherry flavor / tree nut / mushroom Attending: ___. Major Surgical or Invasive Procedure: None attach Pertinent Results: ADMISSION LABS =============== ___ 02:00PM BLOOD WBC-5.5 RBC-4.16 Hgb-13.5 Hct-41.9 MCV-101* MCH-32.5* MCHC-32.2 RDW-13.6 RDWSD-50.1* Plt ___ ___ 02:00PM BLOOD Neuts-56.9 ___ Monos-7.2 Eos-3.6 Baso-0.7 Im ___ AbsNeut-3.14 AbsLymp-1.72 AbsMono-0.40 AbsEos-0.20 AbsBaso-0.04 ___ 02:00PM BLOOD ___ PTT-30.1 ___ ___ 02:00PM BLOOD Glucose-92 UreaN-15 Creat-0.8 Na-142 K-5.7* Cl-101 HCO3-27 AnGap-14 ___ 07:25AM BLOOD Glucose-92 UreaN-17 Creat-0.9 Na-143 K-4.0 Cl-104 HCO3-26 AnGap-13 ___ 02:00PM BLOOD ALT-13 AST-35 CK(CPK)-202* AlkPhos-85 TotBili-0.4 ___ 02:00PM BLOOD Albumin-4.3 ___ 09:50PM BLOOD VitB12-463 ___ 09:50PM BLOOD TSH-1.5 ___ 09:50PM BLOOD T4-6.0 MICROBIOLOGY: ============= URINE CULTURE (Final ___: ENTEROCOCCUS SP.. >100,000 CFU/mL. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. \| AMPICILLIN------------ <=2 S NITROFURANTOIN-------- <=16 S TETRACYCLINE---------- <=1 S VANCOMYCIN------------ ___hest/abd/pel ___ IMPRESSION: 1. No acute intra-abdominal or chest pathology. Specifically, no evidence of a hematoma. 2. High density material is seen in the renal pelvises bilaterally as well as dependently in the bladder, and may represent blood or contrast from prior contrast administrations in the correct clinical scenario. Consider correlation with urinalysis. 3. There is a 3-4 mm pulmonary nodule in the lingula (3: 62). RECOMMENDATION(S): For incidentally detected single solid pulmonary nodule smaller than 6 mm, no CT follow-up is recommended in a low-risk patient, and an optional CT in 12 months is recommended in a high-risk patient. LABS ON DISCHARGE: ================== ___ 07:10AM BLOOD WBC-5.4 RBC-3.71* Hgb-12.0 Hct-38.6 MCV-104* MCH-32.3* MCHC-31.1* RDW-13.7 RDWSD-51.7* Plt ___ ___ 07:10AM BLOOD Glucose-85 UreaN-15 Creat-0.6 Na-143 K-4.5 Cl-109* HCO3-24 AnGap-10 Brief Hospital Course: Ms. ___ is a ___ female with h/o chronic heart failure, EF unknown, HTN, dementia presents with vagina abrasions and blood in underwear. # Goals of Care: Patient with known end-stage dementia and is oriented x1 at baseline. She was previously ambulatory with walker but is likely deconditioned from pro-longed hospitalization. Patient noted to have poor PO intake in the context of end-stage dementia. Discussed with daughter/HCP who confirmed that artificial nutrition is not within her GOC. She understands the natural progression of dementia and understands that her mother is likely approaching the end of life. She is confirmed DNR/DNI and no artificial nutrition but did not discuss whether she would want the patient to be re-hospitalized. # Hematuria: # Recurrent UTIs: First noticed in the setting of vaginal abrasions below. UA with RBCs as well as pyuria. Urine culture from ED with enterococcus sensitive to nitrofurantoin (___). She was treated with 5 day course of nitrofurantoin, and U/A was repeated, which revealed resolution of both pyuria and hematuria. However, on the day of discharge patient again noted to have hematuria with very foul smelling urine raising concern for recurrent UTI, which she is very high risk given incontinence. She was started on amoxicillin given prior sensitivity data with planned course for 7 days with end date ___. Given finding of high density material on CT in renal pelvises bilaterally and dependently in bladder, did arrange for urology follow up after discussion with daughter given desire to understand significance of these findings. # ? Vaginal abrasions: Per speculum exam in ED, concerning for possible abuse although alternatively could represent self-inflicting injury from scratching in the setting of UTI. Patient had been observed scratching herself by nursing. Due to end-stage dementia, patient unable to recount etiology of injury. External vaginal exam on day of discharge without evidence of persistent/nonhealing wounds. # Hypertension: Continued home lisinopril 40 mg daily. CHRONIC/STABLE PROBLEMS: # CHRONIC SYSTOLIC HEART FAILURE: Home diuretics held given euvolemia and poor PO intake. These were not resumed on discharge. Transitional issues: =================== # Continue ongoing ___ discussion given patient's end stage dementia. See above for details regarding conversations thus far. # Patient started on amoxicillin x 7 days for recurrent UTI, last day is ___ for 7 days of therapy. # Urology follow up arranged to discuss significance of CT findings and ? hematuria. > 30 mins spent coordinating discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 10 mg PO QPM 2. Furosemide 60 mg PO DAILY 3. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever 4. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line 5. Docusate Sodium 100 mg PO BID 6. Simethicone 40-80 mg PO QID:PRN gas 7. Lisinopril 40 mg PO DAILY 8. TraZODone 25 mg PO QHS:PRN insomnia 9. Vitamin D 1000 UNIT PO DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever 2. Atorvastatin 10 mg PO QPM 3. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line 4. Docusate Sodium 100 mg PO BID 5. Lisinopril 40 mg PO DAILY 6. Simethicone 40-80 mg PO QID:PRN gas 7. TraZODone 25 mg PO QHS:PRN insomnia 8. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ ___ Diagnosis: vaginal abrasions Hematuria Urinary tract infection Dementia, delirium Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Sometimes lethargic. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. ___, You were admitted to the hospital after it was noticed that you had blood in your underwear. There was some concern that this could have been vaginal blood although it's also possible that it was from the urinary tract as there was blood noticed in your urinalysis. We also saw evidence of an infection in your urine culture, so we treated you with antibiotics. We repeated your urine test after completion of antibiotics and found that the infection had resolved. Your CT scan showed some abnormalities in your kidneys of unclear significance so we have arranged follow up with a urologist discuss if any further investigation is required. Please take care, we wish you the best! Sincerely, Your ___ Care Team Followup Instructions: ___
19566912-DS-19	19,566,912	20,107,656	DS	19	2136-07-10 00:00:00	2136-07-10 16:52:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Left arm weakness Major Surgical or Invasive Procedure: None. History of Present Illness: ___ is a ___ RH man with a h/o migraines and a ?VSD repair as a child who presents as a code stroke for left arm weakness that began suddenly at approximately 3:30pm. The patient had been in a meeting at work, he is a ___ at ___ when he suddenly noticed that his left arm was flaccid and weak. He also felt as if his left face was drooping, but did not look in a mirror and it is not clear if anyone else noticed. Since the onset of symptoms his strength has improved slowly and he how has only weakness in the fingers. He does not think there were any associated sensory changes. He does note that he felt a little bit light headed at the time of symptom onset. He had a similar episode within the past few months which was nearly identical, except for that the weakness was in the right hand and resolved completely within minutes. He did not seek medical attention at that time. He has had migraines with aura in the past, but auras have been visual in nature. He has not had a headache today. He notes that he had been on a long flight shortly prior to each episode of weakness. On neuro ROS, the pt denies headache, loss of vision, blurred vision, diplopia, dysarthria, dysphagia, vertigo, tinnitus or hearing difficulty. Denies difficulties producing or comprehending speech. Denies focal numbness, parasthesiae. No bowel or bladder incontinence or retention. Denies difficulty with gait. On general review of systems, the pt denies recent fever or chills. No night sweats or recent weight loss or gain. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Denies rash. Past Medical History: ?VSD repair as young child Migraines with visual auras - now has visual auras several times per week, no severe headaches since college Social History: ___ Family History: Sister with recent stroke and "small hole" found in work up (?PFO). No other neurologic family history. No other history of familial clotting disorders Physical Exam: ======================= ADMISSION PHYSICAL EXAM ======================= Vitals: 98.0 78 132/70 18 99% RA GEN: Awake, cooperative, NAD. HEENT: NC/AT, anicteric, MMM, no lesions noted in oropharynx NECK: Supple RESP: non-labored CV: RRR ABD: soft, NT/ND EXT: No edema, no cyanosis SKIN: no rashes or lesions noted. NEURO EXAM: MS: Alert, oriented x 3. Able to relate history without difficulty. Attentive. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Speech was not dysarthric. Pt was able to name both high and low frequency objects. Able to follow both midline and appendicular commands. Good knowledge of current events. No evidence of apraxia or neglect. CN: II: PERRLA 4 to 2mm and brisk. VFF to confrontation. III, IV, VI: EOMI, no nystagmus. Normal saccades. V: Sensation intact to LT. VII: Facial musculature symmetric. VIII: Hearing intact to conversation. IX, X: Palate rise symmetric. XI: Trapezius and SCM ___ bilaterally. XII: Tongue protrudes midline. Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements. No asterixis. Delt Bic Tri WrE FE IO FFl IP Quad Ham TA ___ L ___ ___ ___ ___ 5 R ___ ___ 5 5 ___ 5 Sensory: No deficits to light touch. No extinction to DSS. Reflexes: Bi Tri ___ Pat Ach L ___ 2 2 R ___ 2 2 Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF or HKS bilaterally. ========================= DISCHARGE EXAM ========================= *template, VITALS are correct Vitals: GEN: Awake, cooperative, NAD. HEENT: NC/AT, anicteric, MMM, no lesions noted in oropharynx NECK: Supple RESP: non-labored CV: RRR ABD: soft, NT/ND EXT: No edema, no cyanosis SKIN: no rashes or lesions noted. NEURO EXAM: MS: Alert, oriented x 3. Able to relate history without difficulty. Attentive. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Speech was not dysarthric. Pt was able to name both high and low frequency objects. Able to follow both midline and appendicular commands. Good knowledge of current events. No evidence of apraxia or neglect. CN: II: PERRLA 4 to 2mm and brisk. VFF to confrontation. III, IV, VI: EOMI, no nystagmus. Normal saccades. V: Sensation intact to LT. VII: Facial musculature symmetric. VIII: Hearing intact to conversation. IX, X: Palate rise symmetric. XI: Trapezius and SCM ___ bilaterally. XII: Tongue protrudes midline. Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements. No asterixis. Delt Bic Tri WrE FE IO FFl IP Quad Ham TA ___ L ___ ___ ___ ___ 5 R ___ ___ 5 5 ___ 5 Sensory: No deficits to light touch. No extinction to DSS. Reflexes: Bi Tri ___ Pat Ach L ___ 2 2 R ___ 2 2 Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF or HKS bilaterally. Pertinent Results: ======================== ADMISSION LABS ======================== ___ 05:51PM BLOOD WBC-4.9 RBC-4.70 Hgb-14.6 Hct-40.6 MCV-86 MCH-31.1 MCHC-36.0 RDW-12.0 RDWSD-37.7 Plt ___ ___ 05:51PM BLOOD ___ PTT-30.9 ___ ___ 05:51PM BLOOD Plt ___ ___ 05:51PM BLOOD UreaN-15 ___ 05:57PM BLOOD Creat-1.0 ___ 05:51PM BLOOD ALT-32 AST-22 AlkPhos-44 TotBili-0.5 ___ 05:51PM BLOOD cTropnT-<0.01 ___ 05:51PM BLOOD Albumin-4.5 ___ 05:51PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 05:57PM BLOOD Glucose-81 Na-139 K-3.7 Cl-101 calHCO3-24 ================ OTHER LABS ================ ___ 07:00AM BLOOD WBC-4.5 RBC-4.62 Hgb-14.2 Hct-39.8* MCV-86 MCH-30.7 MCHC-35.7 RDW-12.1 RDWSD-37.6 Plt ___ ___ 07:00AM BLOOD Plt ___ ___ 07:00AM BLOOD Glucose-95 UreaN-13 Creat-0.9 Na-140 K-3.7 Cl-106 HCO3-24 AnGap-14 ___ 07:00AM BLOOD CK(CPK)-65 ___ 07:00AM BLOOD CK-MB-2 cTropnT-<0.01 ___ 07:00AM BLOOD Calcium-8.8 Phos-3.5 Mg-1.9 Cholest-157 ___ 07:00AM BLOOD %HbA1c-4.9 eAG-94 ___ 07:00AM BLOOD Triglyc-69 HDL-47 CHOL/HD-3.3 LDLcalc-96 ======================== DISCHARGE LABS ======================== ___ 07:00AM BLOOD WBC-4.7 RBC-4.81 Hgb-14.6 Hct-41.9 MCV-87 MCH-30.4 MCHC-34.8 RDW-12.2 RDWSD-38.5 Plt ___ ___ 07:00AM BLOOD Plt ___ ___ 07:00AM BLOOD Glucose-87 UreaN-14 Creat-0.9 Na-140 K-4.2 Cl-106 HCO3-25 AnGap-13 ================== IMAGING ================== CTA head and neck w/ and w/out contrast ___ 1. Normal head and neck CTA. 2. No acute intracranial abnormality. ECHO ___ No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. Right atrial appendage ejection velocity is good (>20 cm/s). A small secundum atrial septal defect is present with a predominantly left-to-right shunt across the interatrial septum at rest, but with agitated saline/microbubbles at rest, there is premature appearance of saline contrast in the left atrium through a patent foramen ovale. Overall left ventricular systolic function is normal (LVEF>55%). The interventricular septum below the aortic valve is aneurysmal, likely secondary to prior repaired/closed perimembranous VSD. There is no 2D or color flow evidence of a shunt across the interventricular septum. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. There are simple atheroma in the descending thoracic aorta and aortic arch. There are three aortic valve leaflets. Significant aortic regurgitation is present, but cannot be quantified. The mitral valve leaflets are structurally normal. No mass or vegetation is seen on the mitral valve. Trivial mitral regurgitation is seen. There is a trivial/physiologic pericardial effusion. CLINICAL IMPLICATIONS: Secundum atrial septal defect/stretched foramen ovale with bidirectional shunt (predominantly left-to-right) at rest. Significant aortic regurgitation, unable to quantify. Mildly dilated aortic root.No spontaneous echo contrast or thrombi in the ___. Simple atheroma in the descending aorta. If clinically indicated and patient management would change, a cardiac MRI may be considered to further quantify the severity of aortic regurgitation and assess the interventricular and interatrial septa. MR head without contrast ___: 1. No acute intracranial abnormality. 2. Findings of small chronic vessel ischemic disease. Bilateral lower extremity ultrasound ___: No evidence of deep venous thrombosis in the right or left lower extremity veins. MRV pelvis ___: No evidence of deep venous thrombosis in the right or left lower extremity veins. Brief Hospital Course: ___ is a ___ RH man with a h/o migraines w/ visual auras and a ?VSD repair as a child who presented with acute LUE weakness on ___ (NIHSS 0), no tPA treatment, no acute stroke on MRI, with improvement by the evening of ___. Equal strength with 5- strength in IO and finger flexors of hands bilaterally on ___. Event concerning for TIA in motor hand area on right, with PFO on TEE, no DVT on lower extremity u/s or MRV pelvis, without any other stroke risk factors (no HTN, no diabetes, HbA1c 4.9%, LDL 96). TIA: MRI/A head and neck showed no acute process, with findings of small chronic vessel ischemic disease, though these findings can be present in patients with chronic migraines as well. We found a PFO on TEE, and no DVT on MRV or lower extremity ultrasound. He does not have hypertension, and on this admission found his HbA1c 4.9%, LDL 96, HDL 47 and total cholesterol 157. We started aspirin 81 mg. He does not have many cardiovascular risk factors (his ___ ___ year cardiovascular risk is <5%) for stroke other than the PFO. CV: His SBP throughout admission were 100-120's. We allowed his BP to autoregulate as he did not have any issues with blood pressure, and did not require hydralazine for elevated blood pressures. There was no evidence of paroxysmal atrial fibrillation on telemetry. TEE showed +PFO, evidence of membranous VSD repair, overriding aorta with +AR. TTE ordered for evaluation of severity of AR, which showed preserved biventricular systolic function. Mildly dilated aortic root and ascending aorta. Aortic regurgitation is present, but unable to be quanitified secondary to a markedly eccentric jet. Mild pulmonary artery systolic hypertension. Migraines: Has a long history of migraines since childhood, and has not had severe headaches since he was in college. He still continues to have ___ visual auras per week, which he occasionally takes advil for. He did not require any medication for any headaches during this admission. Medications on Admission: None Discharge Medications: 1. Aspirin 81 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Transient Ischemic Attack Patent Foramen Ovale Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were admitted due to left arm weakness and possible left facial drooping on ___ that occurred around 3:30 ___, and lasted through the late evening. You had had one similar episode in ___ in your right arm. The left arm weakness was initially most concerning for an acute stroke, so we ordered an MRI/A head and neck which showed no acute process, although there were findings consistent with possible chronic vessel ischemic disease. However, these findings can be found in patients who have had many migraines as well. We also assessed your risk factors for stroke. You did not have hypertension, your glycosylated hemoglobin was very low at 4.9%, and LDL was low at 96. We started you on an aspirin 81 mg. Based on your LDL, you do not need to start a statin medication. Your cholesterol levels should continue to be monitored. We also did an ECHO to assess for any abnormalities in your cardiac function, and to assess for presence of patent foramen ovale (PFO). Your ECHO showed a secundum atrial septal defect/stretched foramen ovale with bidirectional shunt (predominantly left-to-right) at rest. The echo showed aortic regurgitation and mildly dilated aortic root, which may be a result of your past congenital heart valve repair. When there is a PFO, we always assess for the presence of deep venous thrombi in your legs. We did an ultrasound of your leg veins, as well as an MRV of the pelvis. Both studies did not show any clots. Ultimately, we think you had two episodes of TIAs, or transient ischemic attacks. It is possible that a small clot broke off from somewhere in your legs after the long flight and travelled through the PFO into your brain. It seems that it only occluded the vessels for a short amount of time, as your functional status returned to baseline quickly. We recommend medical management with aspirin. We sent for blood tests to evaluate the possibility that you have intrinsic hypercoagulability from other process. Those blood tests are pending at time of discharge and will be followed up in Stroke Clinic. You should follow up with Dr. ___ neurologist attending, as well as with cardiology, as below. Followup Instructions: ___
19567117-DS-15	19,567,117	25,801,519	DS	15	2115-10-01 00:00:00	2115-10-01 15:21:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: E-Mycin / IV Dye, Iodine Containing Contrast Media / Iodine / Influenza Virus Vaccine / Juniper / Latex / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / aspirin / simvastatin / hydrochlorothiazide / clarithromycin / levofloxacin / noshel / Sulfa (Sulfonamide Antibiotics) / erythromycin base Attending: ___. Chief Complaint: Toe pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ ___ Atrial fibrillation on Coumadin 1mg daily, AAA, GERD, gastric antral vascular ectasia, CAD, HTN, AS, HF(?pEF) p/w worsening lower extremity pain. -Patient has been pain in her right foot for 3 months, particularly in her ___ toe. She has also had pain in her left foot for 1 month, particularly in the tip of her ___ toe -The pain has been gradually worsening and increases with movement and walking. -She had a significant increase of the pain in her right ___ toe yesterday night and she consulted ___ today in the morning. -She was seen at ___ and referred here for vascular surgery evaluation. -At ___ she had an elevated WBC count of 11.6K/mm3, an INR of 2.04, and a BUN 38mg/dL with Creatinine 4.32mg/dL (similar to ___ levels of 35 and 4.52, respectively but increased from ___ when creatinine was 1.92mg/dL. Patient had a workup ___ including imaging and lab studies available via ___ EMR on ___, including a normal renal US and a UA showing signs of UTI and 3+blood. -She had a Dupplex of Aorta and lower extremities in ___ w/moderate arterial insufficiency bilaterally. -Patient also reports increasing shortness of breath for the past 1 month. No orthopnea, no PND. She now gets short of breath when walking a few meters. In the ED, initial vitals: 98 60 146/57 18 95% RA - Exam notable for: Vital signs stable, no acute distress JVP elevated 9-10cm at 30 degrees Plurifocal systolic murmur radiating to carotids, ___ Lungs with bilateral crackles up to the mid-lung, no wheezing, no rhonchi Abdomen s/nt/nd, bowel sounds present No peripheral edema DP and ___ Doppler signal is present on both the right and left lower extremities The distal ___ right toe is necrotic with proximal erythema, with tenderness to touch, dry The tip of the left ___ toe is dark and painful, dry Rectal Exam: Brown-colored stool Guaiac (-) - Labs notable for: Cr 3.9 WBC 10.9 H/H 8.7/26.9 INR 2.3 - Imaging notable for: Foot and chest xrays not read - Pt given: ___ 13:51 PO OxyCODONE (Immediate Release) 5 mg ___ 14:05 IV Piperacillin-Tazobactam Started - Vitals prior to transfer: 98.0 51 148/65 18 96% RA On arrival to the floor, pt reports severe pain in right foot. Severe dyspnea on exertion that occurs intermittently over the last year and has reached the point now where she has difficulty walking to the bathroom, though she is comfortable at rest. She reports 30lb weight loss over past several months. Past Medical History: 1. CARDIAC RISK FACTORS: +Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: -a fib dx in her ___, previously on warfarin (complicated by GIB) -known AS, dx ___ -CABG: none -PERCUTANEOUS CORONARY INTERVENTIONS: none -PACING/ICD: 3. OTHER PAST MEDICAL HISTORY: -GAVE syndrome w/ h/o GI bleeding, dx ___ -anemia ___ GI blood loss -recurrent UTIs -goiter s/p partial thyroidectomy -s/p vaginal sling procedure, unsuccessful. Uses pessary. -sessile cecal polyp, biopsy results: sessile serrated adenoma Social History: ___ Family History: Mother died at ___ from CVA. Father died in ___ of pancreatic cancer. Brother died at ___ from MI. Sister died at ___ from ovarian cancer. Sister died at ___ of pancreatic CA. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 97.3 167 / 80 56 20 93 RA General: Alert, oriented, no acute distress HEENT: Sclerae anicteric, MMM, oropharynx clear Lungs: basilar crackles, no rales, rhonchi CV: RRR, Nl S1, S2, IV/VI early systolic murmur loudest over apex Abdomen: soft, NT/ND bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: No palpable pulses, weak Doppler signals. warm, e/o gangrene on left ___ and right ___ toes. R ___ with purlence and surrounding erythema c/s with infection, visible suture on proximal aspect of eschar on plantar surface of ___ digit Neuro: CN2-12 intact, no focal deficits DISCHARGE PHYSICAL EXAM: Vitals: 97.7; 122/75; 106; 20; 96 RA General: Teary, in distress, talking frequently about wanting to die HEENT: Sclerae anicteric, MMM Lungs: clear to auscultation besides trace crackles at bases CV: RRR, nl S1, S2, IV/VI systolic murmur Abdomen: soft, nontender, non distended Ext: unchanged exam with no palpable pulses, weak Doppler signals. warm, e/o gangrene on left ___ and right ___ toes, unchanged. R ___ without purulence today, surrounding erythema. Pertinent Results: ADMISSION LABS ============== ___ 12:55PM BLOOD WBC-10.9* RBC-2.98# Hgb-8.7# Hct-26.9# MCV-90 MCH-29.2 MCHC-32.3 RDW-15.3 RDWSD-49.8 Plt ___ ___ 12:55PM BLOOD Neuts-70.7 Lymphs-9.1* Monos-8.9 Eos-10.2* Baso-0.7 Im ___ AbsNeut-7.67* AbsLymp-0.99* AbsMono-0.97* AbsEos-1.11* AbsBaso-0.08 ___ 12:55PM BLOOD ___ PTT-33.3 ___ ___ 12:55PM BLOOD Glucose-85 UreaN-40* Creat-3.9# Na-138 K-3.8 Cl-102 HCO3-21 AnGap-19 ___ 12:55PM BLOOD CK-MB-2 cTropnT-<0.01 ___ ___ 06:36AM BLOOD Calcium-8.1* Phos-5.2* Mg-1.8 ___ 12:55PM BLOOD PEP-NO SPECIFI IgG-1320 IgA-856* IgM-33* IFE-NO MONOCLO ___ 01:05PM BLOOD Lactate-1.3 DISCHARGE LABS ============== ___ 07:00AM BLOOD WBC-14.0* RBC-3.03* Hgb-8.9* Hct-27.6* MCV-91 MCH-29.4 MCHC-32.2 RDW-18.5* RDWSD-51.6* Plt ___ ___ 07:00AM BLOOD ___ PTT-30.0 ___ ___ 07:00AM BLOOD Glucose-136* UreaN-98* Creat-5.7* Na-136 K-3.8 Cl-95* HCO3-18* AnGap-27* ___ 07:00AM BLOOD Calcium-7.7* Phos-7.3* Mg-2.3 REPORTS ======= ___ CXR IMPRESSION: Progressive interstitial abnormality may represent interstitial edema or may be progression of an underlying process. ___ Foot XR IMPRESSION: Findings concerning for osteomyelitis at the tuft of the terminal phalanx of the right fourth ray. ___ Echo Conclusions The left atrium is mildly elongated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. There is moderate global left ventricular hypokinesis (biplane LVEF = 38%). The estimated cardiac index is normal (>=2.5L/min/m2). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). The ascending aorta is mildly dilated. The aortic valve leaflets are moderately thickened. There is severe aortic valve stenosis (valve area <1.0cm2). Mild to moderate (___) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] 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:Severe aortic valve stenosis. Mild-moderate aortic regurgitation. Severe pulmonary artery systolic hypertension. Normal biventricular cavity sizes with moderate global left ventricular hypokinesis. Moderate mitral regurgitation. Moderate to severe tricuspoid regurgitation. Mildly dilated ascending aorta. Compared with the prior study (images reviewed) of ___, the severity of aortic stenosis, estimated PA systolic pressure, and mitral regurgitation have alll progressed. Left ventricular systolic dysfunciton is now present. ___ GU US IMPRESSION: No evidence of obstruction. A 1.4 cm cyst is seen in the superior pole the right kidney. It is not well visualized due to the patient's difficulty with breath holds, but no suspicious features are identified. ___ ___ arterial US Findings Doppler evaluation is performed of both lower extremities. All waveforms are triphasic bilaterally the right ankle-brachial index is 1.05 the left is 1.02. Pulse volume recordings are difficult to interpret because of movement but appear normal. Impression essentially normal arterial Doppler study lower extremity at rest ___ CXR IMPRESSION: In comparison with the study of ___, there again is enlargement of the cardiac silhouette with moderate pulmonary edema. No joint effusion or acute focal pneumonia. Brief Hospital Course: ___ with A Fib on Coumadin, AAA, CAD and CHF presenting with dry gangrene of R4th digit, L3rd digit w/ some focal cellulitis of R4th digit as well as acute renal failure. #Goals of Care: after conversations with patient and her family regarding likely need of renal biopsy, with then further imaging and possible interventions as below, Ms. ___ decided that she would not want further procedures and workup to take place. She wanted to be set up with hospice care. She has had two close family members go through hospice, and was able to verbalize how she would like to be comfortable given her age. She had a clear understanding of these decisions. Thus plan was to not pursue biopsy, IV antibiotics were changed to PO clindamycin and plan for outpatient podiatry followup. #Acute renal failure: Creatinine gradually rising based on trend in ___ record. Ddx includes vascular pathology given known AAA or glomerulonephritis, ATN now also likely given prolonged AIN + prerenal etiology, with some muddy casts on recent urine. Patient reports increased PO intake and decreased uop as well for prerenal etiology. Obstruction unlikely given time course and urine output. Patient reports weight loss of 30lbs over last several months, malignancy workup, neg SPEP/UPEP. Renal US without obstruction. Urine microscopy with many WBC and acanthocytes, concerning for AIN. Omeprazole discontinued, replaced with ranitidine and prednisone 60mg daily for 2 weeks started ___. She was taking prednisone however had significant delirium with this. She was due for a renal biopsy however with discussion with patient and family, she did not want further interventions. She understood the risk of worsening renal failure and did not want dialysis. Renal team and primary team agreed given goals of care to discontinue prednisone. #Dry Gangrene: #Cellulitis/Osteomyelitis: Dry ganagrene of multiple acral sites with associated erythema and swelling of the right ___ toe consistent with cellulitis. Given other known vascular disease, likely secondary to PAD. Seen by vascular surgery and podiatry in the ER who recommended no acute intervention and will follow along. Per discussion as above, IV antibiotics changed to PO with plan for PO clindamycin until she follows up with podiatry outpatient. #Encephalopathy: Secondary to steroids, agitated primarily overnight. Generally redirectable but did require haldol on one occasion. Redirectable and not confused once prednisone stopped. #Severe AS/Acute Systolic CHF: Dyspnea on exertion likely secondary to pulmonary edema in the setting of renal failure vs critical AS initially. Last ___ echo in ___ with preserved EF, moderate AS. She reports a history of symptomatic a fib requiring cardioversions. She was in normal sinus rhythm on admission, but subsequently converted to A Fib. Cardiology was consulted, felt a TAVR workup would be appropriate, but would require contrast for cath given known CAD and TAVR and likely PCI would both require DAPT, which could be challenging in the setting of her GAVE. These options were discussed and patient and family decided against any further cardiology workup. #A Fib: Patient was in NSR on admission, but later converted to A Fib. Home amiodarone 200 mg daily was resumed. Home metoprolol was given in fractionated doses of metoprolol tartrate. Warfarin was held for procedures. Warfarin was resumed per patient wishes to continue home medications and her understanding of risks and benefits of stroke prevention. #Hypothyroidism: Continued home levothyroxine 125 mcg daily #GERD: Home omeprazole was discontinued as a possible cause of AIN. Ranitidine was started. #CAD: statin discontinued given less likely immediate to short term benefits, continued on metoprolol TRANSITIONAL ISSUES ====================== -Transition to hospice -16-day course of clindamycin (d16 = ___ -Code status changed from Full code to DNR/DNI Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Omeprazole 20 mg PO DAILY 2. Metoprolol Succinate XL 50 mg PO DAILY 3. Simvastatin 10 mg PO QPM 4. Levothyroxine Sodium 125 mcg PO DAILY 5. Amiodarone 200 mg PO DAILY 6. Warfarin 1 mg PO DAILY16 7. ofloxacin 0.3 % ophthalmic BID 8. Fluorometholone 0.1% Ophth Susp. 1 DROP BOTH EYES BID Discharge Medications: 1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild 2. Clindamycin 600 mg PO Q8H 3. Morphine Sulfate (Concentrated Oral Solution) 20 mg/mL ___ mg PO Q1H:PRN Shortness of breath or pain RX morphine concentrate 100 mg/5 mL (20 mg/mL) ___ mg by mouth q1h Refills:0 4. Ranitidine 150 mg PO BID 5. sevelamer CARBONATE 1600 mg PO TID W/MEALS 6. Sodium Bicarbonate 650 mg PO BID 7. Metoprolol Succinate XL 37.5 mg PO DAILY 8. Amiodarone 200 mg PO DAILY 9. Fluorometholone 0.1% Ophth Susp. 1 DROP BOTH EYES BID 10. Levothyroxine Sodium 125 mcg PO DAILY 11. ofloxacin 0.3 % ophthalmic BID 12. Warfarin 1 mg PO DAILY16 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary: Acute Renal Failure Severe Aortic Stenosis Gangrene/osteomyelitis of toe Secondary: CAD PAD 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 transferred to ___ for evaluation of your toe infection by our podiatry and vascular surgery specialists. We found that your kidneys were not working well and had declined significantly over a few months. We consulted our kidney specialists, who felt that this might have been a complication of a medication called pantoprazole. We stopped the medication and treated you with steroids. With regard to your toe, we started you on IV antibiotics and saw some improvement. The podiatrists and vascular surgeons felt that you could not get imaging until your kidneys improved. We also found that you have severe aortic stenosis, which we think is the reason you are getting so short of breath. Similarly, any further workup or treatment of this condition would require your kidneys to be healthy. Ultimately, you with your family decided that you would not want further testing and interventions, so we changed your medications to oral medications and set you up with hospice care. Please continue taking antibiotics so that your foot does not worsen Best, Your ___ Care team Followup Instructions: ___
19567247-DS-9	19,567,247	28,396,182	DS	9	2180-10-30 00:00:00	2180-11-01 11:23:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Abnormal HCG, abdominal pain Major Surgical or Invasive Procedure: laparoscopic salpingectomy for ectopic pregnancy History of Present Illness: ___ G1P0 at 6w4d by LMP presents to ED for abnl rising HCG in setting of abd pain and no IUP. Pt initially presented to ED on ___ with abd pain and vaginal bleeding. Her HCG at the time was 509, and PUS demonstrated no IUP and ?right cystic structure. The patient was discharged to home with precautions. Her pain improved but she continued to have vaginal bleeding. Repeat HCG 48hours later u/s with right cystic structure, no IUP. HCG=509. F/u HCG 48hours later had rised appropriately to ___. The patient then was seen by her former ob/gyn who checked her HCG on ___ and it had dropped to 900. the patient was told she most likely had a mab and just need f/u HCGs. The patient then had sudden onset increased abd pain last night. She had an HCG checked today in the office and it was elevated at 1257. The patient was instructed to go to the ED for concern for ectopic pregnancy. Here in the ED the patient reports continued abd pain but less pain than she had yesterday. HCG here is ___. Pt is still c/o vaginal bleeding like a light period. She denies any CP/sob/dizziness. HCG: ___ ___ ___ 900 (OSH) ___ ___ Past Medical History: OBHx: G1 GYNHx: Patient denies any h/o abnl paps, STIs, gyn surgery. she is sexually active in a monogamous relationship with her husband ___: seasonal asthma PSHx: wisdom teeth Physical Exam: Pre operative: O: 100.3 88 111/68 18 100% ra NAD RRR CTAB ABD: soft, tender to palaption in lower abd L>R, no R/G EXT: NT Pelvic: os appears closed, slow trickle of blood from vagina BiManual: very tender on exam, L>R, fullness noted on L side Post operative: Afebrile, vital signs stable Gen: no acute distress Abd: soft, non distended, appropriate tenderness to palpation, no rebound/guarding. Incisions dressed, and clean/dry/intact Extr: non tender/ nonedematous Pertinent Results: ___ 04:25PM BLOOD WBC-9.8# RBC-3.84* Hgb-11.9* Hct-33.3* MCV-87 MCH-31.1 MCHC-35.9* RDW-13.4 Plt ___ ___ 04:25PM BLOOD Neuts-66.7 ___ Monos-4.6 Eos-5.5* Baso-0.8 ___ 04:25PM BLOOD Glucose-81 UreaN-14 Creat-0.8 Na-139 K-3.9 Cl-104 HCO3-24 AnGap-15 ___ 04:25PM BLOOD HCG-1423 IMAGING: Pelvic ultrasound: New 4.3 x 2.5 cm left adnexal complex structure separatefrom the left ovary, in the setting of a rising HCG is concerningfor an ectopic pregnancy. Moderate complex fluid in the cul de sac concerning for rupture Brief Hospital Course: Ms. ___ underwent a laparoscopic left salpingectomy, right paratubal cyst excision, and evacuation of hemoperitoneum for a left sided ruptured ectopic pregnancy. Please see the operative note for further details regarding the procedure. Post operatively, she was admitted to the GYN service for observation. Her pain was well controlled with PO pain medication. She was advanced to a regular diet without difficulty. Her foley was discontinued and she was voiding spontaneously prior to discharge. Of note, Ms. ___ had a temperature of 100.5 prior to her surgery. Post operatively, she was afebrile with a normal WBC count and no localizign signs on exam. She remained afebrile throughout the rest of her stay. Ms. ___ was discharged home in stable condition on POD#1. Discharge Medications: 1. Percocet ___ mg Tablet Sig: ___ Tablets PO every ___ hours as needed for pain. Disp:30 Tablet(s) Refills:0 2. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO every ___ hours as needed for pain. Disp:30 Tablet(s) Refills:2 3. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. Disp:60 Capsule(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: ectopic pregnancy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs * No strenuous activity until your post-op appointment * You may eat a regular diet * use contraception for 6 months Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. Call your doctor for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication Followup Instructions: ___
19567278-DS-17	19,567,278	20,986,102	DS	17	2177-10-08 00:00:00	2177-10-08 14:39:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: pollen extracts Attending: ___ Chief Complaint: Back and abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ with a PMH significant for poorly controlled DM complicated by right below knee amputation and chronic left foot ulceration who was recently admitted at ___ for MSSA vertebral osteomyelitis and abscesses, R psoas abscess, and phlegmon. She was discharged on ___ with plans to continue a 6-week abx course with oxycodone for pain control, and had f/u appointments pending with CHA ID, podiatry, vascular surgery, and her PCP. Yesterday the patient experienced worsening ___ R flank/midline pain and intermittent stabbing RLQ pain not controlled with her pain meds. She presented to ___, had a CT scan and workup that was unrevealing of acute concern, and transferred to ___ for pain management. Social History: ___ Family History: non-contributory Physical Exam: ADMISSION EXAM: Vital Signs: 98.4 \| 157/86 \| 72 \| 20 \| 95%RA \| ___ General: Alert, oriented, lying in bed, no acute distress, non toxic appearing HEENT: Sclerae anicteric, PERRL, MMM Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, tender to light and deep palpation in RLQ and periumbilical area, universally distended per Pt, bowel sounds present, no rebound tenderness or guarding, no splenomegaly, Ext: Warm, well perfused, weak L DP and ___ pulses, cyanosis or edema, L foot appears recently wrapped. R BKA. Skin: Ecchymosis in RLQ and LLQ, 3 1mm erythematous lesions on left cheek Neuro: Alert and oriented to situation, no sensation to light pressure in left toes DISCHARGE EXAM: 98.0 ___ 20 93 ra General: Alert, oriented, lying in bed, no acute distress, non toxic appearing HEENT: Sclerae anicteric, PERRL, MMM Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, minimally tender in RLQ Ext: Warm, well perfused, weak L DP and ___ pulses, cyanosis or edema, L foot appears recently wrapped. R BKA. Skin: Ecchymosis in RLQ and LLQ, 3 1mm erythematous lesions on left cheek Neuro: Alert and oriented to situation, no sensation to light pressure in left toes Pertinent Results: ====================== ADMISSION LABS ====================== ___ 02:00AM BLOOD WBC-8.7 RBC-4.19 Hgb-9.4* Hct-31.6* MCV-75* MCH-22.4* MCHC-29.7* RDW-17.1* RDWSD-46.2 Plt ___ ___ 05:37AM BLOOD WBC-6.8 RBC-4.16 Hgb-9.2* Hct-31.4* MCV-76* MCH-22.1* MCHC-29.3* RDW-16.9* RDWSD-45.6 Plt ___ ___ 02:00AM BLOOD Plt ___ ___ 02:00AM BLOOD Glucose-174* UreaN-14 Creat-0.6 Na-133 K-4.2 Cl-98 HCO3-22 AnGap-17 ___ 09:35AM BLOOD ALT-6 AST-15 LD(LDH)-154 AlkPhos-80 TotBili-0.3 ___ 09:35AM BLOOD ALT-6 AST-15 LD(LDH)-154 AlkPhos-80 TotBili-0.3 ___ 02:00AM BLOOD cTropnT-<0.01 ___ 09:35AM BLOOD CK-MB-2 cTropnT-<0.01 ___ 09:35AM BLOOD Calcium-9.7 Phos-3.7 Mg-1.7 ==================== MICROBIOLOGY ====================== ___ BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT ___ BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT NO growth to date ===================== IMAGING ===================== Plain film ___ : There is a right-sided PICC line whose distal tip is poorly seen but likely in the distal SVC. Heart size is within normal limits. There is again seen subsegmental atelectasis at the lung bases bilaterally. There are no signs for overt pulmonary edema or pneumothoraces. Overall findings are stable. CT abdomen OSH ___ Brief Hospital Course: SUMMARY: ___ with a PMH significant for poorly controlled DM compicated by right below knee amputation and chronic left foot ulceration recently discharged from ___ on outpatient abx for MSSA vertebral oseomyelitis, T9-12 abcesses/phlegmon, and psoas abscess transferred from OSH with back and abdominal pain uncontrolled with home oxycodone. She had a CT scan performed which did not show any progression of infection. She improved with PO medications and was discharged home with plan for close follow up. TRANSITIONAL ISSUES: - Discharge pain regimen: oxycodone 10mg q3h PRN, pregabalin 300mg BID (restarted), acetaminophen 1000mg q8h - Continuing cefazolin 2gm IV q8h (to be completed ___ - Outpatient ID appointment on ___ # CODE: DNR, OK to intubate # CONTACT: ___ (___) ___ ADDITIONAL TRANSITIONAL ISSUES PER RECENT ___ Discharge: [ ] FOLLOW-UP LABS/IMAGING: - Repeat MRI 6 weeks after admission (___) to assess for improvement of osteomyelitis and thoracic phlegmon. - Weekly CBC, Chem-10, LFT, CRP, and ESR with home ___, to be directed to the office ___. [ ] FOLLOW-UP APPOINTMENTS: - f/u appointment with outpatient podiatrist to reschedule elective L BKA. - f/u with Infectious Disease at CHA, to determine if longer antibiotic course needed. Will need antibiotics at least through ___. [ ] HERPES LABIALIS: - Pt with outbreak of "fever blisters" on her left cheek, scabbed over and unable to be assessed during hospital stay. Provided with one day of prophylactic valacyclovir PRN:further outbreaks. Please consider further testing as outpatient. [ ] COPING: - Pt with recent loss of her mother in law. Please discuss counseling or outpatient therapy with patient [ ] INCIDENTAL FINDINGS: - TEE revealed small secundum atrial septal defect with left to right shunting at rest. Normal biventricular systolic function. ALL LAB RESULTS SHOULD BE SENT TO: ATTN: ___ CLINIC - FAX: ___ WEEKLY CBC with differential, BUN, Cr, Cr, AST, ALT, TB, ALK PHOS, CRP Medications on Admission: The Preadmission Medication list is accurate and complete. 1. CeFAZolin 2 g IV Q8H 2. amLODIPine 5 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. DULoxetine 60 mg PO DAILY 5. FLUoxetine 20 mg PO DAILY 6. Fluticasone Propionate NASAL 2 SPRY NU DAILY 7. Senna 8.6 mg PO QHS 8. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 9. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 10. Docusate Sodium 200 mg PO BID 11. Ferrous Sulfate 325 mg PO DAILY 12. Asmanex HFA (mometasone) 200 mcg/actuation inhalation BID 13. Atorvastatin 10 mg PO QPM 14. Levemir FlexTouch (insulin detemir) 100 unit/mL (3 mL) subcutaneous BID 15. MetFORMIN (Glucophage) 1000 mg PO DAILY 16. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation Q6H:PRN SOB 17. Lidocaine 5% Patch 1 PTCH TD QAM 18. Polyethylene Glycol 17 g PO DAILY 19. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line flush 20. OxyCODONE (Immediate Release) 10 mg PO Q3H:PRN Pain - Moderate 21. Lisinopril 10 mg PO DAILY 22. Omeprazole 20 mg PO DAILY 23. Milk of Magnesia 15 mL PO Q6H:PRN Constipation 24. TraZODone 150 mg PO QHS:PRN insomnia 25. Nortriptyline 20 mg PO QHS 26. naloxone 4 mg/actuation nasal DAILY:PRN Discharge Medications: 1. naloxone 4 mg/actuation nasal DAILY:PRN 2. Pregabalin 300 mg PO BID 3. Acetaminophen 1000 mg PO TID 4. Lisinopril 10 mg PO DAILY 5. amLODIPine 5 mg PO DAILY 6. Asmanex HFA (mometasone) 200 mcg/actuation inhalation BID 7. Aspirin 81 mg PO DAILY 8. Atorvastatin 10 mg PO QPM 9. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 10. CeFAZolin 2 g IV Q8H 11. Docusate Sodium 200 mg PO BID 12. DULoxetine 60 mg PO DAILY 13. Ferrous Sulfate 325 mg PO DAILY 14. FLUoxetine 20 mg PO DAILY 15. Fluticasone Propionate NASAL 2 SPRY NU DAILY 16. Levemir FlexTouch (insulin detemir) 100 unit/mL (3 mL) subcutaneous BID 17. Lidocaine 5% Patch 1 PTCH TD QAM 18. MetFORMIN (Glucophage) 1000 mg PO DAILY 19. Milk of Magnesia 15 mL PO Q6H:PRN Constipation 20. Nortriptyline 20 mg PO QHS 21. Omeprazole 20 mg PO DAILY 22. OxyCODONE (Immediate Release) 10 mg PO Q3H:PRN Pain - Moderate RX oxycodone 10 mg 1 tablet(s) by mouth q3h:prn Disp #14 Tablet Refills:*0 23. Polyethylene Glycol 17 g PO DAILY 24. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation Q6H:PRN SOB 25. Senna 8.6 mg PO QHS 26. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line flush 27. TraZODone 150 mg PO QHS:PRN insomnia Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS: Vertebral osteomyelitis Psoas abscess Acute pain SECONDARY DIAGNOSIS: Diabetes mellitus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted to ___ due to severe flank and abdominal pain. We did a CT scan that did not show any severe worsening of your infection. We treated your pain and you felt improved so you were discharged home. Please make sure to keep all your follow up appointments. It will be very important for your doctors to follow ___ closely. We wish you all the best! - Your ___ care team Followup Instructions: ___
19567278-DS-18	19,567,278	25,948,900	DS	18	2177-10-24 00:00:00	2177-10-28 15:30:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: pollen extracts Attending: ___ Chief Complaint: Back/flank pain Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ y/o woman with Type 2 IDDM complicated by complex infectious history notable for multiple recent admissions for treatment of T9-12 Osteomyelitis/Abscess/Phlegmon/Psoas abscess and subsequent pain control, presenting again for worsening pain. Patient was initially admitted ___ as an OSH transfer from ___ after being diagnosed with T9-T12 vertebrla osteomyelitis/abscesses with possibly infected phlegmons, and R psoas abscess for possible neurosurgical intervention. During that admission, neurosurgery felt this to be non-operative as there was no evidence of cord compression and the patient was started on course of daptomycin initially due to reported vancomycin allergy (___), with subsequent addition of zosyn (___) as wound culture from LLE grew MRSA, MSSA, and Corynebacterium. She was switched to cefazolin on ___, which has been continued with anticipated duration of antibiotics expected to continue through ___. Of note, she had TEE that did not show any evidence of endocarditis. She was discharged with planned outpatient follow-up. Patient was readmitted between ___ to ___ with initial concern for progressive infection, again as an OSH transfer. She had CT demonstrating no interval progression of infection and her care was focused on pain control. During that admission, the patient's regimen was titrated closely and analgesic control was established with multimodal regimen of hot packs, acetaminophen, lidocaine patch on R flank, and uptitrated oxycodone frequency (10mg q3h:PRN). Since discharge, the patient has had increasing pain again. She saw her podiatrist, who prescribed her 90 tablets of Percocet on ___. She states that she has been taking these in addition to the short supply of oxycodone prescribed to her to make a total dose of up to 20mg PO oxycodone several times a day. However, this is not managed her pain. She endorses the same type of constant dull pain over her lower back that radiates to her right flank with added component of intermittent sharp pain. She has nausea due to the pain without vomiting. She has not been able to eat or drink much with the pain. As such, she has noticed increasing foul smell in of her urine without any pain in her urine. She has not had any more fevers since going home and endorses ongoing chronic neuropathic pain in her left foot. She denies any abdominal pain and is making BM's every 2 days (last BM on ___. She denies SOB, chest pain, or increased ___ swelling. No weakness in arms or legs or new sensations of tingling/numbness apart from baseline neuropathy. She ultimately presented today due to worsening pain. In the ED, initial vitals were: -99.6 84 198/99 20 100% RA -BP improved to 168/88 on subsequent recheck Exam notable for: -Known R BKA -Left foot with 2cm diameter ulcer on plantar aspect of midfoot, c/d, chronic, with no surrounding erythema or drainage Labs notable for: -U/A with 100 protein, 1000 glucose, trace blood, few bacteria, otherwise bland -Chem10 with K 3.6, Cr 0.6, glucose 308 -CRP 31.7 (down from 90.8 on prior presentation) -Hgb 9.3, Hct 31.4 with MCV 73 (baseline) -INR 1.2 -lactate 1.5 -Ucx pending -Bcx pending Patient was given. -NS x1L -morphine 4mg IV x1 -Dilaudid 1mg IV x1 -Zofran 4mg IV x1 -Cefazolin 1g IV x1 ordered but apparently not given Upon arrival to the floor, patient reports the above symptoms and is quite tearful about everything going on. She endorses current pain in back, right flank, and legs. She denies any current nausea or other complaints. REVIEW OF SYSTEMS: As per HPI. Past Medical History: -HTN -Chronic back pain, on opioids -Poorly controlled T2 diabetes complicated by chronic foot ulcers (s/p R BKA, scheduled for L BKA) -T9-T12 Vertebral Osteomyelitis c/b abscess/phlegmon and R psoas abscess ___ - present) -Depression Social History: ___ Family History: Notable for heart attacks in both mother and father, multiple cancers including leukemia in mother. Physical Exam: ADMISSION EXAM: VITAL SIGNS: 98.4 177/102 (down to 156/88 on recheck) 77 20 97 RA GENERAL: tearful, in pain, but NAD HEENT: NC/AT, EOMI, PERRL, MMM, symmetric smile, palatal elevation; midline tongue on protrusion NECK: symmetric, supple CARDIAC: RRR, no m/r/g LUNGS: CTAB, no c/r/w ABDOMEN: Soft, ND, NTTP, no r/g, BS+ EXTREMITIES: all extremities WWP, R BKA, L foot with ulcer as below; no pitting edema in b/l ___ NEUROLOGIC: alert and oriented x3; PSYCH: mood is frustrated, labile affect SKIN: R BKA stump intact; L foot with 3x3cm well healed ulcer without any surrounding erythema, no expressed purulence on plantar aspect of midfoot DISCHARGE EXAM: VS: 98.2 120 / 79 74 18 95 Ra GENERAL: NAD, alert, interactive. A&Ox3. Patient initially appeared forgetful, but upon repeat interview seemed clear and coherent. HEENT: NC/AT, EOMI, PERRL, MMM, symmetric smile, palatal elevation; midline tongue on protrusion NECK: symmetric, supple CARDIAC: RRR, no m/r/g LUNGS: CTAB, no c/r/w ABDOMEN: Soft, ND, NTTP, no r/g, BS+ BACK: No CVA tenderness. Mild to moderate vertebral tenderness in the thoracic spine. Buttocks examined, raised pustule on the buttocks above the rectum near midline. Minor redness surrounding the area. No warmth or tenderness. No drainage. EXTREMITIES: all extremities WWP, R BKA, L foot with ulcer NEUROLOGIC: alert and oriented x3; ___ strength in b/l upper and lower extremities, SILT. MOYB backwards with no problems. Pertinent Results: ==================== ADMISSION LABS ==================== ___ 05:30PM BLOOD WBC-4.9 RBC-4.28 Hgb-9.3* Hct-31.4* MCV-73* MCH-21.7* MCHC-29.6* RDW-17.3* RDWSD-45.7 Plt ___ ___ 05:30PM BLOOD Neuts-66.4 ___ Monos-5.9 Eos-2.0 Baso-0.4 Im ___ AbsNeut-3.26 AbsLymp-1.23 AbsMono-0.29 AbsEos-0.10 AbsBaso-0.02 ___ 05:30PM BLOOD ___ PTT-33.3 ___ ___ 05:30PM BLOOD Plt ___ ___ 05:30PM BLOOD Glucose-308* UreaN-13 Creat-0.6 Na-138 K-3.6 Cl-100 HCO3-24 AnGap-18 ___ 05:30PM BLOOD ALT-6 AST-19 AlkPhos-89 TotBili-0.2 DirBili-<0.2 IndBili-0.2 ___ 05:30PM BLOOD Albumin-3.4* Calcium-8.9 Phos-3.6 Mg-1.6 ___ 03:16PM BLOOD Vanco-18.9 ___ 05:30PM BLOOD CRP-31.7* ================= DISCHARGE LABS ================= ___ 05:13AM BLOOD WBC-9.0 RBC-3.79* Hgb-8.6* Hct-28.8* MCV-76* MCH-22.7* MCHC-29.9* RDW-18.1* RDWSD-49.5* Plt ___ ___ 05:13AM BLOOD Plt ___ ___ 05:13AM BLOOD ___ PTT-32.5 ___ ___ 05:13AM BLOOD Glucose-133* UreaN-17 Creat-0.7 Na-137 K-4.6 Cl-96 HCO3-29 AnGap-17 ___ 05:13AM BLOOD ALT-6 AST-17 AlkPhos-84 TotBili-0.4 ___ 05:13AM BLOOD Calcium-9.3 Phos-4.5 Mg-2.0 ================ IMAGING ================= CXR ___ : Right PICC line tip is difficult to see, is probably at the level of cavoatrial junction. Lateral radiograph would be helpful to confirm position. Shallow inspiration accentuates heart size, which is stable. Normal pulmonary vascularity. No edema. Bibasilar atelectasis has nearly resolved. No pneumothorax. MRI C/T/L Spine ___: 1. Study is mildly degraded by motion. + 2. Again seen is right T12 marrow signal abnormality likely related to infectious or inflammatory process, similar to the prior study. 3. Right T12 through L2 posterior paraspinal edema. With diffuse enhancement suggestive of phlegmon, decreased from the prior study, with resolution of previously seen intramuscular abscess. 4. Multilevel degenerative changes as described, including moderate spinal canal stenosis at C4-5 through C6-7 and L2-3, and multilevel neural foraminal narrowing, severe at left L4-L5 compressing the exiting L5 nerve root. 5. Small bilateral pleural effusions. If clinically indicated, consider dedicated chest imaging for further evaluation. ================ MICROBIOLOGY ================ ___ BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT ___ BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT ___ BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT ___ URINE URINE CULTURE-FINAL INPATIENT ___ BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT ___ CATHETER TIP-IV WOUND CULTURE-FINAL INPATIENT ___ BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT ___ BLOOD CULTURE Blood Culture, Routine-FINAL {LACTOBACILLUS SPECIES}; Aerobic Bottle Gram Stain-FINAL INPATIENT ___ BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT ___ BLOOD CULTURE Blood Culture, Routine-FINAL ___ Aerobic Bottle Gram Stain-FINAL INPATIENT ___ BLOOD CULTURE Blood Culture, Routine-FINAL ___ Aerobic Bottle Gram Stain-FINAL INPATIENT ___ BLOOD CULTURE Blood Culture, Routine-FINAL ___ Aerobic Bottle Gram Stain-FINAL INPATIENT ___ URINE URINE CULTURE-FINAL EMERGENCY WARD ___ BLOOD CULTURE Blood Culture, Routine-FINAL {STAPHYLOCOCCUS, COAGULASE NEGATIVE}; Aerobic Bottle Gram Stain-FINAL Blood Culture, Routine (Final ___: ___. Consultations with ID are recommended for all blood cultures positive for Staphylococcus aureus, yeast or other fungi. FINAL SENSITIVITIES. Fluconazole MIC <= 0.25 MCG/ML. Antifungal agents reported without interpretation lack established CLSI guidelines. Results were read after 24 hours of incubation. Sensitivity testing performed by Sensititre. FINAL REPORT ___ Blood Culture, Routine (Final ___: LACTOBACILLUS SPECIES. Isolated from only one set in the previous five days. Aerobic Bottle Gram Stain (Final ___: Reported to and read back by ___ @ 2340, ___. GRAM POSITIVE ROD(S) IN CHAINS. Brief Hospital Course: ___ h/o poorly controlled T2/IDDM c/b R BKA and L foot ulcer pending BKA, recently diagnosed MSSA bacteremia, T9-T12 Vertebral Osteomyelitis with associated phelgmon/abscesses, and R psoas abscess, recent admission for pain control, admitted again for worsening back/flank pain. There was initial concern for worsening infection; however, an MRI showed improvement in abscesses and CRP was downtrending. A blood culture was initially positive for GPCs and she was started on vancomycin; later this culture speciated to a single set of coag-negative staph felt to be contaminant and vancomycin was discontinued. The chronic pain service was consulted and her pain regimen was adjusted to a comfortable level upon discharge. She then was noted to have multiple blood cultures positive for ___ ___, which was treated with PO fluconazole for a planned 2-week course and a ___ line holiday. After starting fluconazole, she was noted to be more somnolent, thought to be due to interactions between fluconazole and oxycodone/tizanadine. These doses of her pain medications were reduced and her mental status improved. # MSSA bacteremia \| Osteomyelitis \| T9-12 abcess \| Psoas abcess: Patient presented at week 3 of 6 of a cefazolin course. There was initial concern for worsening infection due to the patient's pain, however all laboratory evidence trended toward improvement: downtrending CRP, platelets, and other inflammatory surrogates. MRI C/T/L spine was performed with resolution of abscesses. She was continued on cefazolin 2gm IV q8h with end date ___ and she will follow up with OPAT as outpatient. # Candidemia: Blood culture x3 from ___ and ___ positive for ___, which is concerning for PICC-associated candidemia. Patient otherwise clinically stable. Ophtho consulted and no evidence for involvement on eye exam. She was treated initially with IV micafungin and transitioned to PO fluconazole per the consulting Infectious Disease team. She was discharged and PO fluconazole (end date ___. # Skin abscess: Patient has on exam furunculosis x2 on the buttocks. No signs of surrounding cellulitis or active drainage. Evaluated by Acute Care Surgery who feels there is no need for intervention. # Pain control: Ongoing issue for patient. Her regimen was adjusted and she had adequate analgesic control with initial IV hydromorphone PRN breakthrough pain with uptitration of home oxycodone frequency as well as hot packs, acetaminophen, lidocaine patch on R flank, and pregabalin. She was discharged on oxycodone, pregabalin, lidocaine ointment, tizanadine, hot packs. # Altered mental status: Near end of admission patient was noted to be confused, saying unusual things and feeling lightheaded upon standing. This was thought to be due to the interaction between fluconazole and oxycodone/tizanadine. The doses of her oxycodone/tizanadine were reduced with resolution of altered mental status. # Chronic L Foot Ulcer: The patient's ulcer is chronic and with no evidence of active infection. There is already plan in place to address outpatient BKA with CHA podiatrist. CHRONIC ISSUES: # HTN: continued home lisinopril, amlodipine # Depression/Anxiety: Patient did have prolonged QTc on prior admission. QTc within normal limits. Continued home meds: duloxetine, fluoxetine, pregabalin, nortriptyline # IDDM: patient on levemir 30u qAM and 30u qHS with metformin as well. Held these while inpatient and placed on glargine 30u QAM and QHS with Humalog sliding scale. # Microcytic Anemia: Ferrous sulfate PO 325mg PO daily # Asthma: continued home albuterol with replacement of home mometasone with fluticasone # GERD: continued home omeprazole TRANSITIONAL ISSUES: [] Pain control - Discharge regimen: acetaminophen, pregabalin, lidocaine ointment, ibuprofen, tizanadine, oxycodone. Please continue to adjust as needed - Please monitor pain closely. Fluconazole can increase levels and effects of oxycodone and tizanadine, therefore we reduced the doses of these medications while she is on fluconazole. After she finishes fluconazole on the ___, her pain regimen may need to be adjusted. Please also continue to monitor for sedation. - Please monitor opioid usage closely; patient discharged with narcan prescription. - Patient discharged on ___ oxycodone q4h, please downtitrate to ___ q6h as soon as appropriate - Furunculosis x2 on buttocks noted, surgery team evaluated and recommended no intervention at this time. Please continue to monitor clinically. - Patient will continue with previously planned 6-week course of IV cefazolin and previously scheduled follow up with Infectious Disease outpatient (end date of abx: ___ - Patient should continue to get weekly OPAT labs including weekly CBC with differential, BUN, Cr, Cr, AST, ALT, TB, ALK PHOS, CRP - Please continue evaluation of anemia - Per Ophthalmology: Advised patient on the importance of intensive blood sugar control, as well as blood pressure and lipid control. Furthermore, regular surveillance by an eye care provider with expertise in diabetic retinopathy, as well as to monitor choroidal nevus. # CONTACT: ___ (dtr) ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 1000 mg PO TID 2. amLODIPine 5 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 10 mg PO QPM 5. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 6. CeFAZolin 2 g IV Q8H 7. Docusate Sodium 200 mg PO BID 8. DULoxetine 60 mg PO DAILY 9. FLUoxetine 20 mg PO DAILY 10. Fluticasone Propionate NASAL 2 SPRY NU DAILY 11. Lidocaine 5% Patch 1 PTCH TD QAM 12. Lisinopril 10 mg PO DAILY 13. Milk of Magnesia 15 mL PO Q6H:PRN Constipation 14. Omeprazole 20 mg PO DAILY 15. OxyCODONE (Immediate Release) 10 mg PO Q3H:PRN Pain - Moderate 16. Polyethylene Glycol 17 g PO DAILY 17. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation Q6H:PRN SOB 18. Senna 8.6 mg PO QHS 19. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line flush 20. TraZODone 150 mg PO QHS:PRN insomnia 21. Pregabalin 300 mg PO BID 22. Asmanex HFA (mometasone) 200 mcg/actuation inhalation BID 23. Ferrous Sulfate 325 mg PO DAILY 24. Levemir FlexTouch (insulin detemir) 100 unit/mL (3 mL) subcutaneous BID 25. MetFORMIN (Glucophage) 1000 mg PO DAILY 26. naloxone 4 mg/actuation nasal DAILY:PRN 27. Nortriptyline 20 mg PO QHS Discharge Medications: 1. Fluconazole 400 mg PO Q24H Duration: 2 Weeks RX fluconazole 200 mg 2 tablet(s) by mouth daily Disp #11 Tablet Refills:0 2. Lidocaine 5% Ointment 1 Appl TP BID:PRN pain RX lidocaine 5 % apply to affected area BID:PRN Refills:0 3. naloxone 4 mg/actuation nasal DAILY:PRN RX naloxone [Narcan] 4 mg/actuation 1 spry NAS daily:prn Disp #2 Spray Refills:0 4. Tizanidine 2 mg PO TID:PRN back pain RX tizanidine 2 mg 1 capsule(s) by mouth TID:PRN Disp #40 Capsule Refills:0 5. Lisinopril 10 mg PO DAILY 6. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate RX oxycodone 5 mg ___ tablet(s) by mouth q4h:prn Disp #20 Tablet Refills:0 7. Acetaminophen 1000 mg PO TID 8. amLODIPine 5 mg PO DAILY 9. Asmanex HFA (mometasone) 200 mcg/actuation inhalation BID 10. Aspirin 81 mg PO DAILY 11. Atorvastatin 10 mg PO QPM 12. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 13. CeFAZolin 2 g IV Q8H RX cefazolin in dextrose (iso-os) 2 gram/100 mL 2 g IV every eight (8) hours Disp #53 Intravenous Bag Refills:*0 14. Docusate Sodium 200 mg PO BID 15. DULoxetine 60 mg PO DAILY 16. Ferrous Sulfate 325 mg PO DAILY 17. FLUoxetine 20 mg PO DAILY 18. Fluticasone Propionate NASAL 2 SPRY NU DAILY 19. Levemir FlexTouch (insulin detemir) 100 unit/mL (3 mL) subcutaneous BID 20. Lidocaine 5% Patch 1 PTCH TD QAM 21. MetFORMIN (Glucophage) 1000 mg PO DAILY 22. Milk of Magnesia 15 mL PO Q6H:PRN Constipation 23. Nortriptyline 20 mg PO QHS 24. Omeprazole 20 mg PO DAILY 25. Polyethylene Glycol 17 g PO DAILY 26. Pregabalin 300 mg PO BID 27. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation Q6H:PRN SOB 28. Senna 8.6 mg PO QHS 29. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line flush 30. TraZODone 150 mg PO QHS:PRN insomnia 31.Outpatient Lab Work ALL LAB RESULTS SHOULD BE SENT TO: ATTN: ___ CLINIC - FAX: ___ WEEKLY CBC with differential, BUN, Cr, Cr, AST, ALT, TB, ALK PHOS, CRP ICD9 M86.0 - osteomyelitis Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS: T8-12 osteomyelitis (improving) Pain SECONDARY DIAGNOSIS: Hypertension Depression Anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___: You were admitted to ___ due to increasing pain in your back. We adjusted your pain medications to better control your pain. We also did an MRI and blood tests, which showed that the previous infection in your back had improved. You were evaluated by our chronic pain service and infectious disease service as well and we changed around your pain medications. You seemed to be more comfortable. However you then were found to have a fungal infection with ___, likely associated with your PICC line. We are treating you with fluconazole for your fungal infection and continuing your cefazolin for your previous bone infection. Please take all your medications as regularly scheduled. Please follow up with your primary care doctor and continue to discuss an optimal pain regimen. We wish you all the best! - Your ___ care team Followup Instructions: ___
19567431-DS-15	19,567,431	23,609,129	DS	15	2137-10-04 00:00:00	2137-10-05 13:17:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Compazine / Cinnamon Attending: ___. Chief Complaint: nausea, vomiting, diarrhea and abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ yo F PMH of ?___ diease, anxiety/depression with ?mania, p/w abdominal pain, nausea, vomiting since ___. Prior to ___, has been feeling well. Then, started having LLQ pain, similar to prior episodes of ___ flare". Has not eaten much since ___ due to discomfort and nausea. One BM since ___ till this AM, when she had nonbloody diarrhea x4. Nausea and NBNB vomiting of clear liquids. No sick contacts at home, no fevers, chills, only recent travel is to ___. In the ED, initial vs were: 97.8 90 159/83 18 97% RA, patient ranked her abdominal pain as ___, which was relieved with IV morphine 5 mg x2. She was also given IV zofran 4 mg x2 and 2L NS. Vitals on transfer: 97.9 70 119/66 16 99%RA pain ___. On the floor, vs were: afebrile P 61 BP 125/75 R 18 O2 sat 99% RA. Patient is feeling ok at this time, but feels that her nausea is starting again. Past Medical History: - Chronic abdominal pain, n/v with weight loss, presumed diagnosis of ___ but negative biopsy. Extensive work up in the past with negative GTT and AMA. Followed by Dr. ___ in GI. - Depression/anxiety, ?mania. Now looking for a new provider within ___ system. - B12 deficiency with macrocytic anemia, on monthly B12 injections - Internal hemorrhoids seen on colonoscopy - s/p C-section for delivery of her son in ___ Social History: ___ Family History: - 2 cousins with ___, significant CAD history in father's family, including father with MI and triple bypass at age ___. Both parents with type II DM. Physical Exam: ADMISSION EXAM: Vitals: afebrile P 61 BP 125/75 R 18 O2 sat 99% RA General: Alert/awake, no acute distress. Able to relate history as above. HEENT: Sclera anicteric, PERRL, EOMI, MM dry, oropharynx clear. Neck: supple, JVP not elevated, no LAD Lungs: CTAB, no wheezes, rales, rhonchi CV: RRR, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft abdomen with vertical stretch marks, non-distended, bowel sounds present, no rebound tenderness or guarding but tender to palpation diffusely, L>R Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. Mild tenderness in L leg with dorsiflexion but no asymmetry or calf tenderness. Skin: No rashes noted Neuro: alert/awake, fluent speech with intact comprehension. moving all extremities spontaneously. strength grossly intact. DISCHARGE EXAM: Vitals: 98.2 P 66 BP 110/60 R 16 O2 sat 100% RA General: Alert/awake, no acute distress. HEENT: Sclera anicteric, PERRL, EOMI, MMM, oropharynx clear. Neck: supple, JVP not elevated, no LAD Lungs: CTAB, no wheezes, rales, rhonchi CV: RRR, normal S1/S2, no murmurs, rubs, gallops Abdomen: soft abdomen with vertical stretch marks, non-distended, bowel sounds present, no rebound tenderness or guarding. TTP improved. Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. Skin: No rashes noted Neuro: alert/awake, fluent speech. moving all extremities spontaneously. Pertinent Results: ADMISSION LABS: ___ 11:00AM BLOOD WBC-7.6 RBC-4.77 Hgb-16.0 Hct-49.7* MCV-104* MCH-33.5* MCHC-32.2 RDW-13.8 Plt ___ ___ 11:00AM BLOOD Neuts-71.1* ___ Monos-4.0 Eos-1.9 Baso-0.3 ___ 11:00AM BLOOD Glucose-98 UreaN-10 Creat-1.0 Na-141 K-3.9 Cl-104 HCO3-26 AnGap-15 ___ 11:00AM BLOOD ALT-14 AST-16 AlkPhos-119* TotBili-0.3 ___ 11:00AM BLOOD Albumin-4.8 ___ 08:17AM BLOOD Calcium-8.5 Phos-3.3 Mg-1.8 ___ 11:00AM BLOOD Lithium-0.4* INFLAMMATORY MARKERS: ___ 11:00AM BLOOD CRP-3.2 ___ 11:00AM BLOOD ESR-50* DISCHARGE LABS: ___ 07:40AM BLOOD WBC-5.1 RBC-3.78* Hgb-12.7 Hct-39.6 MCV-105* MCH-33.6* MCHC-32.1 RDW-13.2 Plt ___ ___ 07:40AM BLOOD Glucose-81 UreaN-6 Creat-0.9 Na-141 K-4.0 Cl-106 HCO3-27 AnGap-12 ___ 07:40AM BLOOD ALT-8 AST-13 LD(LDH)-123 AlkPhos-87 TotBili-0.4 ___ 07:40AM BLOOD Albumin-3.6 Calcium-8.8 Phos-3.2 Mg-1.7 C1 ESTERASE INHIBITOR PENDING C4 41 URINE: ___ 12:48PM URINE Porphob-NEGATIVE ___ 12:48PM URINE UCG-NEGATIVE MICROBIOLOGY: UCx contaminated with mixed flora STUDIES: ___ KUB: Nonspecific bowel gas pattern without evidence of obstruction. Brief Hospital Course: TRANSITIONAL ISSUES: [ ] f/u on C1 esterase inhibitor =================================== ___ yo F with long history of ?___ with chronic n/v, p/w worsening abd pain, n/v and diarrhea, similar to her past "flares." Improving with bowel rest. # Abd pain, n/v: patient has had these episodes in the past, thought to be ?___ flares at that time. Patient states that her symptoms improve with steroid treatments during those episodes. She was initially started on cipro/metronidazole given concern for flare/infection. However, her ESR and CRP were not elevated, so abx were stopped, and she was only continued on home budesonide. Her sxs improved with bowel rest and supportive symptomatic treatment. Work up for other causes of intermittent abd pain were begun and C4/C1 esterase inhibitor, and urine porphobilinogen were sent. C4 was normal/high, C1 esterase inhibitor is pending and urine porphobilinogen was negative. No stool studies were sent as patient did not have any more episodes of diarrhea in house. Patient was discharged when she was tolerating PO intake, and she was started on probiotic as an outpatient. # Constipation: no BM in 3 days, pt now feels constipated, likely due to morphine which was started for abd pain vs. her underlying GI pathology (pt reports alternating diarrhea/constipation). Patient was started on colace/senna and miralax, and morphine was discontinued. # Anxiety/depression, ?mania: lithium level was checked on admission given concern for lithium toxicity which can p/w n/v. However, the level was low. Home dose was continued as patient reported throwing up pills at home, and the low level was thought not to reflect the true lithium level. She was also continued on her home dose of clonazepam and sertraline. # Elevated alk phos: consistent with prior lab values, unclear etiology. Monitored and resolved during this hospitalization. Medications on Admission: - budesonide 6 mg daily - clonazepam 1 mg TID (uptitrated since being on budesonide) - cyanocobalamin (vitamin B-12) injection monthly - dicyclomine 20 mg 4 times daily - lithium carbonate 300 mg BID - omeprazole 20 mg BID - ondansetron 4 mg q6hrs prn nausea - sertraline 75 mg Tablet daily - ambien 10 qHS Discharge Medications: 1. budesonide 3 mg Capsule, Delayed & Ext.Release Sig: Two (2) Capsule, Delayed & Ext.Release PO DAILY (Daily). 2. clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 3. dicyclomine 10 mg Capsule Sig: Two (2) Capsule PO QID (4 times a day) as needed for cramping, abd pain. 4. lithium carbonate 300 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO BID (2 times a day). 5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 6. ZOFRAN ODT 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO every six (6) hours as needed for nausea. 7. sertraline 50 mg Tablet Sig: 1.5 Tablets PO once a day. 8. Ambien 10 mg Tablet Sig: One (1) Tablet PO at bedtime. 9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:60 Capsule(s) Refills:0 10. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:60 Tablet(s) Refills:0 11. polyethylene glycol 3350 17 gram Powder in Packet Sig: One (1) Powder in Packet PO DAILY (Daily) as needed for constipation. Disp:30 Powder in Packet(s) Refills:0 12. VSL#3 112.5 billion cell Capsule Sig: One (1) Capsule PO twice a day. Disp:60 Capsule(s) Refills:2 13. cyanocobalamin (vitamin B-12) 1,000 mcg/mL Solution Sig: Ten (10) mL Injection once a month. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: - ___ disease flare Secondary Diagnosis: - Anxiety/Depression Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a pleasure to take care of you at ___ ___. You were admitted to the hospital with abdominal pain, nausea/vomiting and diarrhea, which was thought to be a flare of your ___ disease. You were given IV antibiotics for a while, but as there was no evidence of infection, it was stopped. Your symptoms improved with bowel rest and supportive medications and your diet was slowly advanced. These CHANGES were made to your medications: START probiotic (VSL#3) twice a day - this is the specific probiotic that the gastroenterology doctors ___. START colace (stool softener) twice a day as needed for constipation START senna (laxative) twice a day as needed for constipation If these two medications do not help you may also try miralax as listed below. START miralax (laxative) once a day as needed for constipation Followup Instructions: ___
19567431-DS-16	19,567,431	28,414,700	DS	16	2140-02-08 00:00:00	2140-02-08 16:42:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Compazine / Cinnamon / ciprofloxacin Attending: ___. Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: Findings: Mucosa: Normal mucosa was noted in the whole colon and 15cm of the terminal ileum. Impression: Normal mucosa in the whole colon and 15cm of the terminal ileum. There is no evidence for active ___ disease. Otherwise normal colonoscopy to cecum Recommendations: -Follow up with inpatient team -Start an antispasmodic such as levsin three times daily History of Present Illness: ___ w/IBS, anxiety presents with worsening of chronic abdominal pain. Pt reports pain is RLQ, sharp, nonradiating. Associated with nausea/vomiting, worses with BM. No change with food, although pt reports minimal PO intake due to severe nausea. Also reports anorexia for the last several months, generally eating only one meal a day with a 30lb weight loss. Denies fevers/chills. Denies dysuria/hematuria. Denies vaginal bleeding/discharge. In ED pt given morphine, zofran. Started cipro for colitis but pt developed pruritic rash. Infusion stopped and pt given benadryl. On arrival to the floor pt reports pain is well controlled with morphine. Reports thrush for several weeks as low energy level. ROS: +as above, otherwise reviewed and negative Past Medical History: - Chronic abdominal pain, n/v with weight loss, presumed diagnosis of ___ but negative biopsy. Extensive work up in the past with negative GTT and AMA. Followed by Dr. ___ in GI. - Depression/anxiety, ?mania. Now looking for a new provider within ___ system. - B12 deficiency with macrocytic anemia, on monthly B12 injections - Internal hemorrhoids seen on colonoscopy - s/p C-section for delivery of her son in ___ Social History: ___ Family History: - 2 cousins with ___, significant CAD history in father's family, including father with MI and triple bypass at age ___. Both parents with type II DM. Physical Exam: Vitals: T:98 ___ P:75 R:18 O2:98%ra PAIN: 6 General: nad Lungs: clear HEENT: oral thrush? CV: rrr no m/r/g Abdomen: bowel sounds present, soft, tender RLQ no rebound Ext: no e/c/c Skin: no rash Neuro: alert, follows commands Pertinent Results: ___ 02:35PM WBC-6.1 RBC-4.73 HGB-15.6 HCT-46.2 MCV-98 MCH-33.0* MCHC-33.8 RDW-16.1* ___ 02:35PM NEUTS-75.1* ___ MONOS-4.4 EOS-0.9 BASOS-0.3 ___ 02:35PM PLT COUNT-179 ___ 02:35PM GLUCOSE-91 UREA N-7 CREAT-0.8 SODIUM-140 POTASSIUM-4.9 CHLORIDE-105 TOTAL CO2-22 ANION GAP-18 ___ 02:35PM LIPASE-13 ___ 02:35PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 04:30PM URINE UCG-NEGATIVE ___ 04:30PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 04:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-2* PH-7.5 LEUK-NEG ___ 04:30PM URINE RBC-<1 WBC-1 BACTERIA-FEW YEAST-NONE EPI-1 CT Abd/Pel IMPRESSION: 1. The terminal ileum, distal transverse colon, descending and sigmoid colon are not well distended, limiting this examination, and mild colitis within the segments cannot be entirely excluded. 2. Terminal ileum is minimally hyperemic, although assessment is limited secondary to under distension. 3. Fibrofatty proliferation within the ascending colon, which could reflect prior colitis. All findings could be better assessed with an oral contrast-enhanced MRA. 4. Bilateral ovarian cysts Brief Hospital Course: ASSESSMENT AND PLAN: ___ with IBS presenting with RLQ pain and possible colitis on CT scan pt was given IVF, pain medication, and anti-emetics. She was evaluated by the GI consult team. Due to 2 months of RLQ pain, poor po intake, weight loss, and hx of being treated empirically for IBD the GI service recommended a colonscopy. The pt underwent ___ prep and colonscopy. It was determined that she had a normal scope. Her symptoms are most consistent with severe irritable bowel syndrome. She was started on levsin TID. She was seen by nutrition for help with following a low residue diet and recommended to have daily ensure supplement. She was able to take much better PO and was discharged to home in stable condition. Pt will f/u with pcp, ___. In addition, pt was noted to have mouth pain and B white plaques on the buccal surfaces. The etiology of this was unclear. Pt has been taking nystatin. She will continue to do so and is set up to see dermatology next week for further evaluation for these lesions. Pt was otherise continued on her home medications for --anxiety --HTN --chronic knee pain Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Gabapentin 400 mg PO DAILY 2. Omeprazole 20 mg PO BID 3. Ondansetron 4 mg PO Q8H:PRN nausea 4. Venlafaxine XR 225 mg PO DAILY 5. CloniDINE 0.1 mg PO TID Discharge Medications: 1. CloniDINE 0.1 mg PO TID 2. Gabapentin 400 mg PO DAILY 3. Omeprazole 20 mg PO BID 4. Ondansetron 4 mg PO Q8H:PRN nausea RX ondansetron 4 mg 1 tablet(s) by mouth every 8 hours as needed for nausea Disp #30 Tablet Refills:0 5. Venlafaxine XR 225 mg PO DAILY 6. Hyoscyamine 0.125 mg PO TIDAC abdominal pain/spasm RX hyoscyamine sulfate 0.125 mg 1 tablet(s) by mouth three times a day (many people take it before each meal) Disp #90 Tablet Refills:0 7. Lidocaine Viscous 2% 15 mL PO TID:PRN mouth pain RX lidocaine HCl [Lidocaine Viscous] 2 % 15ML swish by mouth three times a day Disp #1 Bottle Refills:0 8. Nystatin Oral Suspension 5 mL PO TID thrush RX nystatin 100,000 unit/mL 5 ml by mouth swish in the mouth three times a day Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Irritable Bowel Syndrome Discharge Condition: alert, interactive. Discharge Instructions: You were admitted with severe abdominal pain, nausea, inability to take food or liquids. You were treated with IV fluids, bowel rest, and anti-nausea medicatons. You also responded well to IV tylenol. The GI team recommended a colonscopy. This showed a normal appearing colon and terminal Ileum (this is the area where ___ tends to show up.) You were started on Levsin before meals and your diet was advanced slowly. You can continue to work with your physicians on the Irritable Bowel Syndrome. You were noted to have white plaques on the inside of the mouth that are painful. You can continue the nystatin and the lidocaine for comfort. Please follow up with dermatology to evaluate further next week. Followup Instructions: ___
19567431-DS-17	19,567,431	28,262,761	DS	17	2144-04-02 00:00:00	2144-04-02 13:53:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Compazine / Cinnamon / ciprofloxacin Attending: ___ Chief Complaint: Severe, recurrent RLQ abdominal Pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ with hx of chronic intermittent abdominal pain, ?Crohns disease on budesonide, severe IBS, anxiety presenting with recurrent severe RLQ pain. She reports at least 20 hospitalizations for RLQ pain, all but one were RLQ (once LLQ), described as stabbing, squeezing pain, ___, with associated nausea and bilious nonbloody emesis, which started at 9 am on the day of presentation while attempting to pass a BM. She denies diarrhea or constipation, with last BM on the morning of admission, small, "mushy," nonbloody, without melena. She denies F/C, no recent travel, no sick contacts. Of note, she wonders if this episode may have been triggered by her therapy appointment the day prior to onset of pain, when she was made to think about major life stressors. Her son is currently in rehab for polysubstance use disorder, and her father was apparently recently diagnosed with metastatic cancer with unknown primary. She does often use marijuana for her abdominal pain, which is highly effective; she has recently run out, and did not have any on hand when this episode began. She reports that she went from >350 lbs to 293 lbs over about 6 months. She states that her weight loss is unintentional, prior notes mention that her weight has fluctuated dramatically with her episodes of abdominal pain. With respect to her prior w/u, she has been followed by Dr. ___ has previously identified that these episodes are triggered by anxiety. She is followed by a therapist and psychiatrist. She has had multiple CT abd/pelvis which have been largely unrevealing, colonoscopy without evidence of inflammatory bowel disease. In the past, she has been started on hyoscyamine with meals, Zofran, and viscous lidocaine with good effect. In the ___ ED: VSS Exam notable for tearful female in acute distress, without peritoneal signs Labs umremarkable Imaging: CT abd/pelvis without acute findings Received: Morphine 4 mg IV x2 Zofran 4 mg IV x2 Dilaudid 1 mg IV x2 IVF On arrival to the floor, pt endorses severe RLQ pain and is actively vomiting. ROS: 10 point review of system reviewed and negative except as otherwise described in HPI Past Medical History: 1. Anxiety. Psychiatrist was Dr. ___ and also has a therapist at ___. 2. Chronic abdominal pain with extensive workup in the past, which has been negative. There was this concern at one point for inflammatory bowel disease, but it is now thought to likely represent severe IBS. She follows with Dr. ___ in Gastroenterology. 3. B12 deficiency anemia. Has been stable off of B12 over the last ___ years. 4. Right knee pain with bone infarcts and mild osteoarthritis on x-rays. I thought the bone infarcts were likely thought to be due to chronic steroid use. 5. Obesity. 6. Borderline hypertension. 7. History of cervical radiculitis. 8. History of remote LEEP about ___ years ago. Social History: ___ Family History: Reviewed and found to be not relevant to this hospitalization/illness Physical Exam: ADMISSION EXAM: VS: ___ 2249 Temp: 97.6 PO BP: 149/93 HR: 68 RR: 18 O2 sat: 96% O2 delivery: RA Dyspnea: 0 RASS: 0 Pain Score: ___ GEN: obese female sitting up at the edge of the bed clutching her abdomen, tearful, frequently shifting position, with active emesis of white, foamy, bilious, nonbloody emesis HEENT: PERRL, anicteric, conjunctiva pink, oropharynx without lesion or exudate, moist mucus membranes, ears without lesions or apparent trauma LYMPH: no anterior/posterior cervical, supraclavicular adenopathy CARDIOVASCULAR: Regular rate and rhythm without murmurs, rubs, or gallops LUNGS: clear to auscultation bilaterally without rhonchi, wheezes, or crackles GI: soft, exquisitely tender at RLQ, with voluntary guarding, nondistended with normal active bowel sounds, unable to assess for hepatomegaly ___ pain EXTREMITIES: no clubbing, cyanosis, or edema GU: no foley SKIN: no rashes, petechia, lesions, or echymoses; warm to palpation NEURO: Alert and interactive, cranial nerves II-XII grossly intact, strength and sensation grossly intact PSYCH: Tearful, appropriate DISCHARGE EXAM: VS: Afebrile, HDS GEN: in NAD HEENT: PERRL, anicteric, conjunctiva pink, oropharynx without lesion or exudate, moist mucus membranes, ears without lesions or apparent trauma LYMPH: no anterior/posterior cervical, supraclavicular adenopathy CARDIOVASCULAR: Regular rate and rhythm without murmurs, rubs, or gallops LUNGS: clear to auscultation bilaterally without rhonchi, wheezes, or crackles GI: soft, +BS, NTND EXTREMITIES: no clubbing, cyanosis, or edema GU: no foley SKIN: no rashes, petechia, lesions, or echymoses; warm to palpation NEURO: Alert and interactive, cranial nerves II-XII grossly intact, strength and sensation grossly intact Pertinent Results: ADMISSION LABS: ___ 02:07PM WBC-7.1 RBC-4.58 HGB-14.4 HCT-44.8 MCV-98 MCH-31.4 MCHC-32.1 RDW-14.1 RDWSD-50.7* ___ 02:07PM NEUTS-72.8* ___ MONOS-5.1 EOS-0.1* BASOS-0.4 IM ___ AbsNeut-5.17 AbsLymp-1.51 AbsMono-0.36 AbsEos-0.01* AbsBaso-0.03 ___ 02:07PM PLT COUNT-182 ___ 02:07PM ___ PTT-29.6 ___ ___ 02:07PM GLUCOSE-84 UREA N-11 CREAT-1.0 SODIUM-145 POTASSIUM-4.2 CHLORIDE-103 TOTAL CO2-27 ANION GAP-15 ___ 02:07PM ALT(SGPT)-10 AST(SGOT)-12 ALK PHOS-137* TOT BILI-0.4 ___ 02:07PM LIPASE-12 ___ 02:07PM ALBUMIN-4.1 CALCIUM-9.6 PHOSPHATE-2.4* MAGNESIUM-1.7 ___ 02:17PM LACTATE-1.4 ___ 03:52PM URINE COLOR-Yellow APPEAR-Hazy* SP ___ ___ 03:52PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30* GLUCOSE-NEG KETONE-40* BILIRUBIN-NEG UROBILNGN-2* PH-6.0 LEUK-NEG ___ 03:52PM URINE RBC-2 WBC-1 BACTERIA-NONE YEAST-NONE EPI-14 ___ 03:52PM URINE HYALINE-4* ___ 03:52PM URINE UCG-NEGATIVE INTERVAL WORK-UP: CT ABdomen & Pelvis with contrast FINDINGS: LOWER CHEST: Visualized lung fields are within normal limits. There is no evidence of pleural or pericardial effusion. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There is no evidence of focal lesions. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is notable for thickening at the fundus likely due to adenomyomatosis. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. There is no evidence of focal renal lesions or hydronephrosis. There is no perinephric abnormality. GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. The colon and rectum are within normal limits. The appendix is normal. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: There is a 3.4 cm left adnexal cyst. IUD noted in the uterus. Right adnexa is unremarkable. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. Circumaortic left renal vein is incidentally noted. BONES: There is no evidence of worrisome osseous lesions or acute fracture. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: No acute intra-abdominal process, no findings to explain patient's symptoms. Normal appendix. Brief Hospital Course: ___ with hx of chronic intermittent abdominal pain, ?Crohns disease on budesonide, severe IBS, anxiety presenting with recurrent severe RLQ pain. Hospital course complicated by severe depression and suicidal ideation. # Recurrent RLQ pain: # Anxiety, life stressors: Underwent extensive radiologic and laboratory workup which was grossly unremarkable. Etiology of right lower quadrant abdominal pain likely secondary to recent social stressors stressors including breaking up with her boyfriend. Her symptoms self resolved and she was tolerating adequate p.o. prior to discharge. #Hx of depression, anxiety #Reported SI She was evaluated by psychiatry who recommended adjusting her lamotrigine to 25 mg every morning and 50 mg every evening. She also met with the social worker. Her mood improved with interventions and she denies suicidal ideation. As such, she was removed off ___ and psychiatry felt that she was safe to be discharged home. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. DULoxetine 80 mg PO DAILY 2. TraZODone 200 mg PO QHS 3. LamoTRIgine 50 mg PO DAILY 4. Ondansetron ODT 4 mg PO Q8H:PRN Nausea/Vomiting - First Line 5. Melatin (melatonin) 3 mg oral QHS 6. CloNIDine 0.2 mg PO BID 7. Budesonide 9 mg PO DAILY 8. ClonazePAM 0.5 mg PO TID 9. Gabapentin 800 mg PO TID 10. Acetaminophen ___ mg PO Q8H:PRN Pain - Mild/Fever Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Abdominal pain Anxiety Recent social stressors Depression Suicidal ideation Discharge Condition: Discharge conditionstable Mental statusalert and oriented x3 Ambulatory Discharge Instructions: You were admitted to the hospital for right sided abdominal pain. You underwent an extensive laboratory and radiologic workup which was grossly unremarkable. Given your recent social stressors, we felt that your abdominal pain was likely related to anxiety. During hospitalization, you were extremely tearful and reporting depressed mood with thoughts of hurting yourself. You were evaluated by our psychiatric team who adjusted your home medication regimen. Following this adjustment, your overall mood improved and you are not reporting thoughts of hurting herself. As such, the psychiatric team felt that you were safe for discharge home with plan to follow-up with your outpatient providers. Followup Instructions: ___
19567431-DS-18	19,567,431	20,801,715	DS	18	2144-04-06 00:00:00	2144-04-06 18:25:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Compazine / Cinnamon / ciprofloxacin Attending: ___. Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ year old woman with PMHx of chronic intermittent abdominal pain, ?Crohns disease (without evidence on colonoscopy/biopsy) on budesonide, severe IBS, anxiety, depression, multiple hospitalizations for abdominal pain most recently ___ ___/b depression and SI, who presents with RLQ abdominal pain. Patient reports that pain started at 0500h this morning following a bowel movement. It is a constant pain associated with nausea and vomiting. She has not had p.o. since onset. Patient reports that she had copious loose stools this morning. Previously her last bowel movement was 1 week ago, and she had taken a laxative to relieve constipation. Similar abdominal pain has been noted intermittently for the last ___ years. Recent admission for the same pain with RLQ tenderness. Per chart review, patient has reported at least 20 previous admissions for the same pain. CT scan done on last admission showed no acute process and normal appendix. She denies fever, chills, chest pain, shortness of breath, change in bowel function, change in vision or hearing, bruising, adenopathy, new rash or lesion. She has had multiple prior admissions for abdominal pain here and at ___, including from ___ without clear etiology identified. Last colonoscopy at ___ from ___ was notable for "question ileitis vs erythematous lymphoid nodules, no signs of colitis. Await biopsies to rule out ileitis." Biopsies subsequently resulted as negative. Per chart review she was initiated on budesonide following admission to ___ from ___ to ___. "Workup during this admission was not particularly revealing, but it was the judgment of her ___ based gastroenterologists to pursue treatment for inflammatory bowel disease with budesonide capsule. Her gastroenterologist based at ___, Dr. ___ that, especially given minor CRP elevation and hint of ileitis, she could have mild ___ disease. Other inflammatory and vasculitic workup was negative. She was started on budesonide capsules which may be modestly helpful." She was seen by her outpatient ___ gastroenterologist Dr. ___ on ___ who per chart review intended to taper budesonide (3 tablets daily for 4 weeks, then 2 tablets x 2 weeks, then 1 tablet x 2 weeks) and requested pt to make an apt with Dr. ___ at ___ however per patient no mention of tapering budesonide was made at appointment and she has continued on her home dose. She reports that budesonide has not made a difference in her symptoms. In the ED: - Initial vital signs were notable for: T98.2 HR86 BP184/106 RR20 O___ - Exam notable for: Tearful. RRR. CTAB. No CVA tenderness. Right lower quadrant tender to palpation. No calf tenderness. - Labs were notable for: WBC 5.3 Lactate 1.3 AST/ALT ___ AP 123 - Studies performed include: Pelvic US: 1. Limited assessment of the right ovary which appears unremarkable without evidence for torsion. The left ovary is not visualized. 2. IUD is in appropriate position without evidence of complication. CXR: Heart size is normal. The mediastinal and hilar contours are normal. The pulmonary vasculature is normal. Lungs are clear. No pleural effusion or pneumothorax is seen. There are no acute osseous abnormalities. No subdiaphragmatic free air. - Patient was given: ___ 08:59 IV Morphine Sulfate 4 mg ___ 08:59 IV Ondansetron 4 mg ___ 08:59 IVF NS ___ 11:25 IV Morphine Sulfate 4 mg ___ 11:25 IV Ketorolac 15 mg ___ 13:30 IV HYDROmorphone (Dilaudid) 1 mg ___ 15:56 IV HYDROmorphone (Dilaudid) 1 mg ___ 15:56 IV Ondansetron 4 mg ___ 16:00 IV LORazepam 1 mg Upon arrival to the floor, the patient endorses the above history. She reports ongoing severe RLQ abdominal pain and nausea. The pain is worsened by eating, no other exacerbating/relieving factors. She vomited prior to presenting to the ED. She had several small loose stools today but denies any further vomiting/BMs while in the hospital. She states that she and her boyfriend ended their relationship yesterday and believes that this stressor is contributing to her current presentation. Her mood is poor in this regard but she denies any SI and states that she needs to live for her ___ year old son. She denies any fevers, chills, chest pain, shortness of breath, black/bloody stools, dysuria. REVIEW OF SYSTEMS: Complete ROS obtained and is otherwise negative. Past Medical History: 1. Anxiety. Psychiatrist was Dr. ___ and also has a therapist at ___. 2. Chronic abdominal pain with extensive workup in the past, which has been negative. There was this concern at one point for inflammatory bowel disease, but it is now thought to likely represent severe IBS. She follows with Dr. ___ in Gastroenterology. 3. B12 deficiency anemia. Has been stable off of B12 over the last ___ years. 4. Right knee pain with bone infarcts and mild osteoarthritis on x-rays. I thought the bone infarcts were likely thought to be due to chronic steroid use. 5. Obesity. 6. Borderline hypertension. 7. History of cervical radiculitis. 8. History of remote LEEP about ___ years ago. Social History: ___ Family History: Mother - DM, HTN. Father - CAD, DM. Two cousins with ___ disease. Physical Exam: ADMISSION PHYSICAL EXAM: VITALS: T97.6 BP131/74 HR70 RR25 O2-05 GENERAL: Alert and interactive. Tearful, intermittently tremulous. HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without injection. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Clear to auscultation anteriorly. No wheezes, rhonchi or rales. No increased work of breathing. ABDOMEN: Normal bowels sounds. Obese, tender to palpation in epigastric and RLQ. No rebound or guarding. No organomegaly. No suprapubic tenderness. EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial 2+ bilaterally. SKIN: Warm. Cap refill <2s. No rash. NEUROLOGIC: Face symmetric. Moving all extremities. Gait not assessed. AOx3. DISCHARGE PHYSICAL EXAM: VITALS: 24 HR Data (last updated ___ @ 253) Temp: 98.0 (Tm 98.0), BP: 115/77 (115-131/74-77), HR: 79 (70-79), RR: 18 (___), O2 sat: 94% (94-95), O2 delivery: Ra, Wt: 294.3 lb/133.49 kg GENERAL: Alert and interactive. Tearful, intermittently tremulous. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Clear to auscultation anteriorly. No wheezes, rhonchi or rales. No increased work of breathing. ABDOMEN: Normal bowels sounds. Obese, tender to palpation in epigastric and RLQ. No rebound or guarding. No organomegaly. No suprapubic tenderness. EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial 2+ bilaterally. SKIN: Warm. Cap refill <2s. No rash. NEUROLOGIC: Face symmetric. Moving all extremities. Gait not assessed. AOx3. Pertinent Results: admission labs: ___ 08:55AM BLOOD WBC-5.3 RBC-4.29 Hgb-13.6 Hct-42.6 MCV-99* MCH-31.7 MCHC-31.9* RDW-14.2 RDWSD-51.4* Plt ___ ___ 08:55AM BLOOD Neuts-68.4 ___ Monos-5.2 Eos-1.1 Baso-0.4 Im ___ AbsNeut-3.65 AbsLymp-1.31 AbsMono-0.28 AbsEos-0.06 AbsBaso-0.02 ___ 08:55AM BLOOD Glucose-92 UreaN-7 Creat-1.0 Na-141 K-5.0 Cl-102 HCO3-24 AnGap-15 ___ 08:55AM BLOOD ALT-12 AST-21 AlkPhos-123* TotBili-0.2 ___ 08:55AM BLOOD Albumin-4.1 ___ 09:07AM BLOOD Lactate-1.3 discharge labs: ___ 05:40AM BLOOD WBC-5.2 RBC-4.00 Hgb-12.8 Hct-39.1 MCV-98 MCH-32.0 MCHC-32.7 RDW-14.3 RDWSD-51.5* Plt ___ ___ 05:40AM BLOOD Glucose-72 UreaN-7 Creat-0.9 Na-145 K-4.4 Cl-106 HCO3-26 AnGap-13 ___ 05:40AM BLOOD Calcium-8.9 Phos-3.3 Mg-2.0 imaging: CXR ___: IMPRESSION: No acute cardiopulmonary abnormality. No subdiaphragmatic free air. Pelvic ultrasound ___: 1. Limited assessment of the right ovary which appears unremarkable without evidence for torsion. The left ovary is not visualized. 2. IUD is in appropriate position without evidence of complication. Brief Hospital Course: SUMMARY: ========= Ms. ___ is a ___ year old woman with PMHx of chronic intermittent abdominal pain, ?Crohns disease (without evidence on colonoscopy/biopsy) on budesonide, severe IBS, anxiety, depression, multiple hospitalizations for abdominal pain most recently ___ ___/b depression and SI, who presents with RLQ abdominal pain. # Acute on chronic abdominal pain: # IBS with constipation: # Chronic pain syndrome: # Nausea, vomiting (reported at home, not in the hospital): Presents with same symptoms as prior presentations. Diffuse abdominal pain, mainly RLQ. Non toxic on exam, abdomen is soft without rebound though tender in all areas, and labs unremarkable. Received several doses of IV dilaudid and IV morphine in the ED, as well as oxycodone. Pt reports that pain is most severe just after she has a bowel movement which is about 1x/week. She also notes that her abdominal pain coincides with her anxiety and suicidal ideation (no SI currently, but did have SI during recent hospitalization at ___. 1) Stopped all opioid medications and counseled on the lack of benefit 2) s/p dose of methynaltrexone SC x1 to try to minimize the constipating effect of the opioids she had been given in the ED 3) Given miralax (standing, not PRN; she should adjust dosing as needed for goal 1 BM every ___ days at home) and discharged on standing miralax BID, standing bisacodyl every other day, standing Colace and PRN senna. Also advised to drink plenty of fluids and ambulate as much as possible. 4) Tolerated regular, bland diet 5) We did NOT wait for patient to have BM prior to discharge (she suggested this early in our discussion and we counseled her that would not be a metric for discharge as she has reported it can be up to a week for her to have BMs at baseline). There is no clinical indication at this time to wait for her to have a BM prior to discharge. 6) If this patient presents to the ___ ED again with similar symptoms as on this presentation (___) and her most recent presentation (___), would encourage ED providers to avoid opioid medications and also to check a urine tox screen at the time of presentation. # Anxiety, depression # Recently with suicidal ideation Recommended that she continue seeking care with her therapist and consider cognitive behavioral therapy. Continued home medications though decreased clonidine from BID to once daily per patient request. . . TRANSITIONAL ISSUES: ========================== [] Consider referring for cognitive behavioral therapy if possible [] Please titrate budesonide per GI recs, pt continues on 9mg daily at this time [] We encouraged patient to take miralax and adjust amount for goal of 1 BM every ___ days (instead of her current baseline of 1 BM every ~7 days) [] She is scheduled for follow-up with ___ GI specialist, Dr. ___: her chronic abdominal symptoms. [] Please consider alternative to Zofran as this may also contribute to constipation [] We counseled the patient re: the existence of cannabinoid hyperemesis syndrome, if she continues to use marijuana and continues to have episodes of sudden onset nausea, vomiting and abdominal pain above her baseline, without other apparent explanation, suspicion for cannabinoid hyperemesis as the underlying cause would certainly increase . . *FOR FUTURE EMERGENCY DEPARTMENT PROVIDERS* =============================================== This patient has had chronic abdominal pain for many years with an extensive negative work-up and constipation-predominant IBS. If she presents with her typical symptoms of acute on chronic abdominal pain (often RLQ pain) with or without nausea, vomiting or diarrhea, this is NOT an indication for giving opioid medications. Please avoid opioid medications unless there is clear evidence of a NEW process that would benefit from acute pain management with opioid medications. In her case, the administration of opioid medications exacerbates her constipation and prolongs her hospitalization, and may also contribute to repeat emergency department visits. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. budesonide 9 mg oral DAILY 2. ClonazePAM 0.5 mg PO TID 3. CloNIDine 0.2 mg PO BID 4. DICYCLOMine 20 mg PO TID abdominal cramps 5. DULoxetine 80 mg PO DAILY 6. Gabapentin 800 mg PO TID 7. LamoTRIgine 25 mg PO QAM 8. LamoTRIgine 50 mg PO QPM 9. Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - First Line 10. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First Line 11. TraZODone 200 mg PO QHS:PRN insomnia 12. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild/Fever 13. Melatin (melatonin) 3 mg oral QHS:PRN 14. Senna 8.6 mg PO BID:PRN Constipation - First Line Discharge Medications: 1. Bisacodyl 10 mg PO EVERY OTHER DAY 2. Docusate Sodium 100 mg PO BID 3. CloNIDine 0.2 mg PO DAILY 4. Polyethylene Glycol 17 g PO BID 5. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild/Fever 6. budesonide 9 mg oral DAILY 7. ClonazePAM 0.5 mg PO TID 8. DICYCLOMine 20 mg PO TID abdominal cramps 9. DULoxetine 80 mg PO DAILY 10. Gabapentin 800 mg PO TID 11. LamoTRIgine 25 mg PO QAM 12. LamoTRIgine 50 mg PO QPM 13. Melatin (melatonin) 3 mg oral QHS:PRN 14. Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - First Line 15. Senna 8.6 mg PO BID:PRN Constipation - First Line 16. TraZODone 200 mg PO QHS:PRN insomnia Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary: ============ Acute on chronic abdominal pain IBS (constipation-predominant) Chronic pain syndrome Secondary: ============ Nausea & Vomiting Constipation Anxiety disorder, depression Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted to the hospital because you were having abdominal pain. What happened while I was here? - You were given pain medication and anti-nausea medication which helped your symptoms - You were given a strong medication called Methylnaltrexone to help relieve your constipation - You were able to tolerate a bland diet What should I do when I go home? - Please go to all of your follow up appointments (see below) - We have made some changes to your medication list, so please take your medications as prescribed - Please continue to keep yourself hydrated and eat small, frequent meals - Please try to exercise daily or walk at least 30 minutes every day after a meal - Please try to decrease the frequency of marijuana smoking as this can lead to pain as well - Please talk to your doctors about ___, specifically nortryptyline or amitriptyline, as these may be good options for both anxiety/depression and abdominal pain. - Please consider finding a therapist or psychiatrist and partaking in cognitive behavioral therapy as a method to manage your symptoms. It was a pleasure taking part in your care. We wish you all the best with your future health. Followup Instructions: ___
19567431-DS-23	19,567,431	22,530,073	DS	23	2144-10-25 00:00:00	2144-10-25 21:28:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Compazine / Cinnamon / ciprofloxacin / lamotrigine Attending: ___. Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: no History of Present Illness: Ms. ___ is a ___ y/o female with hx of chronic abdominal pain ___ IBS (3 admissions in the past 6 months, work-up including colonoscopy, abdominal imaging studies, pelvic U/S), possible ___ disease (without evidence on colonoscopy/biopsy) on budesonide, severe anxiety and depression, prior dx of somatic symptom disorder (previous inpatient on DEAC4), presenting to the ED with abdominal pain. Abdominal pain is RLQ, sharp, constant, ___, radiates to back. Also has nausea and 2 episodes of NBNB emesis, but no diarrhea. Last PO intake was last night. Denies having fever/chills, urinary symptoms, CP/SOB, hematemesis, melena. Patient reports that the symptoms are similar to previous episodes of abdominal pain. Most recent admission in ___, and thought that the pain was likely from IBS or functional pain, managed with Tylenol and toradol. Patient also on budesonide, though indication for this remains unclear. Patient saw gastroenterogist at ___ in ___, presented with similar symptoms, assessment suggests IBS vs IBD (___), plan for capsule endoscopy. At this visit, patient reported a history ___ disease which was apparently diagnosed at ___ many years ago, but we do not have those records and that has never been verified. Colonoscopy here x2 (most recently ___ with no evidence of IBD. In the ED, initial vitals were Temp 98.6, HR 80, BP 154/79, RR 18, O2 sat 94% RA. Exam was notable for abdomen moderately tender to palpation in RLQ, soft, non-distended, no significant rebound or guarding. Labs were notable for unremarkable CBC, BMP, UA. Lactate 1.0, LFT wnl except AP 151, phos 2.3. The patient was given 1L LR, gabapentin 600mg, oxcarbazepine 300mg, clonazepam 5mg, zofran 4mg, toradol 30 mg, haldol 1mg IV, morphine 4mg. On arrival to the floor, patient is afebrile and hemodynamically stable. Continues to have ___ RLQ pain and mild nausea. Past Medical History: - Anxiety/Depression - Chronic abdominal pain with extensive negative workup - B12 deficiency anemia - Right knee pain with bone infarcts and mild osteoarthritis - Obesity - Borderline hypertension - History of cervical radiculitis - History of remote LEEP about ___ years ago Social History: ___ Family History: - Mother: DM, HTN - Father: CAD, DM, metastatic cancer (unknown primary) - Two cousins with ___ disease. Physical Exam: GENERAL: Alert and interactive. In no acute distress. HEENT: PERRL, EOMI. Sclera anicteric. Moist oral mucosa. CARDIAC: Regular rhythm, normal rate. No murmurs/rubs/gallops. LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or rales. BACK: No CVA tenderness. ABDOMEN: Normal bowels sounds, tender to deep palpation in RLQ, No guarding or rebound tenderness. EXTREMITIES: No cyanosis, or peripheral edema. SKIN: Warm. NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs spontaneously. ___ strength throughout. Normal sensation. Pertinent Results: ADMISSION LABS ============= ___ 01:46PM BLOOD WBC-5.4 RBC-4.66 Hgb-14.3 Hct-43.3 MCV-93 MCH-30.7 MCHC-33.0 RDW-15.1 RDWSD-51.8* Plt ___ ___ 01:46PM BLOOD Neuts-70.0 ___ Monos-5.8 Eos-1.1 Baso-0.2 Im ___ AbsNeut-3.78 AbsLymp-1.20 AbsMono-0.31 AbsEos-0.06 AbsBaso-0.01 ___ 01:46PM BLOOD Glucose-95 UreaN-6 Creat-0.9 Na-140 K-4.2 Cl-102 HCO3-25 AnGap-13 ___ 01:46PM BLOOD ALT-10 AST-12 AlkPhos-151* TotBili-0.3 ___ 01:46PM BLOOD Lipase-15 ___ 01:46PM BLOOD Albumin-4.0 Calcium-9.1 Phos-2.3* Mg-1.8 ___ 01:46PM BLOOD CRP-36.9* CTA ABDOMEN PELVIS ================= IMPRESSION: 1. Normal vasculature. 2. Suspected underlying chronic bowel pathology although mild active ileal and/or sigmoid inflammation is possible. A prior study from ___ showed severe ileitis and colitis, which almost fully resolved at that time in only 3 days on follow-up imaging. More recent study from ___ arguably showed lower sigmoid wall thickening, which is difficult to assess on this study. Possibilities may include ___ disease, or alternatively, vasculitis or angioedema might be considered, although there is not necessarily an active process on imaging at this time. It is also possible that the striking abnormalities on the initial CT from ___ may have been due to acute infectious enterocolitis. DISCHARGE LABS ============= ___ 01:46PM BLOOD WBC-5.4 RBC-4.66 Hgb-14.3 Hct-43.3 MCV-93 MCH-30.7 MCHC-33.0 RDW-15.1 RDWSD-51.8* Plt ___ ___ 04:38AM BLOOD Plt ___ ___ 04:38AM BLOOD Glucose-75 UreaN-6 Creat-0.8 Na-141 K-3.9 Cl-106 HCO3-24 AnGap-11 Brief Hospital Course: Ms. ___ is a ___ yo female with hx of chronic abdominal pain ___ IBS, work-up including colonoscopy, abdominal imaging studies, pelvic U/S), possible ___ disease on budesonide, severe anxiety and depression, prior dx of somatic symptom disorder, presenting with RLQ abdominal pain. We consulted our gastroenterology colleagues who recommended that the patient follow up on an outpatient basis for capsule endoscopy. We also ordered a CT Angiogram (CTA) to look for a possible vascular cause of the abdominal pain and the results of the CTA showed normal vasculature. The patient's abdominal pain was managed with toradol. Her home ___ medications (budesonide, dicyclomine) were continued throughout the admission. ACUTE/ACTIVE ISSUES: ==================== # Acute on chronic abdominal pain, RLQ. Likely IBS vs Crohns, vs functional pain vs mesenteric ischemia. CRP is elevated and trending up. Unlikely ectopic pregnancy (IUD and pregnancy test negative) and UTI (urinalysis negative). GI recommends outpatient follow up (capsule endoscopy) or repeat imaging. -CTA of abdomen and pelvis ordered to elucidate vascular reasons for the pain (ie mesenteric ischemia, etc). -Continue home budesonide -Continue home dicyclomine -Needs outpatient GI follow up after discharge for scheduling of capsule endoscopy -Regular diet, can eat as tolerated #Reported unintended weight loss of 20 lbs. Patient looks well nourished. Reports not being able to eat due to abdominal pain. Most recent weights ___- 126kg; ___ -Get one time weight during admission CHRONIC/STABLE ISSUES: ====================== # Anxiety, depression, bipolar disease - No active SI - Continue home clonazepam, duloxetine, gabapentin, mirtazapine, oxcarbazepine # Insomnia - Continue home trazodone PRN TRANSITIONAL ISSUES =================== - Patient needs to follow up with her gasteroentologist for capsule endoscopy to further elucidate the cause of her abdominal pain # CODE: full code # CONTACT: ___ ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Budesonide 9 mg PO DAILY constipation 2. ClonazePAM 0.5 mg PO QAM 3. DICYCLOMine 20 mg PO TID:PRN cramps 4. DULoxetine 60 mg PO DAILY 5. Gabapentin 600 mg PO TID 6. Mirtazapine 22.5 mg PO QHS 7. TraZODone 100 mg PO QHS:PRN insomnia 8. Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - First Line 9. OXcarbazepine 300 mg PO QAM 10. OXcarbazepine 600 mg PO QPM 11. Acetaminophen ___ mg PO Q8H:PRN Pain - Mild/Fever Discharge Medications: 1. Acetaminophen ___ mg PO Q8H:PRN Pain - Mild/Fever 2. Budesonide 9 mg PO DAILY constipation 3. ClonazePAM 0.5 mg PO QAM 4. DICYCLOMine 20 mg PO TID:PRN cramps 5. DULoxetine 60 mg PO DAILY 6. Gabapentin 600 mg PO TID 7. Mirtazapine 22.5 mg PO QHS 8. Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - First Line 9. OXcarbazepine 300 mg PO QAM 10. OXcarbazepine 600 mg PO QPM 11. TraZODone 100 mg PO QHS:PRN insomnia Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Abdominal pain of unclear etiology Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity status: Ambulatory Discharge Instructions: Dear Ms. ___, It was a pleasure taking part in your care here at ___! Why was I admitted to the hospital? - You were admitted for work up of your abdominal pain. What was done for me while I was in the hospital? - We ordered a CT Angiogram to look for vascular causes of your pain, which showed that the vasculature of your abdomen and pelvis were normal. - You were given a medication called toradol to manage your pain. - We consulted our gastroenterology colleagues, who recommended that you follow up with them on an outpatient basis for capsule endoscopy. What should I do when I leave the hospital? - Take all your medications as prescribed - Keep all your doctors' appointments Sincerely, Your ___ Care Team Followup Instructions: ___
19567525-DS-19	19,567,525	20,545,110	DS	19	2123-07-29 00:00:00	2123-07-29 20:02:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Allergies/ADRs on File Attending: ___. Chief Complaint: chest pain Major Surgical or Invasive Procedure: None History of Present Illness: Ms ___ is a ___ year old ___ woman with history of NIDDM and HTN, presenting with right sided chest pain. She is visiting a friend in ___, having travelled from her home in ___irplane. Other than an isolated episode of nausea and vomiting 5 days ago, occurring after eating "bad food" she has been in her usual state of health. She is active with exercise (15 minutes on exercise bike per day, stretching and light weight strengthening exercises), which she started doing in order to lose weight after being diagnosed with diabetes. Two days ago (one day prior to presentation) she developed right sided chest pain, sharp and piercing in quality, intermittent, pleuritic in nature. She initially attributed it to being cold as she has had similar pains in the past that improved with warmth, however despite putting on extra closes and applying heat to the area her pain continued, intermittently, into the next day, prompting her to seek medical care. She reports a similar incident ___ years ago, with negative stress test at that time. She has no associated dyspnea, radiation or pain, palpitations, nausea, diaphoresis, lightheadedness, or fevers. No leg swelling or pain. ED Course: (presented ___ at 10am) - VS: afebrile, HR 59-79; BP 104-122/50s-60s; 100% RA; ___ 72-132 - Trops negative x 2; DD-dimer 1536. Chem 10 unremarkable - Meds administered: ASA 324 -> 81, lisinopril 5 She underwent exercise stress testing this morning, and experienced atypical chest pain, similar to her symptoms, with onset at 8 minutes, but resolution before she reached peak exercise at 10 minutes. However, she was noted to have 1-1.5mm downsloping STD in the inferior and lateral leads, resolving with rest. She notes that her chest pain improved with Tylenol in the ED. Vitals prior to tranfer were T 98, HR 74,BP 114/68, RR 16, SPO2 100RA. On the floor she continues to note right sided sharp chest pain with deep inspiration. Past Medical History: 1. CARDIAC RISK FACTORS: +hypertension, +diabetes 2. CARDIAC HISTORY: - CABG: None - PERCUTANEOUS CORONARY INTERVENTIONS: None - PACING/ICD: None 3. OTHER PAST MEDICAL HISTORY: osteoarthritis PAST SURGICAL HISTORY: -Hysterectomy Social History: ___ Family History: No early hx of CAD, SCD or arrhythmia. Physical Exam: ADMISSION EXAM: VS: T 97.7, BP 129/80, HR 77, RR 17, SPO2 100RA 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. Moist oral mucosa. NECK: Supple, no JVP noted. CARDIAC: PMI located in ___ intercostal space, midclavicular line. RR, normal S1, S2. No murmurs/rubs/gallops. No thrills, lifts. Able to reproduce pain with palpation in right mid-axillary line above right breast. No chest wall tenderness in other locations or along spinous processes. 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. No flank pain or palpable masses EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Distal pulses palpable and symmetric at radii, DP, ___ DISCHARGE EXAM: Vitals: T 97.7, BP 117/65, HR 66, RR 18, SPO2 100RA Tele: No alarms, sinus rhythm, HR 60-70s Last 24 hours I/O: not recording Last 8 hours I/O: not recording 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. Moist oral mucosa. NECK: Supple, no JVP noted. CARDIAC: PMI located in ___ intercostal space, midclavicular line. RR, normal S1, S2. No murmurs/rubs/gallops. No thrills, lifts. Able to reproduce pain with palpation in right mid-axillary line above right breast, unchanged since admission. No chest wall tenderness in other locations or along spinous processes. 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. No flank pain or palpable masses EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Distal pulses palpable and symmetric at radii, DP, ___ Pertinent Results: ADMISSION LABS: ___ 10:58AM ___ PTT-28.5 ___ ___ 10:58AM PLT COUNT-187 ___ 10:58AM NEUTS-79.0* LYMPHS-14.4* MONOS-5.3 EOS-1.1 BASOS-0.3 ___ 10:58AM WBC-10.8 RBC-4.75 HGB-14.5 HCT-40.7 MCV-86 MCH-30.6 MCHC-35.7* RDW-12.8 ___ 10:58AM D-DIMER-1536* ___ 10:58AM ALBUMIN-4.6 CALCIUM-9.2 PHOSPHATE-3.4 MAGNESIUM-1.8 ___ 10:58AM cTropnT-<0.01 ___ 10:58AM ALT(SGPT)-13 AST(SGOT)-16 LD(LDH)-183 ALK PHOS-61 TOT BILI-0.3 ___ 10:58AM GLUCOSE-140* UREA N-17 CREAT-0.8 SODIUM-139 POTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-24 ANION GAP-17 ___ 05:00PM cTropnT-<0.01 ___ 09:20PM URINE RBC-1 WBC-3 BACTERIA-NONE YEAST-NONE EPI-1 TRANS EPI-<1 ___ 09:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-MOD IMAGING: EKG (___) at rest: sinus at 81, nl intervals/axis, early precordial R wave transition, no Qs or TW changes c/w ischemia ETT (___): Ischemic EKG changes with non-anginal type symptoms. - 10 minutes of modified ___ protocol (stopped for fatigue); estimated peak MET = 8.2 (good functional capacity) - Baseline ___ shapr, right-sided waxing and waning chest discomfort, worse with inspiration and palpation - In the presence of baselien NSSTWs at 8.75 minutes of exercise there was 1.0-1.5 mm horizontal to downslopwing ST segment depression seen in leads II, III, F and V4-6. These changes initially resolved 1 minute post exercise and returned at 3 minutes of recovery, downsloping in contoour before returning to baseline by 12 mins of recovery. - Appropriate BP and HR response to exercise and recovery. - Duke Treadmill score of -0.5 consistent w/ moderate risk of CAD CTA Chest (___): - No e/o pulmonary embolism or aortic abnormality. No PNA. - Subcmm hypodensities throughout the liver left lobe are too small to characterize on CT. - 1.3cm hypodense lesion in the left lobe is consistent with hepatic cyst. - 9mm hypodense lesion in the interpolar region of the left kidney demonstrates enhancement and is concerning for a mass. MRI of the left kidney recommended due to concern for RCC CXR (PA/Lat) (___): No acute cardiopulmonary process MICROBIOLOGY: ___: Urine Culture Negative Brief Hospital Course: ___ year old woman with cardiac risk factors of hypertension and diabetes mellitus type 2 presenting with chest pain. #CHEST PAIN: Patient developed intermittent, sharp, reproducible, right-sided pleuritic chest pain, without dyspnea, radiation, diaphoresis or nausea, occurring both at rest and with exertion. This pain is atypical for angina, and she had negative troponins x2 and no changes in her resting EKG. This is possibly due to musculoskeletal source, although the exact cause is unclear. Although she has no dyspnea, hypoxemia, or tachycardia, with elevated D-Dimer she was checked for PE, however CTA chest showed no PE. However she did develop abnormal EKG findings on exercise stress testing, and she has CV risk factors of diabetes and hypertension. Therefore, given these factors and the new onset of this pain, she was initially approached as having unstable angina. She underwent repeat exercise nuclear stress testing, which was normal. Of note during this second exercise test she did have 1-1.5mm ST depressions in inferior leads that resolved with stress; it is possible that this represents small vessel disease in the setting of diabetes. She was started on aspirin 81mg and atorvastatin 80mg. Additionally, her chest pain was well controlled with a lidocaine patch and tylenol. #RENAL MASS: On CT of the chest there was incidentally noted 9mm hypodense enhancing lesion in the interpolar region of the left kidney, along with subcentimeter hypodensities throughout the liver. DDx includes renal cell carcinoma (most common), angiomyolipoma, oncocytoma, and other rare tumors. The solid nature and contrast enhancement of this lesion are concerning as there is high likelihood of malignancy. However, an incidental lesion <1 cm is unlikely to be further characterized by additional imaging or biopsy, and these patients can be offered surveillance, noting that neither tumor size at diagnosis nor the growth rate are accurate predictors of the presence of RCC. Active surveillance may be associated with the loss of the window of opportunity for curative surgical therapy given the small but real risk of cancer progression, and there are limitations of the current literature on the outcomes of active surveillance, and there is no validated ___ protocol. Treatment, should she choose to pursue it, would like be resection with partial nephrectomy, since for patient's with isolated solid renal masses this provides diagnosis and definitive therapy. As she lives in ___, recommend that patient ___ in short interval with her primary care provider for referral to urology and further work-up. #HYPERTENSION: BP well controlled since presentation. -continued home dose lisinopril #DIABETES MELLITUS TYPE 2: Reportedly well controlled on metformin 500mg BID. Patient has been doing aerobic exercise and controlling her diet and has been losing weight. -held metformin, gave low dose insulin sliding scale while admitted TRANSITIONAL ISSUES: =========================== #Left renal mass: With contrast enhancement on CT this should be further evaluated for possible malignancy. Recommended patient ___ with primary care provider in ___, for active surveillance and referral to urology. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Gabapentin 300 mg PO QHS 2. Lisinopril 5 mg PO DAILY 3. MetFORMIN (Glucophage) 500 mg PO BID Discharge Medications: 1. Lisinopril 5 mg PO DAILY 2. Gabapentin 300 mg PO QHS 3. Acetaminophen 650 mg PO Q8H RX acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet(s) by mouth Q8H:PRN Disp #21 Tablet Refills:0 4. Aspirin 81 mg PO DAILY RX aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 5. Atorvastatin 80 mg PO QPM RX atorvastatin 80 mg 1 tablet(s) by mouth QPM Disp #30 Tablet Refills:0 6. Lidocaine 5% Patch 1 PTCH TD QAM Use 12 hours on, 12 hours off. apply directly to painful area RX lidocaine 5 % (700 mg/patch) apply one patch to painful area QAM Disp #7 Patch Refills:0 7. MetFORMIN (Glucophage) 500 mg PO BID Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSES: -Atypical chest pain -Left renal mass SECONDARY DIAGNOSES: -Hypertension -Diabetes mellitus type 2 Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms ___, It was a pleasure meeting you and taking care of you during your hospitalization at ___. Unfortunately you were admitted to the hospital after developing pain on the right side of the chest. There were features of this pain that are typical of musculoskeletal causes (problem with the ribs or the muscles between the ribs). A CT scan of the chest did not show any evidence of a blood clot in the lungs. Your initial exercise stress test was a little abnormal, so you were admitted for a more detailed nuclear stress test. This test was normal, and showed no signs of ischemia. Also of note, our CT scan showed an abnormal, small (9mm) mass in your left kidney. Its not clear what the mass is you - you will need further scan as an outpatient to further clarify if this is something we need to be concerned about. We have talked to your primary care doctor about arranging follow up imaging within 6 months. Followup Instructions: ___
19567872-DS-14	19,567,872	23,882,532	DS	14	2111-01-20 00:00:00	2111-01-22 00:02:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Amoxicillin Attending: ___. Chief Complaint: HOSPITALIST ADMISSION HISTORY AND PHYSICAL cc: constipation Major ___ or Invasive Procedure: CT guided biopsy of abdominal mass History of Present Illness: ___ yo w/presented to ___ due to 1 week of constipation. Found to have large abdominal mass concerning for lymphoma, but not causing obstruction. Transferred from ED to BID for further work up of mass. Pt reports ~40lb weight loss over unknown amount of time. Denies fevers, night sweats, malaise. ROS: 10 point ROS otherwise negative Past Medical History: Glaucoma Macular Degeneration Osteoarthritis Diverticulosis Nephrolithiasis PSH: ccy, hysterectomy Social History: ___ Family History: no history of malignancy Physical Exam: Admission PE VS: 98.2 155/80 98 20 98%ra Pain: 3 Gen: nad, sitting up in bed Lymph: no cervical, axillary, supraclavicular or inguinal LAD Resp: ctab CV: rrr Abd: nabs, soft, nt/nd, no palpable masses Ext: no e/c/c Neuro: alert, answering questions appropriately . Discharge PE VSS General:AAOX3, NAD HEENT: OP clear, MMM CV: RRR, no RMG Lungs: CTAB, no WRR Abdomen: NTND, active BS X4 quadrants, biopsy site shows no expanding hematoma Extremities: WWP, pulses equal Psyc: mood and affect wnl Neuro: MS and ___ wnl, strength and sensation wnl . Pertinent Results: ___ 04:07AM GLUCOSE-126* UREA N-16 CREAT-0.9 SODIUM-141 POTASSIUM-3.8 CHLORIDE-103 TOTAL CO2-22 ANION GAP-20 ___ 04:07AM ALT(SGPT)-11 AST(SGOT)-20 ALK PHOS-89 TOT BILI-0.6 ___ 04:07AM ALBUMIN-3.7 ___ 04:07AM WBC-7.8 RBC-5.04 HGB-15.5 HCT-45.4 MCV-90 MCH-30.7 MCHC-34.1 RDW-13.4 ___ 04:07AM NEUTS-77.8* LYMPHS-9.0* MONOS-12.1* EOS-0.8 BASOS-0.3 ___ 04:07AM PLT COUNT-143* ___ 04:07AM ___ PTT-29.1 ___bd/Pelvis Impression: large mesenteric mass which encases the distal right ureter and is inseparable from adjacent bowel loops concerning for neoplastic process such as lymphoma. There is also retroperitoneal lymphadenopathy. Mild fullness of the right collecting system. The left kidney appears somewhat faceless suggesting involvement of a neoplastic process however limited without IV contrast. Nonobstructing left nephrolithiasis. Probable right pericardial cyst. Calcified pleural plaques. Diverticulosis. ___ CT guided bx IMPRESSION: Technically successful CT-guided core biopsy of large abdominal mass. Samples sent for cytology and pathology as requested. Cytology Touch prep of core, intraabdominal mass: SUSPICIOUS FOR MALIGNANCY. Abundant lymphocytes, suspicious for involvement by a lymphoproliferative disorder, see Note. Note: See associated surgical pathology report (___) and flow cytometry report (___) for further characterization. Specimen adequacy evaluation by Dr. ___ on ___: Pass #1 - Adequate. Atypical lymphoid cells; requested more for RPMI. . Immunophenotyping ___ ___ ___ Female ___ ___ Report to: ___. ___ ___ by: ___. ___ SPECIMEN SUBMITTED: immunophenotyping - Intra abdominal mass Procedure date Tissue received Report Date Diagnosed by ___ ___. ___ Previous biopsies: ___ XTP (1 JAR) DIAGNOSIS: FLOW CYTOMETRY REPORT FLOW CYTOMETRY IMMUNOPHENOTYPING The following tests (antibodies) were performed: Kappa, Lambda, and CD antigens 19, 45. RESULTS: Three color gating is performed (light scatter vs. CD45) to optimize lymphocyte yield. A limited panel is performed to determine B-cell clonality. B cells are scant in number precluding evaluation of clonality. INTERPRETATION Non-diagnostic study. Clonality could not be assessed in this case due to insufficient numbers of B cells. Diagnostic immunophenotypic features of involvement by lymphoma are not seen in specimen. Correlation with clinical findings and morphology (see ___ is recommended. Flow cytometry immunophenotyping may not detect all lymphomas due to topography, sampling or artifacts of sample preparation. . Pathology-pending at the time of this report . Brief Hospital Course: ___ yo F with a PMHx of glaucoma, OA, diverticulosis initially p/t ___ with 1 week of constipation, found to have a newly discovered abdominal mass concerning for lymphoma, transferred to ___ for further work up # Mesenteric mass with retroperitoneal lymphadenopathy The most likely cause of this mass was lymphoma. As a result, a tissue diagnosis was sought. The case was discussed with ___ and a CT guided biopsy of the mass was done on ___. Uric acid was checked and it was slightly high and an LDH was checked which was wnl. Oncology was contacted to arrange follow up once a tissue diagnosis was obtained. The felt the current work up was appropriate and further testing would be ordered once a diagnosis was obtained. They requested a PET/CT, but this was unable to be done in house. Ideally, this would be ordered by the patients PCP and done prior to follow up with Oncology. The patient agreed that she would prefer to go home and continue testing and treatment as an outpatient. . # Constipation: Patient typically has a bowel movement every day but she presented to 7 days of constipation. The patient moved her bowels on the day of discharge. She was sent home with a bowel regimen to attempt to prevent further episodes of constipation. The cause of this is likely bowel involvement of the abdominal mass. . # Calcified pleural plaques The patient does not have a clear exposure history that would explain this. Imaging via either a PET/CT or CT thorax with contrast would further characterize this as an outpatient. . # Transitional Issues: - follow up with PCP ___ ___ weeks and follow up with the final results of the biopsy and consider getting a PET/CT prior to follow up with Oncology - follow up with Oncology in ___ weeks for possible further testing and review of treatment options . Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Timolol Maleate 0.25% 1 DROP RIGHT EYE DAILY Discharge Medications: 1. Timolol Maleate 0.25% 1 DROP RIGHT EYE DAILY 2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation RX bisacodyl 5 mg 2 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 3. Docusate Sodium 100 mg PO BID RX docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #90 Capsule Refills:0 4. Polyethylene Glycol 17 g PO DAILY:PRN constipation RX polyethylene glycol 3350 17 gram 17 g by mouth once a day Disp #30 Packet Refills:0 5. Senna 1 TAB PO BID RX sennosides [senna] 8.6 mg 1 tab by mouth twice a day Disp #90 Capsule Refills:0 Discharge Disposition: Home Discharge Diagnosis: Constipation likely due to mechanical obstruction from abdominal mass Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You intially presented to ___ with constipation. You were found to have an abdominal mass. You were transfered to ___ for further work up. You had a biopsy of the mass, the pathology of which is pending at the time of discharge. This should be followed up by your PCP. Your constipation resolved while in house and you tolerated the procedure well. Please follow up with your PCP ___ ___ weeks. You will be discharged home with close follow up. . You will be on several new medications to prevent constipation, see below . Followup Instructions: ___
19568227-DS-17	19,568,227	28,552,432	DS	17	2146-04-15 00:00:00	2146-04-16 19:05:00	Name: ___ Unit ___: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Lyrica / niacin / atorvastatin / Lopid / Flu Vaccine Attending: ___. Chief Complaint: OSH transfer for ?LV thrombus Major Surgical or Invasive Procedure: ___ placement (___) History of Present Illness: ___ with past medical history of spinal stenosis and psoriasis, transfer from outside hospital for ?LV thrombus. Beginning ___eveloped RLQ pain which he has also had in the past, last multiple years ago. He states the pain was worse with movement, and unchanged by eating. He initially presented to ___ yesterday due to after VNS was concerned about abdominal pain. At ___, was tachycardic to 110s, w/ a leukocytosis and low grade fever. Had a CT abd which shows bilateral perinephric stranding and ?LV thrombus. Received ceftriaxone. Cardiology at ___ recommended transfer to ___ for echo, as they did not have capability to do echo overnight. In the ED, initial vitals were 98.9, 156/98, 124, 16 94% RA. Pt max T of 101.8. WBC 17.7. Per report, pt was not started on heparin. He was admitted to have echo performed. On the floor, initial vitals were: 97.9, 100/69, 89, 16, 98% RA. EKG showed TWIs v3-v5, new from EKG earlier in the morning. Echo was done which showed severe regional left ventricular systolic dysfunction with anterior, ___, distal LV/apical akinesis, as well as a large apical thrombus is the LV. Cardiac enzymes were negative. This morning pt states abdominal pain has resolved. He has not eaten since yesterday due to poor appetite. Denies f/c, N/V, dysuria. Pt reports feeling confused beginning when the pain started. States confusion now resolved, feels he is as baseline mentation. He denies chest pain, SOB, palpitation, cardiac history, seeing a cardiologist in the past. Past Medical History: -spinal stenosis, s/p neck surgery in ___ with chronic pain -psoriasis -delusions of parasitosis Social History: ___ Family History: Mother with possible spinal stenosis, father with DM Physical Exam: Admission: Vitals: 97.9, 100/69, 89, 16, 98% RA. GENERAL: NAD, awake and alert, slow/some difficulty responding to questions although appears to speak fluent ___ HEENT: anicteric sclera, dry MM, OP clear BACK: ___ spinal process tenderness, + L CVA tenderness CARDIAC: RRR, nl S1 S2, ___ MRG LUNG: CTAB, ___ rales wheezes or rhonchi, ___ accessory muscle use ABDOMEN: +BS, soft, non-tender, non-distended, ___ rebound or guarding, negative ___ EXT: warm and well-perfused, ___ cyanosis, clubbing or edema PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII tested and intact, strength 4+/5 strenght RLE, ___nd L extremities, 2+ patellar reflex bl SKIN: scaly pink patches on arm, leg, abdomen Discharge: Vitals: 98.9 161/97 90 18 100% RA GENERAL: Ill-appearing male appears older than stated age, lying in bed, NAD CARDIAC: RRR, S1/S2, S4, ___ murmurs Pulm: CTAB ABDOMEN: +BS, soft, nontender, non-distended, ___ rebound or guarding Rectal: good tone, brown stool guaiac negative EXT: L arm with PICC without erythema or purulence; ___ LUE edema; ___ edema HEENT: anicteric sclera, EOMI, dry MM, oropharynx clear NEURO: alert, oriented x3, CN ___ intact, ___ strength in UE and LLE, 4+/5 strength in RLE SKIN: scaly pink patches on extremities; erythema in L antecubital area associated with tegaderm Pertinent Results: ==================== Labs: ==================== ___ 03:45AM BLOOD WBC-17.7* RBC-4.88 Hgb-14.7 Hct-43.5 MCV-89 MCH-30.1 MCHC-33.7 RDW-13.1 Plt ___ ___ 05:47AM BLOOD WBC-14.7* RBC-3.30* Hgb-9.8* Hct-31.0* MCV-94 MCH-29.5 MCHC-31.5 RDW-14.5 Plt ___ ___ 03:45AM BLOOD Neuts-80* Bands-2 Lymphs-9* Monos-9 Eos-0 Baso-0 ___ Myelos-0 ___ 05:50AM BLOOD Neuts-87* Bands-0 Lymphs-8* Monos-4 Eos-1 Baso-0 ___ Myelos-0 ___ 03:45AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL ___ 05:50AM BLOOD Hypochr-1+ Anisocy-OCCASIONAL Poiklo-NORMAL Macrocy-1+ Microcy-NORMAL Polychr-OCCASIONAL Ovalocy-1+ Burr-2+ Acantho-1+ ___ 04:49AM BLOOD ___ PTT-31.1 ___ ___ 05:27AM BLOOD ___ PTT-54.6* ___ ___ 05:04AM BLOOD ___ PTT-38.1* ___ ___ 04:32AM BLOOD ___ ___ 05:50AM BLOOD ___ ___ 06:20AM BLOOD ___ PTT-44.4* ___ ___ 05:47AM BLOOD ___ PTT-46.0* ___ ___ 06:30AM BLOOD ESR-89* ___ 06:45AM BLOOD Ret Aut-0.9* ___ 03:45AM BLOOD Glucose-140* UreaN-14 Creat-0.7 Na-134 K-3.2* Cl-98 HCO3-23 AnGap-16 ___ 05:47AM BLOOD Glucose-110* UreaN-10 Creat-0.9 Na-141 K-3.9 Cl-105 HCO3-24 AnGap-16 ___ 03:45AM BLOOD ALT-13 AST-19 AlkPhos-75 TotBili-1.5 ___ 05:25AM BLOOD CK(CPK)-634* ___ 06:45AM BLOOD LD(LDH)-302* ___ 05:04AM BLOOD LD(LDH)-193 TotBili-0.8 ___ 03:45AM BLOOD Lipase-13 ___ 03:45AM BLOOD CK-MB-3 cTropnT-<0.01 ___ 01:25PM BLOOD CK-MB-5 cTropnT-<0.01 ___ 05:25AM BLOOD CK-MB-3 cTropnT-<0.01 ___ 03:45AM BLOOD Albumin-4.0 Calcium-8.6 Phos-1.8* Mg-1.5* ___ 05:47AM BLOOD Calcium-8.4 Phos-3.3 Mg-2.1 ___ 06:45AM BLOOD Hapto-328* ___ 05:04AM BLOOD Hapto-306* ___ 05:50AM BLOOD calTIBC-142* Ferritn-411* TRF-109* ___ 05:25AM BLOOD %HbA1c-5.8 eAG-120 ___ 05:25AM BLOOD Triglyc-89 HDL-26 CHOL/HD-4.7 LDLcalc-79 ___ 03:33PM BLOOD HIV Ab-NEGATIVE ___ 04:06AM BLOOD Lactate-1.7 ___ 01:57PM BLOOD Lactate-1.3 ___ 04:40AM URINE Color-Straw Appear-Clear Sp ___ ___ 04:40AM URINE Blood-SM Nitrite-NEG Protein-TR Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG ___ 04:40AM URINE RBC-0 WBC-0 Bacteri-NONE Yeast-NONE Epi-0 ___ 04:40AM URINE Mucous-RARE ==================== Micro: ==================== ___ 4:00 am BLOOD CULTURE FINAL REPORT ___ Blood Culture, Routine (Final ___: STAPH AUREUS COAG +. Consultations with ID are recommended for all blood cultures positive for Staphylococcus aureus, yeast or other fungi. FINAL SENSITIVITIES. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + \| CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN------------- 0.5 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. ___ 3:45 am BLOOD CULTURE FINAL REPORT ___ Blood Culture, Routine (Final ___: STAPH AUREUS COAG +. Consultations with ID are recommended for all blood cultures positive for Staphylococcus aureus, yeast or other fungi. SENSITIVITIES PERFORMED ON CULTURE # ___. STAPH AUREUS COAG +. ___ MORPHOLOGY. 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---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN-------------<=0.25 S TRIMETHOPRIM/SULFA---- <=0.5 S Anaerobic Bottle Gram Stain (Final ___: Reported to and read back by ___ @ 2143 ON ___ - ___. GRAM POSITIVE COCCI. IN CLUSTERS. Aerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN CLUSTERS. ___ 8:45 am BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: STAPH AUREUS COAG +. Consultations with ID are recommended for all blood cultures positive for Staphylococcus aureus, yeast or other fungi. SENSITIVITIES PERFORMED ON CULTURE # ___ FROM ___. Anaerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN CLUSTERS. ___ - ___ blood cultures negative ___ - ___ blood cultures pending ___ urine culture negative ==================== Imaging and other studies: ==================== ECG Study Date of ___ 3:05:24 AM Sinus tachycardia. Anteroseptal myocardial infarction of indeterminate age. ___ previous tracing available for comparison. Intervals Axes Rate PR QRS QT/QTc P QRS T 120 142 94 ___ ECG Study Date of ___ 10:02:04 AM Sinus rhythm. Anteroseptal myocardial infarction of indeterminate age. Compared to the previous tracing the rate is slower. Intervals Axes Rate PR QRS QT/QTc P QRS T 79 152 98 420/453 55 59 142 ECG Study Date of ___ 9:21:38 AM Sinus tachycardia. Prominent Q waves in the precordial leads with ST-T wave abnormalities. Anterior wall myocardial infarction of indeterminate age. Since the previous tracing of ___ the rate is faster. Clinical correlation is suggested. Intervals Axes Rate PR QRS QT/QTc P QRS T 105 138 96 ___ ECG Study Date of ___ 1:07:26 AM Sinus rhythm. Prior anteroseptal and lateral myocardial infarction. Compared to the previous tracing of ___ the rate has slowed and there is further evolution of the ischemic ST-T wave changes. Otherwise, ___ diagnostic interim change. Intervals Axes Rate PR QRS QT/QTc P QRS T 80 152 94 398/433 53 34 123 Portable TTE (Complete) Done ___ at 11:31:30 Findings LEFT ATRIUM: Elongated LA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal interatrial septum. Small secundum ASD. LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Severe regional LV systolic dysfunction. Large LV thrombus. ___ resting LVOT gradient. ___ VSD. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal diameter of aorta at the sinus, ascending and arch levels. AORTIC VALVE: Normal aortic valve leaflets (3). ___ AS. ___ AR. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. ___ MVP. ___ MS. ___ VALVE: Mildly thickened tricuspid valve leaflets. ___ TS. Mild [1+] TR. Mild PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: ___ PS. PERICARDIUM: ___ pericardial effusion. GENERAL COMMENTS: Echocardiographic results were reviewed by telephone with the houseofficer caring for the patient. Conclusions The left atrium is elongated. A small secundum atrial septal defect is present. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is severe regional left ventricular systolic dysfunction with anterior, ___, distal LV/apical akinesis. A large apical thrombus is seen in the left ventricle. There is ___ 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 ___ aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is ___ mitral valve prolapse. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is ___ pericardial effusion. Portable TTE (Focused views) Done ___ at 9:51:39 AM FINAL Findings Conclusions Overall left ventricular systolic function is severely depressed (___), with severe hypokinesis/akinesis of the anterior and anteroseptal walls. The clot is mural and not mobile. The known secundum atrial septal defect was not specifically imaged. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. ___ aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is ___ pericardial effusion. Moderate pulmonary artery systolic hypertension. IMPRESSION: Large mural thrombus in the setting of severely reduced LV function and severe hypokinesis/akinesis of the anterior and anteroseptal walls. Compared with the prior study (images reviewed) of ___ (images reviewed), the findings are similar. CHEST (PA & LAT) Study Date of ___ 4:30 AM IMPRESSION: ___ acute intrathoracic process. LIVER OR GALLBLADDER US (SINGLE ORGAN) Study Date of ___ 2:07 ___ IMPRESSION: 1. Patent hepatic vasculature with appropriate waveforms. 2. Sludge in the gallbladder without gallbladder mural edema or pericholecystic fluid to suggest cholecystitis. MR ___ & W/O CONTRAST Study Date of ___ 12:01 ___ FINDINGS: Evaluation of the cervical and thoracic spine demonstrates evidence for prior fusion at C5 through C7. There are multilevel degenerative changes. There is increased signal at the T1-T2 endplate, which could be related to DJD or spondylosis. Abnormal disc signal is seen at T9-T10 extending into the endplates with a small right rim-enhancing epidural collection measuring approximately 5 x 4 mm, concerning for an epidural abscess. There is also probable small sliver of epidural abscess extending inferiorly on the left to about T11 without significant mass effect.Epidural enhancement extends into the neural foramina and the paravertebral soft tissues bilaterally at T9-T10 and T10-T11. There is abnormal signal within the disc and the adjacent endplates at L3-L4. There is also abnormal signal within the L2-L3 disc. Findings are concerning for discitis/osteomyelitis.There is mild epidural enhancement in the lumber spine at the levels of the discitis, but ___ definite abscess is seen. There are multilevel degenerative changes in the lumbar spine from L3 to S1 causing mild-to-moderate central canal stenosis and moderate foraminal narrowing bilaterally. Right greater than left pleural effusions are seen.There is a right renal cyst. IMPRESSION: Findings concerning for discitis/osteomyelitis at L2-L3 and L3-L4 as well as T9-T10. At T9-T10, there is a small right epidural abscess which causes mild mass effect on the thecal sac and contacts the anterior cord. Other changes as above. MR HEAD W & W/O CONTRAST Study Date of ___ 12:02 ___ FINDINGS: The study is motion degraded. Within limits of the examination, ___ intracranial abscess is seen. There is ___ midline shift or mass effect. There are mild small vessel ischemic changes. There is ___ evidence for acute ischemia or hydrocephalus. Flow voids are maintained. Bilateral ethmoid opacification is seen. IMPRESSION: ___ evidence of acute ischemia or intracranial abscess. Mild scattered small vessel ischemic changes. CTA ABD & PELVIS Study Date of ___ 3:19 ___ FINDINGS: The lung bases have bilateral pleural effusions, right greater than left, with associated atelectasis. The visualized heart and pericardium are normal without pericardial effusion. The liver is normal in size and shape without any focal lesions. The hepatic veins and portal veins are patent. The liver does not have any intrahepatic or extrahepatic biliary dilation. The gallbladder is normal without any radiopaque gallstones. The spleen is normal without focal abnormalities. The pancreas enhances homogeneously without any ductal dilatation or peripancreatic stranding. The kidneys display symmetric nephrograms and are normal in size and shape bilaterally. There are ___ masses or perinephric abnormalities. There is ___ evidence of hydronephrosis or obstruction. The distal esophagus is normal without any hiatal hernia. The stomach is mildly distended without any gross abnormalities. The small bowel opacifies with contrast without any wall thickening, masses or obstruction. Large bowel contains feces but ___ abnormal dilatation or wall thickening. There is ___ intraperitoneal free air or free fluid. The urinary bladder is normal without wall thickening. The rectum is normal without wall thickening or masses. ___ pelvic sidewall or inguinal lymph nodes are enlarged by CT size criteria. The abdominal aorta does not have aneurysmal dilatation. The aorta and its major branches including the celiac trunk, SMA, bilateral renal arteries and ___ are patent. The external iliac and internal iliac arteries are patent. ___ retroperitoneal or mesenteric lymph nodes are enlarged by CT size criteria. Continued degenerative changes of the lumbar spine from L3-S1 causing mild to moderate canal stenosis, previously described on MRI from ___. There is retrolisthesis of L3 on L4 and disc space loss and endplate destruction, consistent with osteomyelits and discitis. There is retroperitoneal soft tissue thickening adjacent to this area (4a:67). IMPRESSION: 1. Bilateral pleural effusions, right greater than left. 2. ___ evidence of infection or abscess within the abdomen or pelvis. 3. The aorta and its major branches are patent without evidence of emboli or ischemia. 4. ___ evidence of bowel obstruction. 5. Degenerative changes of the lumbar spine, previously described on MR from ___. Continued retrolisthesis of L3 on L4 and disc space height loss consistent with osteomyelitis and discitis. Brief Hospital Course: BRIEF HOSPITAL COURSE ___ year old gentleman with past medical history of spinal stenosis and psoriasis, who was transferred from outside hospital for ?LV thrombus, with recent abdominal pain. Here, he was found to have severe LV hypokinesis and LV thrombus, with evolving EKG changes. Cards was consulted and recommended cardiac catheterization as an outpatient. He was also found to have MSSA bacteremia with associated small epidural abscess and osteomyelitis. Needs likely 8 weeks of IV nafcillin. Finally, had abdominal pain consistent with prior, initially constipated but began having loose BMs once placed on bowel regimen. Will follow up with Neurosurgery and ID. ACTIVE ISSUES # LV hypokinesis and thrombus, likely recent MI. Pt presented with recent evolving EKG changes. Felt by cardiology to have likely had recent MI within the last 2 months in LAD distribution. Pt did not have chest pain, and cardiac enzymes were negative. Pt remained hemodynamically stable throughout admission. TTE on ___ confirmed apical LV thrombus with severe LV systolic dysfunction with anterior, ___, distalLV/apical akinesis without significant valvular disease or vegetations. Repeat TTE ___ confirmed severely depressed LV (___), with severe hypokinesis/akinesis of the anterior and anteroseptal walls. Cardiology decided against performing revascularization attempt during admission and elected to review this again as an outpatient once infection was fully treated. Pt was initially placed on heparin drip which was switched to lovenox; warfarin started ___. INR ___ was 1.6. Will follow up with cardiology for possible cath as outpatient, with repeat TTE prior to appointment. In addition to anticoagulation, patient was treated with aspirin, beta blocker, and lisinopril. Statins were not given as patient had tried multiple statins previously with elevated LFTs and muscle aches. # Epidural abscess, discitis/osteomyelitis, MSSA bacteremia. Pt had leukocytosis throughout admission. Blood cultures demonstrated MSSA on ___ and ___ (though 2 colonies, both were represented in the sensitivities). Psoriatic skin lesions are areas with higher concentration of staph aureus and we postulate that staph from the skin somehow got into the blood stream without evidence for psoriatic flare or skin infection (denied IVDU). Acute worsening of lumbar back pain was highly concerning for metastatic spine focus in patient with hardware and previous surgery and MRI ___ confirmed multi-level discitis/osteomyelitis at L2-3, L3-4 and T9-10 with small R epidural abscess at T9-10. Neurosurgery recommended medical management. MRI brain performed ___ to rule out septic emboli potentially causing cognitive disturbance only showed mild small vessel ischemic change. Pt was initially started on vanc then switched to nafcillin, and cultures cleared. Pt did not have heart murmur or findings of endocarditis on exam or CT abdomen. ___ was not pursued as patient required long term antibiotics due to epidural abscess regardless and had minimal cardiac exam findings. Pt will follow up with neurosurgery as outpatient in 8 weeks. He will need repeat spine MRI at conclusion of antibiotic course (planned 8 weeks) and again 8 weeks after finishing antibiotics. PICC was placed; planned to continue nafcillin for 8 week total course. - ID at ___ will sign out to ID at ___, who will follow him there. # Anemia: Per PCP, pt has baseline hct of 37-42. Hct has declined during admission, before stabilizing near 30, and pt did not require any transfusions and was not symptomatic. CT abdomen negative for bleed. Labs were not consistent with hemolysis. Retic count was inappropriately low. ___ obvious medication etiology was identified. Anemia was thought likely secondary to anemia of inflammation given infection as well as blood loss from serial phlebotomy. # Abdominal pain: Pt had intermittent abdominal pain throughout admission, generally right-sided. Etiology thought to be extension of back pain from epidural abscess. CT did not show evidence of infection or embolic disease. Lactate was normal. Pt had constipation treated with a bowel regimen. For pain he was treated with tylenol, amitriptyline (dose increased from 10 to 20 qhs during admission), methadone, and fentanyl. He refused a trial of gabapentin. # Loose stools: Near end of admission, constipation resolved and pt developed ___ loose stools per day on an aggressive bowel regimen. Had fecal incontinence but good rectal tone and ___ neurological changes. Given ongoing leukocytosos and thrombocytosis, in the setting of ongoing antibiotic treatment, there was concern for c diff, but test was not sent prior to discharge as loose stool resolved temporarily. This was discussed with ___ and they will rule out for c. difficile at their facility given low pre test probability. ___ concerning abdominal exam findings. # Hypokalemia: Pt had intermittent hypokalemia during admission. Etiology possibly secondary to poor intake, as well as loose stools near end of admission, as well as possible medication effect of nafcillin. Potassium was repleted as needed. # Spinal stenosis with chronic pain: Pt was continued on home meds of amitriptyline(dose increased from 10 to 20 qhs during admission), methadone, fentanyl; also treated with tylenol and lidocaine patch. Pt refused trial of gabapentin; reported his pain increased with prior trial several years ago. # Delusions of parasitosis, history of depression: Pt on aripiprazole as outpatient, for delusion of parasitosis per PCP. Also reports depression in past. He was continued on home aripiprazole. - Please consider psych f/u while at ___. Transitional issues: ===================== - Code status: Full, confirmed. - Emergency contact: ___ (some ___ and mother ___ only) at home number ___ - Studies pending on discharge: Blood cultures ___ (previous cx were clear) - Verbal sign out given to on call physician at ___ ___ on ___ by Dr. ___. . # Epidural abscess, osteomyelitis, MSSA bacteremia: -continue nafcillin for 8 weeks, until ___ - Per ID at ___ at ___ will follow patient at that facility. - Please repeat spine MRI at completion of antibiotic course and 8 weeks later - follow up with neurosurgery (Dr. ___ in ___ weeks. Our doctor to doctor line ___ contact pt at home with appointment- please ensure that this appointment is made. - please draw the following labs, which ID at ___ will follow up: CBC with differential (weekly) ( X ) Chem 7 (weekly) ( X ) AST/ALT (weekly) ( X ) Alk Phos (weekly) ( X ) Total bili (weekly) ( X ) ESR/CRP (weekly) ( X ) - Regarding hypokalemia: Patient NOT discharged on small dose of standing potassium (regarding potassium repletion, he was given 60meQ every ___ days - this is in contrast to what was discussed with on call physician. Please check next potassium on ___ and replete as appropriate. # LV thrombus and hypokinesis, recent MI: -outpatient follow up with cardiology for consideration of cath, with TTE prior to appointment. Will need warfarin with goal INR ___. Please check next INR on ___ and stop enoxaparin once patient is therapeutic on warfarin for at least 24 hours given high risk LV thrombus. # Statin intolerance: pt with reported statin intolerance in past, with elevated LFTs and muscle aches. -consider trial of different statin as outpatient Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Amitriptyline 10 mg PO HS 2. Aripiprazole 15 mg PO DAILY 3. Methadone 5 mg PO TID 4. Fentanyl Patch 50 mcg/h TD Q72H Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Epidural abscess MSSA bacteremia Left ventricular thrombus, likely MI in ___ months prior to admission 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 has been a pleasure to care for you. You were admitted to our hospital because of concern at ___ that there was a blood clot in your heart. Un ultrasound of your heart found that there was a clot. We treated you with medicine to thin your blood. You also have a bacterial infection near your spine, and had a bacterial infection in your blood. We treated you with antibiotics. You will need to continue these antibiotics for several more weeks, likely for 8 weeks total until ___. When you are done with antibiotics, you will need a repeat MRI scan of your spine to ensure the bacterial infection has healed. Followup Instructions: ___
19568383-DS-7	19,568,383	20,104,391	DS	7	2118-11-02 00:00:00	2118-11-03 13:32:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: UROLOGY Allergies: some statins Attending: ___. Chief Complaint: fever, altered mental status Major Surgical or Invasive Procedure: NONE during this admission. ___: Robotic radical cystectomy, ileal conduit, implantation of parastomal mesh History of Present Illness: ___ PMH COPD, CABG and Bladder CA s/p cystectomy with loop diversion ___ here at ___, seen in the ED, for fever and infectious symptoms. Past Medical History: ASTHMA BLADDER CANCER CHRONIC OBSTRUCTIVE PULMONARY DISEASE DEPRESSION EMPHYSEMA HAYFEVER HEARING LOSS HEART FAILURE HIGH BLOOD PRESSURE SEASONAL ALLERGIES SHORTNESS OF BREATH HEART MURMUR Surgical History updated, no known surgical history. Social History: ___ Family History: Father ___ CONGESTIVE HEART FAILURE HIGH BLOOD PRESSURE Physical Exam: General: NAD. cooperative. articulate. A&O x3 chest: no tachypnea Abd: soft, urostomy pink and viable. no stents. yellow uop. Incision sites c/d/I; healing well. steristrips peeled off. No gross distention. No tenderness. Ext: WWP, SCDs on. No l/e e/p/c/d. No calf pain bilaterally. Pertinent Results: ___ 04:58AM BLOOD WBC-6.6 RBC-2.97* Hgb-9.2* Hct-28.9* MCV-97 MCH-31.0 MCHC-31.8* RDW-12.6 RDWSD-44.8 Plt ___ ___ 09:49PM BLOOD WBC-7.6 RBC-2.96* Hgb-9.2* Hct-28.7* MCV-97 MCH-31.1 MCHC-32.1 RDW-13.0 RDWSD-45.8 Plt ___ ___ 07:10AM BLOOD WBC-9.3 RBC-3.29* Hgb-10.2* Hct-32.0* MCV-97 MCH-31.0 MCHC-31.9* RDW-12.9 RDWSD-46.4* Plt ___ ___ 05:40PM BLOOD WBC-10.9* RBC-3.58* Hgb-11.1* Hct-34.4* MCV-96 MCH-31.0 MCHC-32.3 RDW-12.9 RDWSD-46.0 Plt ___ ___ 05:40PM BLOOD Neuts-80.5* Lymphs-7.0* Monos-10.5 Eos-1.3 Baso-0.2 Im ___ AbsNeut-8.79* AbsLymp-0.76* AbsMono-1.14* AbsEos-0.14 AbsBaso-0.02 ___ 04:58AM BLOOD Glucose-90 UreaN-11 Creat-0.9 Na-139 K-4.1 Cl-103 HCO3-25 AnGap-11 ___ 09:49PM BLOOD Glucose-158* UreaN-15 Creat-1.1 Na-133* K-4.0 Cl-101 HCO3-24 AnGap-8* ___ 07:10AM BLOOD Glucose-96 UreaN-12 Creat-1.0 Na-138 K-4.2 Cl-103 HCO3-21* AnGap-14 ___ 05:40PM BLOOD Glucose-106* UreaN-17 Creat-1.0 Na-135 K-4.5 Cl-99 HCO3-24 AnGap-12 ___ 04:58AM BLOOD Calcium-8.0* Mg-2.0 ___ 09:49PM BLOOD Calcium-7.6* Phos-2.5* Mg-1.8 ___ 05:50PM BLOOD Lactate-1.2 ___ 5:53 pm URINE FINAL REPORT ___ URINE CULTURE (Final ___: PSEUDOMONAS AERUGINOSA. 10,000-100,000 CFU/mL. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA \| CEFEPIME-------------- 4 S CEFTAZIDIME----------- 8 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ 2 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- 8 S TOBRAMYCIN------------ <=1 S ___ 10:15 am CATHETER TIP-IV Source: RUE PICC . WOUND CULTURE (Pending): * PENDING *** Brief Hospital Course: Mr. ___ has a history of COPD, CAD s/p CABG, who presented to the ED POD ___ s/p robotic assisted cystoprostatectomy with ileal loop diversion and implantation of parastomal mesh with fever and lethargy from ___. He presented with concerns for altered mental status and fevers. He was found to have pseudomonas urinary tract infection (pan sensitive) and was initially on empiric IV antibiotics but converted to oral ciprofloxacin. His hospital course was not complicated although he triggered once for tachycardia that resolved with Valsalva. Mr. ___ was discharged to home on hospital day four on a two week course of antibiotics, as suggested by our esteemed colleagues of medicine. Mr. ___ follow up next week as initially scheduled. His PICC line was removed and he will continue with home ___ services for his ostomy care. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 10 mg PO DAILY 2. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 3. Metoprolol Succinate XL 50 mg PO DAILY 4. Sertraline 150 mg PO DAILY 5. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 6. Docusate Sodium 100 mg PO BID 7. Enoxaparin Sodium 40 mg SC DAILY 8. Nitrofurantoin Monohyd (MacroBID) 100 mg PO DAILY 9. Famotidine 20 mg PO Q12H 10. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild 11. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line flush 12. Albuterol Sulfate (Extended Release) 4 mg PO Q12H 13. Aspirin 325 mg PO DAILY 14. Fluticasone Propionate NASAL 2 SPRY NU BID 15. irbesartan-hydrochlorothiazide 300-12.5 mg oral DAILY 16. Rosuvastatin Calcium 40 mg PO QPM 17. umeclidinium 62.5 mcg/actuation inhalation DAILY 18. Ringers 1 L intravenous EVERY OTHER DAY Discharge Medications: 1. Ciprofloxacin HCl 500 mg PO Q12H Duration: 5 Days RX ciprofloxacin HCl 500 mg ONE tab by mouth twice a day Disp #26 Tablet Refills:0 2. Metoprolol Tartrate 12.5 mg PO BID hold for SBP < 115, HR < 60 RX metoprolol tartrate 25 mg HALF tablet(s) by mouth twice a day Disp #30 Tablet Refills:0 3. Senna 17.2 mg PO HS 4. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 5. Albuterol Sulfate (Extended Release) 4 mg PO Q12H 6. amLODIPine 10 mg PO DAILY hold for SBP < 115, HR < 60 7. Aspirin 325 mg PO DAILY 8. Docusate Sodium 100 mg PO BID 9. Enoxaparin Sodium 40 mg SC DAILY 10. Famotidine 20 mg PO Q12H 11. Fluticasone Propionate NASAL 2 SPRY NU BID 12. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 13. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild 14. Rosuvastatin Calcium 40 mg PO QPM 15. Sertraline 150 mg PO DAILY 16. umeclidinium 62.5 mcg/actuation inhalation DAILY 17. HELD- irbesartan-hydrochlorothiazide 300-12.5 mg oral DAILY This medication was held. Do not restart irbesartan-hydrochlorothiazide until ADVISED BY CARDIOLOGY/PCP 18.BLOOD PRESSURE MONITORING RECORD BP/HR AT LEAST TWICE DAILY. Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: urinary tract infection; pseudomonas Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: -Please also refer to the instructions provided to you by the Ostomy nurse specialist that details the required care and management of your Urostomy -You will be sent home with Visiting Nurse ___ services to facilitate your transition to home, care of your urostomy, Lovenox injections, etc. -home infusion services for IV fluid will be stopped. The PICC line will be removed prior to discharge to home. -Lovenox is an injection that you will use once daily to reduce your risk of dangerous blood clot. Please follow the provided instructions on administration and disposal of syringes/needles ("sharps"). --You will be sent home on the a continued or reduced dose of the beta-blocker (metoprolol, propanalol, labetalol, etc.). *The metoprolol succinate 50mg was decreased to metoprolol tartrate 12.5mg PO BID with holding parameters.* -BLOOD PRESSURE/HR should be monitored TWICE daily and before taking your anti-hypertensives. Your goal for SBP is over 110. If in the AM and ___ you check your BP, and the SBP is less than 115, skip the dose. If your SBP creeps up or is persistently over 130; Increase to metoprolol to 25mg PO BID and notify your cardiologist and/or PCP. Ongoing persistent elevation indicates that you may need to increase the dose of your beta-blocker again or restart other agents (like the irbesartan-HCTZ). -IT IS IMPERATIVE that you continue to monitor your BP at least two times per day and keep track of this in your log book. -To reduce the strain/pressure on your abdomen and incision sites; remember to log roll onto your side and then use your hands to push yourself upright while taking advantage of the momentum of putting your legs/feet to the ground. -IBUPROFEN (the ingredient of Advil, Motrin, etc.) may be taken even though you may also be taking Tylenol/Acetaminophen. You may alternate these medications for pain control. For pain control, alternate ACETAMINOPHEN (AKA Tylenol) and IBUPROFEN. -Ibuprofen should always be taken with food. Please discontinue taking and notify your doctor should you develop blood in your stool (dark, tarry stools) -Do not eat constipating foods for ___ weeks, drink plenty of fluids to keep hydrated -No vigorous physical activity or sports for 4 weeks or until otherwise advised. Light household chores/activity and leisurely walking/activity is OK and should be continued. Do NOT be a couch potato -Max daily Tylenol (acetaminophen) dose is THREE grams from ALL sources AVOID lifting/pushing/pulling items heavier than 10 pounds (or 3 kilos; about a gallon of milk) or participate in high intensity physical activity (which includes intercourse) until you are cleared by your Urologist in follow-up. -No DRIVING for THREE WEEKS from surgery or until you are cleared by your Urologist -You may shower normally but do NOT immerse your incisions or bathe -Colace (docusate sodium) may have been prescribed to avoid post-surgical constipation or constipation related to use of narcotic pain medications. Discontinue if loose stool or diarrhea develops. Colace is a stool-softener, NOT a laxative. -Senokot (or any gentle laxative) may have been prescribed to further minimize your risk of constipation. -If you have fevers > ___ F, vomiting, or increased redness, swelling, or discharge from your incision, call your doctor or go to the nearest emergency room. Followup Instructions: ___
19568452-DS-11	19,568,452	21,233,465	DS	11	2148-11-25 00:00:00	2148-11-27 18:28:00	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 Major Surgical or Invasive Procedure: None History of Present Illness: ___ yo F with metastatic NSCLC to the brain s/p surgical resection and whole brain radiation, NPH s/p VP shunt and HTN who presents from home with nausea/vomiting. She was admitted from ___ - ___ with dizziness/nausea/vomiting symptoms thought to be due to a peripheral vertigo most likely a vestibular neuritis given resolution without any intervention vs orthostatic hypotension due to hypovolemia given resolution of dizziness after initiation of IV hydration. Central vertigo excluded by unremarkable CT and MRI of the brain. This morning when she woke up and felt "funny." She had milk, gatorade, and toast for breakfast and felt nauseous then vomited and felt relief. She denies any CP, SOB, dizziness, sensation the room was spinning, HA, vision change, or any focal neuro deficits. Vitals in the ER: 98.2 67 138/80 17 99% ra. She was given 1L NS, Zofran, and Ceftriaxone for a UTI. On arrival to the floor, she states that she feels like her normal self. . Review of Systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies blurry vision, diplopia, loss of vision, photophobia. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies chest pain or tightness, palpitations, lower extremity edema. Denies cough, shortness of breath, or wheezes. Denies diarrhea, constipation, abdominal pain, melena, hematemesis, hematochezia. Denies dysuria, stool or urine incontinence. Denies arthralgias or myalgias. Denies rashes or skin breakdown. No numbness/tingling in extremities. All other systems negative. . Past Medical History: NSCLC with mets to the brain -Left frontal resection on ___ by Dr. ___. -Whole brain radiation ___ to 3000 cGy. -Excision epidermoid cyst ___ by Dr. ___. -Strata ___ valve VP shunt ___ by Dr. ___ ___ hypertension obesity dyslipidemia left kidney cyst possible type 2 diabetes Left cataract surgery ___ multiple falls Social History: ___ Family History: brother with lung ca Physical Exam: ADMISSION EXAM: T 97.5 bp 158/70 HR 65 RR 20 SaO2 94 RA Appearance: alert, NAD, obese Eyes: eomi, anicteric ENT: OP clear, no lesions, slightly dry mucous membranes, no JVD, neck supple Cv: +s1, s2 -m/r/g, no peripheral edema, 2+ dp/pt bilaterally Pulm: clear bilaterally Abd: obese, soft, nt, nd, +bs Msk: ___ strength throughout Neuro: cn ___ grossly intact, Skin: no rashes Psych: appropriate, pleasant . DISCHARGE EXAM: unchanged Pertinent Results: ADMISSION LABS: ___ 02:45PM BLOOD WBC-10.9 RBC-4.49 Hgb-13.1 Hct-41.2 MCV-92 MCH-29.2 MCHC-31.9 RDW-14.1 Plt ___ ___ 02:45PM BLOOD Glucose-97 UreaN-21* Creat-1.1 Na-142 K-4.2 Cl-104 HCO3-28 AnGap-14 ___ 02:45PM BLOOD Calcium-10.1 Phos-3.0 Mg-1.9 ___ 02:56PM BLOOD Lactate-1.6 DISCHARGE LABS: ___ 06:40AM BLOOD WBC-8.5 RBC-3.81* Hgb-11.2* Hct-35.3* MCV-93 MCH-29.3 MCHC-31.7 RDW-14.8 Plt ___ ___ 06:40AM BLOOD Glucose-96 UreaN-20 Creat-1.2* Na-141 K-4.1 Cl-106 HCO3-27 AnGap-12 ___ 06:40AM BLOOD Calcium-9.1 Phos-4.0 Mg-1.7 URINALYSIS ___ 01:45PM URINE Color-Straw Appear-Hazy Sp ___ ___ 01:45PM URINE Blood-TR Nitrite-POS Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-LG ___ 01:45PM URINE RBC-<1 WBC-13* Bacteri-FEW Yeast-NONE Epi-1 TransE-<1 MICROBIOLOGY: ___ BLOOD CULTURE- Blood Culture, Routine (Preliminary): STAPHYLOCOCCUS, COAGULASE NEGATIVE. Isolated from only one set in the previous five days. SENSITIVITIES PERFORMED ON REQUEST.. ___ BLOOD CULTURE - NGTD ___ URINE CULTURE- no growth IMAGING: # CT HEAD W/O CONTRAST Study Date of ___ IMPRESSION: 1. New low-density subdural collection along the left convexity, compatible with either chronic subdural hematoma or hygroma. No mass effect. 2. VP shunt terminating in the left lateral ventricle, similar to prior with unchanged size of the ventricles. No ventriculomegaly. 3. Right mastoid air cell opacification, similar to prior # CHEST (PA & LAT) Study Date of ___ IMPRESSION: Unchanged rounded opacity within the lingula compatible with patient's known malignancy. No new areas of consolidation identified. Brief Hospital Course: ___ yo F with metastatic NSCLC to the brain s/p surgical resection and whole brain radiation, NPH s/p VP shunt and HTN who presents from home with nausea/vomiting which had resolved by the time of admission. ACTIVE ISSUES: #Nausea, Vomiting: Pt was admitted with one episode of nausea/vomiting that resolved by time of admission. She had a head CT done in the ED which was unrevealing. Neurosurgery evaluated the patient and felt that she was neurologically intact with VP shunt at previous settings. There was no need for acute neurosurgical intervention. Pt was able to tolerate a regular diet and was ambulating well at time of discharge. # Urinary tract infection: Pt with UA concerning for UTI. She received 1 dose of ceftriaxone in the ED, with transition to cefpodoxime on discharge. She was asymptomatic and remained afebrile. CHRONIC ISSUES. #Metastatic NSCLC: Pt is followed by Dr. ___ with her last chemotherapy in ___. She has follow up scheduled in the next month with plan for repeat imaging for staging. She was continued on Keppra during this admission. #Hypothyroidism - Pt was continued on home Synthroid dose . #Dyslipidemia: Continued simvastatin 40mg daily. . TRANSITIONAL ISSUES: Pt should follow up in 8 weeks with a CT of the head non contrast with Dr ___. She was DNR/DNI during this admission. *On the night of discharge, pt returned with one blood culture positive for coagulase negative staph. The family was contacted who stated that the patient was afebrile and feeling well. They were advised that, while this may be a contaminant, it is also possible that this was a true infection. They opted not to bring the patient back to the ED, but agreed to do so if she developed a fever or any other concerning symptoms. She will continue to complete a 7 day course of cefpodoxime. Medications on Admission: . 1. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 2. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Tablet(s) 3. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 4. Colace 100 mg Capsule Sig: One (1) Capsule PO once a day as needed for constipation. 5. Synthroid ___ PO daily . Discharge Medications: 1. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 2. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 5. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. citalopram 20 mg Tablet Sig: One (1) Tablet PO once a day. 8. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea. Disp:10 Tablet(s)* Refills:0 9. cefpodoxime 100 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:14 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Gastroenteritis urinary tract infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a pleasure taking care of you at ___ ___. You were admitted for nausea and vomiting which resolved when you were in the Emergency Room. You were given intravenous fluids. Given you had no further symptoms of nausea or vomiting, you are being discharged from the hospital. Please make the following changes to your medications: # START compazine every 6 hours if needed for nausea # START cefpedoxime 100 mg twice a day for 7 days Followup Instructions: ___
19568452-DS-12	19,568,452	21,278,648	DS	12	2148-12-11 00:00:00	2148-12-12 16:31:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: n/v, lightheadedness Major Surgical or Invasive Procedure: none History of Present Illness: . ONC ___ NEURO-ONC ___ . ___ yo F with metastatic NSCLC to the brain s/p surgical resection and whole brain radiation, NPH s/p VP shunt and HTN with two recent admissions for nausea/vomiting of unclear etiology presents to the ED with nausea/vomiting and lightheadedness. . Patient reports sudden onset of lightheadedness when she sat up in bed this am. Denies any room-spinning dizziness. She laid back down and symptoms resolved. Her son came to assist her, sat up again with recurrent lightheadedness, nausea and vomiting x 1 (nbnb). She again laid back down, took compazine, drank water and ate toast. When she sat up again she vomited. These symptoms continued throughout the morning, last episode of N/V was at 10 am. Denies any visual changes, headaches, muscle weakness or parasthesias. No fevers, cough, cp/sob, abdominal pain or leg swelling. No recent falls. Denies any dysuria or new urinary symptoms. Started a medication for overactive bladder 2 weeks ago, does not recall the name, takes it in the evenings. . Patient was admitted ___ with nausea/vomiting and vertigo thought to be due to a peripheral vertigo vs orthostatic hypotension. Symptoms resolved after IV hydration. CT and MRI of the brain were unremarkable. Patient admitted again ___ - ___ after one episode of nausea/vomiting. Head CT was unremarkable. Neurosurgery evaluated patient and felt she was neurologically intact with no need for further intervention. During this admission she was found to have a positive UA, treated with cefpodoxime x 7 days on discharge. Her urine culture was mixed bacterial flora consistent with fecal contamination. Her blood culture on the night of discharge grew CNS, family contacted and given that patient felt well, thought to be a contaminant. . ED: 97.8 62 131/70 18 99%RA; CTX 1gm for UA with 3 wbc's; 1L NS given; CXR no acute process; Head CT no acute findings . ROS as per HPI, 10 pt ROS otherwise negative Past Medical History: NSCLC with mets to the brain -Left frontal resection on ___ by Dr. ___. -Whole brain radiation ___ to 3000 cGy. -Excision epidermoid cyst ___ by Dr. ___. -Strata ___ valve VP shunt ___ by Dr. ___ ___ hypertension obesity dyslipidemia left kidney cyst possible type 2 diabetes Left cataract surgery ___ multiple falls Social History: ___ Family History: brother with lung ca Physical Exam: Admission PE VS: 97.6 148/80 61P 18 94%RA Appearance: alert, NAD, obese Eyes: eomi, perrl, anicteric ENT: OP clear s lesions, mmm, no JVD, neck supple Cv: +s1, s2 -m/r/g, no peripheral edema, 2+ dp/pt bilaterally Pulm: clear bilaterally Abd: obese, soft, nt, nd, +bs Msk: ___ strength throughout Neuro: cn ___ grossly intact, 3 beats horizontal nystagmus, ___ strength throughout, no pronator drift, normal finger-to-nose and heel-to-shin, downgoing toes, 2+ reflexes throughout, lightheadedness with sitting - unable to have patient stand Skin: no rashes Psych: appropriate, pleasant Heme: no cervical ___ . Discharge PE Pertinent Results: ___ 03:20PM PLT COUNT-225 ___ 03:20PM NEUTS-68.1 ___ MONOS-3.8 EOS-1.2 BASOS-0.4 ___ 03:20PM WBC-9.5 RBC-4.10* HGB-12.1 HCT-36.8 MCV-90 MCH-29.6 MCHC-33.0 RDW-14.5 ___ 03:20PM ALBUMIN-4.3 ___ 03:20PM cTropnT-<0.01 ___ 03:20PM LIPASE-16 ___ 03:20PM ALT(SGPT)-13 AST(SGOT)-15 ALK PHOS-109* TOT BILI-0.4 ___ 03:20PM GLUCOSE-106* UREA N-21* CREAT-1.1 SODIUM-138 POTASSIUM-4.4 CHLORIDE-102 TOTAL CO2-27 ANION GAP-13 ___ 04:00PM URINE MUCOUS-RARE ___ 04:00PM URINE RBC-1 WBC-3 BACTERIA-FEW YEAST-NONE EPI-<1 TRANS EPI-1 ___ 04:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-MOD ___ 04:00PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 04:00PM URINE GR HOLD-HOLD ___ 04:00PM URINE HOURS-RANDOM . ___ CT Head with contrast: 1. No acute intracranial process. 2. Unchanged intermediate density subdural collection along the left convexity, compatible with a chronic subdural hematoma or hygroma. No mass effect or change. 3. Ventricular shunt without complications. No change in ventricular size. . ___ CXR: IMPRESSION: No significant interval change since prior. . EKG ___ Sinus bradycardia. Baseline artifact. Non-specific inferior ST-T wave changes. Compared to the previous tracing of ___ no diagnostic interim change. Brief Hospital Course: ___ yo F with metastatic NSCLC to the brain s/p surgical resection and whole brain radiation, NPH s/p VP shunt and HTN with two recent admissions for nausea/vomiting/dizziness of unclear etiology presents to the ED with nausea/vomiting and lightheadedness. . #Nausea/vomiting/lightheadedness: The etiology of these symptoms was thought to be either UTI, dehydration, VP shunt malfunction, meningeal carcinomatosis, BPPV or medication effect. The patient was initially hydrated and treated symptomatically. The patients symptoms resolved soon after her admission. Her orthostatics were negative for several days following IV fluids. The patient CXR and UA was wnl and her cultures showed mixed flora. TSH and cortisol were wnl. Dr. ___ the ___ team and the Neurosurgery team did not feels as though this was a shunt malfunction. Head imaging over the course of her 3 presentations are unchanged. The patient also had no clear findings of physical exam that this was consistent with BPPV. There was also no temporal relationship with her symptoms and when her oxybutinin was started (2 weeks ago). The patient symptoms could be due to variation in intracranial pressure due to her functioning VP shunt. She was advised to stay hydrated with either a oral rehydration solution or gatorade and follow up with Dr. ___ as an outpatient. . #HTN: Patient and daughter were unsure if the patient was taking this medication. As a result it was held in house and her BP's were in the SBP 160-130 range. The medication should be held for the time being and she should re-address with her PCP. . Transitional Issues: -please follow up blood cultures from ___ -please follow up with Dr. ___, Dr. ___ your PCP ___ ___ weeks . Medications on Admission: Per OMR - please verify with dtr in am levetiracetam 1000mg bid simvastatin 40mg daily folic acid 1mg daily colace 100mg bid prn levothyroxine 125 mcg daily lisinopril 20mg daily - patient unsure if still taking citalopram 20mg daily compazine prn Discharge Medications: 1. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 2. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 5. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. citalopram 20 mg Tablet Sig: One (1) Tablet PO once a day. 7. tolterodine 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: multifactorial episodic nausea and vomiting possibly due to dehydration Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to ___ with complaints of nausea, vomiting and lightheadedness. CT of your head was unchanged from previous and you had no obvious soruce of infection. You were hydrated and your symptoms improved. Please stay hydrated at home. You will discharged home with close follow up with your doctors. ___ changes: You reported not being on lisinopril and it was held in the hospital. Your blood pressure was on the high end of normal in the hospital. Do not restart this medication until your follow up with your PCP or Dr. ___. Followup Instructions: ___
19568452-DS-13	19,568,452	24,444,859	DS	13	2150-05-13 00:00:00	2150-05-13 14:59:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: fatigue Major Surgical or Invasive Procedure: None this hospitalization History of Present Illness: ___ feeling with a hx of Metastatic non-small-cell lung cancer to brain s/p resection/WBR/VP SHUNT on keppra, ALK neg, EGFR pos on erlotinib c/b diarrhea and rash, htn, hld, hypothyroidism, who presented to the ED with complaints of feeling unwell and dizzy. She also mentions having had a slight headache that resolved. She states last ___ days she has been feeling lightheaded and dizzy when she ambulates. She has been slightly nauseated without vomiting. She is not dizzy when she lays still. She has been eating well. No cough or shortness of breath. No fevers or chills. Patient denies falling and states she has been getting slightly better. Patient with urinary frequency at baseline but feels she is peeing more often. No dysuria. Past Medical History: PAST ONCOLOGIC HISTORY: ___: Presented with neurologic symptoms and found to have on head CT two lesions in the left frontal lobe area. ___: One CNS lesion was resected completely by Dr. ___. The other was left in place and treated as part of her postop whole brain radiation therapy ___ 3000 cGy). Pathology positive for metastatic lung cancer. ___: PET scan: FDG-avid lingular mass as well as a FDG-avid mediastinal lymphadenopathy concerning for additional metastatic disease. ___: Status post VATS thoroscopy by Dr. ___ to rule out meddiastinal node involvement. Pathology was positive for metastatic large cell undifferentiated carcinoma. ___: PET scan: CNS recurrence - in left frontal lobe in close proximity to site of prior resection. Also, interval enlargement of the lingular nodule in the prevascular node (SUV 10 -->20). No bone lesions. ___: Carboplatin and Taxol chemotherapy started. ___: Brain MRI showed no evidence of disease recurrence. ___: PET/CT scan after four cycles of carboplatin/Taxol showed interval decrease in FDG avidity of lingular pulmonary nodule without change in size, decrease in avidity of right inguinal lymph node. ___: Two additional cycles of carboplatin/Taxol started (cycle #5 and 6). ___: Torso CT with Increased size of left upper lobe lung lesion and right inguinal adenopathy. ___: Restaging PET CT scan showed increased uptake in size of right inguinal lymph node. ___: FNA of her right inguinal lymph node positive for metastatic nonsmall cell lung cancer. ___: Alimta started 4 ___: Torso CT with stable disease and ___ brain MRI without residual or recurrent disease. ___: last Alimta dose as got VP shunt ___: VP shunt for NPH by Dr. ___ ___: CT and MRI brain WNL after admission ___: head CT WNL during admission ___: progression of brain and systemic disease, particularly in lung and a gradually enlarging right inguinal node that has never been palpable in part related to her large body habitus. ___: start of erlotinib. Took through approximately ___, then 2 weeks off and restarted. ___: She has shown objective response to the erlotinib both in the CNS by MR in ___ as well as a torso CT in late ___. continues to struggle with diarrhea and rash with erlotinib. ___: followed up in clinic, doing well but still with diarrhea on immodium and rash from erlotinib. skipping doses a few times per week due to side effects Hypothyroidism hypertension obesity dyslipidemia left kidney cyst possible type 2 diabetes Left cataract surgery ___ multiple falls Social History: ___ Family History: father: deceased of stomach cancer at age ___ mother: deceased at age ___ siblings: brother with lung ca children: healthy Physical Exam: ============================ admission ============================ VITALS: 97.7, HR 68, BP 142/75, RR 18, SP02 96%/RA, Pain ___ ECOG: 1 GENERAL: She is a well-nourished, well-developed female in no acute distress, alert and oriented. Slow, deliberate speech and hard of hearing. HEENT: S/p frontal surgical changes. Right fronto-temporal vp SHUNT INPLACE. Oropharynx is clear, moist mucous membranes. Pupils are equal, round and reactive to light. EOMI. LYMPH NODES: No anterior or posterior cervical, occipital, SCV, inguinal lymphadenopathy. HEART: Regular rate and rhythm. No murmurs, rubs or gallops. LUNGS: Clear to auscultation bilaterally. ABDOMEN: OBESE, Soft, nontender, nondistended EXTREMITIES: NO C,C,E. multiple linear excoriations/scratch ___ over lower extremities. NEURO: AOx3, CN II-XII intact, strength equal all extremities =============================== discharge =============================== VITALS:97.9 130/65 68 18 98% RA General: NAD, A+Ox3, hard of hearing HEENT: S/p frontal surgical changes. Right fronto-temporal vp SHUNT INPLACE. Oropharynx is clear, moist mucous membranes. Pupils are equal, round and reactive to light. EOMI. LYMPH NODES: No anterior or posterior cervical, occipital, SCV, inguinal lymphadenopathy. HEART: RRR. No murmurs, rubs or gallops. LUNGS: Clear to auscultation bilaterally, no wheeze ABDOMEN: OBESE, Soft, nontender, nondistended EXTREMITIES: NO C,C,E. multiple linear excoriations/scratch ___ over lower extremities. NEURO: AOx3, CN II-XII intact, strength equal all extremities. Pertinent Results: ========================= admission ========================= ___ 02:35PM BLOOD WBC-11.6* RBC-4.32 Hgb-13.1 Hct-41.4 MCV-96 MCH-30.2 MCHC-31.6 RDW-13.3 Plt ___ ___ 02:35PM BLOOD Neuts-59.1 ___ Monos-4.4 Eos-2.3 Baso-0.7 ___ 06:20AM BLOOD ___ PTT-31.0 ___ ___ 02:35PM BLOOD Glucose-90 UreaN-14 Creat-1.0 Na-142 K-4.4 Cl-105 HCO3-27 AnGap-14 ___ 02:35PM BLOOD ALT-14 AST-32 AlkPhos-77 TotBili-0.4 ___ 06:20AM BLOOD Calcium-9.6 Phos-3.6 Mg-1.8 ___ 02:35PM BLOOD Albumin-4.2 ___ 06:20AM BLOOD TSH-3.0 ========================== imaging ========================== ___ CT SHUNT: prelim IMPRESSION: VP shunt catheter appears contiguous without breaks with an acute turn in the upper abdomen where it enters the peritoneum; however, this is unchanged compared to CT examination from ___. ___ CT HEAD: prelim IMPRESSION: 1. No hemorrhage, edema, or other acute findings. MRI is more sensitive for the detection of metastatic disease. 2. Ventriculostomy shunt without complications. ============================= discharge ============================= ___ 06:20AM BLOOD WBC-10.1 RBC-4.08* Hgb-12.5 Hct-39.2 MCV-96 MCH-30.7 MCHC-31.9 RDW-13.6 Plt ___ ___ 06:20AM BLOOD Neuts-61.7 ___ Monos-5.4 Eos-2.9 Baso-0.3 ___ 06:20AM BLOOD Glucose-82 UreaN-16 Creat-1.1 Na-139 K-4.2 Cl-102 HCO3-26 AnGap-15 ============================= microbiology ============================= Time Taken Not Noted Log-In Date/Time: ___ 3:31 pm URINE Site: NOT SPECIFIED TAKEN FROM 60396T. URINE CULTURE (Preliminary): GRAM NEGATIVE ROD(S). >100,000 ORGANISMS/ML.. =========================== urine =========================== ___ 02:45PM URINE Blood-TR Nitrite-POS Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-LG ___ 02:45PM URINE RBC-9* WBC-51* Bacteri-MOD Yeast-NONE Epi-0 Brief Hospital Course: Ms. ___ is a ___ woman with metastatic NSLC lung cancer to the brain s/p s/p resection/WBR on keppra with persistent stable lung and right inguinal lesion on erlotinib who presents with feeling unwell and was found to have a urinary tract infection. # UTI with leukocytosis - Urine culture with gram negative rods. Past cultures sensitive to klebsiella. Will complete a three day course of ciprofloxacin. # dizziness - unknown etiology. In the past, has been dizzy in the past secondary to dehydration. However, she had negative orthostatics. She does have underlying CNS disease, which may be contributing to her dizziness but neurologically, the pt is intact. Her shunt series and CT head final reads are pending. She states that her symptoms have improved with treatment of her UTI. # Metastatic NSLC lung cancer to the brain s/p s/p resection/WBR on keppra with persistent stable lung and right inguinal lesion on erlotinib c/b diarrhea and rash. She will continue erlotinib as an outpatient, keppra, and imodium. # Hypothyroidism, last TSH 0.33 in ___. TSH pending at discharge. # HLD - continued simvastatin but unlikely to have much benefit given pts poor prognosis. # Depression/anxiety - not on any medications. # Pre-DM - f/u A1C however secondary to limited life expectancy, would probably not be beneficial to initiate any treatment since most diabetic complications are long term complications. # Scaral Stage 2 decub - home wound care. ============================== transitional issues ============================== * final urine culture and sensitivities * home physical therapy * home occupational therapy * wound care - please keep gluteal wound clean and dry, apply triple antibiotic ointment as needed and cover with gauze * help with self-care and ADLs * home safety evaluation Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Erlotinib 150 mg PO DAILY 2. LeVETiracetam 1000 mg PO BID 3. Levothyroxine Sodium 125 mcg PO DAILY 4. Simvastatin 40 mg PO DAILY 5. Triamcinolone Acetonide 0.1% Cream 1 Appl TP DAILY:PRN rash 6. Miconazole Powder 2% 1 Appl TP QID:PRN rash 7. Calcium Carbonate 600 mg PO DAILY 8. Vitamin D 400 UNIT PO DAILY 9. folic acid-vit B6-vit B12 2.2-25-0.5 mg oral daily Discharge Medications: 1. LeVETiracetam 1000 mg PO BID 2. Levothyroxine Sodium 125 mcg PO DAILY 3. Miconazole Powder 2% 1 Appl TP QID:PRN rash 4. Simvastatin 40 mg PO DAILY 5. Triamcinolone Acetonide 0.1% Cream 1 Appl TP DAILY:PRN rash 6. Vitamin D 400 UNIT PO DAILY 7. Ciprofloxacin HCl 500 mg PO Q12H uti RX ciprofloxacin 250 mg 1 tablet(s) by mouth twice a day Disp #5 Tablet Refills:*0 8. Calcium Carbonate 600 mg PO DAILY 9. Erlotinib 150 mg PO DAILY 10. folic acid-vit B6-vit B12 2.2-25-0.5 mg oral daily Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY: 1. urinary tract infection 2. metastatic lung cancer 3. orthostatic hypotension SECONDARY: 4. hypothyroidism Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. ___, It was a pleasure taking care of you at the ___ ___. You came into the hospital because you were feeling unwell. You were found to have a urinary tract infection. We started you on antibiotics. You will complete these antibiotics on ___. We also set you up with home health services, home physical therapy, and home occupational therapy. Thank you for choosing ___. Followup Instructions: ___
19568826-DS-17	19,568,826	22,974,534	DS	17	2179-11-02 00:00:00	2179-11-02 16:07:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: iodine / codeine / erythromycin base / vancomycin / Sulfa (Sulfonamide Antibiotics) / sulfamethoxazole / trimethoprim / oxycodone / propoxyphene Attending: ___. Chief Complaint: Left kidney/RP bleed s/p lithotripsy Major Surgical or Invasive Procedure: Left renal artery embolization ___ History of Present Illness: ___ F with h/o Afib on ___ who went to an outside hospital for an extracorporeal shock wave lithotripsy for left-sided nephrolithiasis on ___. She tolerated the procedure without issue, and had some expected post-operative pain on and off over the next several days. She states that she stopped her Xarelto as instructed 3 days before the procedure and resumed her Xarelto the evening after the procedure as instructed. She last took Xarelto ___ in the evening. She states that she then developed severe abdominal and left flank pain the day of presentation on ___ with some nausea. No additional symptoms. This pain was "unrelenting" and she presented to an outside hospital. She did get a CT scan there that showed a large left perinephric hematoma. She also had a drop in her hematocrit from her baseline of 34.7 on ___ to 25.7 at the outside hospital. She was also noted to be hypotensive to the ___. She was resuscitated with 1U PRBC/1U FFP and vitamin K. It was determined that she would need embolization by ___, and she was transferred to ___. Upon initial evaluation in the ED here, she was tachycardic and hypotensive but mentating appropriately. Initial re-check of CBC showed hematocrit of 26.2 (after the 1U of PRBC at OSH). INR 1.9 on presentation. ACS was consulted as there was question of intraabdominal bleeding. Decision was made for pt to go to ___ for left main renal artery embolization after premedication with diphenhydramine 50mg IV and methylprednisolone 125mg IV for contrast allergy. Pt continued to be resuscitated with ___ products before and during the ___ procedure (total 5U PRBCs and 2U FFP). During procedure, received Kcentra 4025U. Was easy intubation for procedure (Mac 3, gr 1 view). UOP 200cc, EBL for procedure 20cc, 1800cc NS + ___ products. Received 250mcg fentanyl for pain intra-op. Cefazolin 1g. Kept intubated after the procedure due to large volume resuscitation and c/f hypoxic respiratory failure and volume overload. Past Medical History: -Afib s/p multiple ablations, on Xarelto -Nephrolithiasis s/p lithotripsy ___ at OSH -Mild aortic stenosis -CVA ___ (no residual deficits) -Anxiety, panic attacks -Multinodular goiter -Rotator cuff syndrome -Psoriatic arthritis -CKD -HLD -HTN -Cervical disc/lumber spinal disease PSH: -Appendectomy -Cholecystectomy -Hysterectomy (___) -Right knee replacement -Circumferential ablation of pulmonary vein (___) -Left kidney extracorporeal shock wave lithotripsy ___ Social History: ___ Family History: mother w/PVD, father w/MI, sister and daughter w/DM Physical Exam: ADMISSION PHYSICAL EXAM ====================== V/S: T97.7, HR96, BP111/56, RR18, Sat100% 2L NC GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, nondistended, tender to palpation diffusely more pronounced on L side; No flank or periumbilical ecchymosis Ext: No ___ edema, ___ warm DISCHARGE PHYSICAL EXAM ====================== 98.7 109 / 64 81 18 93 1L General: Well-appearing, no apparent distress CV: Irregularly irregular rhythm, ___ holosystolic murmur best heard at the upper sternal border, regular rate Pulmonary: Clear to auscultation bilaterally without wheezes or rales Abdominal: Soft, nontender, non-distended Extremities: Warm, well-perfused, no lower extremity edema Pertinent Results: ADMISSION LABS ============== ___ 03:12PM ___ WBC-9.4 RBC-2.99* Hgb-8.7* Hct-26.2* MCV-88 MCH-29.1 MCHC-33.2 RDW-14.5 RDWSD-44.7 Plt ___ ___ 03:12PM ___ Neuts-82.4* Lymphs-8.1* Monos-8.9 Eos-0.0* Baso-0.1 Im ___ AbsNeut-7.72* AbsLymp-0.76* AbsMono-0.83* AbsEos-0.00* AbsBaso-0.01 ___ 03:12PM ___ ___ PTT-23.3* ___ ___ 03:12PM ___ Glucose-163* UreaN-38* Creat-2.1* Na-134* K-5.4* Cl-97 HCO3-23 AnGap-14 ___ 03:12PM ___ ALT-9 AST-29 AlkPhos-51 TotBili-0.8 ___ 03:12PM ___ Albumin-2.9* Calcium-8.1* Phos-4.7* Mg-2.0 ___ 07:16PM ___ Type-ART pO2-267* pCO2-43 pH-7.33* calTCO2-24 Base XS--3 ___ 03:15PM ___ Lactate-2.1* K-4.5 ___ 07:16PM ___ Glucose-138* Lactate-1.6 Na-130* K-3.9 Cl-102 NOTABLE LABS ============= ___ 03:20AM ___ WBC-12.3* RBC-2.61* Hgb-7.5* Hct-23.8* MCV-91 MCH-28.7 MCHC-31.5* RDW-16.0* RDWSD-52.1* Plt ___ ___ 01:00PM ___ Glucose-97 UreaN-63* Creat-3.4* Na-138 K-5.2* Cl-102 HCO3-21* AnGap-15 ___ 09:20PM ___ Glucose-97 UreaN-66* Creat-3.6* Na-135 K-4.8 Cl-99 HCO3-23 AnGap-13 ___ 04:05AM ___ Glucose-98 UreaN-52* Creat-1.8* Na-140 K-4.2 Cl-96 HCO3-35* AnGap-9* ___ 06:25AM ___ Glucose-115* UreaN-61* Creat-2.5* Na-143 K-4.2 Cl-98 HCO3-30 AnGap-15 IMAGING/STUDIES ============== ___ Renal arteriogram 1. Left renal arteriogram in AP, ___ and ___ views demonstrated at least 4 areas of vascular anomalies compatible with pseudoaneurysms within the superior and inferior poles of the kidney as well as marked compression of the renal parenchyma due to perirenal hemorrhage. Avulsion of capsular arteries was also noted. 2. Gel-Foam embolization of the left kidney from the distal main left renal artery demonstrated multiple suspicious areas of active extravasation and pseudoaneurysms involving both the superior and inferior poles. 3. Post Gel-Foam and coil embolization arteriogram demonstrated stasis of flow within the left main renal artery. 4. Final aortogram demonstrated satisfactory embolization of the left renal artery without evidence of additional areas of vascular injury or active extravasation with attention to the adrenal vasculature. IMPRESSION: Technically successful left renal artery embolization. ___ CXR The ET and NG tube have been removed. Right IJ sheath has also been removed. Pulmonary edema has worsened. There are superimposed multiple bilateral nodular opacities which could represent edema rather than pneumonia given large volume resuscitation. Small bilateral effusions left greater than right is unchanged. No pneumothorax is seen. ___ RENAL ULTRASOUND No right-sided hydronephrosis. Small volume ascites is noted. ___ TTE The left atrial volume index is severely increased. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is unusually small. Overall left ventricular systolic function is normal (LVEF = 70%). However, there is focal inferior posterior akinesis. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). The right ventricular free wall is hypertrophied. The right ventricular cavity is dilated with normal free wall contractility. [Intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation.] The ascending aorta is mildly dilated. There are focal calcifications in the aortic arch. The aortic valve leaflets are severely thickened/deformed. There is severe (low gradie) aortic valve stenosis (valve area = 0.9 cm2). The mitral valve leaflets are mildly thickened. There is severe mitral annular calcification. There is mild functional mitral stenosis (mean gradient 5 mmHg) due to mitral annular calcification. Severe (4+) mitral regurgitation is seen. Moderate to severe [3+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. [In the setting of at least moderate to severe tricuspid regurgitation, the estimated pulmonary artery systolic pressure may be underestimated due to a very high right atrial pressure.] There is no pericardial effusion. ___ CXR Support lines and tubes are unchanged in position. Cardiomediastinal silhouette is within normal limits. There is again seen airspace opacities throughout both lungs most prominent on the right. This may represent pneumonia with or without superimposed pulmonary edema. Findings are stable. There are no pneumothoraces. DISCHARGE LABS ============== ___ 08:13AM ___ WBC-8.2 RBC-3.81* Hgb-11.4 Hct-36.1 MCV-95 MCH-29.9 MCHC-31.6* RDW-17.3* RDWSD-57.4* Plt ___ ___ 08:13AM ___ Glucose-106* UreaN-66* Creat-2.5* Na-144 K-4.2 Cl-101 HCO3-29 AnGap-14 ___ 08:13AM ___ Calcium-9.1 Phos-3.5 Mg-2.4 Brief Hospital Course: SICU COURSE: ============ For SICU course, only able to obtain course as documented in the SICU personalized team census without edits: ___: Afib with HR ___. Gave 500cc LR bolus with HR decreasing from 130s -> 110s and metoprolol 2.5mg x2 with HR decreasing from 110s -> 90s/100s. Therefore, started metoprolol 5mg q6h standing. Increased amiodarone from 200mg alternating with 100mg every other day to 200mg daily. Neo weaned from 0.3 to off. Cr downtrending 2.4 -> 2.0 -> 1.9 -> 1.8. UOP 50-150 cc/hr. Net fluid balance +414cc. Renal signed off. Phos remained 2.3 despite 2 packets Neutra-phos in the AM, so gave 30mmol K-phos IV x1, after which AM phos 3.6. ___: Following commands. MAP>65 on average. Developed afib yesterday afternoon with heart rate was at 130s - 150s yesterday. She received 5mg of metoprolol which brought her heart rate down to the low 110s. She was started on 0.3 phenylephrine to improve her BP, with MAPs in the ___. Mild wheezes on exam yesterday morning, on 2L NC. Tolerating regular diet. She continues to put out high volumes of urine and our goal was to make her net even yesterday. We bloused her 2L of fluid to keep up with her UOP. Net fluid balance was -337cc at midnight and -6cc by this am. Phos was repleted at ___ yesterday. AM labs Cr 2.4 (from 2.7), BUN 63 (from 72). K 3.8 (from 3.9). ___: Despite increased crackles and wheezes on exam, appeared more comfortable breathing following profound diuresis. At one point put out 860cc urine during one hour on Lasix 10 -> reduced to 5mg/hr and eventually discontinued. Echo done AM, showed severe AS with severe MR. ___ pressure stable on diuresis, AM Cr 3.3, ___ 3.2. One unit pRBC in afternoon, which assisted with weaning pressor, given for cardiac comorbidities. Fluid balance for day -4.8L. Neo weaned to off throughout day. Continued to auto-diurese throughout rest of day approx. 150cc per hour spontaneously. Breathing improved, speaking full sentences, less symptomatic respiratory-wise. ___: Increased Lasix gtt from 10 to 15mg/hr and gave 5mg metolazone in the AM, UOP only ___. Continued the Lasix gtt at 15mg/hr and gave 120mg Lasix and 10mg metolazone in the afternoon, after which UOP was 150-300cc/hr. Net negative ~1L for the day (negative an additional ~900cc since MN). Given that pt was already negative almost 1L, decreased Lasix gtt to 10 cc/hr this AM. Cr was uptrending 3.1 -> 3.4 -> 3.6, but then downtrended to 3.3 this AM. Changed from NC to high-flow NC (30 L/min, 60% FiO2; currently 25 L/min, 40% FiO2) due to increased work of breathing, after which breathing improved. Renal US showed no hydronephrosis, stones, or masses in the right kidney. Became acutely hypotensive to SBP ___ in the afternoon. Bedside TTE w/o any obvious wall motion abnormalities or major reduction in EF. Aortic valve heavily calcified, which is c/w reported diagnosis of mild AS. Started Neo at 1, weaned down to 0.7, goal MAP >65. Hct stable, so unlikely that active bleeding is source of hypotension (23.4 -> 24.2 -> 24.5 -> 23.8). ___: Pain well controlled. Following commands. Hemodynamically stable. MAP > 65, NRS. Lung exam had bilateral crackles during yesterday's AM labs. Oxygen saturation drops to 89% with bed turns or movement. Currently on 5L nasal cannula. Currently tolerating regular diet without nausea or emesis. UOP was low yesterday morning. She received a total of 160mg of Lasix with minimal response. At 4pm yesterday, her UOP was 450. We consulted with renal and they recommended giving her 160mg of Lasix and starting a Lasix drip. Net fluid balance at midnight was 318cc and -176 this am. UOP was 200cc since midnight. Na 136, K 5.1, BUN 56, Cr 3.1. Hcrt down from 26 to 23. Held any transfusions in the setting of fluid overload. Anticoagulation held in the setting of hematoma. ___: N: Post-extubation, mental status returned quickly to baseline. Breathing well, weaning O2, currently on nasal cannula. Hemodynamically stable, borderline RVR- 100s throughout day. ___ and ___ pulled. Started taking clear liquids -> KVO. UOP ___ throughout day. HCT slightly drifting down: 25.9 on last check. Cr slight downtrend at 2.0. Urology did not accept patient as transfer- ACS discussing directly with Urology. Called out to floor. ___: Presented to ___ ED as transfer from OSH with large left perinephric hematoma and retroperitoneal hematoma s/p left lithotripsy ___. Has Afib and takes Xarelto (last dose ___, INR 1.9 on presentation. Transfused 1U PRBCs and 1U FFP at OSH ED prior to transfer and an additional 5U PRBCs and 2U FFP here. Hct 26.2 on presentation. Taken to ___ for left main renal artery embolization after premedication with diphenhydramine and methylprednisolone for contrast allergy. Kept intubated after the procedure due to large volume resuscitation and concern for hypoxic respiratory failure. Procedural UOP 200cc, EBL 20cc, 1800cc NS + ___ products. Post-op Hct 31 -> 30.1 this AM. Post-op ABG 7.37/40/221/24/-1, lactate 1.1. Cr 2.1 -> 2.0. Propofol weaned down to 10 mcg/kg/min. Following commands when awake. Passed SBT (RSBI 50). On PSV/CPAP at ___, FiO2 50%. O2 sats high-90s. CARDIOLOGY COURSE (___) ================================ Ms. ___ is a ___ year old woman with PMHx Afib on Xarelto, CVA, severe aortic stenosis, CKD (baseline Cr 1.2), psoriatic arthritis, nephrolithiasis who underwent Lt sided lithotripsy ___ and subsequently presented with subcapsular hematoma and active retroperitoneal hemorrhage s/p ___ guided embolization of the left renal artery on ___, now with episodes of atrial fibrillation with RVR. ACTIVE ISSUES: #Atrial fibrillation: Chads2vasc=6. On xarelto at home, held due to bleed, as below. Rates still higher to 130s with activity. Amiodarone was increased to 200mg daily for better control, though then decreased to 200mg/100mg alternating daily per patient preference/symptoms. Metoprolol initiated and uptitrated to 12.5mg Q6H. Discharged on succinate 50mg daily. Due to persistently high rates with activity, digoxin loaded and started at mainteance of 0.0625mg daily. On day of discharge rates <100. Due to worsened renal function, plan made to switch Xarelto to eliquis, to start on ___. Prior auth submitted on day of discharge but not yet approved as over weekend. #Volume overload in the setting of #Severe Aortic stenosis, Severe mitral regurgitation: Patient says she do not have a diagnosis of heart failure before her most recent hospitalization. She does have some akinetic segments visualized on echocardiogram, with preserved ejection fraction and multiple valvular defects; per outside hospital transfer notes, she has a history of cardiac catheterization with no significant CAD seen in ___. TTE this admission shows severe aortic valve stenosis and severe mitral valve regurgitation, thus the patient has difficult volume status to manage. As detailed above had required diuresis with furosemide drip up to 15/h, as well as boluses of 120 mg IV furosemide. Received IV diuresis on ___ and ___. Over 1L negative on ___ with 80mg IV lasix. Felt was euvolemic and Discharged on 80mg PO Lasix. #Acute ___ loss ___ loss anemia: #Left perinephric bleed s/p ___ embolization of left renal artery Left renal artery embolized by ___ after significant bleed requiring a total of 7 units PRBC during this admission as detailed above. Now hemodynamically stable with stable Hb. Held rivaroxaban. Per urology, will restart ___ but switch to eliquis -- see above. # ___ Previous baseline creatinine 1.2 before embolization of left renal artery. During SICU course increased to mid 3 in setting of hypotension and volume overload. Improved to 1.8 then stabilzed at 2.3-2.5. Unclear if this is new baseline or recovering ATN in setting of significant hemodynamic compromise. #Right-sided erythematous rash: Not itchy or painful per patient. Not warm. No skin lesions. Possibly due to contact dermatitis from green pad. Clobetasol ointment. Sarna lotion for skin hydration CHRONIC/STABLE ISSUES: #History of CVA: Continued home atorvastatin 10mg. Held xarelto as above. #Hypertension: Held ramipril as above. discharged with ramapril held. #Osteoarthritis: Pain control with Tylenol #Anxiety: Continued home alprazolam TRANSITIONAL ISSUES ================== DISCHARGE WEIGHT = 78.7kg (ADMISSION WEIGHT 90 KG) [] Per urology, OK to restart anticoagulation on ___ monitor for signs of bleeding and check CBC twice weekly [] plan will be to switch to eliquis 2.5mg BID from ___ due to decreased GFR [] Check BMP in 1 week [] check digoxin level on ___ [] Monitor creatinine now that she is s/p left renal artery embolization [] Monitor volume status and weight; adjust diuretics to achieve and maintain euvolemia as ___ pressure allows [] ACE held because of SBP ___, restart as able if ___ pressure increases [] Monitor heart rate on amiodarone and metoprolol. Increase metoprolol as needed to keep HR less than 100 as ___ pressure allows. [] Ensure follow up with TAVR team at ___ [] foley in place, please pull foley as early as clinically indicated [] Right IJ sheath stitch in place. Please remove on or before ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. ALPRAZolam 0.25 mg PO QID:PRN anxiety 2. Amiodarone 100-200 mg PO DAILY 3. Atorvastatin 10 mg PO QPM 4. Calcipotriene 0.005% Cream 1 Appl TP BID 5. Clobetasol Propionate 0.05% Cream 1 Appl TP BID 6. Furosemide 60 mg PO DAILY 7. Multivitamins 1 TAB PO DAILY 8. Ramipril 2.5 mg PO DAILY 9. Rivaroxaban 20 mg PO DAILY 10. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain - Severe Discharge Medications: 1. Apixaban 2.5 mg PO BID To start on ___ 2. Atorvastatin 10 mg PO/NG QPM Start: Upon Arrival 3. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 4. Digoxin 0.0625 mg PO DAILY 5. Metoprolol Succinate XL 50 mg PO DAILY 6. Multivitamins W/minerals 1 TAB PO DAILY 7. Polyethylene Glycol 17 g PO DAILY 8. Sarna Lotion 1 Appl TP TID:PRN itchy skin 9. Senna 8.6 mg PO BID:PRN constipation 10. Furosemide 80 mg PO DAILY 11. ALPRAZolam 0.25 mg PO QID:PRN anxiety 12. Amiodarone 100-200 mg PO DAILY Alternating 200mg/100mg every other day 13. Calcipotriene 0.005% Cream 1 Appl TP BID 14. Clobetasol Propionate 0.05% Cream 1 Appl TP BID 15. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain - Severe RX hydrocodone-acetaminophen 5 mg-325 mg 1 tablet(s) by mouth q6h PRN Disp #20 Tablet Refills:0 16. HELD- Ramipril 2.5 mg PO DAILY This medication was held. Do not restart Ramipril until you talk to your cardiologist Discharge Disposition: Extended Care Facility: ___ ___ Diagnosis: Primary: Renal capsular bleed complicated by retroperitoneal bleed Pulmonary edema Severe Aortic Stenosis Severe Mitral Stenosis Atrial fibrillation Secondary: Hypertension Anxiety Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Ms. ___, You were admitted to ___ with a bleed around the kidney. The bleed was severe and you had a procedure to stop ___ flow to the left kidney called an embolization. You were quite sick around the procedure and had to be supported in the surgical intensive care unit. You were given ___ transfusions, medications to help raise the ___ pressure, and medications to help remove extra fluid. Your atrial fibrillation led to a fast heart rate. Your medications were increased. We also started 2 new medications to help her heart rate: Metoprolol and digoxin. You will restart ___ thinner on ___. It was held because of the bleeding. However when you restart will be a new type of ___ thinner called Eliquis, which is better for you because your kidneys are not working as well at the moment. Your discharge weight is 78.6kg Please weight yourself daily and call your doctor if your weight increases by 3 pounds in one day or 5 pounds in one week. It was a pleasure taking care of you. We wish you the best in your health. Sincerely, Your ___ Team Followup Instructions: ___
19568880-DS-13	19,568,880	28,317,175	DS	13	2137-08-03 00:00:00	2137-08-04 07:42:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins / Iodinated Contrast- Oral and IV Dye / Gadolinium-Containing Contrast Media Attending: ___. Chief Complaint: HA, CP Major Surgical or Invasive Procedure: None History of Present Illness: HOSPITALIST ADMISSION NOTE PCP: Name: ___ ___: ___ Address: ___, ___ Phone: ___ Fax: ___ HPI: Mr. ___ is a ___ yo M with HTN poorly controlled, DM2, OSA, HL, who presents with severe hypertension in the setting of chronic HA and intermittent hand numbness. The patient reports intermittent HA for several weeks/months followed by contant HA the last week. He reports his HA as in the back, sharp, on the L side, not assoc with vision change, double/loss of vision. In the setting of this, he reports intermittent L hand numbness for several months, worse over the last few days. He denies any weakness, difficulty speaking. Moreover, he denies any CP, SOB, palps, leg pain or swelling. He is urinating normally. At the advice of his fiancé, he presented to ___. At ___ was noted to be >190/>110. CT head was performed. He was given labetalolol, nitro, metoprolol, and transferred. His symptoms have resolved and now feels well. "When can I go home?" He denies any new medications, use of NSAIDs, significant EtOH use. He is currently in no pain 10 point review of systems reviewed, all others negative except as listed above Past Medical History: HTN HL DM2 OSA Collagenous Gastritis Social History: ___ Family History: Reviewed. Positive for kidney disease Physical Exam: VS: afebrile, 154 / 100 HR 95, RR 16, 94%RA GEN: obese well appearing in NAD HEENT: NC/AT, ext ears wnl no erythema, PERRL, anicteric sclera, MMM, OP clear no erythema NECK: supple no LAD, unable to appreciate JVD CV: RRR nl S1 S2 no mrg PULM: CTAB no wheezes or crackles GI: soft NT/ND +BS no rebound or guarding GU: deferred prostate exam EXT: warm well perfused no pitting edema DERM: no rashes or bruising noted NEURO: CNII-XII intact, fluent speech, ___ strength in all extremities, gross sensation intact Discharge exam: No change Pertinent Results: ___ 05:20AM GLUCOSE-85 UREA N-21* CREAT-2.2* SODIUM-140 POTASSIUM-3.5 CHLORIDE-101 TOTAL CO2-22 ANION GAP-21* ___ 05:20AM estGFR-Using this ___ 05:20AM cTropnT-<0.01 ___ 05:20AM WBC-6.3 RBC-5.25 HGB-13.3* HCT-42.2 MCV-80* MCH-25.3* MCHC-31.5* RDW-14.4 RDWSD-41.6 ___ 05:20AM NEUTS-45.9 ___ MONOS-7.6 EOS-1.3 BASOS-0.5 IM ___ AbsNeut-2.91 AbsLymp-2.81 AbsMono-0.48 AbsEos-0.08 AbsBaso-0.03 ___ 05:20AM PLT COUNT-216 CXR, ___: FINDINGS: There is no infiltrate, effusion or pneumothorax. The cardiomediastinal silhouette is within normal limits. The osseous structures are grossly intact. IMPRESSION: No acute cardiopulmonary process. CT head, ___ IMPRESSION: 1. Nonspecific areas of decreased density in the white matter, new compared with ___. The differential would be broad but in the setting of hypertension would include posterior reversible encephalopathy syndrome. Further evaluation with HEAD MRI WITHOUT AND WITH CONTRAST should be considered. EKG, my review: NSR, TWI I, aVL, with TW flattening in precordial leads, similar to EKG performed earlier. MRI BRAIN: IMPRESSION: 1. No evidence of acute infarction intracranial hematoma. 2. Mild FLAIR signal abnormality within the bilateral posterior fossa, which may be related to PRES given the history of hypertension. 3. Nonspecific additional bilateral white matter FLAIR signal abnormality, some of which appear perpendicular to the ependymal surface, and may be related to multiple sclerosis in a patient of this age. Recommend clinical correlation. 4. Probable foci of micro hemorrhages along the right periventricular white matter. Recommend correlation with outside imaging. DC LABS: ___ 05:20AM BLOOD WBC-6.3 RBC-5.25 Hgb-13.3* Hct-42.2 MCV-80* MCH-25.3* MCHC-31.5* RDW-14.4 RDWSD-41.6 Plt ___ ___ 06:50AM BLOOD Glucose-77 UreaN-16 Creat-1.9* Na-142 K-3.6 Cl-104 HCO3-27 AnGap-15 ___ 06:50AM BLOOD CK(CPK)-262 ___ 05:00PM BLOOD ALT-20 AST-17 AlkPhos-71 TotBili-0.3 ___ 05:00PM BLOOD cTropnT-<0.01 ___ 05:20AM BLOOD %HbA1c-5.8 eAG-120 ___ 05:20AM BLOOD Triglyc-108 HDL-63 CHOL/HD-3.3 LDLcalc-124 ___ 05:20AM BLOOD TSH-1.6 Brief Hospital Course: Mr. ___ is a ___ yo M with HTN, HL, DM2, OSA, who presents with acute on chronic HA and left hand numbness since resolved, found to have severe hypertension and changes on CT head, consistent with malignant HTN, now improved. Malignant HTN: Hypertensive Emergency: Patient with known HTN treated with low dose Metoprolol in the past. In discussion with ___ clinic, was previously on higher dose Metoprolol and even an ACE inhibitor, stopped for unclear reasons. His obesity and untreated OSA is likely playing a role, though otherwise it is unclear if there are secondary contributors. Once his BP is fully controlled, further evaluation for esoteric causes can be considered. LFTS and TFTs wnl. Upon hospitalization he was given IV hydralazine and then started on Labetalol and Amlodipine. His labetalol was uptitrated to 400mg TID over 48 hrs. His BP responded well and we achieved about a 25% drop in his BP, range 150-160s/90-110s. He was asymptomatic. He was discharged on this regimen with instructions for daily BP checks and close outpatient follow up. Further titration to achieve better control in the coming weeks is necessary. If possible Lisinopril should be considered. ARF vs CKD: Unclear baseline. Improved slightly with IVF. FENa <1%. UA positive for protein not consistent with nephrotic syndrome. I suspected his renal disease was both acute (hypertension, pre-renal), and chronic (HTN, DM). On going monitoring is recommended and I recommend nephrology follow up for him. Recommend repeat labs within 1 week. Headache with Hand Numbness: Resolved. HA and hand numbness concerning for neurologic effects of hypertension, especially given his CT head findings. PRES was suspected given his hypertension, which usually resolves with treatment of BP which we are now doing. MRI performed and results above. Discussed with neurology who agreed with cont BP control and close follow up with them or at ___. He will need repeat imaging. This was reviewed in detail with the patient who expressed understanding about the importance of close follow up of this. DM2/HL: A1c indicates good control. Lipid panel reviewed. Would benefit from statin but will defer to outpatient setting - Hold metformin on DC pending repeat renal function OSA: Per the patient he used to have a machine which was stolen by his ex wife. He has had a sleep study but has had difficulty obtaining a new machine. This is likely contributing to his HTN. Recommended close follow up with PCP and his sleep specialist to obtain a new machine - CPAP while in house Nutrition: low salt diet Code: FULL presumed Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Metoprolol Succinate XL 50 mg PO DAILY 2. MetFORMIN (Glucophage) 1000 mg PO BID Discharge Medications: 1. amLODIPine 5 mg PO DAILY RX amlodipine 5 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:1 2. Labetalol 400 mg PO TID RX labetalol 200 mg 2 tablet(s) by mouth three times a day Disp #120 Tablet Refills:1 3. HELD- MetFORMIN (Glucophage) 1000 mg PO BID This medication was held. Do not restart MetFORMIN (Glucophage) until PCP follow up and recheck kidney function 4.Outpatient Lab Work Chem 7, BUN, Creatinine dx: hypertension, chronic kidney disease - please check on next follow up appointment Discharge Disposition: Home Discharge Diagnosis: Malignancy hypertension/hypertensive emergency Possible PRES ARF on CKD Diabetes Mellitus OSA Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with headache, hand numbness, and severe high blood pressure. You required several medications to better control your blood pressure. Your blood pressure is improved, but will need to be controlled better in the coming weeks. It is very important that you take your medications as prescribed. Please adhere to a low salt diet as we discussed, no more than 2 grams per day. Please take your blood pressure every day and keep a log. Please see a healthcare provider ___ 1 week for follow up. We also found that you have kidney disease for which we recommend referral to a Nephrologist. Finally, we saw changes in your brain on MRI due to your high blood pressure. We want you to follow up with a neurologist as well. You will be called with an appointment at ___, or speak with your PCP about ___ referral closer to home in the next few weeks Followup Instructions: ___
19568913-DS-19	19,568,913	20,922,619	DS	19	2127-07-27 00:00:00	2127-07-27 18:24:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Ciprofloxacin Attending: ___. Chief Complaint: abdominal fullness Major Surgical or Invasive Procedure: s/p 5L paracentesis History of Present Illness: ___ female with peritoneal carcinomatosis likely from gyn cancer, started chemotherapy at ___ on ___ with carboplatin who presented to ___ last night with abdominal pain. She reports she at dinner and shortly after developed worsening epigastric abdominal discomfort as well as a "warmth" on her R side. She says it wasn't really a pain. It felt like the same pressure as when she had too much fluid buildup and required paracentesis. She also noted more reflux and spitting up over the last week. She has not noted early satiety but says her appetite has not been that great anyway. She has no fevers or chills. She denies any other symptoms. She was seen in ___ where a diagnostic paracentesis was performed. also with UA concerning for UTI. started on cefepime to cover for SBP and UTI and transferred to ___ for admission to ___. REVIEW OF SYSTEMS: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain. Denies dysuria, arthralgias or myalgias. Denies rashes or skin changes. All other ROS negative Past Medical History: Problems (Last Verified - None on file): ACUTE RENAL FAILURE BILATERAL KNEE REPLACEMENTS BREAST CANCER CARPAL TUNNEL SYNDROME CENTRAL RETINAL ARTERY OCCLUSION CHRONIC OBSTRUCTIVE PULMONARY DISEASE CRACKLES LEFT BASE EMAIL: ___ HYPERLIPIDEMIA HYPERTENSION MACULAR DEGENERATION OSTEOPENIA PNEUMOVAX STROKE TENDINITIS UTERINE PROLAPSE AORTIC STENOSIS NASAL SEPTAL PERFORATION Social History: ___ Family History: from outpatient oncology note, confirmed with patient: The patient had three children. Two of her daughters died. ___ died at approximately age ___ for what the patient called ovarian cancer, although as you mentioned of endometrial cancer in other places of medical record. Her daughter, ___, died at age ___ of breast cancer. Apparently, this all happened back in the ___, and although genetic testing for BRCA mutations was considered, the patient ultimately chose not to pursue the testing out of concerns about what it might do to health insurance and life insurance and the likes for her remaining healthy daughter. The patient has grandchildren from her two deceased daughters as well as great-grandchildren. Her remaining daughter lives ___ and is recently divorced and mother to two girls. Physical Exam: Physical Examination: VS: 98.3 129/74 86 22 92%RA GEN: Alert, oriented to name, place and situation. no acute signs of distress. HEENT: NCAT, Pupils equal and reactive, sclerae non-icteric, MMM. Neck: Supple CV: normal S1S2, reg rate and rhythm, systolic murmur RESP: Good air movement bilaterally, no rhonchi or wheezing. ABD: obese, distended, firm but not taut, nontender, fluid wave, unable to assess for hepatosplenomegaly EXTR: 1+ pitting edema both legs up to shin DERM: No active rash. healing hand surgery wounds on R hand Neuro: muscle strength grossly full and symmetric in all major muscle groups PSYCH: Appropriate and calm. Pertinent Results: ================================== Labs ================================== ___ 10:55AM BLOOD WBC-6.3 RBC-4.91 Hgb-14.6 Hct-43.2 MCV-88 MCH-29.7 MCHC-33.8 RDW-12.7 Plt ___ ___ 10:55AM BLOOD ___ PTT-30.5 ___ ___ 10:55AM BLOOD Glucose-105* UreaN-12 Creat-0.7 Na-139 K-4.5 Cl-104 HCO3-24 AnGap-16 ___ 10:55AM BLOOD ALT-31 AST-28 LD(LDH)-225 AlkPhos-59 Amylase-35 TotBili-1.1 ___ 10:55AM BLOOD Albumin-3.9 Calcium-9.6 Phos-2.9 Mg-1.9 ___ 10:55AM BLOOD Lipase-48 ___ 11:49AM ASCITES WBC-310* ___ Polys-2* Lymphs-31* Monos-8* ___ Macroph-39* Other-20* ================================== Procedures ================================== Final Report INDICATION: ___ year old woman with peritoneal carcinomatosis likely gyn cancer. Diagnostic and therapeutic paracentesis for malignant ascites TECHNIQUE: Ultrasound guided diagnostic and therapeutic paracentesis COMPARISON: Ultrasound paracentesis ___, CT chest with contrast ___. FINDINGS: Limited grayscale ultrasound imaging of the abdomen demonstrated a large amount of ascites. A suitable target in the deepest pocket in the left lowerquadrant was selected for paracentesis. PROCEDURE: The procedure, risks, benefits and alternatives were discussed with the patient and written informed consent was obtained. A preprocedure time-out was performed discussing the planned procedure, confirming the patient's identity with 3 identifiers, and reviewing a checklist per ___ protocol. Under ultrasound guidance, an entrance site was selected and the skin was prepped and draped in the usual sterile fashion. 1% lidocaine was instilled for local anesthesia. A 5 ___ catheter was advanced into the largest fluid pocket in the left lower quadrant and 5 L of serosanguinous, brownish red fluid was removed. The patient tolerated the procedure well without immediate complication. Estimated blood loss was minimal. Dr. ___, the attending radiologist, was present throughout the critical portions of the procedure. IMPRESSION: Successful diagnostic and therapeutic paracentesis with 5 L of serosanguineous, brownish red fluid removed. Brief Hospital Course: ___ female with ___ transferred from ___ for management of malignant ascites. #ascites: she had fluid analysis at ___ and here that showed only a small number of WBCs and no bacteria. Her clinical exam was not consistent with SBP. She received 1 dose of cefepime at ___ this was not continued here. She had a therapeutic paracentesis in ___ which removed 5 liters of a red/brown fluid. There are a high number of RBCs, but the fluid was not described as gross blood. A fluid hematocrit is pending but suspicion for bleeding is low and her hgb has been stable. We discussed diuretics but these will not be started at this time given almost a month between paracenteses and chemotherapy may actually help control the fluid buildup. #UTI: no symptoms but UA suggestive of UTI. DC with Bactrim for 3 days #fungal rash: intertriginous area of groin, has been using nystatin cream, doesn't feel it is helping much. will try antifungal powder to help dry the area #reflux: likely related to increased intra-abdominal pressure from ascites. Expect some improvement with paracentesis but will also start omeprazole. Her home medications will be continued as before. She will follow up with Dr. ___ oncologist in ___, later this week or early next week (has appt on ___. Discharge Medications: 1. albuterol sulfate 90 mcg/actuation inhalation q4h:prn wheeze/SOB 2. Aspirin 81 mg PO DAILY 3. Enalapril Maleate 10 mg PO DAILY 4. Eye Health Formula (vits A,C,E-lutein-zeax-zn-copp) 9,650 unit-195 mg-95 unit oral BID 5. Ipratropium Bromide MDI 2 PUFF IH Q6H:PRN wheeze/SOB 6. Lorazepam 0.5 mg PO HS:PRN insomnia 7. Nystatin Cream 1 Appl TP BID 8. Ondansetron 8 mg PO Q8H:PRN nausea 9. Prochlorperazine 10 mg PO Q6H:PRN nausea 10. Simvastatin 10 mg PO DAILY 11. Omeprazole 40 mg PO DAILY RX omeprazole 40 mg 1 capsule(s) by mouth daily Disp #30 Capsule Refills:2 12. Miconazole Powder 2% 1 Appl TP TID:PRN rash RX miconazole nitrate 2 % apply to affected area three times a day Disp #2 Spray Refills:1 13. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 3 Days RX sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by mouth twice a day Disp #6 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: malignant ascites Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear ___ was a pleasure taking care of you during your stay at ___ ___. You were admitted for abdominal pain which we feel was related to a fluid buildup in your abdomen called ascites. We removed 5 liters of fluid and you feel much better. For your UTI we will start an antibiotic. For your fungal rash you will get an antifungal powder. You will follow up with Dr. ___ this week or early next week. Good luck and take care! Followup Instructions: ___
19569062-DS-18	19,569,062	23,776,392	DS	18	2154-04-11 00:00:00	2154-04-24 15:29:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) Attending: ___. Chief Complaint: weakness Major Surgical or Invasive Procedure: None History of Present Illness: ___ h/o AS, CAD with stent placed ___ and MI ___, Afib on coumadin, DM, HTN, HLD, CVA ___ with persistent word-finding difficulty, non hodgkins lymphoma s/p XRT, MDS, anemia, h/o vertebral compression fracture and spinal stenosis s/p surgical repair who presents with bilateral lower extremity weakness and difficulty walking which started yesterday. Patient's history of falls, lives at home with her son and husband. Reported difficulty walking with them, they referred her to an outside hospital emergency department where she was seen - ___ ___. At that times she was AF with BP 151/75. labs notable for WBC8.8, Hct 39.2, plt 290. 805 PMNs. ESR 97. creat 1.5. LFTs not elevated. UA pos for nitrite with large leuks and 1 epi. She was transferred here for MR of the back to rule out cauda equina, however she has a pacemaker. Note Pt was last to BIMD in ___ for a fem-pop bypass after urgent embolectomy. ___ ED COURSE: V/s: triage: 00:23 98.1 62 146/48 15 94% - Labs notable for: CBC: 7.8 (76%) > 11.39.0 <348. Last HCT in our system from ___ and was 27. ___ 67 PTT 87.7 INR 6.2 chem: 142/4.6; 104/23; 43/1.5 <152. Unclear recent b/l cr. lactate 1.0 UA; Lg leuks, tr bld, tr pro, 1RBC 84WBC, many bact, <1epi UNa 90. K:51. Cl:115. Osmolal:476. On exam in ED no appreciable lower extr weakness or paresthesias. Diffuse thoracic spinal tenderness, normal rectal tone, no saddle anesthesia; normal perianal sensation. Reduced neck rotation and flexion/extension - although pt did not allow examinar to move her neck or do so herself ___ pain. Evidence of pinprick/temperature circumferential decrease in keeping with neuropathy with reduced but present ankle jerks. Some midline tenderness in whole of C spine and step in lower thoracic spine. Was actually able to sit, stand unaided and take a few steps aided with much cajoling. CT showed multi-level degenerative changes and disc disease /moderate spinal stenosis in L spine with old L1/2 compression fractures without evidence of compression. Prelim reads: ___: Left frontal hypodensity likely reflects known area of prior infarct (per report from Dr. ___ without acute intracranial pathology. CT spine shows multi-level degenerative changes and disc disease /moderate spinal stenosis in L spine with old L1/2 compression fractures without evidence of compression. Pt received 1g CTX at 4:30 AM ___. Pt was admitted for pain control, UTI tx, and management of INR. Vitals prior to transfer @5AM 97.7 60 156/66 16 96% RA. On arrival to the floor, pt is comfortable. States she is not staying here and wants to go back to ___. States she has some continued shoulder (bilateral) and right sided hip pain but it is much improved. Pt denies ever having dysuria although has had prior UTIs with severe burning on urination. Past Medical History: Aortic stenosis Myocardial Infarction ___ Coronary Artery Disease Coronary PTCA/Stent ___ Permanent atrial fibrillation Diabetes Mellitus Hypertension Hyperlipidemia CVA ___ - Continues with mild word finding difficulty Non-hodgkin's lymphoma s/p Oral and Abdominal radiation + Chemo Tachybrady syndrome Myelodysplastic syndrome Anemia (heme positive stools with endoscopy done at ___ which showed gastritis but no active bleeding) Prolapsed bladder Urinary incontinence Vertebral compression fracture PVD Spinal stenosis Past Surgical History: Pacemaker insertion - ___ Dr. ___ with resection of abdominal tumor ___ Cholecystectomy (open) ___ Hysterectomy Incisional hernia repair Hemorrhoidectomy Appendectomy Bilateral greater saphenous vein stripping/ligation Repair of prolapsed bladder which failed Bilateral femoral artery vs. Iliac stents Back surgery for Spinal stenosis Social History: ___ Family History: Father died of MI at age ___ and Mother died at age ___ of stroke Physical Exam: ADMISSION PE: VS - 98 158/64 72 20 95% RA GENERAL - well-appearing female in no distress, comfortable, appropriate HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, dry mucous membranes, OP clear NECK - supple, no thyromegaly, no JVD, no carotid bruits LUNGS - could only examine sides and anterior fields - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - PMI non-displaced, RRR, ___ systolic murmur ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength ___ throughout, sensation grossly intact throughout Pertinent Results: ADMISSION LABS: ___ 02:00AM BLOOD WBC-7.8 RBC-5.01# Hgb-11.7# Hct-39.0# MCV-78# MCH-23.3# MCHC-29.9 RDW-18.0* Plt ___ ___ 02:00AM BLOOD ___ PTT-87.7* ___ ___ 02:00AM BLOOD Glucose-152* UreaN-43* Creat-1.5* Na-142 K-4.6 Cl-104 HCO3-23 AnGap-20 ___ 02:00AM BLOOD Albumin-3.8 Calcium-9.8 Phos-3.2 Mg-1.4* PERTINENT ___ 03:15AM URINE Color-Straw Appear-Hazy Sp ___ ___ 03:15AM URINE Blood-TR Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG ___ 03:15AM URINE RBC-0 WBC-84* Bacteri-MANY Yeast-NONE Epi-<1 Blood Culture, Routine (Final ___: NO GROWTH. URINE CULTURE (Final ___: Culture workup discontinued. Further incubation showed contamination with mixed skin/genital flora. Clinical significance of isolate(s) uncertain. Interpret with caution. ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. CEFEPIME sensitivity testing confirmed by ___. Piperacillin/Tazobactam sensitivity testing performed by ___ ___. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI \| AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- =>64 R CEFEPIME-------------- <=1 S CEFTAZIDIME----------- =>64 R CEFTRIAXONE----------- =>64 R CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 64 I PIPERACILLIN/TAZO----- I TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S DISCHARGE ___ 08:15AM BLOOD WBC-6.1 RBC-4.74 Hgb-11.2* Hct-36.9 MCV-78* MCH-23.6* MCHC-30.3* RDW-18.1* Plt ___ CT T-SPINE W/O CONTRAST ___ NOTE ADDED AT ATTENDING REVIEW: There is sclerosis and angulation of the left T10 posterior rib, series 2 images 69-73. Although the sclerosis may represent healing of a prior fracture, we cannot exclude the possibility of an underlying sclerotic lesion with a pathologic fracture. Thus, consider the possibility of malignancy. This appearance is new since the abdominal CT of ___. CT HEAD W/O CONTRAST ___ Left frontal chronic infarction. No evidence of hemorrhage or recent infarction. CT L-SPINE W/O CONTRAST ___ No acute fracture or malalignment with multilevel degenerative changes contributing to moderate-to-severe canal stenosis. Compression fractures of L1 and L2. CT C-SPINE W/O CONTRAST ___ Multilevel degenerative disease resulting in moderate multilevel canal stenosis without evidence of subluxation or fracture. CHEST (SINGLE VIEW) ___ Perhaps mild pulmonary edema. Brief Hospital Course: ___ h/o AS, CAD with stent placed ___ and MI ___, Afib on coumadin, DM, HTN/HLD, CVA ___ with persistent word-finding difficulty, DLBCL s/p XRT, MDS roughly ___ years ago, h/o vertebral compression fracture and spinal stenosis s/p surgical repair who presents with subjective bilateral lower extremity weakness but no evidence of cord compression on CT spine imaging. # Back Pain, Neck Pain, and weakness - CT C/T/L spine show extensive degenerative disc disease and canal narrowing of the lower cervical vertebrae with disc protrustions in the Lspine. Has good strength on exam. Neuro evaluated patient in ED, agrees that there are no signs or concerning findings that would indicate cord compression. Most likely pt felt subjectively weak because her movement was limited by pain from severe DJD disease. Her pain was controlled with standing tylenol and tramadol as needed, which she takes at home. Cyclobenzaprine Qhs was also added as there was a componenent of muscle spasms contributing to her pain. Spoke with PCP over the phone, who confirmed that patient had presented to ___ 4 weeks ago with neck pain, was found to be a muskoloskeletal in origin. Patient states that the pain has not worsened, and is roughly the same as it was 4 weeks ago. She will continue ___ for her neck as an outpatient. # Sclerotic finding on CT spine: CT T spine read: "sclerosis and angulation of the left T10 posterior rib, series 2 images 69-73. Although the sclerosis may represent healing of a prior fracture, we cannot exclude the possibility of an underlying sclerotic lesion with a pathologic fracture. Thus, consider the possibility of malignancy." Patient states that she did fall 4 weeks ago, did not directly impact her ribs, but afterwards, her left side of her rib cage hurt and was bruised ; thus, finding on CT scan may be from trauma. PCP informed of the finding and will follow up as an outpatient. # UTI - positive UA in ED. Remained afebrile after 2 doses of ceftriaxone, then switched to ciprofloxacin. Urine culture grew E coli sensitive to Ciprofloxacin. The patient was discharged on Ciprofloxacin with plan to complete a seven day course. #CKD - Cr at 1.5 - 1.6 throughout admission, which per PCP, is at her baseline. Restarted HCTZ and ACEI by discharge. #HTN - at home on lisinopril20, hctz 25, and metoprolol 50mg BID. Lisinopril and HCTZ intially held, then restarted on discharge. #DM - held metformin, continued on discharge. # Permanent atrial fibrillation Patient anticoagulated on warfarin, however, INR was supratherapeutic on admission to 6.2. As such, warfarin was initially held, however, INR on day of discharge was 1.4. Warfarin was resumed upon discharge and patient was prescribed Enoxaparin for anticoagulation until INR therapeutic. Patient instructed to follow up in the outpatient setting with repeat INR for further assessment. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. TraMADOL (Ultram) 50 mg PO BID 2. Gemfibrozil 600 mg PO BID 3. Hydrochlorothiazide 25 mg PO DAILY 4. MetFORMIN (Glucophage) 500 mg PO BID 5. Lisinopril 20 mg PO DAILY 6. Metoprolol Tartrate 50 mg PO BID hold for sbp<100 or hr<60 7. Aspirin 81 mg PO DAILY 8. Calcium Carbonate Dose is Unknown PO Frequency is Unknown 9. FoLIC Acid ___ mg PO DAILY 10. Warfarin Dose is Unknown PO Frequency is Unknown Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. FoLIC Acid ___ mg PO DAILY 3. Metoprolol Tartrate 50 mg PO BID hold for sbp<100 or hr<60 4. TraMADOL (Ultram) 50 mg PO BID 5. Acetaminophen 500 mg PO Q6H RX acetaminophen 500 mg 1 (One) tablet(s) by mouth every six (6) hours Disp #30 Tablet Refills:0 6. Ciprofloxacin HCl 500 mg PO Q12H Duration: 7 Days RX ciprofloxacin 500 mg 1 (One) tablet(s) by mouth twice a day Disp #11 Tablet Refills:0 7. Calcium Carbonate 1500 mg PO DAILY 8. Gemfibrozil 600 mg PO BID 9. Hydrochlorothiazide 25 mg PO DAILY 10. Lisinopril 20 mg PO DAILY 11. MetFORMIN (Glucophage) 500 mg PO BID 12. Warfarin 2.5 mg PO DAILY16 13. Enoxaparin Sodium 70 mg SC Q24H RX enoxaparin [Lovenox] 80 mg/0.8 mL Inject 70mg subcutaneously Every 24 hours Disp #8 Syringe Refills:0 14. Cyclobenzaprine 5 mg PO HS:PRN neck pain This medication can cause drowsiness. RX cyclobenzaprine 5 mg 1 (One) tablet(s) by mouth at bedtime Disp #30 Tablet Refills:0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Urinary Tract Infection Chronic Pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were seen in the hospital with weakness and lower back pain. You were evaluated by our neurologists, who felt that you did not have any spinal cord injury. We treated your pain with standing tylenol and a medication called tramadol. You cleared a physical therapy evaluation and will continue to receive physical therapy at home. You were also found to have a urinary tract infection so we started you on antibiotics. Your INR was also very high when you were admitted, so we held your coumadin initially. Your INR dropped too low after this so we started you on a medication, Enoxaparin, to thin your blood until your INR gets to goal. You are being discharged on a lower coumadin dose because the antibiotic you are on can affect the INR also. You should have your INR checked by you primary care physician's office on ___ and continue to take your coumadin until you speak with your PCP. Followup Instructions: ___
19569095-DS-15	19,569,095	22,010,010	DS	15	2122-09-27 00:00:00	2122-09-27 10:26:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: PLASTIC Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Left hand crush injury Major Surgical or Invasive Procedure: 1. Irrigation and debridement of open dislocation. 2. Open reduction and internal fixation of carpal dislocation (trapezoid). 3. Open reduction, internal fixation of second metacarpal. 4. Open reduction, internal fixation, and primary repair of the scapholunate disruption. 5. Application of uniplanar external fixator. 6. Intermediate closure of volar hand wound (5 cm). History of Present Illness: Mr. ___ is a ___ right-hand dominant male who is transferred from ___ with left hand crush injury resulting in multiple deep soft tissue injuries and metacarpal fracture. He reports that he was working on pinch roller at work in a ___ facility when his left hand got caught by the turning rotors and dragged through the machine. He was able to hit the emergency stop pedal and remove his hand from the machine after 5 seconds. He was seen at ___, where he was thought to be neurovascularly intact. Plain films of the hand demonstrated widening of the space between ___ and ___ metacarpals with possible bony fragment suspicious for fracture-dislocation and subluxation injury. He was transferred to ___ for further evaluation and treatment. Past Medical History: Borderline diabetes Social History: ___ Family History: Noncontributory Physical Exam: Discharge Physical Exam: VS: T 99.4, BP 131/85, HR 82, RR 18, 97% RA, FSBG 143-226 Constitutional: Well-appearing, A&Ox3, NAD Resp: No respiratory distress Ext: Focused exam LUE: Hand in splint and wrapped in ace bandage. External fixator in place. SILT all distal phalanges. Able to flex/extend distal phalanges. Fingers WWP w/ brisk capillary refill. Dorsal hand and forearm compartments soft. Soft, nontender ecchymosis medial arm without induration. Pertinent Results: ___ 09:40PM WBC-15.9* RBC-4.87 HGB-14.6 HCT-43.7 MCV-90 MCH-29.9 MCHC-33.3 RDW-13.3 ___ 09:40PM PLT COUNT-255 ___ 09:40PM GLUCOSE-155* UREA N-9 CREAT-0.9 SODIUM-139 POTASSIUM-4.9 CHLORIDE-109* TOTAL CO2-19* ANION GAP-16 ___ 11:05PM ___ PTT-28.9 ___ ___ 12:58AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG ___ 12:58AM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 12:58AM URINE RBC-0 WBC-4 BACTERIA-NONE YEAST-NONE EPI-<1 Brief Hospital Course: Mr. ___ is a ___ right-hand dominant male who sustained a left hand crush injury resulting in a ___ metacarpal base fracture dislocation, capitotrapezoid dislocation, scapholunate ligament dissociation, and lacerations to the first web space and the volar ulnar side of the hand. He was taken to the OR on ___ for exploration, washout, ORIF of ___ metacarpal base fracture dislocation and capitotrapezoid dislocation, repair of SL ligament complete dissociation, and closure of the web space laceration. The ulnar laceration was uable to be closed and was left open. The patient was then placed in a spanning ex-fix to prevent contracture at the first webspace. The patient tolerated the procedure well and was taken to the floor for pain control and continued IV antibiotics. . Neuro: Post-operatively, the patient's pain was adequately controlled and he was transitioned to oral pain medications. . CV: The patient was stable from a cardiovascular standpoint; vital signs were routinely monitored. . Pulmonary: The patient was stable from a pulmonary standpoint; vital signs were routinely monitored. . GI/GU: Post-operatively, the patient was given IV fluids until tolerating oral intake. His diet was advanced when appropriate, which was tolerated well. She was also started on a bowel regimen to encourage bowel movement. Intake and output were closely monitored. . ID: Post-operatively, the patient was started on IV cefazolin, then switched to PO cefadroxil for discharge home. The patient's temperature was closely watched for signs of infection. . Prophylaxis: The patient received subcutaneous heparin during this stay, and was encouraged to get up and ambulate as early as possible. . At the time of discharge on POD#2, the patient was doing well, afebrile with stable vital signs, tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. Medications on Admission: None Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain 2. Docusate Sodium 100 mg PO BID costipation Take this medication while using narcotic pain medicine. RX docusate sodium [Colace] 50 mg 1 capsule(s) by mouth twice a day Disp #60 Capsule Refills:0 3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain Take if the tylenol does not adequately control your pain. RX oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #60 Tablet Refills:0 4. Senna 1 TAB PO BID:PRN constipation You may purchase over the counter and use as needed. 5. cefaDROXil 500 mg oral BID Duration: 7 Days Please take until you follow up in clinic. RX cefadroxil 500 mg 1 capsule(s) by mouth twice a day Disp #14 Capsule Refills:0 Discharge Disposition: Home Discharge Diagnosis: 1. Open capitotrapezoid dislocation 2. ___ metacarpal base fracture 3. Scapholunate ligament disruption 4. Volar ulnar hand wound 5. Avulsion laceration of first web space Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: -You should continue taking the antibiotics as prescribed. -Elevate your left arm as much as possible and maintain it in a splint. -Please keep your left arm dry - If your left arm begins to worsen after discharge home with an acute increase in swelling or pain, please call the Hand Clinic at the number given and ask to speak with a doctor. . Medications: Resume your regular medications unless instructed otherwise. * You may take your prescribed pain medication for moderate to severe pain. You may switch to Tylenol or Extra Strength Tylenol for mild pain as directed on the packaging. Please note that Percocet and Vicodin have Tylenol as an active ingredient so do not take these meds with additional Tylenol. * Take prescription pain medications for pain not relieved by tylenol. * Take Colace, 100 mg by mouth 2 times per day, while taking the prescription pain medication to prevent constipation. You may use a different over-the-counter stool softerner if you wish. * 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. . 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. Followup Instructions: ___
19569181-DS-17	19,569,181	24,020,353	DS	17	2170-05-13 00:00:00	2170-05-13 15:07:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Compazine Attending: ___. Chief Complaint: epigastric pain, weight loss Major Surgical or Invasive Procedure: EUS History of Present Illness: ___ y/o F with PMHx of CAD s/p PCI, HTN, HL, DM (not on insulin), Spinal stenosis/chronic LBP, CKD stage III and recent history of pancreatitis who presented to ___ with recurrent epigastric pain, unable to tolerate po and mild ___. LAbs were notable for elevated lipase and normal LFTs - pt was transferred to ___ for possible ERCP given recurrent pancreatitis. Pt is a meandering historian but after getting addl records from ___ - pt was first admitted in ___ with acute pancreatitis without gallstones or ETOH history. It was attributed to hydralazine and pt improved with supportive care. She returned on ___ with acute epigastric pain and labs concerning for pancreatitis. RUQ u/s showed small gallbladder polyp without stones and CBD was 3mm. MRCP showed mixed IPMN and pt was referred to ___ for possible ERCP/EUS to further evaluate. Pt was treated supportively and discharged home over ___. She returned to the ___ ED on ___ with epigastric pain, inability to tolerate po and mild ___. Labs were again notable for acute pancreatitis and pt endorsed 17lb weight loss over the last month. Pt was transferred to ___ ED without any imaging or notes for consideration of ERCP. Labs from the ED this morning revealed improved ___, normal LFTs and Lipase elevated at 257. Currently, pt is denying any pain. She has been NPO with IVF and reports that pain is typically brought on by taking anything by mouth. Denies any recent N/V/D or bloody stools. No CP, SOB, cough, congestion, HA, URI ___ edema. Pt reports being scheduled for ERCP in mid ___ at ___ has been failing because of recurrent pain at home. Of note, pt denies any ETOH, no NSAID use and no recent infections. Past Medical History: CAD s/p PCI in ___ HTN DM (not on insulin) CKD stage III Spinal stenosis/Chronic back pain Anemia Hx of total hip replacement Social History: ___ Family History: stroke and angina mom, DM+ father Physical ___ Exam: T 98.0 PO BP: 172/73 L Lying HR: 77 RR: 18 O2 sat: 95% O2 RA GENERAL: Alert and in no apparent distress EYES: Anicteric, pupils equally round ENT: dry MM CV: Heart regular, no murmur, no S3, no S4. No JVD. RESP: Lungs clear to auscultation bilaterally GI: Abdomen soft with NABS, tender to deep palpation of the RUQ, no pain in LUQ or lower quadrants GU: No suprapubic fullness or tenderness to palpation MSK: no ___ edema SKIN: No rashes or ulcerations noted, scattered bruises (from recent admission related blood draws per pt) 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, talkative, wandering history Discharge exam Exam: Vital signs reviewed in flowsheet. AF 110s-150s/60s-70s ___ 96-98% RA GENERAL: Alert and in no apparent distress EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. MMMs CV: RRR no m/r/g RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, non-distended, no TTP. EXTR: wwp, mild bilateral pitting edema NEURO: alert and interactive, motor grossly intact/symmetric PSYCH: pleasant, appropriate affect Pertinent Results: ============================================================ Pertinent data: Hgb stable in ___ range Cre mostly in 1.2-1.5 range but downtrended to 0.9-1.1 range after fluids and holding diuretic BUN initially 45, after fluids was ___ range Bicarb in ___ range, chloride in ___ range LFT wnl Lipase 252 (___) CEA 3.1 CA125 24 CA ___ (all wnl) Urine: nitrogen 288, Cre 42, Na 32, K 16, Cl <20, Pro 26, Ca <0.8, phos 9.1, bicarb <3, pro/cre 0.6, osm 214 MRCP MPRESSION: 1. 2.6 cm multiloculated cystic lesion in the pancreatic head which is in continuity with a dilated main pancreatic duct with differential dilation of the pancreatic duct in the head and neck when compared to the tail. Findings raise concern for a combined type intraductal papillary mucinous neoplasm and EUS is suggested for further evaluation. No solid components identified. 2. Pancreatic atrophy with diffuse abnormal signal intensity, likely changes of chronic pancreatitis. EUS ___ Other findings: EUS was performed using a linear echoendoscope at 7.5 and ___ MHz frequency. The head and uncinate pancreas were imaged from the duodenal bulb and the second / third duodenum. The body and tail were imaged from the gastric body and fundus. Pancreas parenchyma: The parenchyma in the uncinate, head, body and tail of the pancreas was homogenous, with a normal salt and pepper appearance. Cystic lesion: A 16.2 x 12.6 mm discrete anechoic lesion, consistent with a cyst, was noted in the head of the pancreas. The walls of the cyst were thin and well-defined. No intrinsic mass or debris were noted within the cyst. Multiple septations were however seen. Pancreatic duct: The main pancreatic duct adjacent to the cyst was dilated. The cyst appeared to communicate with the main pancreatic duct.The pancreas duct measured 6 mm in maximum diameter in the head of the pancreas. In the neck of the pancreas, it measured 4.3 mm. Bile duct: The bile duct was normal in appearance. No intrinsic stones or sludge were noted. The bile duct and the pancreatic duct were imaged within the ampulla and appeared normal. Ampulla: The ampulla appeared normal both endoscopically and sonographically, with no evidence of 'fish mouth' appearance. FNA: FNA was performed. Color doppler was used to determine an avascular path for needle aspiration. A 22-gauge needle with a stylet was used to perform aspiration. One needle passe was made into the cyst. A small amount of thin fluid was aspirated from the cyst. Aspirate was sent for cytology + biochemistry. Of note, the liquid was blood tainted and evidence of self containted bleeding within the cyst was seen after the FNA was performed. Recommendations: Follow for response and complications. If any abdominal pain, fever, jaundice, gastrointestinal bleeding please call ERCP fellow on call ___. Clear liquid diet when awake, then advance diet as tolerated. Cytology report to follow. Further management will depend on results. Ciprofloxacin 500mg PO twice daily X 3 days. Will discuss EUS findings at the Pancreatobiliary Multidisciplinary Conference. Further evaluation and recommendations based on discussion. Results discussed with the primary team. Cytology from EUS DIAGNOSIS: Cyst, head of pancreas, EUS-FNA: VIRTUALLY ACELLULAR SPECIMEN. Rare degenerated epithelial cells and acellular debris. ============================================================ Brief Hospital Course: ___ y/o F with PMHx of CAD, DM, HTN, stage III CKD and recent history of recurrent pancreatitis over the last 2 months who p/w post prandial epigastric pain, weight loss and elevated lipase. Concern is for mixed IPMN causing biliary obstruction, although unclear if potential benefit of surgery would be outweighed by potential risks. #Recurrent acute pancreatitis with combined type IPMN in main pancreatic duct: Pt with recurrent pancreatitis over the last 2 months and 17lb weight loss. Pt returned with symptoms of pancreatitis and MRCP with 2.6 multiloculated cystic lesion in the pancreatic head, continuity with the pancreatic duct and dilation of PD in head and neck more than tail, concerning for combined type IPMN. EUS on ___ with polyseptated cyst communicating with PD, felt to be likely cause of pancreatitis, s/p FNA with nondiagnostic results. CEA, CA125, ___ wnl. Case discussed extensively with pancreatic surgery team and with advanced endoscopy team. Pancreatic duct stent was considered but ultimately felt to be of unclear benefit, and so this was not pursued but might be in the future should her pancreatitis recur. The surgical team felt she might be a surgical candidate but wished to pursue further evaluation in the outpatient setting. During the ___ hospital course she intermittently had brief self resolving LUQ pain, although this did not occur in the days prior to her discharge. She will continue a low fat diet (received nutrition education) and follow-up with surgery in the outpatient setting. #Acute on chronic CKD: #Metabolic acidosis She had initially presented with mild ___, although after fluids and holding diuretics her Creatinine improved. Per report her baseline was ~1.5, but during the admission she was initially in the 1.2-1.5 range, and subsequently trended down further to the 0.9-1.1 range. Suspect that some of her baseline may be due to diuresis. She also intermittently had hyperchloremic metabolic acidosis, which appeared to be mixed anion gap/non-anion gap. VBG initially showed mild concomitant metabolic and respiratory acidosis with mild acidemia, but on repeat was normal. Urine studies notable for elevated urine anion gap, potentially consistent with mild RTA, although not a clear cut diagnosis. She was briefly trialed on sodium bicarb but due to concern for sodium load and mild nature of acidosis, which may be self-resolving, this was stopped. Also suspect that this may improve once back on Lasix, which was restarted at lower dose on discharge. She has close follow-up with her PCP and will need BMP checked as outpatient. #HTN: #Edema Patient reports challenging BP control as outpatient, with dizziness at high doses of antihypertensives but high systolics when doses have been reduced. (Of note has a high pulse pressure). Titration of labetalol sounds as though it has been the recent focus. Here her valsartan and Lasix were held during most of the admission, and amlodipine initially increased. BPs fluctuated from 100s-180s, suggesting a degree of dysautonomia. A strategy of mild permissive hypertension seemed to minimize her dizziness, and this may be considered given her large pulse pressure. At discharge she was restarted on a reduced dose of Lasix since she had developed some mild peripheral edema, and her amlodipine was reduced back to the home doseage of 2.5. Her labetalol was continued at home dose. Her ___ was held but should likely be restarted in the outpatient setting. #CAD s/p PCI in ___: asymptomatic currently Continued ASA, statin, labetalol #Chronic neuropathic pain: Neurontin dosing initially reduced due to ___, but given improvement in Creatinine was discharged on prior dose. #DM: held oral hypoglycemic during admission with sliding scale coverage ======================================= Transitional issue: - patient will follow-up in clinic with pancreaticobiliary surgery team - should patient have recurrent pancreatitis should be transferred to ___ for consideration of pancreatic duct stent - close follow-up with PCP, at which time she should have BMP to evaluate renal function and acid-base status - continued titration of BP regimen; given wide pulse pressure and erratic pressure, and dizziness at higher doses, may adopt a strategy of some permissive HTN or consider 24 hour monitoring at home ======================================= >30 minutes in patient care and coordination of discharge ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Creon 12 1 CAP PO TID W/MEALS 2. Labetalol 200 mg PO BID 3. Furosemide 20 mg PO DAILY 4. GlipiZIDE 2.5 mg PO BID 5. DICYCLOMine 10 mg PO Q8H:PRN abd pain 6. amLODIPine 2.5 mg PO DAILY 7. Valsartan 320 mg PO DAILY 8. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild 9. Calcitriol 0.25 mcg PO DAILY 10. Alendronate Sodium 70 mg PO QSUN 11. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY 12. Ferrous GLUCONATE 324 mg PO DAILY 13. Omeprazole 20 mg PO DAILY 14. Aspirin 81 mg PO DAILY 15. Gabapentin 400 mg PO TID 16. Multivitamins 1 TAB PO DAILY 17. Atorvastatin 80 mg PO QPM Discharge Medications: 1. Senna 8.6 mg PO BID:PRN Constipation 2. Furosemide 10 mg PO DAILY 3. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild 4. Alendronate Sodium 70 mg PO QSUN 5. amLODIPine 2.5 mg PO DAILY 6. Aspirin 81 mg PO DAILY 7. Atorvastatin 80 mg PO QPM 8. Calcitriol 0.25 mcg PO DAILY 9. Creon 12 1 CAP PO TID W/MEALS 10. DICYCLOMine 10 mg PO Q8H:PRN abd pain 11. Ferrous GLUCONATE 324 mg PO DAILY 12. Gabapentin 400 mg PO TID 13. GlipiZIDE 2.5 mg PO BID 14. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY 15. Labetalol 200 mg PO BID 16. Multivitamins 1 TAB PO DAILY 17. Omeprazole 20 mg PO DAILY 18. HELD- Valsartan 320 mg PO DAILY This medication was held. Do not restart Valsartan until instructed by your PCP ___: Home With Service Facility: ___ Discharge Diagnosis: -Recurrent acute pancreatitis with combined type IPMN in main pancreatic duct: -Acute on chronic CKD: -Metabolic acidosis -HTN -DM Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted because of your recent pancreatitis episodes and found to have a cystic lesion in your pancreas, which we believe is an "IPMN" (intraductal papillary mucinous neoplasm), which are typically benign lesions, although they in some cases can develop into cancers. After evaluation by the advanced endoscopy team, it was felt that at this time a pancreatic duct stent would not be helpful. However if you develop pancreatitis again this might be considered. You were also evaluated by the pancreatic surgeons, who plan to see you in the office as an outpatient to further consider the possibility of a surgery, with the goal of preventing future episodes. In the mean time we have recommended a low fat diet, since fat can stimulate the pancreas. If you develop severe abdominal pain you should seek care. It is ok to go to ___ initially, but if you are found to have another episode of pancreatitis then you should be sent from there back to ___. While you were here we also made some minor adjustments to your blood pressure medications, which Dr. ___ continue to work on when he sees you. Followup Instructions: ___
19569259-DS-15	19,569,259	20,712,841	DS	15	2159-10-28 00:00:00	2159-10-28 19:35:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins Attending: ___. Chief Complaint: lower back pain, positive blood cultures Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ year old M w/ PMH bicuspid aortic valve, aortic insufficiency who presents with positive blood cultures. The patient reports about 6 weeks of low back pain. He denies any falls, trauma. No weakness, numbness, tingling. No chest pain, shortness of breath. He was seen by his primary care doctor and had blood cultures performed. These resulted today and showed gram-positive cocci in chains. He was referred to the emergency department. In the ED, initial vitals were: 98.5 88 159/70 18 100% RA. - Exam notable for: Rectal tone intact. No saddle anesthesia. No prostate TTP. Brown stool. Guiaic negative. - Labs notable for: CRP 115.7, WBC 12.8, negative UA. Blood cultures grew GPCs in chains ___. ASO negative. - Imaging was notable for: normal CXR. - Patient was given: IVF NS, IV Morphine 4 mg, IV Cefepime 2g, IV Vancomycin, Acetaminophen 1000 mg. - Vitals prior to transfer: 102.6 105 158/78 16 99% RA. Upon arrival to the floor, patient reports that he went traveling to ___ for business in ___ and when he came back he noticed that he was feeling "unwell", achy and lethargic. He continued to have decreased energy and achy and he thought that it was due to the flu. He started to have low back pain in ___. He then developed neck stiffness. During this time he was having night sweats and chills. He was using ibuprofen and Tylenol for pain in his back. He measured his temperature at home and it was never elevated but he was also taking ibuprofen and tylenol before he took his temperature. He feels that he can't move very well and for one week in ___ he was using a cane to get out of bed. He also cannot move his neck much from side to side or turn his head either direction. He was seeing his PCP for his back pain and there was concern that it was due to autoimmune disorder so he was sent to rheumatology. His rheumatologist ordered blood cultures on ___ and it grew GPCs in chains by ___ and he was sent to the ED. He denies headaches, visual changes, numbness, tingling, weakness, chest pain, palpitations, SOB, cough, flank pain, dysuria, hematuria, skin changes, rash. Patient denies any recent trauma/accidents, skin breaks, rashes, cuts. He denies IVDU. REVIEW OF SYSTEMS: (+) Per HPI (-) 10 point ROS reviewed and negative unless stated above in HPI Past Medical History: Bicuspid Aortic Valve Aortic Insufficiency HLD s/p left inguinal hernia repair s/p varicocele repair Social History: ___ Family History: Father with an MI in his ___. No history of diabetes, no history of colon or prostate cancer. Physical Exam: ADMISSION PHYSICAL EXAM Vital Signs: 98.7 147 / 60 95 18 92% Ra General: Alert, oriented, no acute distress, uncomfortable and stiff when moving to sit up in bed for exam HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL. Neck: Unable to rotate head more than 30 degrees each direction due to neck stiffness. JVP not elevated. no LAD CV: Regular rate and rhythm. Normal S1+S2, no rubs, gallops. II/VI diastolic and systolic murmur heard best at RUSB and LUSB. Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. No purpura, petechiae. No splinter hemorrhages, ___ nodes appreciated. Neuro: CNII-XII intact, strength exam limited by back pain but appears to have full strength ___ in all upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred. Has pain in back from both upper and lower extremity strength exam. Non- tender with percussion on spine. DISCHARGE PHYSICAL EXAM: VS: 98.2, BP 102-149/49-66, HR 73-79, RR 18, O2 96-99% Ra GENERAL: In no acute distress, comfortable sitting in chair HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM, good dentition NECK: nontender supple neck, no LAD, no JVD HEART: Normal rate and rhythm, S1/S2, III/VI systolic and I/V diastolic murmur heard best at the R sternal border radiating to carotids, no gallops or rubs LUNGS: Clear to auscultation bilaterally, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no cyanosis, clubbing or edema, moving all 4 extremities with purpose BACK: negative straight leg test, no tenderness to palpation of the back. PULSES: 2+ DP pulses bilaterally NEURO: A&O x3. Full strength in the upper extremities, lower extremities full strength but hip flexion limited by pain. Sesnsation in tact in LEs and UEs. GAIT: walking cautiously but with easy, normal stride SKIN: warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: ADMISSION LAB: ------------------- ___ 02:50PM URINE RBC-0 WBC-0 BACTERIA-NONE YEAST-NONE EPI-0 ___ 02:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG ___:50PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 02:50PM CRP-115.7* ___ 02:50PM ALT(SGPT)-17 AST(SGOT)-19 IMAGING/STUDIES - ECG: sinus rhythm, normal axis. Normal intervals. Q waves in II, III, aVF. - CXR: No acute cardiopulmonary abnormality. - MRI: 1.Findings raise concern for early L1-L2 discitis-osteomyelitis given history, although inflammatory Schmorl's node formation can demonstrate a similar appearance. No drainable fluid collection or frank epidural abscess formation. Clinical correlation is advised with low threshold for repeat imaging if symptoms progress. 2. No cord signal abnormality. 3. Degenerative changes at other levels, as described above. - ___: FINDINGS: There is small focus of round hyperdensity within or abutting posterior right temporal lobe, probably intra-axial, series 2, image 12, 13, measuring 0.6 cm, brighter than the vascular pool, indeterminate. MRI brain without and with gadolinium recommended in further evaluation. There is no edema, shift of normally midline structures, or evidence of acute major vascular territorial infarction. Normal ventricular, sulcal size. The imaged paranasal sinuses are clear. There is chronic bilateral maxillary sinus atelectasis, from chronic inflammation. Otherwise, paranasal sinuses, mastoid air cells and middle ear cavities are well aerated. The bony calvarium is intact. IMPRESSION: There is subtle hyperdensity involving or abutting posterior right temporal lobe, differential considerations include small parenchymal or subarachnoid hemorrhage, cavernoma, vein ___ thrombosis, less likely meningioma or hemorrhagic mass. MRI brain without and with gadolinium recommended in further evaluation. RECOMMENDATION(S): MRI brain without and with gadolinium recommended in further evaluation. -MRI Head w/o contrast: FINDINGS: There is no abnormal focus of slow diffusion. In the right posterior temporal lobe, corresponding to the hyperdensity seen on CT, there is a curvilinear focus of low signal on T1/T2 weighted images that demonstrates blooming on the gradient echo sequence. The curvilinear signal abnormality appears to extend to the junction of the right transverse and sigmoid sinuses, but the exact location intra versus extra-axial is unclear. If extra-axial, it may represent a chronically thrombosed cortical vein although a vein would be expected to be more tubular on CT. If intraparenchymal, it could represent hemorrhage. However, lack of adjacent edema would be in favor of chronic hemorrhage or an occult vascular malformation. There is no evidence of hemorrhage, edema, mass, mass effect, or infarction. The ventricles and sulci are age-appropriate. Principal intracranial vascular flow voids are preserved. The dural venous sinuses are patent on postcontrast MP-RAGE sequences. IMPRESSION: 1. Hyperdensity along the periphery of the right posterior temporal lobe seen on recent CT, corresponds to a focus of susceptibility artifact without associated edema or enhancement on MRI. As discussed above, this may represent a focus of chronic parenchymal hemorrhage, an occult vascular malformation, or a chronically thrombosed cortical vein. 2. No evidence of hemorrhage, infarction, or mass. 3. The dural venous sinuses are patent. MICROBIOLOGY: __________________________________________________________ ___ 6:02 am BLOOD CULTURE #1. Blood Culture, Routine (Pending): __________________________________________________________ ___ 6:02 am BLOOD CULTURE #2. Blood Culture, Routine (Pending): ____________________________________________________________ 9:15 am BLOOD CULTURE #2. Blood Culture, Routine (Pending): __________________________________________________________ ___ 6:25 am BLOOD CULTURE Blood Culture, Routine (Pending): __________________________________________________________ ___ 4:04 pm BLOOD CULTURE Blood Culture, Routine (Preliminary): VIRIDANS STREPTOCOCCI. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # ___. Aerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN CHAINS. Anaerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN CHAINS. __________________________________________________________ ___ 3:05 pm BLOOD CULTURE Blood Culture, Routine (Preliminary): VIRIDANS STREPTOCOCCI. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # ___. Aerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN PAIRS AND CHAINS. Anaerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN CHAINS. __________________________________________________________ ___ 2:00 pm URINE FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. __________________________________________________________ ___ 2:50 pm SEROLOGY/BLOOD FINAL REPORT ___ ASO Screen (Final ___: < 200 IU/ml PERFORMED BY LATEX AGGLUTINATION. Reference Range: < 200 IU/ml (Adults and children > ___ years old). __________________________________________________________ ___ 2:50 pm BLOOD CULTURE FINAL REPORT ___ Blood Culture, Routine (Final ___: VIRIDANS STREPTOCOCCI. further identification on request. FINAL SENSITIVITIES. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ VIRIDANS STREPTOCOCCI \| CEFTRIAXONE-----------<=0.12 S CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN---------- 2 R PENICILLIN G----------<=0.06 S VANCOMYCIN------------ 1 S Aerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN CHAINS. Reported to and read back by ___ ___ ___ AT 1049). Anaerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN CHAINS. __________________________________________________________ ___ 2:50 pm URINE FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. __________________________________________________________ ___ 2:50 pm URINE *FINAL REPORT ___ Chlamydia trachomatis, Nucleic Acid Probe, with Amplification (Final ___: Negative for Chlamydia trachomatis by ___ System, APTIMA COMBO 2 Assay. Validated for use on Urine Samples by the ___ Microbiology Laboratory. Performance characteristics on urine samples were found to be equivalent to those of FDA- approved TIGRIS APTIMA COMBO 2 and/or COBAS Amplicor methods. NEISSERIA GONORRHOEAE (GC), NUCLEIC ACID PROBE, WITH AMPLIFICATION (Final ___: Negative for Neisseria gonorrhoeae by ___ System, APTIMA COMBO 2 Assay. Validated for use on Urine Samples by the ___ Microbiology Laboratory. Performance characteristics on urine samples were found to be equivalent to those of FDA- approved TIGRIS APTIMA COMBO 2 and/or COBAS Amplicor methods. DISCHARGE LABS: -------------------- ___ 06:20AM BLOOD WBC-6.5 RBC-3.31 Hgb-9.6* Hct-28.9* MCV-87 MCH-29.0 MCHC-33.2 RDW-13.7 RDWSD-43.1 Plt ___ ___ 06:20AM BLOOD Plt ___ ___ 06:20AM BLOOD Glucose-87 UreaN-12 Creat-0.9 Na-140 K-4.0 Cl-107 HCO3-24 AnGap-13 Brief Hospital Course: Mr. ___ is a ___ year old M w/ ___ bicuspid aortic valve, aortic insufficiency who presents with body aches x 2 months, low back pain, night sweats/chills, neck stiffness x 1 month who was found to have S. viridans bacteremia, endocarditis, and discitis-osteomyelitis on MRI. ACTIVE ISSUES: # S. Viridans bacteremia: Patient found to have GPCs in chains in blood cultures drawn ___ in ___ ___. Unclear how patient could have developed this infection (no IVDU, skin wounds, or recent dental procedures). With aortic insufficiency, concern that patient could have endocarditis. Back pain w concern for infection discussed below. Initially started on IV vancomycin/ceftriaxone. Speciated with S. viridans and narrowed to ceftriaxone only. Daily blood cultures drawn until negative x72hrs. TTE revealed large vegetation on aortic valve. Antibiotic course, given concerning MRI discussed below: continued CTX 2g IV Q24H to finish 6 week course. TEE was deferred given it would not change managment. # Aortic valve endocarditis: Echo on ___ showing moderate sized vegetation associated with the bicuspid aortic valve. Patient educated about embolic risk and stoke signs to be aware of. EKG unchanged from admission with rate of 74, normal axis, and normal PR, QRS, QTc segments. No ST elevations or T wave inversions. He was evaluated by C-surg and will likely have valve replacement after 6 week course of ABX. He was also seen by OMFS and had panorex taken. They did not feel that any oral lesions were responsible for his bacteremia/endocarditis. # New Head CT findings: Subtle hyperdensity of posterior right temporal lobe involving or abutting posterior right temporal lobe, differential considerations include small parenchymal or subarachnoid hemorrhage, cavernoma, vein ___ thrombosis, less likely meningioma or hemorrhagic mass. Patient has no focal neurologic deficits. Found on work up for endocarditis sequelea. MRI with and w/out contrast revealed lesion more c/w chronic thrombosis and not septic emboli. # Back pain/neck stiffness: Concerning for metastatic site of infection from GPC bacteremia. MRI with concern for early L1-L2 discitis-osteomyelitis, no fluid collection or drainable abscess. No signs of neurologic deficits or compromise on exam. ___ negative. Pain was well controlled with tylenol, ibuprofen as needed. Antibiotics as above. # Normocytic anemia: Most likely in setting of infection. Relatively stable Hgb since ___. Prior Hgb was normal at 15 but this was in ___. No signs of bleeding. Monitored H/H and levels remained stable. CHRONIC ISSUES: #HLD: continued on simvastatin 40 mg daily #Aortic Insufficiency: Patient has been monitored with TTE by Dr. ___. Continued on lisinopril 10 mg for after load reduction. ============================= TRANSITIONAL ISSUES ============================= [ ] Antibiotic course: Patient to complete 6 week course of Ceftriaxone 2g IV Q24H (___) [ ] Patient had cardiac surgery workup performed prior to discharge. He will need dental clearance and cardiac cath prior to surgery [ ] Patient to follow up with Dr. ___ with ___ cardiology and Dr. ___ with ___ cardiac surgery # CODE: Full Code confirmed # CONTACT: ___ ___ Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Diazepam 5 mg PO Q8H:PRN back pain 2. Ibuprofen 800 mg PO Q8H:PRN Pain - Moderate 3. Lisinopril 10 mg PO DAILY 4. Simvastatin 40 mg PO QPM 5. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H RX acetaminophen 500 mg 2 tablet(s) by mouth every eight (8) hours Disp #80 Tablet Refills:0 2. CefTRIAXone 2 gm IV Q 24H RX ceftriaxone in dextrose,iso-os 2 gram/50 mL 2 grams IV once a day Disp #38 Intravenous Bag Refills:0 3. Famotidine 20 mg PO Q12H RX famotidine 20 mg 1 tablet(s) by mouth twice a day Disp #40 Tablet Refills:0 4. Lidocaine 5% Patch 1 PTCH TD QAM RX lidocaine 5 % Apply 1 patch to the affected area QAM Disp #30 Patch Refills:0 5. Diazepam 5 mg PO Q8H:PRN back pain 6. Ibuprofen 800 mg PO Q8H:PRN Pain - Moderate 7. Lisinopril 10 mg PO DAILY 8. Multivitamins 1 TAB PO DAILY 9. Simvastatin 40 mg PO QPM Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary Diagnoses: S. viridans bacteremia S. viridans endocarditis Aortic insufficiency Bicuspid aortic valve L1-L2 discitis-osteomyelitis Secondary Diagnoses: Normocytic anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were admitted to the hospital with lower back pain, fevers, and body aches and were found to have an infection in your blood stream caused by strep viridans. An ultrasound of your heart revealed that this infection was also affecting the aortic valve. It is unclear where this infection came from, but you were evaluated by the oral surgeons who did not feel like you had any areas in your mouth where the infection began. Because of how large the infected vegetation (or growth) was, you were evaluated by the cardiac surgeons to have your valve potentially replaced. As part of this evaluation you had a CT of your head which showed a very small lesion in your brain. Further imaging with MRI showed this was probably an old blocked vein but does not likely have anything to do with the infection in your heart. After speaking with Dr. ___ plan is to discharge you with 6 weeks of IV antibiotic therapy. When you are discharged, it is important to take all of your medications as directed. You will be finish 6 weeks of IV ceftriaxone. You will follow up with your PCP and with Drs. ___. You will potentially have your valve replaced at that time. All our best, Your ___ Care Team Followup Instructions: ___
19569325-DS-12	19,569,325	27,114,888	DS	12	2176-04-20 00:00:00	2176-04-20 17:43:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Gait instability, weight loss, cognitive decline, tremor, slowed speech. Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ year-old man with a history of heart failure, HTN, HLD, COPD, and diabetes who presents with 3 months of gait instability, tremor, and slowed speech. Per patient report, his issues started around 3 months prior to presentation. He was hospitalized for a CHF exacerbation at ___ and was diuresed aggressively with subsequent renal failure. Of that time, patients states that "I didn't know who people were," and that he almost needed dialysis but it didn't get there. After discharge he started with gait issues that he described as "drunk walking" to neurology team. He had no falls, but felt off balance and would support himself by holding railings and other furniture whenever possible. He also developed tremor in both of his hands and jerking in his shoulders. He has noticed weakness in his right leg which has worsened over the course of the last 3 months. He also noticed atrophy of the muscles in the dorsum of his right. He also notes that his girlfriend and friends have noticed slowing of his speech in the past month. He is here in ___ visiting a friend, who felt that patient's speech deficit was so severe that he should come to the hospital immediately. Past Medical History: Diabetes mellitus Diabetic neuropathy Heart failure Hypertension Hyperlipidemia COPD Social History: ___ Family History: No family history of strokes, seizures, neurodegenerative diseases, or autoimmune diseases. Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VS: Temp 98.5 BP 113 / 71 HR 67 RR 20 SaO2 93% GENERAL: NAD , able to recite days of the week backwards and forwards without issue. HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM NECK: supple, no LAD, no appreciable JVD though difficult to assess HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly. Multiple well-healed surgical scars. EXTREMITIES: no cyanosis, clubbing, or edema PULSES: 2+ DP pulses bilaterally NEURO: A&Ox3, moving all 4 extremities with purpose. Clear, low frequency flapping asterixis in left hand. ___ strength UEs bilaterally ___ to hip flexion bilaterally. Normal tone. Wasting of ___ dorsal interosseous muscle on right hand. Decreased proprioception great toes bilaterally. Positive Romberg. No dysmetria noted on finger to nose. Narrow gait. DISCHARGE PHYSICAL EXAM: ======================== VS: T 97.6F BP 134/75 HR 60 RR 18 O2 95% 2L NC GENERAL: resting comfortably in bed, able to recite days of the week backwards and forwards without issue. HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM NECK: supple, no LAD, no appreciable JVD though difficult to assess HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, nontender in all quadrants, no rebound/guarding, palpable liver edge 2 cm beyond costal margin. Multiple well-healed surgical scars. EXTREMITIES: no cyanosis, clubbing, or edema PULSES: 2+ DP pulses bilaterally NEURO: A&Ox3, moving all 4 extremities with purpose. No asterixis, hands without tremor. ___ strength UEs bilaterally ___ to hip flexion bilaterally. Normal tone. Wasting of ___ dorsal interosseous muscle on right hand. Decreased proprioception great toes bilaterally. SKIN: warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: ADMISSION LABS: =============== ___ 09:55PM BLOOD WBC-18.4* RBC-3.76* Hgb-11.6* Hct-35.2* MCV-94 MCH-30.9 MCHC-33.0 RDW-18.9* RDWSD-63.8* Plt ___ ___ 09:55PM BLOOD Neuts-74.0* Lymphs-14.9* Monos-6.3 Eos-3.3 Baso-0.4 NRBC-0.3* Im ___ AbsNeut-13.60* AbsLymp-2.73 AbsMono-1.16* AbsEos-0.61* AbsBaso-0.07 ___ 02:30AM BLOOD ___ PTT-29.6 ___ ___ 09:55PM BLOOD Glucose-51* UreaN-54* Creat-1.7* Na-145 K-5.3* Cl-98 HCO3-31 AnGap-16 ___ 09:55PM BLOOD ALT-21 AST-54* AlkPhos-48 TotBili-0.5 ___ 09:55PM BLOOD cTropnT-0.01 ___ 09:55PM BLOOD Albumin-4.1 Calcium-9.8 Phos-4.0 Mg-1.7 ___ 11:41PM BLOOD Lactate-1.7 ___ 09:55PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG PERTINENT LABS: ============== ___ 06:35AM BLOOD calTIBC-347 Ferritn-368 TRF-267 ___ 02:30AM BLOOD VitB12-1455* ___ 08:15AM BLOOD %HbA1c-8.2* eAG-189* ___ 03:20AM BLOOD Ammonia-40 ___ 02:30AM BLOOD TSH-4.1 ___ 02:30AM BLOOD PTH-36 ___ 06:40AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG HAV Ab-NEG ___ 02:30AM BLOOD ___ CRP-12.1* ___ 06:40AM BLOOD HCV Ab-NEG IMAGING: ======== CT CHEST W/ CONTRAST ___: IMPRESSION: 1. No evidence of malignancy in the chest. 2. Prominent mediastinal, and borderline hilar lymph nodes have a very low likelihood of representing lymphoma. However, ___ chest CT in ___ months is recommended for re-evaluation. 3. Please refer to separate report for same day CT abdomen pelvis study for discussion of findings below the diaphragm. CT ABD/PELVIS W/ CONTRAST ___: MPRESSION: 1. No concerning hepatic lesions or definite CT evidence of cirrhosis. 2. Please see report from separate CT chest for description of the intrathoracic findings. DISCHARGE LABS: =============== ___ 07:00AM BLOOD WBC-8.8 RBC-3.45* Hgb-10.5* Hct-32.3* MCV-94 MCH-30.4 MCHC-32.5 RDW-18.3* RDWSD-62.0* Plt ___ ___ 07:00AM BLOOD Glucose-285* UreaN-34* Creat-1.2 Na-143 K-4.7 Cl-99 HCO3-30 AnGap-14 Brief Hospital Course: Mr. ___ is a ___ yo man with history of heart failure, DM and COPD who presents with 3 month progressive neurologic deceline characterized by right arm weakness, muscle wasting, tremor and cognitive decline as well as subacute dyspnea and weight loss, found to have leukocytosis of 18.4, hypoglycemia and renal injury of unclear chronicity. ACUTE ISSUES: ============= #Tremors #Gait instability #Fatigue #Leukocytosis #Weight loss The patient presented with 3 months of fatigue, gait instability, tremors, slowed speech and foggy thinking. Over this time, he also endorsed a significant unintentional weight loss of at least 20 lbs. On exam, his tremors were most consistent with asterixis. Initial labs were notable for a leukocytosis to 18.4. Neurology was consulted in the emergency department and was concerned for a systemic process causing secondary neurological symptoms including a paraneoplastic syndrome. Neurology recommended holding his Lyrica as this has known side effects consistent with the patient's presentation. He had CT imaging of his chest, abdomen, and pelvis that was unremarkable for malignancy. There was concern for cirrhosis in light of this asterixis and a history of heavy alcohol use. LFTs were unremarkable with intact liver synthetic function and negative hepatitis serologies. CT abdomen showed a normal liver. Hepatology was consulted and determined that his presentation was not consistent with cirrhosis. B12, TSH and PTH were normal. Over the course of his admission, the patient's symptoms improved. Per neurology, this is most consistent with Lyrica as the causative agent for the patient's symptoms. His leukocytosis also resolved over the course of his admission. #Acute kidney injury The patient presented with a Cr of 1.6 with an unknown baseline. Renally excreted medications including MS ___ and Lyrica were held. Cr improved to 1.2 on the second day of admission. The etiology of this kidney injury is unclear, but may be due to poor PO intake in the setting of his neurologic symptoms. #Diabetes mellitus, type II #Hypoglycemia The patient was noted to have a FSBG of 53 in the ED. During admission, his home metformin and U500 were held as he was placed on a sliding scale. His blood sugars were poorly controlled and ___ was consulted for help managing his hyperglycemia and insulin regimen. They recommended that he be discharged on Lantus 50 units at bedtime, humalog with meals (16 units with each meal) and HISS (BG target 150, CF 25). He met with a DM educator prior to discharge. #Opiate use disorder The patient was prescribed MS ___ and oxycodone by an outside provider prior to admission. He noted irregularly taking these despite pharmacy records showing that he was diligently filling the prescriptions each month. These medications were held during his admission and he experienced no signs of withdrawal, which may suggest that he does not take this opioid regimen on a daily basis. As his stated home opioid regimen was held during his hospital stay, this has continued to be held on discharge. This matter should be addressed at future PCP ___. #Anemia The patient presented with a normocytic anemia (Hgb 10.6 MCV 95) without a known baseline. There was concern for occult bleeding, but a stool guaiac was negative. Iron studies and B12 were unremarkable. CHRONIC ISSUES: =============== #Heart failure Patient's records indicate all echocardiograms to date with a preserved ejection fraction. Coronary catheterization records only notable for 50% stenosis of RCA. He was euvolemic to dry on exam. His home metoprolol was fractionated. He was continued on his home isosorbide dinatrate. His home quinapril, torsemide, and metalazone were all held in light of his ___. Quinapril and Torsemide were started on discharge. Metolazone has been held on discharge until PCP ___. #Hyperlipidemia His home fenofibrate and pravastatin were continued. #Chronic back pain His home pain medications were held as above. TRANSITIONAL ISSUES: =================== [ ] Patient presented with variety of neurologic symptoms in the setting of Lyrica use. Please ___ resolution of his symptoms with continued discontinuation of his Lyrica and ensure that he returns to his baseline. If he has remaining neurological symptoms or signs, consider further neurologic work-up including a brain MRI. [ ] For an alternative agent for his neuropathic pain, can consider Duloxetine (Cymbalta) or Venlafaxine (Effexor). [ ] Recommend follow up with neurologist in ___ (where patient lives) for management of diabetic neuropathy. [ ] Patient presented with an unintentional weight loss that was not fully explained by the work-up this hospitalization. CT chest/Abdomen/pelvis negative for malignancy. Please review with the patient his age-appropaite cancer screening, his diet, and psychosocial stressors. [ ] Patient presented with hypoglycemia and had difficult-to-control blood sugars during this hospitalization. Takes U-500 at home though there is concern for poor compliance with that regimen. During this hospitalization, ___ advised that he be discharged on the following regimen: Lantus 50 units at bedtime, humalog with meals (16 units with each meal) and HISS (BG target 150, CF 25). He met with a DM educator prior to discharge. [ ] Please ___ his new diabetes regimen as listed above and ensure he is euglycemic. If needed, please make appropriate referral to an endocrinologist [ ] Patient presented on opiate medications for chronic back pain that he does not take as prescribed. These medications were held during this hospitalization. Please avoid any unnecessary opioid prescriptions and attempt non-opioid pain relief as a first option. [ ] Patient presented with a normocytic anemia without any clear source of bleeding. Especially in light of his unintentional weight loss, would ensure that he is up-to-date on his colonoscopy screening [ ] Patient will need repeat CT chest in ___ months for re-evaluation of lymph nodes. [ ] Patient hepatitis B non-immune. Given ___ hepatitis B vaccine in hospital, will need ___ hepatitis vaccine in ___ weeks and around 16 weeks for the third. - Holding Metolazone as patient did not require it during his hospitalization. Torsemide was restarted on discharge. Please discuss whether Metolazone is needed after discharge - MEDICATIONS STOPPED: METFORMIN, U-500, METOLAZONE #Code: Full #Contact: ___ ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Pregabalin 200 mg PO TID 2. Torsemide 20 mg PO TID 3. MetFORMIN (Glucophage) 1000 mg PO BID 4. Vitamin D 1000 UNIT PO DAILY 5. Quinapril 10 mg PO DAILY 6. Pravastatin 40 mg PO QPM 7. Metoprolol Succinate XL 25 mg PO DAILY 8. Pantoprazole 40 mg PO Q24H 9. Isosorbide Dinitrate 10 mg PO BID 10. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain - Moderate 11. Fenofibrate 48 mg PO DAILY 12. Montelukast 10 mg PO DAILY 13. Metolazone 5 mg PO EVERY OTHER DAY 14. Senna 8.6 mg PO BID 15. Morphine SR (MS ___ 60 mg PO Q12H 16. ___ Unknown Dose 17. Albuterol Inhaler 1 PUFF IH Q6H:PRN wheezing 18. Klor-Con M20 (potassium chloride) 20 mEq oral DAILY 19. Loratadine 10 mg PO DAILY Discharge Medications: 1. BD Ultra-Fine Nano Pen Needles (pen needle, diabetic) 32 gauge x ___ miscellaneous QIDACHS RX pen needle, diabetic 32 gauge X ___ check your blood sugar at every meal and before bedtime QIDACHS Disp #100 Each Refills:2 2. OneTouch Delica Lancets (lancets) 30 gauge miscellaneous QIDACHS RX lancets [Easy Touch Lancets] 32 gauge check blood glucose with every meal and at bedtime QIDACHS Disp #100 Each Refills:2 3. OneTouch Ultra Test (blood sugar diagnostic) miscellaneous QIDACHS RX blood sugar diagnostic [OneTouch Ultra Test] check blood glucose with every meal and at bedtime QIDACHS Disp #100 Strip Refills:2 4. Glargine 50 Units Bedtime Humalog 16 Units Breakfast Humalog 16 Units Lunch Humalog 16 Units Dinner Insulin SC Sliding Scale using HUM Insulin RX insulin glargine [Lantus Solostar] 100 unit/mL (3 mL) AS DIR 50 Units before BED; Disp #30 Syringe Refills:2 RX insulin lispro [Humalog KwikPen] 100 unit/mL AS DIR see below Disp #30 Syringe Refills:*2 5. Albuterol Inhaler 1 PUFF IH Q6H:PRN wheezing 6. Fenofibrate 48 mg PO DAILY 7. Isosorbide Dinitrate 10 mg PO BID 8. Klor-Con M20 (potassium chloride) 20 mEq oral DAILY 9. Loratadine 10 mg PO DAILY 10. Metoprolol Succinate XL 25 mg PO DAILY 11. Montelukast 10 mg PO DAILY 12. Pantoprazole 40 mg PO Q24H 13. Pravastatin 40 mg PO QPM 14. Quinapril 10 mg PO DAILY 15. Senna 8.6 mg PO BID 16. Torsemide 20 mg PO TID 17. Vitamin D 1000 UNIT PO DAILY 18. HELD- Metolazone 5 mg PO EVERY OTHER DAY This medication was held. Do not restart Metolazone until you see your PCP ___: Home Discharge Diagnosis: PRIMARY DIAGNOSES: ================== TREMORS GAIT INSTABILITY FATIGUE WEIGHT LOSS ACUTE KIDNEY INJURY SECONDARY DIAGNOSES: ===================== ANEMIA HEART FAILURE DIABETES MELLITUS, TYPE II OPIATE USE DISORDER Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure being involved in your care. Why you were admitted to the hospital: You were admitted to the hospital after several months of tremors, difficulty walking, slowed speech and thoughts, as well as an unintentional weight loss. What happened in the hospital: - You were seen by neurologists who evaluated you for potential causes of your symptoms. They recommended stopping your Lyrica, which resulted in improvement in your symptoms. - You had blood tests and imaging of your chest and abdomen/pelvis to look for other causes of your symptoms and these were all normal. What to do when you leave the hospital: - Attend all of your ___ appointments described below. - Take all of your medications as described below. - Please avoid taking Lyrica in the future as this medication likely caused your symptoms. - WE HAVE STARTED A NEW DIABETES REGIMEN. DO NOT TAKE METFORMIN OR U-500 ANY LONGER. YOUR NEW DIABETES REGIMEN IS: Lantus 50 units at bedtime, humalog with meals (16 units with each meal), and Humalog sliding scale - MEDICATIONS STOPPED: METFORMIN, U-500, METOLAZONE We wish you the best! Your ___ Team. Followup Instructions: ___
19569569-DS-3	19,569,569	20,562,513	DS	3	2147-01-12 00:00:00	2147-01-13 19:57:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: fall Major Surgical or Invasive Procedure: none History of Present Illness: ___ year old female with mild dementia that initially presented to her nursing home after a witnessed fall with head strike. Imaging done at ___ ruled out a cervical frx or a bleed in her brain. She did not have frank evidence of PNA on CXR, however did have a bimalleolar fracture of her L ankle. She was transferred to ___ for operative management. Notably at ___ her initial WBC was 18.3 with a neutrophilic predominance. While in our ED, she spiked a fever to 100.8 and her blood pressure throughout the day had trended down to 130's SBP to 100's (unclear baseline). She has not received any fluids or antibiotics, but has received morphine and oxycodone. Orthopedics evaluated the patient in the emergency department and determined fracture was non-operative. Past Medical History: Hypothyroid (s/p tx or hyperthyroid) Constipation Hypertension Depression Obesity CAD SIADH Glucocorticoid deficiency Cardiomegaly Alcohol induced dementia Social History: ___ Family History: Unknown, patient has dementia. Unable to tell hospital staff. Physical Exam: ============================= ADMISSION EXAM: ============================ VS: 97.7PO 111 / 68 79 18 93 RA Gen: alert and pleasant HEENT: Bilateral cateracts. Atraumatic. MM dry. CV: RRR no m/g/r Pulm: Mild diffuse crackles bilaterally Abd: Soft ND NT Ext: LLE in a cast. RLE with area of erythema and warmth with sharply demarcated borders on raising up of skin Skin: See description of RLE Neuro: No focal neuologic deficits. AOx1-2 ================================= DISCHARGE EXAM: ================================= VS: 98.6PO 125 / 59R Lying 98 26 93% RA Gen: alert and pleasant, in NAD HEENT: NC/Atraumatic. MM dry. CV: RRR no m/g/r Pulm: CTA Abd: Soft ND NT Ext: LLE in a cast, RLE with erythema and cellulitis which has significantly receded from the margins of the original outline. Skin: See description of RLE Neuro: Responding to questions appropriately, moving all extremities. Pertinent Results: ============================== ADMISSION LABS: ============================== ___ 10:00PM WBC-13.6* RBC-3.49* HGB-9.4* HCT-29.3* MCV-84 MCH-26.9 MCHC-32.1 RDW-14.9 RDWSD-45.8 ___ 10:00PM NEUTS-81.9* LYMPHS-9.8* MONOS-6.8 EOS-0.7* BASOS-0.1 IM ___ AbsNeut-11.09* AbsLymp-1.33 AbsMono-0.92* AbsEos-0.09 AbsBaso-0.02 ___ 10:00PM ___ PTT-31.3 ___ ___ 10:00PM GLUCOSE-108* UREA N-29* CREAT-1.3* SODIUM-133 POTASSIUM-3.7 CHLORIDE-95* TOTAL CO2-29 ANION GAP-13 ___ 06:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5 LEUK-NEG ============================== DISCHARGE LABS: ============================== ___ 06:17AM BLOOD WBC-11.3* RBC-3.45* Hgb-9.2* Hct-29.8* MCV-86 MCH-26.7 MCHC-30.9* RDW-14.9 RDWSD-47.1* Plt ___ ___ 06:17AM BLOOD Glucose-125* UreaN-15 Creat-0.9 Na-142 K-4.2 Cl-99 HCO3-29 AnGap-18 ___ 06:17AM BLOOD Calcium-9.0 Phos-3.6 Mg-1.9 ================ IMAGING: ================ EKG ___: Probable sinus rhythm. Left axis deviation. Intraventricular conduction delay of left bundle-branch block type. Q waves in leads V1-V2. Consider septal infarction. No previous tracing available for comparison. Clinical correlation is suggested. LEFT ANKLE XRAY ___: FINDINGS: Overlying cast obscures fine bony detail. Bones are diffusely demineralized further limiting detailed evaluation. There is a fracture identified through the distal left fibular just proximal to the syndesmosis. Lucency compatible fracture through the medial malleolus is also seen. Ankle mortise demonstrates no gross abnormality on this limited exam.Degenerative changes are seen at the knee with joint space loss and osteophyte formation. CXR ___: IMPRESSION: There are low lung volumes. Cardiomediastinal silhouette is within normal limits. There has been worsening of the pulmonary interstitial prominence since the prior study. There are new consolidations at the lung bases since previous which may be due to pneumonia or aspiration. There are no pneumothoraces. Right humeral head appears dislocated anteriorly in relation to the glenoid. Please correlate clinically and dedicated shoulder radiographs would be helpful for further assessment. CXR ___: FINDINGS: The heart is enlarged but likely exaggerated related to lower lung volumes. Pulmonary vascular congestion is unchanged. The left hemidiaphragm is obscured secondary to a small left pleural effusion and increasing adjacent atelectasis though given patient's current symptoms a superimposed pneumonia cannot be excluded. No pulmonary edema or pneumothorax are seen. IMPRESSION: Small left pleural effusion and adjacent atelectasis though superimposed left lower lobe pneumonia cannot be excluded. LEFT LOWER EXTREMITY DVT ___: IMPRESSION: No evidence of deep venous thrombosis in the right lower extremity veins. Brief Hospital Course: Ms. ___ is a ___ hx Dementia, HTN, CAD who presented from her nursing home s/p fall with ankle fracture, found to have leukocytosis and fever and ?___ (unknown baseline). Found to have right lower extremity cellulitis and community acquired pneumonia, improved on antibiotics prior to discharge. # Left bimalleolar fracture: XRAY showed left ankle fracture in the ED. She was evaluated by orthopedics, who recommended nonoperative management. She was admitted for physical therapy evaluation and pain control. Pain controlled with Tylenol and low dose oxycodone. She will have follow up appointments with orthopedics ___. # Fever/leukocytosis ___ # cellulitis # community acquired pneumonia: T 100.8 in ED with mild leukocytosis. Exam significant for RLE cellulitis. Was treating cellulitis with keflex, but minimal improvement. Repeat CXR concerning for pneumonia as well. She didn't have IV access because she kept puling them out. She was started doxy on ___ for MRSA cellulitis and better pneumonia coverage. Respiratory status and erythema improved. Discharged on doxycycline and Keflex with planned duration through ___ (for total of 10 days of Keflex and 7 days of doxy). # ___: Cr 1.3 on admission, given IVF without resolution of Cr, however, once restarted home Lasix creatinine improved to 0.9. Maintained on home Lasix. # Witnessed fall with headstrike prior to admission vs Syncope: CT of head and C-spine at ___ unremarkable. Rest of syncope workup unremarkable. TTE as outpatient, unable to be done as inpatient. # Dementia: Has documented dementia secondary to alcohol use per nursing home records. She remained call and AOx2 throughout hospitalization. No evidence of psychosis. # Anemia: stable throughout hospitalization. Hgb 9.2 at discharge. # Hypothyroidism: TSH 8.7 but free T4 normal at 7.5. Continued on home levothyroxine. # CAD: - continue ASA # HTN: Initially held lisinopril on admission for elevated Cr. Restarted prior to discharge. - continue home NIFEdipine CR 30 mg PO DAILY - Continue on home Metoprolol Tartrate 25 mg PO/NG BID # Adrenal insufficiency: documented history in Nursing home paperwork. -continue home fludrocort # Acute on chronic Heart failure: home Lasix 40mg BID and lisinopril held initially for ___, but restarted prior to discharge. Patients ___ may have been related to volume overload in the setting of heart failure given that Cr fell once initiated on lasix. Continued home metoprolol. Patient needs outpatient ECHO done. # SIADH: documented in ___ home transfer note. Demeclocycline held during hospitalization. Restarted at discharge. # Incidental finding: Right humeral head appeared dislocated in CXR picture. Patient denied pain in bilateral shoulders. Had full range of motion bilaterally. Further imaging not performed. ========================== TRANSITIONAL ISSUES: ========================== - Discharged on doxycycline 100mg Q12H and Keflex ___ q8h, with end date ___. Total duration of Keflex is 10 days, and doxycycline is 7 days. - Please monitor for signs of esophagitis while patient is on doxycycline. - Patient has follow up appointment with orthopedics on ___ ___. - Please repeat CBC and CHEM 10 on ___ to evaluate wbc and Cr, Na - Patient needs outpatient Echocardiogram. - Patient needs follow up chest XRAY in ___ weeks from discharge - Please follow up TSH, FT4, 6 weeks after discharge # CODE: Presumed, Full # CONTACT: ___, Legal guardian is ___ at ___ or ___. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Aspirin 81 mg PO DAILY 3. demeclocycline 150 mg oral BID 4. Docusate Sodium 100 mg PO BID 5. fludrocortisone 0.1 mg oral DAILY 6. Furosemide 40 mg PO BID 7. Levothyroxine Sodium 75 mcg PO DAILY 8. Lisinopril 2.5 mg PO DAILY 9. Metoprolol Succinate XL 25 mg PO BID 10. Multivitamins 1 TAB PO DAILY 11. NIFEdipine CR 30 mg PO DAILY 12. TraZODone 50 mg PO QHS Discharge Medications: 1. Cephalexin 500 mg PO Q8H End date ___ 2. Doxycycline Hyclate 100 mg PO Q12H End date ___ 3. OxyCODONE (Immediate Release) 2.5 mg PO Q4H:PRN Pain - Severe RX oxycodone 5 mg 0.5 (One half) tablet(s) by mouth every 6 hours Disp #10 Tablet Refills:*0 4. Senna 17.2 mg PO HS 5. Acetaminophen 650 mg PO Q8H 6. Aspirin 81 mg PO DAILY 7. demeclocycline 150 mg oral BID 8. Docusate Sodium 100 mg PO BID 9. fludrocortisone 0.1 mg oral DAILY 10. Furosemide 40 mg PO BID 11. Levothyroxine Sodium 75 mcg PO DAILY 12. Lisinopril 2.5 mg PO DAILY 13. Metoprolol Succinate XL 25 mg PO BID 14. Multivitamins 1 TAB PO DAILY 15. NIFEdipine CR 30 mg PO DAILY 16. TraZODone 50 mg PO QHS Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS: left bimalleolar fracture right lower extremity cellulitis community acquired pneumonia SECONDARY DIAGNOSIS: Dementia Anemia SIAHD Hypothyroidism Glucocorticoid deficiency 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. ___, It was a pleasure taking care of ___ at ___. ___ came to the hospital after ___ had a fall. In the emergency room, an XRAY showed that ___ broke your left ankle. ___ do not need surgery for your ankle. Instead, ___ will be in a cast and follow up with the orthopedic surgeons on ___. ___ were also found to have cellulitis, which is a skin infection, of your right leg. ___ were also found to have a pneumonia. Both of these infections likely caused ___ to fall. ___ were started on antibiotics, which ___ will take for through ___. Please follow up with the orthopedic surgeons tomorrow. We wish ___ the best of health, Your medical team at ___ Followup Instructions: ___
19570250-DS-20	19,570,250	22,262,971	DS	20	2188-05-09 00:00:00	2188-05-11 16:37:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Chest pain after motor vehicle collision Major Surgical or Invasive Procedure: none History of Present Illness: This patient is a ___ year old male who complains of MVC. The patient fell asleep at the wheel and ran into a bolder and then a fence. There was no airbag deployed. The patient hit the steering wheel. There was damage to the steering wheel. He is complaining of anterior chest pain. No abdominal pain or neurologic symptoms. No headache or neck pain or back pain. REVIEW OF SYSTEMS Positive for Chest pain. All other systems reviewed and negative. Past Medical History: Past Medical History: None Social History: ___ Family History: unknown Physical Exam: ADMISSION PHYSICAL EXAM: ======================= Constitutional: Uncomfortable HEENT: Normocephalic, atraumatic, Pupils equal, round and reactive to light, Extraocular muscles intact Chest: Clear to auscultation anterior chest wall tenderness and left chest wall tenderness Cardiovascular: Regular Rate and Rhythm, Normal first and second heart sounds Abdominal: Soft, Nontender Extr/Back: No cyanosis, clubbing or edema back is nontender. There is right knee tenderness medial. There is right knee abrasion. The right lower extremity is neurovascular intact. Skin: No rash Neuro: Speech fluent A/O X 3 DISCHARGE PHYSICAL EXAM: ============================ Gen: well appearing, NAD, fluent speech CV: NSR, no mrg Pulm: CTAB, no respiratory distress, tender to palpation along fx sites ABD: Non tender, non distended, +BS ___: no edema Pertinent Results: ADMISSION LABS: ================ ___ 08:30AM BLOOD WBC-7.4 RBC-6.09 Hgb-13.4* Hct-42.7 MCV-70* MCH-22.0* MCHC-31.4* RDW-16.8* RDWSD-38.9 Plt ___ ___ 08:30AM BLOOD Plt ___ ___ 08:30AM BLOOD ___ PTT-24.8* ___ ___ 08:30AM BLOOD ___ ___ 08:30AM BLOOD UreaN-14 Creat-1.2 ___ 08:30AM BLOOD Lipase-24 ___ 08:30AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 08:44AM BLOOD pO2-70* pCO2-32* pH-7.45 calTCO2-23 Base XS-0 Comment-GREEN TOP ___ 08:44AM BLOOD Glucose-110* Lactate-2.3* Na-140 K-4.4 Cl-103 ___ 08:44AM BLOOD Hgb-14.0 calcHCT-42 O2 Sat-91 COHgb-5 MetHgb-0 ___ 08:44AM BLOOD freeCa-1.21 ___ 10:00AM URINE Blood-NEG Nitrite-NEG Protein-TR* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG ___ 10:00AM URINE RBC-5* WBC-1 Bacteri-NONE Yeast-NONE Epi-0 ___ 10:00AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-POS* amphetm-NEG oxycodn-NEG mthdone-NEG DISCHARGE LABS: ==================== ___ 06:38AM BLOOD WBC-6.6 RBC-5.84 Hgb-13.0* Hct-41.0 MCV-70* MCH-22.3* MCHC-31.7* RDW-16.5* RDWSD-38.2 Plt ___ ___ 06:38AM BLOOD Plt ___ ___ 06:38AM BLOOD Glucose-108* UreaN-13 Creat-1.3* Na-138 K-4.1 Cl-102 HCO3-25 AnGap-11 ___ 06:38AM BLOOD Calcium-9.8 Phos-3.3 Mg-1.9 MICROBIOLOGY: ==================== URINE CULTURE (Final ___: < 10,000 CFU/mL. IMAGING: ==================== ___ CXR, PORT IMPRESSION: 1. Known bilateral anterior upper lobe pulmonary contusions and left anterior ___ to 4th rib fractures from same day chest CT are not visible on this conventional chest radiograph. 2. Mild bibasilar atelectasis. ___ CT CHEST/ABD/PELVIS W/ IMPRESSION: 1. Left anterior ___ - 4th rib fractures. 2. Bilateral anterior upper lobe pulmonary contusions. Otherwise no additional acute organ injuries in the chest, abdomen, or pelvis. No evidence of posttraumatic aortic injury. 3. 2 mm nonobstructing stone in the right lower renal pole. ___ CT C-SPINE W/O CONTRAST IMPRESSION: 1. No fracture. 2. Degenerative changes. 3. Mild fullness post cricoid hypopharynx, suboptimally evaluated, may be fromsecretions. ___ CT HEAD W/O CONTRAST IMPRESSION: 1. No acute findings. ___ KNEE (AP, LAT & OBLIQUE IMPRESSION: No acute fracture or dislocation. ___ CHEST (PA & LAT) IMPRESSION: PRIOR IMAGING, INCLUDING OUTSIDE CHEST CT AND PORTABLE CHEST RADIOGRAPH PERFORMED HERE ARE NO LONGER ELECTRONICALLY AVAILABLE. Atelectasis, left lower lobe is relatively mild. Lungs otherwise clear. Cardiomediastinal and hilar silhouettes and pleural surfaces are normal. Right lung clear. Rib fractures are not demonstrated by this conventional radiography. Brief Hospital Course: Patient Summary For Admission: Mr. ___ is a ___ year old male who presents following a motor vehicle collision complaining of anterior chest pain and imaging findings consistent with L ___ rib fractures. Collision involved his car hitting a boulder in the setting of having fallen asleep at the wheel. Airbags were not deployed. #Rib fractures, Left Anterior ___ #Pulmonary Contusion, bilateral anterior On presentation the patient was hemodynamically stable and satting well on RA. CT chest was remarkable for left anterior ___ to 4th rib fractures and bilateral anterior upper lobe pulmonary contusions. Toxicology studies positive for cocaine, otherwise unremarkable. No acute abnormalities were noted on CT Abd/Pelv, C-Spine, CT Head, or R Knee radiograph. He was admitted for pain which was controlled on oxycodone, tramadol, and standing tylenol. Prior to discharge he received a CXR to ensure there was no developing pneumothorax. Ambulatory oxygen saturation was mid-high ___ on the day of discharge. 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 Transitional Issues: []Patient was prescribed 12 pills of 5mg oxycodone and 8 Tramadol 50mg for pain []Urine Toxicology + for cocaine, please follow up as outpatient []2 mm nonobstructing stone in the right lower renal pole seen on CT Abd Medications on Admission: none Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H RX acetaminophen [8 Hour Pain Reliever] 650 mg 1 tablet(s) by mouth three times a day Disp #32 Tablet Refills:0 2. Lidocaine 5% Patch 1 PTCH TD QAM RX lidocaine [Lidocaine Pain Relief] 4 % please apply to ribs at site of pain one a day for 12 hours Disp #4 Patch Refills:0 3. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate RX oxycodone [Oxaydo] 5 mg 1 tablet(s) by mouth every 4 hours as needed Disp #12 Tablet Refills:0 4. TraMADol 50 mg PO Q6H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity RX tramadol [Ultram] 50 mg 1 tablet(s) by mouth every 6 hours as needed Disp #8 Tablet Refills:0 Discharge Disposition: Home Discharge Diagnosis: Left Rib Fractures (___) Pulmonary Contusion Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure to care for you at the ___ ___. Why did you come to the hospital? - You were involved in a motor vehicle collision and fractured your left ___ - 4th ribs. What did you receive in the hospital? - We performed several scans to make sure we did not miss any other injuries. - We monitored your breathing and vital signs while providing you with medicines for your pain. What should you do once you leave the hospital? - Please schedule follow up appointments with your primary care provider within the next ___ weeks. - For Pain: 1) Take Tylenol ___ every 6 hours around the clock. This is an over the counter medication. 2) Add Oxycodone as needed for increased pain. Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and consider a bowel regimen. These meds (senna, colace, miralax) are over the counter and may be obtained at any pharmacy. - Please adhere to the recommendations noted below. * 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). We wish you the best! Your ___ Care Team Followup Instructions: ___
19570901-DS-31	19,570,901	22,173,467	DS	31	2163-11-28 00:00:00	2163-11-28 17:07:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: linezolid / Bactrim / allopurinol Attending: ___ Chief Complaint: L cellulitis Major Surgical or Invasive Procedure: none History of Present Illness: ___ w/ secondary MS ___ some baseline neurocognitive impairment), and non-Hodgkin's lymphoma (recurrent s/p SCT; s/p Rituxan/IVIG), chronic L>R LEx edema (not heart failure) admitted ___ - ___ for LLEx cellulitis and discharged on Doxycycline with improvement, seen by PCP and referred to ___ clinic ___ (but hasn't yet gone) presented to ER ___ with 1+ week worsening LLExt erythema and fever 100.5 at home after abrading L anterior shin with her fingernail last week. In ER has been afebrile >24hr, nl lactate, no leukocytosis or L shift. There were no criteria met for sepsis. She received IV Vancomycin ___ at 22:06, with mild improvement from outlined area over today (and also received pregabalin, baclofen, Adderall, vitamin d, duloxetine and lisinopril ___. She denies any other localizing symptoms, no abdominal pain, no urinary symptoms, no cough, no sick contacts. She denies diarrhea or rigors. Other ROS neg in 10 systems Past Medical History: Mantel cell lymphoma Progressive MS ___ pain Chronic ___ Prior ECHO nl EF, nl E/e', ___ AI (___) Social History: ___ Family History: Grandmother with diabetes. MGF had bowel cancer. Physical Exam: Discharge physical exam: 24 HR Data (last updated ___ @ 1426) Temp: 98.8 (Tm 98.8), BP: 99/61 (95-145/54-65), HR: 70 (65-74), RR: 20 (___), O2 sat: 96% (95-98), O2 delivery: RA, Wt: 133.4 lb/60.51 kg Eyes: PERLL, EOMI, no conjuctival injection, anicteric ENT: OP clear, no ___ LUNGS: CTA b/l COR: RR, S1 and S2 wnl, no audible murmurs/rubs/gallops CHEST: CTAB GI: nd, +b/s, soft, nt, no masses or HSM EXT: 2+ pitting edema bilat L > R LExts, R teds in place SKIN: please see photos in OMR dated ___ denuded superficial ulcer over anterior shin with satellite black eschar, blood-filled blister and separate fluid-filled blister proximal shin; erythema receding from marked borders (and re-marked today from ankle to mid-shin) NEURO: AOx3, CN II-XII intact. ___ strength throughout. No sensory deficits to light touch appreciated. Sensation grossly intact throughout. PSYCH: pleasant, appropriate affect Pertinent Results: Admission labs: ___ 06:24PM BLOOD WBC-6.7# RBC-4.12 Hgb-10.9* Hct-35.3 MCV-86 MCH-26.5 MCHC-30.9* RDW-17.1* RDWSD-53.1* Plt ___ ___ 06:24PM BLOOD Glucose-84 UreaN-29* Creat-1.1 Na-141 K-4.4 Cl-99 HCO3-24 AnGap-18 ___ 05:50AM BLOOD proBNP-1084* ___ 06:44PM BLOOD Lactate-1.0 Discharge labs: WBC 3.3 (from 3.6), Hct 28 (from 27.6), Plt 152 Na 145, BUN 35 (from 37), Cr 1.2 (from 1.3, 1.1 on admission) UCx (___): negative BCx (___) pending x2 LENIs ___: no DVT TTE ___: Mild non-obstructive focal hypertrophy of the basal septum with normal biventricular cavity sizes and regional/global systolic function. Mild-moderate aortic regurgitation. Mild mitral regurgitation. Brief Hospital Course: ___ w/ secondary MS ___ some baseline neurocognitive impairment), and non-Hodgkin's lymphoma(recurrent s/p SCT; s/p Rituxan/IVIG), LLEx lymphedema with prior cellulitis who presents with LLEx cellulitis and bilat pitting edema. # LLExt Cellulitis: # Lower extremity edema: The patient has a hx of recurrent LLE cellulitis. She again presented with L lower extremity cellulitis in the setting of scratching herself while dressing, which improved significantly on IV vancomycin (initiated ___. On ___ she was transitioned to Augmentin/Doxycycyline to complete a 10 day course through ___. Superimposed lymphedema was thought to be contributing, and she underwent a trial of Lasix 40mg IV, which resulted in ___ without significant improvement. TTE as below showed no evidence of systolic heart failure or significant valvular disease (mild MR, mild AI). LENIs were negative for clot. Photos of the lower extremity were taken on the day of discharge and uploaded to OMR. She will receive ___ for wound care and will f/u with her PCP this week. She was encouraged to elevate her legs while seated/asleep and to f/u with her PCP's referral to ___ clinic. # ___: Cr bumped from 1.0 on admission to 1.4 on ___ in setting of attempted diuresis for lower extremity edema as above. Additional diuresis was held, and Cr slowly improved. Cr was 1.2 on the day of discharge. Home lisinopril was held in hospital and on discharge. Would recommend repeat BMP as outpatient to ensure continued resolution with consideration of resumption of lisinopril when appropriate. # HTN Home lisinopril was held in hospital and on discharge. Would recommend repeat BMP as outpatient to ensure continued resolution with consideration of resumption of lisinopril when appropriate. # Progressive MS # Chronic Pain - continued home baclofen - continued home pregabalin - continued home duloxetine Transitional issues: [ ] repeat BMP; resume lisinopril if appropriate [ ] wound check; ensure continued improvement on Augmentin/Doxy (please see photos in OMR for comparison) Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Baclofen 20 mg PO TID 3. DULoxetine 120 mg PO DAILY 4. Lisinopril 20 mg PO DAILY 5. Multivitamins 1 TAB PO DAILY 6. Pregabalin 150 mg PO TID 7. imiquimod 5 % topical 3X/WEEK 8. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP DAILY 9. calcium carb-magnesium ox,carb 200 mg calcium- 100 mg oral DAILY 10. FiberCon (calcium polycarbophil) 625 mg oral DAILY 11. Vitamin D3 (cholecalciferol (vitamin D3)) 1,000 unit oral DAILY 12. Lactobacillus acidophilus unknown mg oral unknown 13. Vitamin E 200 UNIT PO DAILY 14. dextroamphetamine-amphetamine 10 mg oral BID Discharge Medications: 1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H RX amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by mouth every 12 hours Disp #10 Tablet Refills:0 2. Bacitracin Ointment 1 Appl TP BID:PRN apply to scrape on leg RX bacitracin zinc [Antibiotic (bacitracin zinc)] 500 unit/gram Apply to left leg twice a day Disp #1 Tube Refills:0 3. Doxycycline Hyclate 100 mg PO Q12H RX doxycycline hyclate 100 mg 1 tablet(s) by mouth every 12 hours Disp #10 Tablet Refills:*0 4. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 5. Baclofen 20 mg PO TID 6. calcium carb-magnesium ox,carb 200 mg calcium- 100 mg oral DAILY 7. dextroamphetamine-amphetamine 10 mg oral BID 8. DULoxetine 120 mg PO DAILY 9. FiberCon (calcium polycarbophil) 625 mg oral DAILY 10. imiquimod 5 % topical 3X/WEEK 11. Lactobacillus acidophilus unknown oral Frequency is Unknown 12. Lisinopril 20 mg PO DAILY 13. Multivitamins 1 TAB PO DAILY 14. Pregabalin 150 mg PO TID 15. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP DAILY 16. Vitamin D3 (cholecalciferol (vitamin D3)) 1,000 unit oral DAILY 17. Vitamin E 200 UNIT PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: L leg cellulitis 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 L leg celluitis. This improved remarkably with Vancomyicin and you will complete a 10 day course of antibiotics with Doxycycline and Augmentin (through ___. You had swelling in your legs, but ultrasound showed no evidence of clot. An ultrasound of your heart was largely normal. Please follow up with your primary care doctor on ___ and follow up with your PCP's referral to the ___ clinic. A ___ referral is made for wound follow-up. With best wishes, ___ Medicine Followup Instructions: ___
19570901-DS-32	19,570,901	29,529,276	DS	32	2163-12-28 00:00:00	2163-12-28 18:07:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: linezolid / Bactrim / allopurinol Attending: ___. Chief Complaint: Weakness Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ female with history of secondary progressive MS ___ some baseline neurocognitive impairment), non-Hodgkin's lymphoma s/p auto SCT with recurrence on maintenance Rituxan/IVIG, and chronic L>R lower extremity edema with recent admission for LLE cellulitis who presents with weakness. She reports over the last 2 days has been having increased fatigue and difficulty walking. She reports non-bloody diarrhea while on antibiotics for her cellulitis that has recently decreased in frequency over the past few days. Her husband notes that this has been an abrupt change particularly in her mobility and cognition. She uses a rolling walker to ambulate and is usually very independent. She has felt unsteady and woobly and has had had several unwitnessed falls but denies head strike and LOC. She has a ___ and home ___. She denies fevers, abdominal pain, and urinary symptoms. She reports stable chronic cough for months but is more concerned about possible wheezing. She thinks her weakness may be related to the diarrhea. On arrival to the ED, initial vitals were 98.9 77 158/55 18 98% RA. No exam documented. Labs were notable for WBC 6.4, H/H 10.6/34.1, Plt 126, INR 1.0, Na 144, K 4.4, BUN/Cr ___, trop < 0.01 x 2, lactate 1.1, and negative UA. Influenza PCR was negative. Blood and urine cultures were done. Head CT was negative for acute intracranial abnormality. CXR was negative for pneumonia. Patient was given 1L NS. Discussed with Dr. ___ in Neurology who noted patient had similar symptoms before and did not feel consistent with MS flare. Discussed case with ___ fellow who recommended admission to ___ vs. HMED if overflow. Prior to transfer vitals were 98.6 79 153/72 16 96% RA. On arrival to the floor, patient reports feeling okay. She denies any pain. She denies fevers/chills, night sweats, headache, vision changes, dizziness/lightheadedness, shortness of breath, hemoptysis, chest pain, palpitations, abdominal pain, nausea/vomiting, hematemesis, hematochezia/melena, dysuria, hematuria, and new rashes. Past Medical History: PAST ONCOLOGIC HISTORY: She was followed for several years for lymphadenopathy with diagnosis on biopsy in ___, which at that time was felt to be a low-grade lymphoma. She then was noted for a probable transformation to large cell lymphoma and she received EPOCH with an excellent response followed by autologous stem cell transplantation in ___. At the beginning of ___, Ms. ___ was noted for increasing adenopathy as well as increasing lymphocytosis. The initial speculation was this was a CLL type picture, but karyotype and cytogenetic analysis was done on her peripheral blood, which demonstrated a highly complex karyotype with reciprocal translocation of 2 and 7. These were also noted on her initial B-cell lymphoma as well as in addition to other chromosome abnormalities, now present. Review of her previous tissue block showed that there was similarity in the clonal peak suggesting that this was in fact a relapse of her lymphoma in a more atypical CLL like picture. Because of Ms. ___ ongoing MS issues, we have been carefully evaluating treatment while exploring allogeneic transplantation options and she has proceeded forward with rituximab treatment. As she was responding to monotherapy with Rituxan, we have been continuing this with one dose, now every 12 weeks(extending the interval). We are attempting to keep her at a lymphocyte count of ~ 20%. In addition, she has been continuing on IVIG every 6 weeks, as she remains hypogammaglobulonemic and to prevent infections which can be quite debilitating in the setting of her MS. ___ MEDICAL HISTORY: - Progressive MS - Chronic Pain - Chronic Raynaud's - Hypertension Social History: ___ Family History: Grandmother with diabetes. MGF had bowel cancer. Physical Exam: ON ADMISSION ============= VS: Temp 98.5, BP 122/59, HR 78, RR 18, O2 sat 97% RA. GENERAL: Pleasant woman, in no distress, lying in bed comfortably. HEENT: Anicteric, PERLL, OP clear. CARDIAC: RRR, normal s1/s2, no m/r/g. LUNG: Appears in no respiratory distress, clear to auscultation bilaterally, no crackles, wheezes, or rhonchi. ABD: Soft, non-tender, non-distended, positive bowel sounds. EXT: Warm, well perfused, ___ bilateral lower extremity edema, bilateral lower extremity symmetric erythema likely consistent with chronic venous stasis dermatitis. NEURO: A&Ox3, good attention and linear thought, CN II-XII intact. Strength full throughout. Sensation to light touch intact. SKIN: No significant rashes. ACCESS: Right chest wall port without erythema. ON DISCHARGE ============= 98 133/57 77 ___ GENERAL: Chronically-ill appearing lady in no distress, lying in bed comfortably. HEENT: Anicteric, PERLL, OP clear. CARDIAC: RRR, normal s1/s2, no m/r/g. LUNG: Appears in no respiratory distress, clear to auscultation bilaterally, except for faint ronchi in RUL. ABD: Soft, non-tender, non-distended, positive bowel sounds. EXT: Warm, well perfused, ___ bilateral lower extremity edema, bilateral lower extremity symmetric hematic pigmentation consistent with chronic venous stasis dermatitis, no induratin or warmth NEURO: A&Ox3, fluent speech, linear thought process, CN II-XII intact. Strength full throughout. Sensation to light touch intact. SKIN: No significant rashes. ACCESS: Right chest wall port without erythema. Pertinent Results: ___ 12:10PM BLOOD WBC-6.4 RBC-4.03 Hgb-10.6* Hct-34.1 MCV-85 MCH-26.3 MCHC-31.1* RDW-17.6* RDWSD-54.0* Plt ___ ___ 06:00AM BLOOD WBC-2.9* RBC-3.58* Hgb-9.4* Hct-30.2* MCV-84 MCH-26.3 MCHC-31.1* RDW-17.3* RDWSD-54.2* Plt ___ ___ 12:10PM BLOOD Glucose-127* UreaN-29* Creat-1.3* Na-144 K-4.4 Cl-102 HCO3-29 AnGap-13 ___ 06:00AM BLOOD Glucose-84 UreaN-30* Creat-1.1 Na-144 K-4.2 Cl-106 HCO3-26 AnGap-12 ___ 06:57AM BLOOD ALT-18 AST-23 LD(LDH)-225 AlkPhos-70 TotBili-0.2 ___ 12:10PM BLOOD cTropnT-<0.01 ___ 05:50PM BLOOD cTropnT-0.01 ___ 12:10PM BLOOD Calcium-9.0 Mg-2.3 ___ 06:00AM BLOOD Calcium-8.3* Phos-3.8 Mg-2.1 ___ 06:57AM BLOOD IgG-555* IgA-13* IgM-12* ___ 01:00PM URINE RBC-4* WBC->182* Bacteri-FEW* Yeast-NONE Epi-1 Brief Hospital Course: Mrs. ___ is a ___ female with history of secondary progressive MS ___ neurocognitive impairment, relapsed B-cell lymphoma s/p auto SCT (___) on rituximab/IVIG, and chronic L>R lower extremity edema with recent admission for LLE cellulitis presenting with weakness and difficulty ambulating following protracted antibiotic associated diarrhea. Improved with IVF. Found to have UTI which was treated. Discharged to rehab. # Weakness # Unsteady gait # Falls Most likely due to hypovolemia secondary to increased GI losses in setting of diarrhea given significant improvement in weakness with overnight infusion of 1L NS. Admitting physician discussed with Dr. ___ felt presentation unlikely to correspond to MS flare. Per husband not quite back to baseline but improved. ___ recommended rehab. #Progressive Multiple Sclerosis #Cognitive impairment #Mood disorder in setting of primary organic brain disease #Functional difficulty Difficult to establish baseline but per husband there has been some decline, perhaps in setting of 3 recent hospital admissions. No new focal deficit suggestive acute MS flare. Progressively improved from the cognitive and functional point of view during hospital stay. She was continued on home adderall, baclofen, pregabalin and duloxetine. Was evaluated by OT who recommended OT for self-care. #Cystitis: New dysuria with >182WBCs in UA. At risk for antibiotic associated diarrhea. Allergic to TMP/SMX and quinolones and beta-lactams at highest risk for AAD. Received fosfomycin 3g x1 with resolution. ___, resolved: Cr baseline at 1.0. 1.3 on admission. Improved to 1.0 with 1L IVF. # Antibiotic Associated Diarrhea: Recently received amoxicillin-clavulanate and doxycycline for LLE cellulitis. Since then had diarrhea with fecal incontinence that has been tapering and appears to have resolved. Given solid stool, it was not tested for toxinogenic C.difficile given low pre-test probability for CDI. Started on S.boulardii 250mg bid x12d # Relapsed lymphoma # s/p Autologous SCT On rituximab and IVIG q6h weeks. With lymphocyte count <20% (established goal). Thrombocytopenia and leukopenia likely secondary to incomplete engraftment after ablative conditioning. IgG >500, no need for IVIG at this time. Discussed with Dr. ___ dose to be deferred by 1 month. # Hypertension: Lisinopril has been on hold since last admission. TRANSITIONAL ISSUES: ==================== 1. Bilateral lower extremity erythema: Secondary to venous stasis. At increased risk for cellulitis but please have very high threshold for empiric treatment as she gets significant side-effects from antibiotics. 2. Frequent UTIs: Secondary to neurogenic bladder due to MS. ___ beta-lactams or quinolones in this patient given higher risk of antibiotic associated diarrhea. Consider 1 time dose of fosfomycin. 3. Probiotics: If absolute need to treat with antibiotics consider concurrent treatment with S.boulardii 250mg bid x10-14d. 4. Close follow-up: Please contact the offices of the 3 providers above prior to discharge from rehab to schedule close follow-up. This patient's discharge plan took 45 minutes to be formulated and co-ordinated. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. dextroamphetamine-amphetamine ___ mg oral BID 2. FiberCon (calcium polycarbophil) 625 mg oral DAILY 3. Vitamin E 200 UNIT PO DAILY 4. calcium carb-magnesium ox,carb 200 mg calcium- 100 mg oral DAILY 5. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 6. DULoxetine 120 mg PO DAILY 7. Multivitamins 1 TAB PO DAILY 8. Pregabalin 150 mg PO TID 9. Vitamin D 1000 UNIT PO DAILY 10. Lactobacillus acidophilus 1 billion cell oral DAILY 11. Baclofen 25 mg PO QAM 12. Baclofen 25 mg PO QPM 13. Baclofen 20 mg PO QHS Discharge Medications: 1. Ascorbic Acid ___ mg PO BID 2. Florastor (Saccharomyces boulardii) 250 mg oral BID Duration: 10 Days 3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 4. Baclofen 25 mg PO QAM 5. Baclofen 25 mg PO QPM 6. Baclofen 20 mg PO QHS 7. calcium carb-magnesium ox,carb 200 mg calcium- 100 mg oral DAILY 8. dextroamphetamine-amphetamine ___ mg oral BID 9. DULoxetine 120 mg PO DAILY 10. FiberCon (calcium polycarbophil) 625 mg oral DAILY 11. Multivitamins 1 TAB PO DAILY 12. Pregabalin 150 mg PO TID 13. Vitamin D 1000 UNIT PO DAILY 14. Vitamin E 200 UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ ___ Diagnosis: Weakness Hypovolemia Acute kidney injury, pre-renal Antibiotic-associated diarrhea Urinary Tract Infection Progressive Multiple Sclerosis Relapsed B-cell lymphoma Stem cell transplant status Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear ___, ___ were admitted to the hospital with weakness and difficulty ambulating in the setting of dehydration from protracted antibiotic-associated diarrhea. Your energy and renal function improved with IV fluids. ___ also developed a urinary tract infection which we treated. ___ were assessed by Physical and Occupational Therapists who determined ___ would benefit from going to rehab to improve your mobility, safety and functionality. It was a pleasure to take care of ___, Your ___ Team Followup Instructions: ___
19570901-DS-35	19,570,901	26,341,724	DS	35	2165-03-15 00:00:00	2165-03-15 22:11:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: linezolid / Bactrim / allopurinol Attending: ___ Chief Complaint: Falls, altered mental status Major Surgical or Invasive Procedure: None History of Present Illness: CC: altered mental status, falls HPI(4): Ms. ___ is a ___ year old female with PMH of Non-Hodgkin's Lymphoma s/p Auto SCT with recurrence on chronic IVIG/rituxan, multiple sclerosis and bilateral venous stasis, who presents with confusion and multiple falls. Patient is only able to provide a limited history secondary to her altered mental status. Her husband reports that over the past few weeks she has had several falls, and this morning seemed much more confused than normal. He has not witnessed any of the falls, but has seen that she seems unbalanced, often starting to fall backwards. She did also fall forwards a few weeks ago, resulting in a black eye. The patient herself also agrees that she has been falling backwards recently. She believes all of her falls are due to poor balance, and denies any chest pain, shortness of breath, or dizziness. She notes that she had a headache in the back of her head after a big fall, but otherwise has not had headaches or vision changes. She does have some issues with ambulation due to her MS and poor sensation in her feet, but her husband notes that the confusion is new. The patient's husband notes that her legs have been more red than normal and her ulcers have been oozing. She is followed closely by a dermatologist, who felt that she likely had a superimposed cellulitis bilaterally, and started Bactrim a week ago. However, this did not seem to improve her symptoms. Minocycline was added, but her husband still without improvement. Her husband notes that she has a history of cellulitis, which at times has been in both legs and has improved with antibiotics. He states that this has also caused her to be confused before, similar to how she is currently. He states that she does not typically have MS flares. Per review of records, patient was last hospitalized at ___ from ___. At this time she was treated for LLE cellulitis. She was started on vancomycin and transitioned to Bactrim to complete a 10 day course. In the ED: Initial vital signs were notable for: T 98.0, HR 72, BP 125/81, RR 16, 99% RA Exam notable for: VS, no fever. She is responding slowly, but appropriately. Oriented to self and place, but unable to recall details of events immediately preceding presentation to the ED. Otherwise normal neuro exam. MM dry. port w/o signs of infection. Exam otherwise notable for b/l ___ L>R, erythema, warmth. There are several draining ___ skin ulcers. Labs were notable for: - CBC: WBC 5.6 (72%n), hgb 9.7, plt 175 - Lytes: 140 / 103 / 27 AGap=15 ------------- 76 4.4 \ 22 \ 1.2 - Trop <0.01 - lactate 0.5 - u/a negative - CSF with 3 WBC, 0 poly, 63%l, 34%m; 29 protein, 54 glucose Studies performed include: - CXR with low lung volumes but no acute findings - NCHCT with no acute intracranial process. Small left frontal scalp hematoma. No fracture. - CT c-spine w/o contrast with no acute fracture or malalignment. Degenerative changes similar to prior. Motion artifact somewhat limits evaluation through the lower C-spine at C7-T1 Patient was given: ___ 17:51 IV Morphine Sulfate 4 mg ___ 18:00 IVF LR 1000 mL ___ 21:01 PO/NG Pregabalin 150 mg ___ 21:03 PO/NG Baclofen 20 mg Vitals on transfer: HR 73, BP 147/77, RR 14, 95% RA Upon arrival to the floor, patient states that she has back pain, but is unable to fully characterize. Otherwise recounts history as above. ROS: Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative. Past Medical History: - Progressive MS ___ frequent UTI ___ neurogenic bladder, and fecal incontinence) - Chronic Pain - Chronic Raynaud's - Hypertension - b/l venous stasis - Non-Hodgkin's lymphoma - s/p auto SCT in ___ with recurrence on maintenance Rituxan (q12w)/IVIG(q6w) Oncologic history: "She was followed for several years for lymphadenopathy with diagnosis on biopsy in ___, which at that time was felt to be a low-grade lymphoma. She then was noted for a probable transformation to large cell lymphoma and she received EPOCH with an excellent response followed by autologous stem cell transplantation in ___. At the beginning of ___, Ms. ___ was noted for increasing adenopathy as well as increasing lymphocytosis. The initial speculation was this was a CLL type picture, but karyotype and cytogenetic analysis was done on her peripheral blood, which demonstrated a highly complex karyotype with reciprocal translocation of 2 and 7. These were also noted on her initial B-cell lymphoma as well as in addition to other chromosome abnormalities, now present. Review of her previous tissue block showed that there was similarity in the clonal peak suggesting that this was in fact a relapse of her lymphoma in a more atypical CLL like picture. Because of Ms. ___ ongoing MS issues, we have been carefully evaluating treatment with some exploration of allogeneic transplantation options and she has proceeded forward with rituximab treatment. As she was responding to monotherapy with Rituxan, we have been continuing this with one dose, now every 12 weeks (extending the interval). We are attempting to keep her at a lymphocyte count of ~ 20%. In addition, she has been continuing on IVIG every 6 weeks, as she remains hypogammaglobulonemic and to prevent infections which can be quite debilitating in the setting of her MS" Social History: ___ Family History: Grandmother with diabetes. MGF had bowel cancer. Physical Exam: ADMISSION: ========== VITALS: T 97.8, HR 79, BP 142/64, RR 20, 94% RA GENERAL: Awake and alert, but confused, requires prompting multiple times EYES: Anicteric, pupils 2-3mm ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate. Able to do chin to chest without pain. Neck is supple. CV: Heart regular, no murmur, no S3, no S4. No JVD. RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, non-distended, non-tender to palpation. Bowel sounds present. No HSM GU: No suprapubic fullness or tenderness to palpation MSK: Neck supple, moves all extremities, globally weak. BACK: no spinal tenderness to palpation EXT: Bilateral lower extremities with 2+ edema past knees with bilateral erythema from ankles to calves. Multiple shallow ulcers bilaterally with no appreciated underlying fluid collection NEURO: Alert, oriented with prompting, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs, sensation to light touch grossly intact throughout. Requires assistance with advanced commands, and often answering questions inappropriately PSYCH: pleasant, appropriate affect IV ACCESS: Port in place with no surrounding erythema or discharge DISCHARGE: ========== 24 HR Data (last updated ___ @ 820) Temp: 97.2 (Tm 98.9), BP: 150/71 (122-150/61-71), HR: 57 (57-78), RR: 18, O2 sat: 94% (94-99), O2 delivery: Ra GENERAL: lying comfortably in bed in NAD EYES: Anicteric, PERRL ENT: OP clear CV: Heart regular, no murmur, no S3, no S4. No JVD. RESP: Decreased BS at bases b/l but poor inspiratory effort GI: Abdomen soft, non-distended, non-tender to palpation. Bowel sounds present. No HSM GU: No suprapubic fullness or tenderness to palpation MSK: Lower ext warm with trace pitting edema BACK: No vertebral TTP SKIN: Multiple, shallow non-drainage ulcers of the anterior shins b/l; erythema b/l from the mid-shins to ankles, receding from marked ___ boundary and improved from admission NEURO: AOx3, following commands, CN II-XII intact, ___ strength all ext, sensation grossly intact to the light touch throughout, gait not tested, no meningismus PSYCH: pleasant, appropriate affect IV ACCESS: Port in place with no surrounding erythema or discharge Pertinent Results: ADMISSION: ========= ___ 01:29PM BLOOD WBC-5.6 RBC-3.71* Hgb-9.7* Hct-31.3* MCV-84 MCH-26.1 MCHC-31.0* RDW-16.7* RDWSD-51.6* Plt ___ ___ 01:29PM BLOOD Neuts-71.9* Lymphs-12.1* Monos-14.2* Eos-0.9* Baso-0.5 Im ___ AbsNeut-4.06 AbsLymp-0.68* AbsMono-0.80 AbsEos-0.05 AbsBaso-0.03 ___ 01:29PM BLOOD ___ PTT-31.0 ___ ___ 01:29PM BLOOD Glucose-76 UreaN-27* Creat-1.2* Na-140 K-4.4 Cl-103 HCO3-22 AnGap-15 ___ 01:29PM BLOOD ALT-19 AST-25 AlkPhos-81 TotBili-<0.2 ___ 01:29PM BLOOD cTropnT-0.01 ___ 01:29PM BLOOD Albumin-3.4* Calcium-8.6 Phos-3.5 Mg-2.0 ___ 05:00AM BLOOD ___ Folate-13 ___ 04:17AM BLOOD calTIBC-267 ___ Ferritn-48 TRF-205 ___ 05:00AM BLOOD TSH-3.4 ___ 01:29PM BLOOD CRP-64.4* ___ 05:17AM BLOOD IgG-437* ___ 01:38PM BLOOD Lactate-0.5 DISCHARGE: ========== ___ 06:00AM BLOOD WBC-3.4* RBC-3.54* Hgb-9.3* Hct-30.1* MCV-85 MCH-26.3 MCHC-30.9* RDW-16.7* RDWSD-52.3* Plt ___ ___ 06:00AM BLOOD WBC-3.6* RBC-3.61* Hgb-9.4* Hct-30.7* MCV-85 MCH-26.0 MCHC-30.6* RDW-16.8* RDWSD-52.9* Plt ___ ___ 06:00AM BLOOD Neuts-45.4 ___ Monos-14.0* Eos-5.1 Baso-1.2* Im ___ AbsNeut-1.52* AbsLymp-1.07* AbsMono-0.47 AbsEos-0.17 AbsBaso-0.04 ___ 06:00AM BLOOD Glucose-77 UreaN-27* Creat-0.9 Na-142 K-4.7 Cl-105 HCO3-26 AnGap-11 ___ 06:00AM BLOOD Calcium-8.6 Phos-3.9 Mg-1.7 WBC 3.6 (from 4.2), Hgb 9.4 (from 9.3), Plt 217 Na 142, K 4.7, BUN 27 (from 24), Cr 0.9 Ca/Mg/Phos WNL Prior: LFTs WNL CK 167 Trop 0.01 CRP 64 Lact 0.5 IgG 437 B12 ___, folate 13 Iron 25, Ferritin 48, TIBC 267 Hapto 190 TSH 3.4 Stox neg UTox + for amphetamines (prescribed) UA (___): mod bld, neg nit, 30 prot, lg ___, 18 RBCs, 117 WBCs, few bact, <1 epi UA (___): negative UCx (___): negative C.diff (___): negative CSF (___): 3 TNC, 1 RBC, 0 polys, Tprot 29, Glu 54 CSF cx (___): negative HCV PCR (___): negative BCx (___): pending x 2 UCx (___): negative Skin swab (___): MRSA _________________________________________________________ STAPH AUREUS COAG + \| CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ <=0.5 S IMAGING: ======== - ___ CT chest w/con 1. Left lower lobe airspace disease corresponding to finding on MRI and suspicious for pneumonia. Correlate with fever and/or elevated white blood cell count. 2. Small bilateral pleural effusions which are likely reactive. 3. 1.6 cm nodule left lobe of the thyroid gland which has demonstrated minimal interval enlargement compared to prior CT from ___ favoring a benign thyroid nodule. Recommend non-urgent outpatient thyroid ultrasound for further characterization if not already performed. 4. Additional chronic changes as above. - ___ TTE: Suboptimal image quality. Mild symmetric left ventricular hypertrophy with normal cavity size and regional/global biventricular systolic function (EF 62%). Mild-moderate aortic regurgitation with mildly thickened leaflets. Mild mitral regurgitation. - ___ MRI T/L spine: 1. Central focus of abnormal high signal signal on T2 weighted images in the posterior spinal cord at T6-T7 without enhancement. This is compatible with the clinical history of multiple sclerosis. 2. Mild degenerative changes of the lumbar spine. 3. Left lower lobe consolidation. Moderate-sized bilateral pleural effusions. RECOMMENDATION(S): CT chest with contrast is recommended. - ___ Chest x-ray (PA): Comparison to ___. No relevant change is noted. Lung volumes are low. Moderate cardiomegaly with enlargement of the left ventricle. Right pectoral Port-A-Cath in situ. No pneumonia, no pulmonary edema, no pleural effusions. No pneumothorax. - ___ CT c-spine w/o contrast: No acute fracture or malalignment. Degenerative changes similar to prior. Motion artifact somewhat limits evaluation through the lower C-spine at C7-T1. - ___ NCHCT: No acute intracranial process. Small left frontal scalp hematoma. No fracture. - ___ EKG: NSR, rate 70, PR 150, QTc 427, No ST depressions or elevations Brief Hospital Course: ___ year old female with PMH of Non-Hodgkin's lymphoma s/p auto SCT (___) with recurrence on chronic IVIG/rituxan, multiple sclerosis, bilateral venous stasis who presents with AMS and possible lower extremity cellulitis in setting of multiple recent falls. # Encephalopathy: Patient presented with transient AMS in the setting of multiple recent falls. Unclear etiology, suspect toxic metabolic in setting of possible cellulitis (see below). No clear initial evidence for alternate infection (initial CXR and UA/UCx without evidence of UTI/PNA). MRI of spine performed later in her hospitalization (see below) did reveal incidental LLL infiltrate, confirmed on CT chest, but suspect aspiration pneumonitis rather than PNA in absence of fever/leukocytosis or respiratory symptoms. Ddx for transient encephalopathy includes concussion given recent head strike, medication effect (although only recent medication changes are Bactrim and minocycline for cellulitis). UTox/Stox positive only for prescribed amphetamines. NCHCT in ED without intracranial bleeding. LP performed in ED without evidence of meningitis/encephalitis. Low suspicion for stroke/TIA given non-focal exam prior to presentation per husband and on admission. Per neurology, MRI brain was not pursued. Encephalopathy resolved completely with treatment of cellulitis, and she was AOx3 at the time of discharge. # Multiple falls: # Multiple sclerosis: Patient's husband reports multiple recent falls (at least 3 in the week PTA). Description of falls sounds mechanical in the absence of premonitory symptoms or LOC, likely related to underlying MS-related gait instability (for which she uses a walker and motorized scooter at baseline). Per neurology, low suspicion for MS flare. MRI T/L spine, performed at neurology's recommendation, showed cord changes c/w hx of MS without active flare and mild degenerative disease without cord compression or cauda equina. No e/o arrhythmias, and TTE this hospitalization showed no significant AS. ___ recommended rehab. Home baclofen, adderall, lyrica, cymbalta and vitamin E were continued. She will f/u with her neurologist, Dr. ___, on ___. # Lower extremity cellulitis vs # Chronic venous stasis: Patient with hx of chronic venous stasis and lower extremity ulcers w/cellulitis (prior swabs w/MRSA) followed by outpatient dermatology (Dr. ___. Was prescribed Bactrim PTA with no improvement, with minocycline added ___. Presented with b/l lower extremity edema, erythema, and warmth, concerning for cellulitis, although bilaterality would be unsual. In absence of clear source of encephalopathy, however, and given that she is immunosuppressed (on rituxan), she was started on Vancomcyin with improvement in her erythema. She was transitioned to Augmentin/Doxycylcine with evidence of ongoing improvement prior to discharge and will complete a 10d course (___). She will f/u with dermatology (Dr. ___ in ___ on ___. # Dysuria: # Pyuria: Complained of transient dysuria while hospitalized. Initial UA negative, but subsequent UA (via straight cath) showed pyuria but negative UCx. She was briefly treated with CTX (___). Dysuria had resolved at discharge. # LLL infiltrate: # B/l pleural effusions: Initial CXR in ED negative. MRI of the spine performed for w/u of falls revealed possible LLL infiltrate. F/u CT chest showed a LLL infiltrate and small b/l pleural effusions; suspect aspiration pneumonitis (in setting of recent fall and encephalopathy) rather than PNA in absence of hypoxia, fevers, or leukocytosis. Small effusions were of unclear etiology, but doubt parapneumonic. TTE this hospitalized showed preserved EF and only mild-mod MR/AR. She was not treated with dedicated pneumonia coverage, although her discharge regimen for cellulitis (Augmentin/Doxycycline) would likely be adequate for aspiration pneumonia. Would repeat CXR as outpatient to document resolution of LLL infiltrate. # Non-Hodgkin's lymphoma: S/p auto SCT ___ with recurrence on maintenance Rituxan/IVIG. Last IVIG infusion on ___ (held ___ for HTN), last Rituxan dose on ___. IgG level 437, borderline low. CT chest this admission without evidence of disease progression in the chest. She was not treated with IVIG while hospitalized. Next IVIG session scheduled for ___, but her oncologist, Dr. ___, was emailed to request a sooner infusion at the patient's request. F/u with Dr. ___ is scheduled for ___. # Normocytic anemia: Hgb 9.7 on admission, at baseline. Stable this hospitalization and 9.3 at discharge, without evidence of active bleeding or hemolysis. Iron studies suggestive of possible iron deficiency (TIBC sat 9%, ferritin 48). Ferrous sulfate every other day initiated on discharge. Further w/u deferred to outpatient providers. # Leukopenia: WBC nl on admission, dipped to 3.4 at the time of discharge (ANC 1520). Of note, pt does have a hx of intermittent chronic leukopenia, likely in setting of lymphoma and Rituxan. As above, suspected cellulitis appeared to be improving and there was no clear evidence of alternate infection. Would recommend repeat CBC w/diff in ___ days at rehab to ensure resolution of leukopenia. # Acute kidney injury: Cr 1.2 on admission, improved to 1.0 with hydration in ED. Cr 0.9 on the day prior to discharge. # Diarrhea: Likely from antibiotics. C.diff negative. Resolved spontaneously. # Thyroid nodule: 1.6 cm thyroid nodule incidentally seen on CT chest. Recommend non-urgent outpatient thyroid U/S if not previously performed. TRANSITIONAL [ ] repeat CBC w/diff in ___ days to ensure resolution of leukopenia and stability of anemia [ ] Augmentin/Doxycycline for cellulitis through ___ [ ] CXR in ___ weeks to ensure resolution of LLL infiltrate [ ] further w/u of chronic anemia as outpatient [ ] non-urgent thyroid U/S for thyroid nodule # Contacts/HCP/Surrogate and Communication: Husband ___ ___ Cell phone: ___ # Code Status/Advance Care Planning: Full (confirmed) Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild/Fever 2. Amphetamine-Dextroamphetamine 10 mg PO BID 3. Baclofen 25 mg PO BID 4. Baclofen 20 mg PO QHS 5. DULoxetine 120 mg PO DAILY 6. Pregabalin 150 mg PO TID 7. Vitamin D ___ UNIT PO DAILY 8. Vitamin E 200 UNIT PO DAILY 9. Cal-Mag (calcium carb-magnesium ox,carb) 200 mg calcium- 100 mg oral DAILY 10. FiberCon (calcium polycarbophil) 625 mg oral DAILY 11. Lactaid (lactase) 3,000 unit oral TID W/MEALS 12. Probiotic (S.boulardii) (Saccharomyces boulardii) 250 mg oral unknown 13. Sulfameth/Trimethoprim DS 2 TAB PO BID 14. Amphetamine-Dextroamphetamine ___ mg PO DAILY PRN brain fog 15. Minocycline 100 mg PO Q12H Discharge Medications: 1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Continue through ___. Docusate Sodium 100 mg PO BID:PRN Constipation - Second Line 3. Doxycycline Hyclate 100 mg PO BID Continue through ___. Ferrous Sulfate 325 mg PO EVERY OTHER DAY 5. Senna 8.6 mg PO BID:PRN Constipation - First Line 6. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild/Fever 7. Amphetamine-Dextroamphetamine 10 mg PO BID 8. Amphetamine-Dextroamphetamine ___ mg PO DAILY PRN brain fog 9. Baclofen 25 mg PO BID 10. Baclofen 20 mg PO QHS 11. Cal-Mag (calcium carb-magnesium ox,carb) 200 mg calcium- 100 mg oral DAILY 12. DULoxetine 120 mg PO DAILY 13. FiberCon (calcium polycarbophil) 625 mg oral DAILY 14. Lactaid (lactase) 3,000 unit oral TID W/MEALS 15. Pregabalin 150 mg PO TID 16. Probiotic (S.boulardii) (Saccharomyces boulardii) 250 mg oral unknown 17. Vitamin D ___ UNIT PO DAILY 18. Vitamin E 200 UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ ___ Diagnosis: Falls Cellulitis Multiple sclerosis Non-Hodgkin's lymphoma Anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. ___, You were admitted to the hospital with falls, transient confusion, and likely cellulitis. You were treated with antibiotics with improvement in your cellulitis and will complete a 10-day course of these antibiotics with outpatient dermatology follow-up. In addition, you were seen by the neurologists, who found no evidence of an MS flare. You were evaluated by physical therapy, who believe you would benefit from a short stay in a rehab facility prior to discharge home. With best wishes for a speedy recovery, ___ Medicine Followup Instructions: ___
19570901-DS-37	19,570,901	28,708,519	DS	37	2165-10-08 00:00:00	2165-10-11 09:49:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: linezolid / allopurinol Attending: ___. Chief Complaint: swollen, red leg, altered mental status and fever Major Surgical or Invasive Procedure: None History of Present Illness: HISTORY OF PRESENT ILLNESS: ___ is a ___ year old woman w/PMH progressive MS, HTN, lymphedema, recurrent cellulitis (admitted ___ for LLE cellulitis), NHL in remission (NOT on therapy), who presents with altered mental status and fever. Per patient's husband, she was not acting like herself this morning. He found her covered in urine and noticed redness of the right leg. He says she is baseline AAOx3, ambulates with walker at home. He checked her temp and it was 102.9. He reports she has had low PO intake over the last 24 hours as well. He reports no new cough or SOB. The patient is more alert on my assessment and does not have any acute complaints. Husband thinks she is not back at full baseline but much better. She describes a upper left quadrant pain which she attributes to rib fractures from ___ years ago, not a new issue. Denies other abdominal or suprapubic pain. Of note, she had a recent admission here for cellulitis of the left leg due to a traumatic injury, and has had this wound managed by wound care upon discharge. She also has h/o UTIs due to neurogenic bladder. She has fecal incontinence as well and follows with CRS. For her NHL, she is off rituximab but is still supposed to be getting IVIG, but due to shortage has not received in months. She is scheduled tomorrow for appt for this. In the ED: - Initial vital signs were notable for: T 99.6 HR 86 BP 132/74 RR 18 SpO2 97% RA - Exam notable for: redness overlying right shin with bullae noted, legs nontender to palpation. - Labs were notable for: WBC 11.7 Hgb 9.9 CRP 65.7 K 6.5 (hemolyzed) repeat K 3.7, flu negative, UA with 15 WBC - Studies performed include: CXR - small to moderate b/l pleural effusions CT RLE - soft tissue edema involving entire calf and knee, skin thickening posteriorly c/w cellulitis, no evidence of necrotizing fasciitis. R ___ - right calf veins not visualized due to pain, no DVT in right femoral or popliteal veins, significant soft tissue swelling in R popliteal fossa. - Patient was given: IVF LR IV Piperacillin-Tazobactam IV Vancomycin Pregabalin 150 mg Baclofen 25 mg - Consults: none. Past Medical History: - Progressive MS ___ frequent UTI ___ neurogenic bladder, and fecal incontinence) - Chronic Pain - Chronic Raynaud's - Hypertension - b/l venous stasis - ___ lymphoma - s/p auto SCT in ___ with recurrence on maintenance Rituxan (q12w)/IVIG(q6w) - Neurogenic bladder - Breast cancer (___) - Macular degeneration - ___ - Depression Social History: ___ Family History: Grandmother with diabetes. MGF had bowel cancer. Uncle with ___ lymphoma and Aunt with NHL. Physical Exam: ADMISSION PHYISCAL EXAM: ============================ ADMISSION PHYSICAL EXAM: VITALS: Per POE GEN: pleasant elderly female in NAD HEENT: MM slightly dry CV: Heart regular, no murmur, rubs or gallops RESP: Lungs with reduced BS bibasilar, clear to auscultation bilaterally otherwise, no respiratory distress GI: Abdomen soft, non-distended, non-tender to palpation MSK: Neck supple, moves all extremities. Port site CDI inright chest wall EXT: large area of erythema overlying right shin/calf within margins of marker, cool to touch. LLE wrapped with ACE, upon unwrapping has small well healing wound over left shin with zinc powder covering the area. NEURO: AAOx3, able to complete days of week backwards, face symmetric, gaze conjugate with EOMI,speech fluent, moves all limbs PSYCH: pleasant, appropriate affect DISCHARGE PHYISCAL EXAM: ============================ ___ 0728 Temp: 98.2 PO BP: 172/66 HR: 71 RR: 18 O2 sat: 92% O2 delivery: Ra GENERAL: Pleasant, lying in bed comfortably HEENT: Normocephalic, atraumatic, PERRLA, EOMI, sclerae anicteric, no conjunctival discharge CARDIAC: Regular rate and rhythm, normal S1+S2, systolic ejection murmur best heard at the apex LUNG: Normal work of breathing, clear to auscultation in upper lung fields bilaterally, diminished breath sounds bilateral lower lung fields ABD: Nontender, nondistended, normal bowel sounds EXT: Warm, bilateral lower extremity edema L>R, left lower extremity wrapped, right lower extremity erythema largely within drawn borders, bullae more tense today, warm to touch, nontender to palpation NEURO: Alert, oriented, CN II-XII intact, moving all extremities, more detail exam deferred SKIN: As above, port in R upper chest wall Pertinent Results: ADMISSION LABS: ==================== ___ 12:32PM BLOOD WBC-11.7* RBC-3.87* Hgb-9.9* Hct-31.4* MCV-81* MCH-25.6* MCHC-31.5* RDW-16.9* RDWSD-49.2* Plt ___ ___ 12:32PM BLOOD Neuts-81.6* Lymphs-7.8* Monos-9.5 Eos-0.3* Baso-0.4 Im ___ AbsNeut-9.56* AbsLymp-0.92* AbsMono-1.11* AbsEos-0.04 AbsBaso-0.05 ___ 12:32PM BLOOD ___ PTT-38.0* ___ ___ 12:32PM BLOOD Glucose-91 UreaN-17 Creat-1.0 Na-137 K-6.5* Cl-103 HCO3-23 AnGap-11 ___ 12:32PM BLOOD Calcium-8.2* Phos-3.9 Mg-2.0 ___ 12:32PM BLOOD CRP-65.7* ___ 12:35PM BLOOD Lactate-0.8 K-3.7 PERTINENT IMAGING: ==================== LOWER EXTREMITY DOPPLERS IMPRESSION: 1. Right calf veins were not evaluated due to patient pain. Otherwise, no deep venous thrombosis visualized in the right femoral and popliteal veins. 2. Significant soft tissue swelling in the right popliteal fossa. CT LOWER EXTREMITY IMPRESSION: 1. Soft tissue edema involving the entire calf and visualized knee, and skin thickening, predominantly posteriorly is most consistent with cellulitis. 2. No evidence for necrotizing fasciitis. 3. Trace knee joint effusion. PERTINENT MICRO: ==================== ___ 3:20 pm URINE *FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. ___ 12:32 pm BLOOD CULTURE Blood Culture, Routine (Pending): No growth to date. DISCHARGE LABS: ==================== ___ 06:00AM BLOOD WBC-5.3 RBC-3.74 Hgb-9.6* Hct-31.5* MCV-84 MCH-25.7* MCHC-30.5* RDW-17.1* RDWSD-52.0* Plt ___ ___ 06:00AM BLOOD Glucose-81 UreaN-22* Creat-1.1 Na-146 K-4.3 Cl-105 HCO3-28 AnGap-13 ___ 06:00AM BLOOD Calcium-8.4 Phos-3.7 Mg-2.0 Brief Hospital Course: TRANSITIONAL ISSUES =================== [] Patient was not able to attend IVIG appointment for NHL. Please ensure this is rescheduled (per oncologist, defer until infection has resolved). [] CXR demonstrated stable pleural effusions since CT chest from ___. Please f/u for symptoms and repeat CXR to assess for resolution. [] Patient and husband reported desire to re-establish care with a psychiatrist/therapist and may need assistance to accomplish this. [] Patient should re-establish care with cognitive neurology. [] Patient should be referred to ___ wound clinic # CODE: FULL # CONTACT/HCP: Husband (___) ___ (cell) BRIEF HOSPITAL SUMMARY: ======================= ___ is a ___ year old woman w/PMH progressive MS, HTN, lymphedema, recurrent cellulitis (admitted ___ for LLE cellulitis), NHL on IVIG therapy, who presented with altered mental status and fever found to have a right lower extremity cellulitis. While inpatient, Ms. ___ was closely monitored and her fever curve was trended. She remained afebrile during her time in the hospital. Her WBC count also downtrended and returned to normal. The right lower extremity was imaged and did not have gas on CT imaging, ruling out necrotizing fasciitis. There was a single flaccid bullae with a large overlying area of erythematous but non-purulent skin which was felt to be related to skin stretching from cellulitis. She was started on IV ceftriaxone and vancomycin for treatment of cellulitis and narrowed to PO Bactrim and Keflex after discharge from the hospital. While here, the patient also had a chest x-ray that demonstrated bilateral pleural effusions. These effusions were stable from a prior CT done in ___. There was little concern for newly acquired pneumonia. A UTI was also ruled out with reassuring UA and urine culture. ACTIVE ISSUES ============= #Fever, altered mental status, RLE cellulitis Patient presented with fever and altered mental status. Per exam and imaging, presentation most likely in the setting of RLE cellulitis. She has a LRINEC score of 2 and had no evidence of deep tissue infection on exam or on CT, so less likely necrotizing fasciitis. LLE wound appeared clean without evidence of infection. Given she is immunosuppressed ___ NHL treatment, she was treated with broad spectrum IV antibiotics (vancomycin and ceftriaxone) and will transition to PO Bactrim and Keflex for a total 7 day course for the treatment of cellulitis. Erythema and tenderness improving at time of discharge. Mental status at baseline at discharge and patient remained afebrile inpatient. #Pleural effusions CXR demonstrated bilateral pleural effusions but effusions are stable since ___ on CT imaging. Source of effusions likely from prior PNA. Patient does not have any respiratory complaints or hypoxemia. Suspicion for new PNA on this admission was low. #CHRONIC ISSUES: =============== ___ Lymphoma Patient underwent auto SCT ___ with recurrence now on maintenance IVIG therapy (prior treatment with Rituxan). Due to IVIG shortage, the patient has not had infusion in a few months. She was originally due to have treatment today ___ but due to admission will have to reschedule after discharge. Dr. ___ ___ oncologist) made aware of this admission. #Multiple Sclerosis Patient was continued on home duloxetine, Lyrica, baclofen, and amphetamine-dextroamphetamine #Fecal Incontinence Patient is followed by CRS outpatient. While inpatient, patient was continued on home loperamide and psyllium. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO BID:PRN Pain - Mild/Fever 2. Amphetamine-Dextroamphetamine 15 mg PO BID 3. Baclofen 25 mg PO BID 4. Baclofen 20 mg PO QHS 5. DULoxetine ___ 120 mg PO DAILY 6. LOPERamide 2 mg PO QID:PRN loose stool 7. Pregabalin 150 mg PO TID 8. Vitamin D 1000 UNIT PO DAILY 9. Vitamin E 200 UNIT PO DAILY 10. Culturelle (Lactobacillus rhamnosus GG) 10 billion cell oral DAILY 11. Digest Probiotic (S.boulardii) (Saccharomyces boulardii) 250 mg oral DAILY 12. Psyllium Powder 1 PKT PO QAM Discharge Medications: 1. Cephalexin 500 mg PO Q6H 2. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 5 Days 3. Acetaminophen 650 mg PO BID:PRN Pain - Mild/Fever 4. Amphetamine-Dextroamphetamine 10 mg PO TID 5. Baclofen 25 mg PO BID 6. Baclofen 20 mg PO QHS 7. Culturelle (Lactobacillus rhamnosus GG) 10 billion cell oral DAILY 8. Digest Probiotic (S.boulardii) (Saccharomyces boulardii) 250 mg oral DAILY 9. DULoxetine ___ 120 mg PO DAILY 10. LOPERamide 2 mg PO QID:PRN loose stool 11. Pregabalin 150 mg PO TID 12. Psyllium Powder 1 PKT PO QAM 13. Vitamin D 1000 UNIT PO DAILY 14. Vitamin E 200 UNIT PO DAILY Discharge Disposition: Home With Service Facility: ___ ___: PRIMARY DIAGNOSIS ================= Right lower extremity cellulitis SECONDARY DIAGNOSIS =================== ___ Lymphoma Multiple sclerosis Lymphedema Fecal incontinence Discharge Condition: Mental Status: Alert and oriented. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory Discharge Instructions: Dear Ms. ___, It was a privilege taking care of you at ___ ___. WHY WAS I ADMITTED TO THE HOSPITAL? =================================== You were admitted to the hospital because you had a fever and were disoriented in the setting of a skin infection in your right lower extremity. WHAT HAPPENED WHILE I WAS IN THE HOSPITAL? ========================================== - While you were in the hospital, you were closely monitored for signs of infection. You did not have a fever and your white blood cell count (cells that fight infections) returned to normal. - You received imaging (chest x-ray, CT of your right leg, ultrasound of your right leg) to determine the source and severity of the infection. The imaging and exam showed that you have a skin infection of the right lower leg. - You were treated for the skin infection in your right lower leg with IV antibiotics (vancomycin and ceftriaxone). - You did NOT receive your scheduled IVIG treatment for your ___ lymphoma. Please be sure to reschedule this appointment after your discharge from the hospital. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? ============================================ - Please take your antibiotics Bactrim and Keflex for 5 more days (last dose on ___. - Please go to your follow up appointment with your primary care physician. - Please follow up with your oncologist, Dr. ___ rescheduling your IVIG treatment. We wish you all the best! Sincerely, Your ___ Care Team Followup Instructions: ___
19570901-DS-38	19,570,901	22,074,823	DS	38	2165-11-28 00:00:00	2165-11-28 20:24:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: linezolid / allopurinol Attending: ___. Chief Complaint: AMS, fever Major Surgical or Invasive Procedure: None History of Present Illness: HISTORY OF PRESENT ILLNESS: ___ year old woman w/PMH progressive MS, HTN, lymphedema, recurrent cellulitis (admitted ___ for LLE cellulitis and ___, NHL on IVIG therapy, who presented with altered mental status and fever. ___ family member reports that patient has been having several days of altered mental status, and somnolence. Patient had a fever 100.5 this morning. Patient otherwise denies any cough, chest pain, shortness of breath, abdominal pain. Has baseline level of diarrhea without bloody stools or black tarry stools. Denies any dysuria. Has chronic lower leg erythema from recurrent cellulitis. No recent dramatic change in leg. No recent falls or trauma. In the ED: - Initial vital signs were notable for: T 98.6, HR 83, BP 174/71, RR 16, O2 sat 90% on RA - Exam notable for: General: Resting in bed and sleepy, but arousable. AN0x2 Cardiac: RRR no rgm Pulmonary: Clear to auscultation bilaterally, no crackles/wheezes Abdominal/GI: No tenderness or masses Renal: No CVA tenderness MSK: No deformities or signs of trauma. Erythema noted in the bilateral extremities. 1+ pitting edema bilaterally to the lower extremities. Psych: Normal judgment, mood appropriate for situation - Labs were notable for: -CBC 6.0 < 9.1 / 29.0 < 200 -___ 10.3, PTT 103.9, INR 0.9 -Na 141, K 4.1, Cl 104, bicarb 27, BUN 21, Cr 0.9, Gluc 83, AG 10 -lactate 0.4 -Flu A/B PCR negative -UA negative - Studies performed include: CT Head W/O Contrast: No acute intracranial abnormality CXR: Right sided vascular access catheter tip at the cavoatrial junction. Patient is rotated. Cardiomediastinal silhouette is unchanged. Right basilar atelectatic changes. Small-to-moderate bilateral pleural effusions with compressive atelectatic changes, underlying infiltrate cannot be excluded. Lungs are low in volume. - Patient was given: 1L LR, Vancomycin 1g - Consults: none Vitals on transfer: HR 77, BP 168/66, RR 14, O2 sat 94% on RA Upon arrival to the floor, history obtained from patient and her husband ___ notes that ___ had her IVIG infusion on ___, and when she arrived home she was disoriented. She seemed slightly better by ___ but again woke up ___ confused. ___ notes that she had missed several months of IVIG iso shortage and restarted ___ weeks ago; at that time, she was also disoriented after infusion, so he was not very concerned about this presentation. She slept most of ___ and again was confused ___ morning with a fever, prompting ED visit. ___ has been having intermittent diarrhea, which has been unchanged over the past few days. She denies nausea, vomiting, or abdominal pain. She denies dysuria, but has had some urinary incontinence, not new for her. In terms of possible cellulitis, she has chronic LLE swelling and erythema which has been mostly stable, however she did drop something on her LLE on ___, resulting in an open wound which they have been dressing at home. The wound was leaking profusely initially but stopped by ___. ___ reports pain in her LLE. She also endorses a recent cough, sometimes productive of sputum, over the past week. She denies dyspnea or URI symptoms. She denies chest pain, nausea, vomiting, dysuria. No recent sick contacts. REVIEW OF SYSTEMS: Complete ROS obtained and is otherwise negative. Past Medical History: - Progressive MS ___ frequent UTI ___ neurogenic bladder, and fecal incontinence) - Chronic Pain - Chronic Raynaud's - Hypertension - b/l venous stasis - ___ lymphoma - s/p auto SCT in ___ with recurrence on maintenance Rituxan (q12w)/IVIG(q6w) - Neurogenic bladder - Breast cancer (___) - Macular degeneration - SCC - Depression Social History: ___ Family History: Grandmother with diabetes. MGF had bowel cancer. Uncle with ___ lymphoma and Aunt with NHL. Physical Exam: ADMISSION PHYSICAL EXAM =============================== VITALS: ___ Temp: 98.5 PO BP: 166/74 R Lying HR: 80 RR: 18 O2 sat: 95% O2 delivery: RA GENERAL: Alert and interactive, not lethargic. In no acute distress. EYES: NCAT. PERRL, EOMI. Sclera anicteric and without injection. ENT: MMM. No cervical lymphadenopathy. No JVD. NECK: no nuchal rigidity CHEST: R POC c/d/I, no tenderness CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. RESP: Clear to auscultation bilaterally with decreased breath sounds bilaterally at the bases. No wheezes, rhonchi or rales. No increased work of breathing. ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. No organomegaly. No CVAT or suprapubic tenderness. MSK: No spinous process tenderness. Pulses DP/Radial 2+ bilaterally. 2+ pitting ___ edema, tender to palpation L>R. SKIN: Warm. Cap refill <2s. Erythema noted in b/l ___ from ankle to below knee. On LLE, there is a 2cm open ulcer with overlying scab, that is more tender to palpation and warm to touch, no drainage noted. No other open wounds. NEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal sensation. AOx3. Somewhat slowed speech and movements (improved per husband) PSYCH: appropriate mood and affect DISCHARGE PHYSICAL EXAM =============================== GENERAL: Alert and interactive. In no acute distress. EYES: Sclera anicteric and without injection. CARDIAC: Regular rate and rhythm. Normal S1 and S2. No murmurs/rubs/gallops. RESP: Decreased breath sounds bilaterally at the bases. No wheezes, rhonchi or rales. No increased work of breathing. ABDOMEN: Normal bowels sounds, non distended, nontender to palpation. No organomegaly. MSK: Pulses DP/Radial 2+ bilaterally. 2+ pitting ___ edema, tender to palpation L>R. SKIN: Erythema noted in ___ from ankle to below knee. LLE: bandaged 2cm ulcer with overlying scab, tender to palpation, warm to touch, no drainage noted. NEUROLOGIC: CN2-12 grossly intact. AOx3. Can name the days of the week backward. Somewhat slowed speech and movements. PSYCH: appropriate mood and affect Pertinent Results: ADMISSION LABS =========================== ___ 01:52PM BLOOD WBC-6.0 RBC-3.58* Hgb-9.1* Hct-29.0* MCV-81* MCH-25.4* MCHC-31.4* RDW-17.9* RDWSD-52.5* Plt ___ ___ 01:52PM BLOOD ___ PTT-103.9* ___ ___ 01:52PM BLOOD Glucose-83 UreaN-21* Creat-0.9 Na-141 K-4.1 Cl-104 HCO3-27 AnGap-10 ___ 07:05AM BLOOD ALT-18 AST-22 LD(LDH)-221 AlkPhos-97 TotBili-<0.2 ___ 07:05AM BLOOD Calcium-8.3* Phos-3.3 Mg-2.0 ___ 01:52PM BLOOD CRP-15.6* ___ 01:59PM BLOOD Lactate-0.4* DISCHARGE LABS =========================== ___ 05:01AM BLOOD WBC-6.5 RBC-3.22* Hgb-7.9* Hct-26.1* MCV-81* MCH-24.5* MCHC-30.3* RDW-18.0* RDWSD-52.3* Plt ___ ___ 05:01AM BLOOD Glucose-98 UreaN-27* Creat-1.2* Na-144 K-4.1 Cl-108 HCO3-26 AnGap-10 ___ 05:01AM BLOOD Calcium-8.0* Phos-3.7 Mg-2.0 PERTINENT STUDIES =========================== ___ CT HEAD WO CONTRAST No acute intracranial abnormality. Brief Hospital Course: ================================================ TRANSITIONAL ISSUES ================================================ [] Patient is being discharged with antibiotics to complete a 7 day course of Cephalexin and Bactrim (last day ___ [] ___ husband expressed concerns with difficulty with continuing to care for patient at home. He would benefit from increased resources at home if this can be arranged. [] Patient was noted with elevated blood pressures. Given review of her outpatient notes, and both her provider and ___ hesitation to start hypertensive medications, the decision was made to defer initiation inpatient. [] Patient had a mild elevation in her Cr. This was thought secondary to initiation of Bactrim given the timing. Please recheck her labs following completion of antibiotics to ensure resolution of Cr. [] Patient on discharge with Hgb 7.9 reflecting a downtrend thought likely ___ hemodilution of lab sample. Recommend repeat CBC within week for Hgb monitoring. ================================================ BRIEF HOSPITAL COURSE ================================================ ___ with progressive MS, HTN, lymphedema, recurrent cellulitis (admitted ___ and ___, and NHL s/p Rituximab ___ hypogammaglobulinemia on maintenance IVIG, who presented with altered mental status and fever thought ___ lower extremity cellulitis vs IVIG reaction. Her symptoms improved with initiation of antibiotics for cellulitis. ACTIVE ISSUES #. Fever Prior admissions ___ and ___ for cellulitis, most recently treated with IV vanc and CTX, transitioned to PO Bactrim and Keflex for total 7d course with clinical improvement. CXR with bilateral pleural effusions, could not rule out infectious process, though low clinical suspicion. Lactate normal. UA unremarkable. Flu swab negative. Patient with chronic diarrhea, unchanged currently, w/o nausea, vomiting or abdominal pain. Meningitis/encephalitis less likely as AMS has been mild and is already improving, with no nuchal rigidity. Overall most concerning for recurrent cellulitis. Given improvement on CTX and IV Vanc, transitioned patient to oral Cephalexin and Bactrim to complete a 7 day course (___). #. AMS Patient presented lethargic but arousable, A&Ox2 in the ED. NCHCT negative for acute intracranial abnormality. A&Ox3 on the floor, but did appear slow to respond with word finding difficulties initially. The following day, patient appeared much improved. After discussion with her husband, her symptoms appeared resolved and back to baseline. Suspect etiology likely represents encephalopathy iso infectious process as above vs secondary to recent IVIG infusion that has largely resolved. Low suspicion for primary neuro infection. CHRONIC ISSUES #Chronic anemia At baseline (Hb ___. #NHL on IVIG therapy ___ Lymphoma Patient underwent auto SCT ___ with recurrence now on maintenance IVIG therapy (prior treatment with Rituxan), last received ___. #Progressive MS ___ home Amphetamine-Dextroamphetamine 15 mg PO BID, DULoxetine ___ 120 mg PO DAILY, Pregabalin 150 mg PO TID, Baclofen 25 mg PO BID (___), Baclofen 20 mg PO QHS, home duloxetine, lyrica, baclofen and amphetamine-dextroamphetamine #HTN Longstanding with SBPs at home from the 100-170s. Elevated to 170s here. Patient reports she has an agreement with PCP to use lifestyle modifications for BP control. Deferred initiation inpatient. #Fecal incontinence Patient is followed by CRS outpatient. Continued home Psyllium Powder 1 PKT PO QAM. Started LOPERamide 2 mg PO TID standing with good improvement in her diarrhea #PAML Cont home Vitamin D 1000 UNIT PO DAILY, Vitamin E 200 UNIT PO DAILY CORE MEASURES: ============== #CODE: Full #CONTACT: Husband (___) ___ (cell) Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO BID:PRN Pain - Mild/Fever 2. Amphetamine-Dextroamphetamine 15 mg PO BID 3. Baclofen 25 mg PO BID 4. Baclofen 20 mg PO QHS 5. DULoxetine ___ 120 mg PO DAILY 6. LOPERamide 2 mg PO QID:PRN loose stool 7. Pregabalin 150 mg PO TID 8. Psyllium Powder 1 PKT PO QAM 9. Vitamin D 1000 UNIT PO DAILY 10. Vitamin E 200 UNIT PO DAILY 11. Culturelle (Lactobacillus rhamnosus GG) 10 billion cell oral DAILY 12. Digest Probiotic (S.boulardii) (Saccharomyces boulardii) 250 mg oral DAILY 13. Cal-Mag (calcium carb-magnesium ox,carb) 200 mg calcium- 100 mg oral DAILY Discharge Medications: 1. Cephalexin 500 mg PO QID 2. Ramelteon 8 mg PO QPM:PRN insomnia 3. Sulfameth/Trimethoprim DS 1 TAB PO BID 4. LOPERamide 2 mg PO TID 5. LOPERamide 2 mg PO BID:PRN loose stool 6. Acetaminophen 650 mg PO BID:PRN Pain - Mild/Fever 7. Amphetamine-Dextroamphetamine 15 mg PO BID 8. Baclofen 25 mg PO BID 9. Baclofen 20 mg PO QHS 10. Cal-Mag (calcium carb-magnesium ox,carb) 200 mg calcium- 100 mg oral DAILY 11. Culturelle (Lactobacillus rhamnosus GG) 10 billion cell oral DAILY 12. Digest Probiotic (S.boulardii) (Saccharomyces boulardii) 250 mg oral DAILY 13. DULoxetine ___ 120 mg PO DAILY 14. Pregabalin 150 mg PO TID 15. Psyllium Powder 1 PKT PO QAM 16. Vitamin D 1000 UNIT PO DAILY 17. Vitamin E 200 UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY ======= Fever Altered Mental Status Cellulitis SECONDARY ========= Multiple Sclerosis ___ Lymphoma HTN Fecal incontinence 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: ================================================ PATIENT DISCHARGE INSTRUCTIONS ================================================ Dear Ms. ___, It was a pleasure taking care of you at the ___ ___! WHY WAS I IN THE HOSPITAL? - You were admitted due to concerns for confusion and fevers. WHAT HAPPENED IN THE HOSPITAL? - It was thought you had another episode of cellulitis, which may have resulted in your confusion. We gave you antibiotics which seemed to improve your symptoms. WHAT SHOULD I DO WHEN I LEAVE THE HOSPITAL? - Be sure to take your medications as prescribed and attend the appointments listed below. Thank you for allowing us to be involved in your care, we wish you all the best! Your ___ Healthcare Team Followup Instructions: ___
19571143-DS-18	19,571,143	29,142,366	DS	18	2175-02-01 00:00:00	2175-02-05 07:34:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: aspirin / Tedral Attending: ___. Chief Complaint: acute-onset low back pain, fevers Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old female presenting transferred from ___ for ___ spinal abscess. Patient was in her usual state of health until 1 week prior to presentation when she developed a headache and fatigue. She was tolerating this until 5 days prior to presentation when she developed rapid onset of chills, rigors, and fever to 102. The next day she noticed pain in her lower back. She was self-treating at home with tylenol for fever and vicodin for pain relief. She reported persistent fevers to 100 over the 2 days prior to presentation with continued back pain and decreased appetite. Her PCP recommended further ___ and referral to the ___. She had an MRI demonstrating fluid collection between the spinous processes of L2-L3. Patient denied any weakness, numbness/tingling, urinary or bowel symptoms. Her WBC was 11 at ___. On arrival to the ___ ___ initial VS were 96.9 73 122/66 14 100% RA. Physical exam revealed a normal rectal tone, normal neuro exam and gait. Her back was tender to palpation over L3-L4. Labs were unremarkable with lactate 0.9, WBC 7.6. Per spine service, the imaging finding was not epidural but rather interspinal and in the surrounding soft tissues. Denied weakness numbness to legs or any bowel or bladder incontinence. Even though patient was afebrile with improving symptoms, further eval with contrast MRI was recommended to rule out osteomyelytis. VS before transfer to the floor: 97.7 76 137/73 16 100% Past Medical History: asthma polypectomy hysterectomy R mastectomy R menisectomy hypothyroidism Social History: ___ Family History: brother: esophageal cancer father: lymphoma Physical ___: Admission Exam: VS: T98.3, BP140/62, HR69, RR16, O2sat 99%RA GENERAL: well appearing HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM NECK: supple LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART: RRR, no MRG, nl S1-S2 ABDOMEN: normal bowel sounds, soft, non-tender, non-distended, no rebound or guarding, no masses EXTREMITIES: no edema BACK: point tenderness over patient's left lower back in the paraspinal area, otherwise benign NEURO: awake, A&Ox3, CNs II-XII grossly intact, muscle strength ___ throughout, sensation grossly intact throughout, DTRs 2+ and symmetric SKIN: patchy macular rash over patient's back with diffuse itchiness Discharge Exam: VS: Tm 98.5 Tc 98.3, BP 99-166/71-84, P 69, R 18 98%RA GENERAL: NAD HEENT: sclerae anicteric, MMM, OP clear HEART: RR, nl S1/S2, no MRG LUNGS: CTAB ABDOMEN: Soft, non-tender, non-distended, +BS, no guarding EXTREMITIES: WWP, no edema SKIN: Warm and dry, scarlet maculo-papular rash with escoriations diffusely over back NEURO: A&Ox3, ___ strength ___ throughout, ___ sensation intact to touch, pinprick and proprioception, normal gait LOW BACK: improved tenderness to palpation over L2-L3 and L3-L4 Pertinent Results: ___ 07:30PM LACTATE-0.9 ___ 06:00PM GLUCOSE-109* UREA N-9 CREAT-0.7 SODIUM-142 POTASSIUM-3.9 CHLORIDE-107 TOTAL CO2-28 ANION GAP-11 ___ 06:00PM CRP-66.2* ___ 06:00PM WBC-7.6 RBC-4.34 HGB-13.6 HCT-40.9 MCV-94 MCH-31.4 MCHC-33.3 RDW-11.5 ___ 06:00PM NEUTS-59.0 ___ MONOS-6.2 EOS-1.9 BASOS-0.3 ___ 06:00PM PLT COUNT-283 ___ 06:00PM ___ PTT-28.5 ___ MRI with and without contrast ___ Signal changes and enhancement between the spinous processes of L2 and L3 are likely secondary to degenerative pannus formation, from likely 'kissing' spinous processes. However, associated infection cannot be completely excluded on MRI appearances alone and clinical correlation recommended. No evidence of discitis or intraspinal abscess. No epidural abscess or paraspinal abscess. No spinal stenosis. CT without contrast ___. No fluid collection was found between the L2-3 spinous processes. A 2 cc saline rinse was performed via a spinal needle and sent for culture to evaluate for bacteria growth. Results pending. No complications. 2. Suspect that the fluid seen on MRI represents infectious or inflammatory process around spinous process pseudoarthrosis. Echochardiogram ___ The left atrium is mildly dilated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). The estimated cardiac index is normal (>=2.5L/min/m2). 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. No masses or vegetations are seen on the aortic valve. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. Trivial mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: Normal global and regional biventricular function. Trivial mitral regurgitation. Normal pulmonary artery systolic pressures. Microbiology: strep pneumo (sensitive to ceftriaxone) Brief Hospital Course: This is a ___ year old female who presented to ___ ___ with low grade fevers for one week and low back pain for five days, transferred to ___ to work up MRI finding of a fluid collection between the posterior spinal processes of L2-L3, found to be + for strep pneumo. ACTIVE ISSUES #) Low back pain: This patient presented with low back pain of acute onset 2 days after spiking fevers. MRI WC was concerning for infectious vs. inflammatory process between L2-L3 lumbar spinous processes. Per Neuroradiology, imaging was consistent with bursitis, but osteomielitis coould not be ruled out. An ___ guided saline wash with a spinal needle followed by aspiration were performed. Cultures of the aspirate grew sparse step pneumo. According to the assessment made by the infectious disease department, this patient may have had sinusitis, a lung or ear infection with development of rigors consistent with bacteremia. Hematogenous seeding of step pneumo to the spine or to heart valves is uncommon. However, an echocardiogram was performed and ruled out cardiovascular seeding with absent masses or vegetations. Blood cultures resulted negative. Patient remained afebrile during her hospital course. On discharge patient denied any pain at rest or with movement. Tenderness to palpation over lumbar spine improved during stay. This patient received 3 days of IV cetriaxone for treatment of possible osteomyelitis and was discharged home with a PICC line for six weeks of ceftriaxone. #) Rash: Patient presented with a maculopapular rash predominant over low back. Her skin findings worsened on hospital day ___ with escoriations over papules. Patient denied any pain over the skin but complained of itching. Both itchintg and severity of the rash improved with fexofenadine, 1% hydrocortisone cream and sarna lotion. CHRONIC ISSUES #) Hypothyroidism: Continued home medications: levothyroxine #) Asthma: Continued home medications: fluticasone propionate TRANSITIONAL ISSUES -PICC line in place for 6 week course of IV ceftriaxone -Two follow up appointment were scheduled for patient to be reevaluated for pain improvement and monitor for antibiotic therapy side effects (treatment week 2 and treatment week 6) -MRI with contrast at treatment week 6 to rule ensure resolution of infection and to evaluate for any underlying pathology of the spine to explain the nidus/seeding of this site by pneumococcus. -Weekly labs to be sent to ___ clinic ('safety' labs while on extended duration CTX therapy; OPAT is part of our ___ clinic) Medications on Admission: 1. Lorazepam 0.5 mg PO DAILY:PRN anxiety 2. Fluticasone Propionate 110mcg 2 PUFF IH DAILY 3. Levothyroxine Sodium 150 mcg PO 6X/WEEK (___) 4. Fluticasone Propionate NASAL 1 SPRY NU DAILY 5. ZYRtec NF 10 mg Oral Daily Discharge Medications: 1. CeftriaXONE 2 gm IV Q24H RX ceftriaxone 2 gram 2 grams IV daily Disp #42 Bag Refills:0 2. Hydrocortisone Cream 1% 1 Appl TP BID:PRN itching 3. Lorazepam 0.5 mg PO DAILY:PRN anxiety 4. Fluticasone Propionate 110mcg 2 PUFF IH DAILY 5. Levothyroxine Sodium 150 mcg PO 6X/WEEK (___) 6. Fluticasone Propionate NASAL 1 SPRY NU DAILY 7. ZYRtec NF* 10 mg Oral Daily 8. Outpatient Lab Work Please draw weekly CBC, BMP, ESR/CRP, LFTs starting ___. Fax results to Dr. ___ FAX: ___ Discharge Disposition: Home With Service Facility: ___ ___ Diagnosis: Primary: Strep pneumoniae bursitis/osteomyelitis Secondary: hypothyroidism Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear ___, It was a pleasure to take part in your care. You were admitted with fevers and low back pain. Imaging showed a fluid collection. Culture of the fluid from the biopsy showed bacteria. We will send you home on a 6-week course of antibiotics. Please make the following changes to your medications: 1. START ceftriaxone 2 grams ever 24 hours. You will need a repeat MRI in 6 weeks to evaluate the area with the infection. You will follow-up with your primary care doctor and they can order this. Followup Instructions: ___
19571384-DS-18	19,571,384	27,352,581	DS	18	2150-05-29 00:00:00	2150-06-04 19:36:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: lisinopril / cefaclor Attending: ___. Chief Complaint: Respiratory Failure Major Surgical or Invasive Procedure: Intubation ___ R IJ CVL ___ History of Present Illness: Ms. ___ is a ___ F with PMH CAD (s/p PCI pLAD ___, ischemic cardiomyopathy (borderline low EF; dry wt 190-195 lbs, Asthma, Stage 3 CKD, HTN, HLD, T2DM on insulin, Morbid Obesity, ?Afib who presented with shortness of breath after recent discharge from ___. Patient reports she was at home resting when she became acutely short of breath which is worsening. There is been no chest pain, fevers, nausea or epigastric pain. Patient has had a cough. Patient has never felt this way before. Of note, she was very recently admitted to ___ from ___ to ___. She presented with urinary frequency and leg pain. Her course there was notable for: - E Coli/Klebsiella UTI s/p 10 days CTX - Neuropathic leg pain, for which was trialed on flexeril/gabapentin - ___. Cr 1.2 --> 1.6, thought pre-renal, gave IVF (unclear how much), restarted BID bumex, with improvement in Cr - AFib (new diagnosis, although mentioned sporadically in chart review since last year). Team there discussed with PCP, deferred anticoagulation given deconditioning and fall risks, discharged on full dose aspirin - DM: She had intermittent asymptomatic hypoglycemia with BGs in ___, her insulin was decreased from Lantus 40 BID, Lispro 25 w/meals to Lantu 20 once daily and no prandial lispro. - On CT scan ___ she was found to have bilateral adrenal nodules (1.9 cm R, 1.2 cm L), multiple foci of enhancements in hepatic lobes(transient hepatic attenuation differences vs small hemangiomas), and minimally enlarged bilateral lymph nodes of uncertain clinical significance. In the ED, - Initial vitals were: T 97.8 HR 70 BP 116/64 RR 20 O2 94% 8L NC - Exam notable for: Initially mentating appropriately with then became so somnolent responsive to sternal rub. Lungs are diminished bilaterally with wheezes. No JVD, no murmur on cardiac exam. Trace peripheral edema - Labs notable for: 1. WBC 14.1; Hgb 9.3; Plt 289 2. BNP 14753 3. Cr 1.6, BUN 57 4. Trop-T 0.03 5. Lactate 1.7 6. VBG 7.42/55/53/37 7. ___ 16.3, INR 1.5 - Studies notable for: CXR with bilateral pleural effusions and pulmonary vascular congestion - Patient was given: ___ 01:03 IH Albuterol 0.083% Neb Soln ___ Administered in Other Location ___ 01:03 IH Ipratropium Bromide Neb ___ Administered in Other Location ___ 01:18 IV MethylPREDNISolone Sodium Succ 125 mg ___ ___ 01:18 IV Furosemide 40 mg ___ ___ 01:18 IV DRIP Nitroglycerin (0.35-3.5 mcg/kg/min ordered) ___ Started 0.5 mcg/kg/min ___ 02:31 IV Furosemide 120 mg ___ On arrival to the CCU, patient was intubated and a history could not be obtained. Past Medical History: HTN Hypercholestrolemia Hypothyroidism MI ___ - acute anterior MI. At CATH, she has a right dominant system. The left main was free of any lesions. The LAD had discrete 99% lesion in the proximal segment that was stented to 0% residual. The left circumflex coronary artery had a discrete 80% lesion. The right coronary artery had a mid 35% lesion and a proximal 40% lesion. LVEF: 50% (___) Coronary angioplasty w/ ___ reflux CKD Stage III CHF w/ normal EF RLD ___ obesity Sleep apnea Asthma Arthritis Stress incontinence Social History: ___ Family History: Both parents passed away from MI. Family history of diabetes. Physical Exam: ADMISSION PHYSICAL EXAMINATION: =============================== VS: Reviewed in metavision GENERAL: Obese, appears stated age, intubated and sedated HEENT: Normocephalic, atraumatic. Sclera anicteric. PERRL. EOMI. NECK: Supple. JVP difficult to assess iso obesity. CARDIAC: Normal rate, irregularly irregularrhythm. No murmurs, rubs, or gallops. LUNGS: No chest wall deformities or tenderness. Intubated ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No splenomegaly. EXTREMITIES: Warm, well perfused. No clubbing, cyanosis. 2+ pitting edema b/l feet, 1+ shins. SKIN: No significant skin lesions or rashes. PULSES: Distal pulses palpable and symmetric. DISCHARGE PHYSICAL EXAMINATION: =============================== VS: Temp: 98.3 (Tm 99.0), BP: 122/64 (100-125/57-73), HR: 76 (56-76), RR: 16 (___), O2 sat: 98% (96-100), O2 delivery: 1L, Wt: 192.9 lb/87.5 kg GENERAL: Obese, appears stated age lying comfortably in chair HEENT: Normocephalic, atraumatic. Sclera anicteric. PERRL. EOMI. NECK: Supple. JVP difficult to assess iso obesity. CARDIAC: Normal rate, irregularly irregular rhythm. No murmurs, rubs, or gallops. LUNGS: No chest wall deformities or tenderness. No adventitious breath sounds. ABDOMEN: Soft, non-tender, non-distended. EXTREMITIES: Warm, well perfused. No clubbing, cyanosis. trace peripheral edema b/l SKIN: No significant skin lesions or rashes. PULSES: Distal pulses palpable and symmetric. Pertinent Results: ADMISSION LABS: =============== ___ 12:52AM BLOOD WBC-14.1* RBC-3.28* Hgb-9.3* Hct-30.9* MCV-94 MCH-28.4 MCHC-30.1* RDW-16.1* RDWSD-55.8* Plt ___ ___ 12:52AM BLOOD Neuts-86.6* Lymphs-6.0* Monos-6.0 Eos-0.0* Baso-0.2 Im ___ AbsNeut-12.22* AbsLymp-0.85* AbsMono-0.84* AbsEos-0.00* AbsBaso-0.03 ___ 12:52AM BLOOD ___ PTT-33.5 ___ ___ 12:52AM BLOOD Glucose-164* UreaN-57* Creat-1.6* Na-140 K-5.0 Cl-93* HCO3-32 AnGap-15 ___ 07:17AM BLOOD ALT-78* AST-110* LD(LDH)-319* CK(CPK)-70 AlkPhos-98 TotBili-0.5 ___ 12:52AM BLOOD ___ ___ 12:52AM BLOOD Calcium-9.8 Phos-5.2* Mg-2.2 ___ 01:05AM BLOOD Lactate-1.7 PERTINENT/DISCHARGE LABS: ========================= ___ 12:52AM BLOOD cTropnT-0.03* ___ 07:17AM BLOOD CK-MB-2 cTropnT-0.04* ___ 03:04PM BLOOD CK-MB-5 cTropnT-0.03* ___ 07:17AM BLOOD TSH-12* ___ 02:39AM BLOOD D-Dimer-513* ___ 05:57AM BLOOD T4-5.9 ___ 12:52AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 05:20AM BLOOD WBC-11.2* RBC-3.13* Hgb-8.9* Hct-29.7* MCV-95 MCH-28.4 MCHC-30.0* RDW-16.0* RDWSD-55.5* Plt ___ ___ 05:20AM BLOOD ___ PTT-33.1 ___ ___ 05:20AM BLOOD Glucose-147* UreaN-72* Creat-1.2* Na-141 K-4.2 Cl-91* HCO3-39* AnGap-11 ___ 05:20AM BLOOD Calcium-8.3* Phos-3.4 Mg-2.2 IMAGING REPORTS: ================ CXR ___: Interval decrease in extent of the pulmonary edema. Mild persisting bibasilar atelectasis. No pleural effusion. TTE ___: The left atrium is elongated. The right atrium is moderately enlarged. There is no evidence for an atrial septal defect by 2D/color Doppler. The right atrial pressure could not be estimated. There is mild symmetric left ventricular hypertrophy with a normal cavity size. There is mild regional left ventricular systolic dysfunction with apical, distal septal and distal inferior akinesis/dyskinesis. Global left ventricular systolic function is normal. There is beat-to-beat variability in the left ventricular contractility due to the irregular rhythm. The visually estimated left ventricular ejection fraction is 40-45%. No ventricular septal defect is seen. There is no resting left ventricular outflow tract gradient. Tissue Doppler suggests an increased left ventricular filling pressure (PCWP greater than 18mmHg). Normal right ventricular cavity size with mild global free wall hypokinesis. There is abnormal septal motion c/w conduction abnormality/paced rhythm. The aortic sinus diameter is normal with normal ascending aorta diameter. There is no evidence for an aortic arch coarctation. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. There is no aortic regurgitation. The mitral leaflets are mildly thickened with no mitral valve prolapse. There is moderate mitral annular calcification. There is an eccentric, inferolateral directed jet of mild to moderate [___] mitral regurgitation. Due to acoustic shadowing, the severity of mitral regurgitation could be UNDERestimated. The tricuspid valve leaflets appear structurally normal. There is mild [1+] tricuspid regurgitation. There is mild pulmonary artery systolic hypertension. There is a prominent anterior fat pad with no significant pericardial effusion. IMPRESSION: Good image quality. Mild regional left ventricular systolic dysfunction c/w CAD (distal LAD territory). At least mild to moderate mitral regurgitation (may be UNDERestimated due to MAC). Increased PCWP. Compared with the prior TTE of (images not available for review) of ___ more mitral regurgitation is seen. Regional dysfunction likley not a significant change. L ANKLE XR ___: IMPRESSION: There are several small ossicles adjacent to the medial malleolus, possibly avulsion fractures, age indeterminate. Please correlate with point tenderness. Osteopenia. Degenerative changes. MICRO RESULTS: ============== NONE PERTINENT DISCHARGE LABS: =============== ___ 09:17AM BLOOD WBC-11.6* RBC-3.17* Hgb-9.1* Hct-30.0* MCV-95 MCH-28.7 MCHC-30.3* RDW-16.3* RDWSD-56.5* Plt ___ ___ 09:17AM BLOOD ___ PTT-38.2* ___ ___ 09:17AM BLOOD Glucose-248* UreaN-75* Creat-1.3* Na-140 K-4.4 Cl-94* HCO3-31 AnGap-15 ___ 09:17AM BLOOD Calcium-8.5 Phos-3.8 Mg-2.1 Brief Hospital Course: Ms. ___ is a ___ F with PMH CAD (s/p PCI pLAD ___, ischemic cardiomyopathy (borderline low EF; dry wt 190-195 lbs, Stage 3 CKD, HTN, HLD, T2DM on insulin, Morbid Obesity, new Afib who presents with hypoxemic respiratory failure, failed BiPAP, intubated. Her course was notable for significant diuresis, extubation, and clinical improvement. She was transferred to the floor and discharged with cardiology follow up. ACUTE ISSUES: ============= # ACUTE ON CHRONIC HEART FAILURE WITH BORDERLINE EF: Known ischemic cardiomyopathy, EF is estimated to be approx. 49% based on perfusion scan ___. Dry weight reportedly 190-195 lbs, on beta blocker, ___, dilt, and bumex at home. Troponin on admission very slightly elevated w/ peak 0.04, less likely a new ischemic event. EF 40-45% on TTE ___, with LV with mild sys dysfunction c/w CAD, RV with mild free wall hypokinesis. Unclear etiology of exacerbation, possibly from underdiuresis during the past 2 weeks. She was diuresed with a bumetanide gtt with good response, and quickly extubated. She was continued on her home losartan and metoprolol. Her PO diuretics were titrated to 40 mg torsemide BID. # ATRIAL FIBRILLATION in ___ was noted on ECG to be in AFib, however not a problem listed on cardiology visit. ECG on admission here shows what appears to be AFib with slow RVR. CHADSVASC 7. She was anti coagulated on apixaban 5mg BID after discussion with her cardiologist and PCP. Metoprolol was continued as above, uptitrated to 150mg daily. Home diltiazem held on discharge with adequate rate control. # L ANKLE PAIN No known recent trauma. X-ray with several ossicles adjacent to the medial malleolus, possibly avulsion fractures, age indeterminate. Pain was controlled with APAP. She was seen by physical therapy who recommended discharge to rehabilitation facility. CHRONIC ISSUES: =============== # CAD s/p PCI to pLAD in ___. Perfusion scan ___ with small region of ischemia in an OM distribution and fibrosis in the septum. Continued atorvastatin 80 mg, aspirin 81 mg, and beta blocker as above. # Normocytic Anemia Baseline hemoglobin ___, likely related to CKD. Admission Hgb here 9.3, stable from discharge from ___. # HTN. Losartan as described as above. # HLD. Continued atorvastatin as above. # T2DM Last A1c 7.1% ___. Previously on Lantus 40 AM/40 ___, Lispro 25 U TID w/ meals; At ___ noted to have BGs as low as ___ and had insulin decreased to only lantus 20 U daily. Her discharge insulin regimen was 15u Lantus at bedtime. She should have ongoing insulin titration as an outpatient. # Stage III CKD Baseline Cr appears to be 1.3-1.6. Likely related to her diabetes. Currently appears at baseline. Discharge Cr: 1.3 # Hypothyroidism. TSH here 12. Continued levothyroxine 150 mcg QD. # GERD. Continued omeprazole 40 mg QD. # Morbid Obesity/OSA. CPAP at night once extubated. TRANSITIONAL ISSUES: ==================== NEW MEDICATIONS Apixaban 5 mg PO BID Torsemide 40 mg PO BID CHANGED MEDICATIONS Aspirin 81 mg PO DAILY Glargine 15 Units Bedtime Losartan Potassium 25 mg PO BID Metoprolol Succinate XL 150 mg PO DAILY ===================== [] Discharge weight 87.5kg/192.9lb [] Diuretic regimen at discharge 40 mg torsemide BID [] Pt will be discharged with a Foley. She should have a voiding trial within 3 days of discharge to rehab. [] Insulin regimen was changed significantly during recent ___ hospitalization. Pt was still having hyperglycemia and will need ongoing close monitoring of her insulin regimen. [] TSH elevated to 12 on home levothyroxine 150mcg daily. Please titrate as needed as outpatient. [] Started on apixaban for anticoagulation for atrial fibrillation. Please monitor for compliance and for bleeding. [ ] On CT scan ___ at ___, she was found to have bilateral adrenal nodules (1.9 cm R, 1.2 cm L), multiple foci of enhancements in hepatic lobes(transient hepatic attenuation differences vs small hemangiomas), and minimally enlarged bilateral lymph nodes of uncertain clinical significance. Please pursue appropriate additional studies as an outpatient. #CODE: FULL CODE #CONTACT/HCP: ___ (daughter) Medications on Admission: The Preadmission Medication list is accurate and complete. 1. acetaminophen-codeine 300-30 mg oral Q8H:PRN 2. calcium carbonate 650 mg calcium (1,625 mg) oral DAILY 3. Diltiazem Extended-Release 180 mg PO DAILY 4. Levothyroxine Sodium 150 mcg PO DAILY 5. Losartan Potassium 50 mg PO DAILY 6. Metoprolol Succinate XL 50 mg PO DAILY 7. Omeprazole 40 mg PO DAILY 8. Oxybutynin 10 mg PO DAILY 9. Triamcinolone Acetonide 0.025% Ointment 1 Appl TP BID 10. Polyethylene Glycol 17 g PO DAILY 11. Docusate Sodium 100 mg PO DAILY 12. Gabapentin 100 mg PO DAILY 13. Bisacodyl 10 mg PR QHS:PRN constipation 14. Bumetanide 1 mg PO BID 15. Aspirin 325 mg PO DAILY 16. Atorvastatin 80 mg PO QPM 17. Glargine 20 Units Bedtime Discharge Medications: 1. Apixaban 5 mg PO BID 2. Torsemide 40 mg PO BID 3. Aspirin 81 mg PO DAILY 4. Glargine 15 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 5. Losartan Potassium 25 mg PO BID 6. Metoprolol Succinate XL 150 mg PO DAILY 7. Atorvastatin 80 mg PO QPM 8. Bisacodyl 10 mg PR QHS:PRN constipation 9. Calcium Carbonate 650 mg calcium (1,625 mg) oral DAILY 10. Docusate Sodium 100 mg PO DAILY 11. Gabapentin 100 mg PO DAILY 12. Levothyroxine Sodium 150 mcg PO DAILY 13. Omeprazole 40 mg PO DAILY 14. Oxybutynin 10 mg PO DAILY 15. Polyethylene Glycol 17 g PO DAILY 16. Triamcinolone Acetonide 0.025% Ointment 1 Appl TP BID Discharge Disposition: Extended Care Facility: ___ ___) Discharge Diagnosis: PRIMARY DIAGNOSIS ================= ACUTE ON CHRONIC SYSTOLIC HEART FAILURE ATRIAL FIBRILLATION LEFT ANKLE PAIN SECONDARY DIAGNOSIS =================== CORONARY ARTERY DISEASE NORMOCYTIC ANEMIA HYPERTENSION HYPERLIPIDEMIA TYPE 2 DIABETES MELLITUS CHRONIC KIDNEY DISEASE HYPOTHYROIDISM GASTROESOPHAGEAL REFLUX DISEASE MORBID OBESITY Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a pleasure to care for you during your admission with us! Why was I admitted to the hospital? - You were having significant trouble breathing at your rehab and your oxygen levels were low What happened while I was admitted? - You had a breathing tube placed to help your breathing. This was taken out soon after you came to the ICU - You were given medications to pee out extra fluid that was making it difficult for you to breathe - You were found to have a new diagnosis of "atrial fibrillation", which increases your risk of a stroke. We emailed your primary care doctor and your cardiologist, who agreed to start you on a blood thinner to prevent such a stroke What should I do when I go home? - Please take your medications as listed and follow up with your doctors ___ - ___ weigh yourself everyday at home and if your weight goes up by more than 3 pounds, call your cardiologist's office to schedule an appointment. We wish you all the best, Your ___ Care Team Followup Instructions: ___
19571384-DS-21	19,571,384	27,923,349	DS	21	2150-09-03 00:00:00	2150-09-03 14:55:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: lisinopril Attending: ___. Chief Complaint: Left leg pain, rash Major Surgical or Invasive Procedure: Left knee and ankle aspiration History of Present Illness: As per admitting resident h/p: ___ w/ PMH of CAD (status post PCI of the proximal left anterior descending artery in ___, heart failure ___ ischemic cardiomyopathy (LVEF ___ in ___, atrial fibrillation on warfarin, chronic kidney disease, HTN, HLD, T2DM on insulin, and morbid obesity, on 2L home oxygen presents to the emergency department with left leg swelling. She reports the pain started five days ago. The pain was described as sharp/stabbing, radiates from her knees to her toes, is intermittent, and she has been having difficulty moving her leg but cannot say if this is due to pain or because the leg is weak. This is different from her usual sciatica. Her daughter reports that she was seen by her primary care doctor two days ago for leg pain. At that time they took ___ of her knee, treated her with Keflex for a likely cellulitis, and sent a uric acid level in case this was gout. However, the pain has gotten worse so they came to the emergency department. She denies any weight gain, subjective fever, chest pain, SOB, worsening dyspnea on exertion, abdominal pain, N&V, diarrhea, or dysuria. In the ED, initial vitals: T98.8, HR 82, BP 118/55, RR 18, Sat 100% 2L NC Exam notable for: Uncomfortable, ___ Head NC/AT, no JVD RRR, no murmur CTA bilaterally, no wheezing or rhonchi Obese, abdomen soft, nontender Bilateral distal ___ swelling and erythema L>R, patient is tender over the left hip/femur and lateral knee, she is able to straight leg raise her leg off the bed and can flex at the hip, 2+ ___ pulses, sensation to light touch intact - Labs notable for: WBC 11.6 (stable since ___ Hgb 8.1 Cr 1.9 INR 3.3 BNP ___ - Imaging notable for: ___ Left: 1. No evidence of deep venous thrombosis in the left lower extremity veins. 2. Interval worsening of subcutaneous edema of the lower leg. CXR: FINDINGS: Cardiac and mediastinal silhouettes are stable, with stable enlargement of the cardiac silhouette. No focal consolidation, pleural effusion, or evidence of pneumothorax is seen. Mild pulmonary vascular congestion is seen. ___ Left Pelvis/Femur: FINDINGS: No acute fracture or dislocation is seen. There are mild to moderate degenerative changes at the hip joints bilaterally. Moderate osteoarthritic changes at the knee joint including narrowing of the medial and lateral joint compartments as well as lateral compartment and patellar spurring. There is suggestion of chondrocalcinosis in the mediolateral compartments of the knee. Partially imaged lower lumbar spine also demonstrates degenerative change. Extensive vascular calcifications are seen. IMPRESSION: No acute fracture seen. Moderate osteoarthritic changes of the hips and left knee, as above. Possible knee chondrocalcinosis. IMPRESSION: Mild pulmonary vascular congestion. - Pt given: ___ 11:06 IV Morphine Sulfate 4 mg ___ 11:06 IV Ondansetron 4 mg ___ 13:05 IV Morphine Sulfate 4 mg ___ 14:31 IV Clindamycin (600 mg ordered) ___ 14:31 IVF NS 125 mL/hr - Vitals prior to transfer: T 98.3, HR 75, BP 118/38, RR 18, Sat 98% 2L NC Upon arrival to the floor, the patient reports confirms the above history. She also reports she has had decrease PO intake over the past few days from general malaise REVIEW OF SYSTEMS: Negative except for HPI Past Medical History: HTN Hypercholestrolemia Hypothyroidism MI ___ - acute anterior MI. At CATH, she has a right dominant system. The left main was free of any lesions. The LAD had discrete 99% lesion in the proximal segment that was stented to 0% residual. The left circumflex coronary artery had a discrete 80% lesion. The right coronary artery had a mid 35% lesion and a proximal 40% lesion. LVEF: 50% (___) Coronary angioplasty w/ ___ reflux CKD Stage III CHF w/ normal EF RLD ___ obesity Sleep apnea Asthma Arthritis Stress incontinence Social History: ___ Family History: Both parents passed away from ___. Family history of diabetes. Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VITALS: ___ 1602 Temp: 98.2 PO BP: 118/64 HR: 70 RR: 18 O2 sat: 95% O2 delivery: 2L General: Alert, oriented, no acute distress Lungs: Mild Ronchi in lung bases. Abdomen: Soft, ___, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: Warm, dry, no rashes or notable lesions. Neuro: No gross motor or sensory deficits.extremities, grossly normal sensation, 2+ reflexes bilaterally. DISCHARGE PHYSICAL EXAM: ======================== General: Alert, oriented, no acute distress, 02 by NC in place. HEENT: Sclera anicteric, MMM, oropharynx clear Lungs: mild bibasilar crackles, no wheezes or rhonchi CV: Normal rate and rhythm, no murmurs, rubs, gallops Abdomen: soft, ___, no rebound tenderness or guarding Ext: Well perfused, 2+ DP pulses, trace bilateral pitting edema. Left leg erythema resolved with evidence of dryness on exam. No tenderness on palpation of left leg. Minimally decreased ROM L ankle due to pain. Full range of motion in left ankle. Bilateral changes consistent with venous stasis. Neuro: Face grossly symmetric. Moving all limbs with purpose against gravity. Not dysarthric. Pertinent Results: ADMISSION LABS: =============== ___ 10:55AM BLOOD ___ ___ Plt ___ ___ 10:55AM BLOOD ___ ___ Im ___ ___ ___ 10:55AM BLOOD ___ ___ ___ 10:55AM BLOOD Plt ___ ___ 10:55AM BLOOD ___ ___ ___ 10:55AM BLOOD ___ ___ 11:08AM BLOOD ___ INTERIM LABS: ============= ___ 01:50PM BLOOD ___ ___ 01:50PM BLOOD ___ ___ 04:50PM JOINT FLUID ___ ___ 04:50PM JOINT FLUID ___ ___ 04:50PM JOINT FLUID ___ ___ DISCHARGE LABS: =============== ___ 06:10AM BLOOD ___ ___ Plt ___ ___ 06:10AM BLOOD ___ ___ ___ 06:10AM BLOOD ___ ___ ___ 06:10AM BLOOD ___ MICROBIOLOGY: ============= ___ 4:50 pm JOINT FLUID Source: Knee. GRAM STAIN (Final ___: 3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Preliminary): NO GROWTH. *FINAL REPORT ___ Lyme IgG (Final ___: NEGATIVE BY EIA. (Reference ___. Lyme IgM (Final ___: NEGATIVE BY EIA. (Reference ___. Negative results do not rule out B. burgdorferi infection. Patients in early stages of infection or on antibiotic therapy may not produce detectable levels of antibody. IMAGING: ======== ___ Left Leg US: IMPRESSION: 1. No evidence of deep venous thrombosis in the left lower extremity veins. 2. Interval worsening of subcutaneous edema of the lower leg. ___ L Pelvis/Femur ___: IMPRESSION: No acute fracture seen. Moderate osteoarthritic changes of the hips and left knee, as above. Possible knee chondrocalcinosis. ___ L Tib/Fib ___: IMPRESSION: No acute fracture. Degenerative changes. ___ CXR: IMPRESSION: Mild pulmonary vascular congestion. Brief Hospital Course: ___ yo woman with hx of CHF (EF 50%), CAD s/p PCI in ___ for MI, IDDM, CKD, and afib (on warfarin) admitted for left leg erythema suspicious for cellulitis as well as left knee and ankle pain suspicious for gout. ACTIVE/ACUTE ISSUES: ==================== ACUTE/ACTIVE PROBLEMS: # Left Leg Cellulitis Patient reporting pain in her L leg for 5 days prior to admission. She has bilateral lower leg erythema on exam but worse on the left. Initially came in with leukocytosis to 11.6 and was started on IV clindamcyin with some improvements in the erythema, tenderness, and normalization of her WBC. No clinical signs of deeper infection throughout admission. Given clinical improvement of left leg, patient was transitioned to PO Clindamycin on ___ for a total antibiotic course of 10 days ___ - ___. She was discharged with clindamycin 450mg q6h and was instructed to continue this until ___. #Gout #Left knee/ankle pain Pain in L knee and ankle not consistent w/ cellulitis. Suspicion high for inflammatory arthritis so rheumatology was consulted. Aspiration of L knee performed, synovial fluid w/ TWC of ___ with 84% PMNs with negative gram stain and no crystals. Per conversation with rheumatology, cell count likely points towards an inflammatory picture especially in the setting of diuretic use despite lack of crystals visualized, but lyme and RA biomarkers also sent in case it was an atypical presentation of either. Uric acid levels returned elevated to 17 indicating most likely this represents gout. Patient's pain and ROM significantly improved on prednisone taper. The patient was treated with prednisone 30mg X 3 days (___) and tapered to 20mg x1 day (___), and discharge with planned taper 20mg x1 day (___), then 10mg x3 days (___), then 5mg daily until follow up with rheumatology. #T2DM Initially continued home regimen but patient required increased basal, mealtime, and sliding scale doses with prednisone treatment for gout. At discharge insulin regimen was back to home Glargine 20 nightly, and Humalog 10 with each meal. Patient will need close outpatient follow up to monitor blood glucose level as she continues prednisone taper. Insulin is managed by her PCP. Will discharge with ___ to aid in checking blood sugars and working with PCP office to titrate insulin. #Afib #Supratherapeutic INR Patient admitted with a supratherapeutic INR. Home warfarin dose held initially and then given 5mg home dose x1 when INR within therapeutic range. INR rose to 5 over next 2 days despite no additional warfarin doses and continued to be elevated to 3.4 at discharge. Etiology likely to be initially poor PO intake at admission in setting of infection and possible subsequent drug interaction with clindamycin. Patient's warfarin continued to be held at discharge and close outpatient follow up of INR is needed. Goal INR ___. She is followed by ___ clinic with ___ checks every ___ and ___. ___ on CKD Patient presenting with Cr 1.9 on admission which worsened to 2.4 on ___ and improved to 1.2 on discharge. Initially felt to be hypovolemic in the setting of infection but Cr did not improve with hydration. At this point it was felt ___ was more likely cardiorenal given extensive history of heart failure. Patient was restarted on Torsemide 60 given BID ___. Cr trended down with diuresis. Home torsemide was continued on discharge, metalozone was held given acute gout flare. #HFrEF EF on ___ TTE 50%. proBNP on admission 6159, down from ___ when last discharged ___. No current symptoms heart failure exacerbation. Continued home metoprolol, amlodipine. CXR on day prior to discharge consistent with pulmonary edema, thus patient's torsemide was resumed. Of note, once weekly dose of Metolazone discontinued in setting of Uric Acid elevation to 17 and acute gout flare as well as c/f possible overdiuresis. She was well controlled on home torsemide 60mg BID and should continue this as an outpatient. She will be at risk for HF exacerbation given her concurrent steroid therapy. Her weight on discharge was 182.1, Cr 1.2. CHRONIC/STABLE PROBLEMS: ========================== # Normocytic Anemia Chronic and stable from last admission. Likely anemia of chronic kidney disease. #CAD Continued on home aspirin, atorvastatin and metoprolol #HTN Continued on home Amlodipine 2.5 Daily #Hypothyroidism Continued on home levothyroxine 150 #GERD: Continued on home omeprazole 40 TRANSITIONAL ISSUES: ==================== []Discharged with clindamycin 650mg q6h to finish on ___ for total antibiotic course of 10 days. Please evaluate her left leg cellulitis and extend antibiotic course as needed. []Continue to monitor weight daily, continuing torsemide 60mg BID for volume control with fluid restriction of 2L. Will hold home metolazone ___ at discharge in setting of acute gout flare []Warfarin was held during admission and discharge for supratherapeutic INR (3.4). Plan to hold warfarin on d/c, with INR check on ___ by ___ with restart of home warfarin then per ___ clinic. []Continue to adjust insulin to steroid taper, was discharged on home insulin regimen. Blood sugars were controlled in ___ with home insulin regimen at time of discharge. []Discharged with steroid taper of 20mg (___), 10mg (___), and 5mg (___) for acute gout flare: to follow up with rheumatology for determination of further management >30 minutes were spent on discharge planning and coordination of care on the day of d/c. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 80 mg PO QPM 3. Calcium Carbonate 650 mg calcium (1,625 mg) oral DAILY 4. Gabapentin 100 mg PO DAILY 5. Levothyroxine Sodium 150 mcg PO DAILY 6. Magnesium Oxide 400 mg PO DAILY 7. Metoprolol Succinate XL 100 mg PO DAILY 8. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain 9. Omeprazole 40 mg PO DAILY 10. Torsemide 60 mg PO BID 11. amLODIPine 2.5 mg PO DAILY 12. Acetaminophen w/Codeine ___ TAB PO Q6H:PRN Pain - Mild 13. Losartan Potassium 50 mg PO DAILY 14. Oxybutynin 10 mg PO DAILY 15. Warfarin 5 mg PO DAILY16 16. Metolazone 5 mg PO 1X/WEEK (FR) 17. Glargine 20 Units Bedtime Discharge Medications: 1. Clindamycin 450 mg PO Q6H RX clindamycin HCl 150 mg 3 capsule(s) by mouth every 6 hours Disp #48 Capsule Refills:0 2. PredniSONE 5 mg PO DAILY please take: 4 tabs on ___ tabs daily from ___ 1 tab daily ___ onwards RX prednisone 5 mg ___ tablet(s) by mouth daily Disp #40 Tablet Refills:*0 3. Glargine 20 Units Bedtime Humalog 10 Units Breakfast Humalog 10 Units Lunch Humalog 10 Units Dinner Insulin SC Sliding Scale using HUM Insulin 4. Acetaminophen w/Codeine ___ TAB PO Q6H:PRN Pain - Mild 5. amLODIPine 2.5 mg PO DAILY 6. Aspirin 81 mg PO DAILY 7. Atorvastatin 80 mg PO QPM 8. Calcium Carbonate 650 mg calcium (1,625 mg) oral DAILY 9. Gabapentin 100 mg PO DAILY 10. Levothyroxine Sodium 150 mcg PO DAILY 11. Losartan Potassium 50 mg PO DAILY 12. Magnesium Oxide 400 mg PO DAILY 13. Metoprolol Succinate XL 100 mg PO DAILY 14. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain 15. Omeprazole 40 mg PO DAILY 16. Oxybutynin 10 mg PO DAILY 17. Torsemide 60 mg PO BID 18. HELD- Metolazone 5 mg PO 1X/WEEK (FR) This medication was held. Do not restart Metolazone until your doctor tells you to 19. HELD- Warfarin 5 mg PO DAILY16 This medication was held. Do not restart Warfarin until your doctor tells you to Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS: ================== Cellulitis Gout Acute on Chronic Kidney Disease Chronic Heart Failure with Reduced Ejection Fraction Type II Diabetes Atrial Fibrilation Supratherapeutic INR Secondary Diagnosis: ==================== CAD Chronic Anemia Hypertension Hypothyroidism GERD Morbid Obesity Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a pleasure to care for you at the ___ ___. Why did you come to the hospital? - You were admitted to the hospital because you were having left leg pain and a rash on your left leg concerning for an infection. What did you receive in the hospital? - We felt that the rash on your leg was most likely a skin infection which we treated with antibiotics. - We found that your kidney was not functioning as well as it normally should. We think this was because you had too much fluid in your body. We gave you medications to help you pee out this extra fluid and your kidneys go better - We had our rheumatology team evaluate you when it was noticed that your left knee and ankle were extremely painful. They took a fluid sample from inside your knee. The tests re performed on this fluid and on your blood told us you were most likely experiencing a condition called gout. - We stopped a medication you were taking at home called metolazone which can increase your uric acid levels. High uric acid levels are associated with gout - We treated your gout flare with a medication called prednisone. This medication makes your blood sugars high so we gave you extra insulin while you were taking prednisone. You will continue to take your insulin as you normally do when you go home. - We found that your INR was too high. We held your warfarin while your INR came back down to the level that it needs to be to prevent complications from your atrial fibrilation. You will need to continue to follow closely with your primary care physician to monitor your INR. What should you do once you leave the hospital? - Please continue to take your medications as prescribed - Please follow up with all your appointments as listed below - Weigh yourself every morning after peeing while wearing light weight loose fitting clothing. Call your primary care physician if your weight goes up more than 3 lbs, and restrict your fluid intake to 1.2L or as instructed by your PCP - ___ you have fevers, increased redness/swelling/pain of your left leg, chest pain, trouble breathing please call your physician and go to a nearby hospital. We wish you the best! Your ___ Care Team Followup Instructions: ___
19571384-DS-24	19,571,384	20,675,087	DS	24	2151-04-17 00:00:00	2151-04-19 10:10:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: lisinopril Attending: ___. Chief Complaint: Chest pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ yo F with hx of HFpEF ___ ischemic cardiomyopathy, HTN, atrial fibrillation, CKD, T2DM who presented to the ED with chest pain. Ms. ___ was recently hospitalized in ___ when she presented with chest pain and troponin that peaked at 0.25, diagnosed with an NSTEMI in the context of a UTI and cellulitis. During that hospitalization, she underwent a coronary angiogram s/p DES to LCx (___). Notably, angioplasty of an 80% LAD lesion was unsuccessful. She was discharged on triple therapy anticoagulation. Patient that at reports at 9 AM, she developed left-sided chest pain, non-radiating. She denied associated shortness of breath or pleuritic pain. The chest pain felt similar to her prior presentation. EMS was called, patient received a full dose aspirin and 3 SLN, without significant relief of her pain. In the ED, she described ___ out of 10 chest pain localized to her left chest. Past Medical History: HTN Hypercholestrolemia Hypothyroidism MI ___ - acute anterior MI. At CATH, she has a right dominant system. The left main was free of any lesions. The LAD had discrete 99% lesion in the proximal segment that was stented to 0% residual. The left circumflex coronary artery had a discrete 80% lesion. The right coronary artery had a mid 35% lesion and a proximal 40% lesion. LVEF: 50% (___) Coronary angioplasty w/ ___ reflux CKD Stage III CHF w/ normal EF RLD ___ obesity Sleep apnea Asthma Arthritis Stress incontinence Social History: ___ Family History: Both parents passed away from ___. Family history of diabetes. Physical Exam: ADMISSION PHYSICAL EXAMINATION: ================================== VS: ___ Temp: 97.6 PO BP: 156/62 HR: 18 RR: 62 O2 sat: 92% O2 delivery: 2L GENERAL: Well developed, well nourished, in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL. EOMI. Conjunctiva were pink. Mild pallor of oral mucosa NECK: Supple. JVP not elevated. CARDIAC: irregularly irregular rhythm. Normal S1, S2. No murmurs, rubs, or gallops. No thrills or lifts. Anterior chest mildly tender to palpation. LUNGS: No chest wall deformities. Respiration is unlabored with no accessory muscle use. Home O2 in place. Trace crackles at the bases bilaterally ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or peripheral edema. SKIN: Scaly pink skin over her left anterior calf (chronic and slowly improving per patient). PULSES: Distal pulses palpable and symmetric. DISCHARGE PHYSICAL EXAM: ========================== 24 HR Data (last updated ___ @ 743) Temp: 98.0 (Tm 98.1), BP: 168/70 (116-168/54-70), HR: 65 (57-67), RR: 18 (___), O2 sat: 98% (94-99), O2 delivery: Ra, Wt: 162.1 lb/73.53 kg GENERAL: Elderly woman resting comfortably in NAD. HEENT: MMM NECK: Supple. No JVP 8 cm. CARDIAC: reg rate and rhythm. Normal S1, S2. No murmurs, rubs, or gallops. LUNGS: clear bilaterally, no crackles, wheezes, or rhonchi. ABDOMEN: Soft, nontender, non-distended. BACK: No CVA tenderness, no spinal tenderness. EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or peripheral edema. SKIN: Skin thickening and erythema over bilateral calves PULSES: Distal pulses palpable and symmetric. Pertinent Results: ADMISSION LABS: =============== ___ 02:35PM BLOOD WBC-4.7 RBC-3.05* Hgb-9.3* Hct-30.6* MCV-100* MCH-30.5 MCHC-30.4* RDW-15.6* RDWSD-57.4* Plt ___ ___ 02:35PM BLOOD Neuts-63.9 ___ Monos-8.3 Eos-4.1 Baso-1.1* Im ___ AbsNeut-3.00 AbsLymp-1.04* AbsMono-0.39 AbsEos-0.19 AbsBaso-0.05 ___ 02:35PM BLOOD ___ PTT-35.8 ___ ___ 02:35PM BLOOD proBNP-6566* ___ 02:35PM BLOOD cTropnT-0.05* ___ 09:20PM BLOOD CK-MB-2 cTropnT-0.06* ___ 06:40AM BLOOD CK-MB-2 cTropnT-0.09* ___ 01:50PM BLOOD CK-MB-3 cTropnT-0.07* ___ 06:40AM BLOOD calTIBC-222* Ferritn-220* TRF-171* ___ 06:40AM BLOOD %HbA1c-8.0* eAG-183* DISCHARGE LABS: =============== ___ 09:10AM BLOOD WBC-5.3 RBC-3.16* Hgb-9.6* Hct-30.2* MCV-96 MCH-30.4 MCHC-31.8* RDW-14.7 RDWSD-52.3* Plt ___ ___ 09:10AM BLOOD ___ PTT-37.1* ___ ___ 09:10AM BLOOD Glucose-224* UreaN-71* Creat-1.2* Na-135 K-4.7 Cl-94* HCO3-25 AnGap-16 ___ 02:57PM URINE RBC-16* WBC->182* Bacteri-MANY* Yeast-NONE Epi-8 ___ 02:57PM URINE Blood-SM* Nitrite-NEG Protein-30* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG* MICRO: ====== ___ 2:57 pm URINE Source: ___. URINE CULTURE (Preliminary): KLEBSIELLA PNEUMONIAE. >100,000 CFU/mL. Piperacillin/tazobactam sensitivity testing available on request. FOSFOMYCIN Susceptibility testing requested per ___ ___ (___) (___). SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE \| AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- =>64 R CEFEPIME-------------- =>64 R CEFTAZIDIME----------- =>64 R CEFTRIAXONE----------- =>64 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 32 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R IMAGING: ======== CXR ___ Mild cardiomegaly without pulmonary edema or pleural effusion. NUCLEAR STRESS TEST ___ INTERPRETATION: This ___ year old IDDM woman with a PMH of NSTEMI ___, PCI to the LCX and failed PCI of the LAD, HFpEF, ischemic CM, AF and CKD III was referred to the lab for evaluation of chest discomfort. Due to limited mobility, the patient was infused with 0.4 mg/5ml 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 one apb. Appropriate hemodynamic response to the infusion and recovery. The regadenoson was reversed with 40 mg of caffeine IV. IMPRESSION: No anginal type symptoms or ST segment changes. Nuclear report sent separately. NUCLEAR REPORT: FINDINGS: Left ventricular cavity size is mildly enlarged. Severe distal anterior and apical defect with partial reversibility of the distal anterior portion of the defect. The area of defect is akinetic on motion images. The calculated left ventricular ejection fraction is 48%. IMPRESSION: 1. Severe distal anterior and apical defect with partial reversibility of the distal anterior portion of the defect. 2. Akinetic apical defect. 3. Mild left ventricular enlargement. Brief Hospital Course: TRANSITIONAL ISSUES: ========================= [] Torsemide decreased from 40mg BID to 40mg daily as patient presented with ___ and appeared dry to euvolemic on exam. [] Labile INR (subtherapeutic on admission) on warfarin, may benefit from transition to apixaban. Spoke with ___ ___ clinic who will be reaching out to her on ___ about the next appropriate lab draw. Should be at least done by ___. [] Noted to have (asymptomatic) sinus bradycardia with junctional rhythm this admission, metoprolol succinate decreased to 25mg daily. [] Consider whether losartan is beneficial in this ___ patient with renal failure (reduced dose to half home dose this admission). [] Discharged with a 5 day course of nitrofurantoin for Klebsiella UTI. Follow up symptoms and if persistent could consider treatment with fosfomycin (sensitivities pending at time of discharge). [] On admission, patient reported occasionally vomiting up food after eating recently. She did not have this issue during admission, however should follow up with workup as outpatient if she continues to experience these symptoms. [] Continued on colchicine dose-reduced to 0.3 mg daily for ___. Follow up kidney function and consider increasing dose to 0.6mg daily if improved. [] Ambulatory O2 sats >95% on room air this admission (had been on 2L home O2) [] Discharge weight: 162 lbs [] Discharge Cr: 1.2 [] Discharge INR: 2.0 PATIENT SUMMARY AND HOSPITAL COURSE: ===================================== ___ yo F with hx of HFpEF ___ ischemic cardiomyopathy, HTN, atrial fibrillation, CKD, T2DM s/p DES to ___ in ___ but unsuccessful LAD stenting, who presented with atypical chest pain of likely musculoskeletal etiology, course complicated by UTI. CORONARIES: Two vessel coronary artery disease. Successful PCI with drug-eluting stent of the circumflex coronary artery. Unsuccessful attempt at PTCA of LAD (lesion failed to dilate). PUMP: 50% RHYTHM: paroxysmal afib ACUTE ISSUES: =============== #Chest pain #Coronary artery disease S/p NSTEMI in ___, cath showing 2VD. S/p DES to LCx, unable to stent ___ LAD lesion. She presented with sharp left axillary pain. Troponin peaked at 0.09 and downtrended and EKGs showed no ischemic changes. Nuclear pharmacologic stress test showed severe distal anterior and apical defect with partial reversibility of the distal anterior portion of the defect, LVEF 48%, mild LV enlargement. Given the small area involved, opted for medical management. Left axillary chest pain was most consistent with a musculoskeletal etiology given her cardiac workup and that as it was reproducible on palpation and improved with lidocaine patch. Isosorbide mononitrate was started given the stress test results, however symptoms were not clearly cardiac in nature based on clinical course. #HFpEF (EF 50%) #Hypertension Suspected ___ ischemic cardiomyopathy. She appeared euvolemic to dry on admission with weight BNP 6566 (down from 17,000 last admission). Diuresis was initially held, then she was restarted on torsemide at reduced dose as Cr improved(40mg daily from home 40mg BID). She was started on isosorbide mononitrate 30mg daily given her signs of decreased perfusion on stress test. She continued on home amlodipine and losartan was dose reduced from home 25mg BID to 25mg daily. #Chronic macrocytic anemia Comparable to recent baseline Hg ___. Hx of iron deficiency anemia, iron studies this admission with normal iron levels and transferrin saturation 28%. B12 and folate normal. #Post-meal vomiting Patient reports that ever since a particular study (where she says she had something placed down her throat), she has been vomiting up food after eating. No dysphagia or odynophagia. She did not have emesis during this admission. She did have some mild epigastric discomfort that improved after eating for which she received Maalox. ================ CHRONIC ISSUES: ================ #T2DM She was initially hypoglycemic on presentation. A1c 8.0 this admission. Lantus dose was decreased and she was given insulin sliding scale. Returned back to home regimen prior to discharge. #Afib #Bradycardia She presented with subtherapeutic INR 1.7 on admission. Warfarin was initially held while on heparin gtt, then restarted. She received 2.5-3 mg this admission. Her metoprolol dose was decreased for bradycardia (see above). INR 2.0 on discharge. #Gout She was continued on colchicine 0.3mg daily, dose reduced for ___ last admission. #Hypothyroidism Continued levothyroxine 150 daily #GERD Continued omeprazole 40mg daily #OSA/OHS Uses 2L O2 at home, however was satting in upper 90's on room air this admission. #Stress incontinence Continued oxybutinin 10mg daily #Joint pains Continued gabapentin 100 daily, acetaminophen prn at bedtime Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen w/Codeine 1 TAB PO QHS 2. amLODIPine 2.5 mg PO DAILY 3. Atorvastatin 80 mg PO QPM 4. Calcium Carbonate 500 mg PO DAILY 5. Gabapentin 100 mg PO DAILY 6. Levothyroxine Sodium 150 mcg PO DAILY 7. Metoprolol Succinate XL 100 mg PO DAILY 8. Omeprazole 40 mg PO DAILY 9. Warfarin 2.5 mg PO DAILY16 10. Clopidogrel 75 mg PO DAILY to prevent stent thrombosis 11. Colchicine 0.3 mg PO DAILY 12. Lidocaine 5% Patch 1 PTCH TD QAM 13. Magnesium Oxide 400 mg PO DAILY 14. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain 15. Oxybutynin XL (NF) 10 mg Other DAILY 16. Losartan Potassium 25 mg PO BID 17. Torsemide 40 mg PO BID 18. Glargine 26 Units Bedtime Humalog 4 Units Breakfast Humalog 4 Units Lunch Humalog 4 Units Dinner Discharge Medications: 1. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 2. Metoprolol Succinate XL 25 mg PO DAILY 3. Nitrofurantoin Monohyd (MacroBID) 100 mg PO BID 4. Torsemide 40 mg PO DAILY 5. Acetaminophen w/Codeine 1 TAB PO QHS 6. amLODIPine 2.5 mg PO DAILY 7. Atorvastatin 80 mg PO QPM 8. Calcium Carbonate 500 mg PO DAILY 9. Clopidogrel 75 mg PO DAILY to prevent stent thrombosis 10. Colchicine 0.3 mg PO DAILY 11. Gabapentin 100 mg PO DAILY 12. Glargine 26 Units Bedtime Humalog 4 Units Breakfast Humalog 4 Units Lunch Humalog 4 Units Dinner 13. Levothyroxine Sodium 150 mcg PO DAILY 14. Lidocaine 5% Patch 1 PTCH TD QAM 15. Losartan Potassium 25 mg PO BID 16. Magnesium Oxide 400 mg PO DAILY 17. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain 18. Omeprazole 40 mg PO DAILY 19. Oxybutynin XL (NF) 10 mg Other DAILY 20. Warfarin 2.5 mg PO DAILY16 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY: =========== Chest pain Left shoulder musculoskeletal pain Urinary tract infection Acute kidney injury SECONDARY: ============= Diastolic heart failure due to ischemic cardiomyopathy Hypertension Atrial fibrillation Chronic kidney disease Type II diabetes mellitus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Discharge Instructions: Dear Ms ___, It was a pleasure taking care of you at ___ ___. WHY WAS I ADMITTED TO THE HOSPITAL? - You were admitted to the hospital because you had chest pain. WHAT HAPPENED WHILE I WAS IN THE HOSPITAL? - You had serial blood work and EKGs performed that showed you were not having a heart attack. - You underwent a cardiac stress test that showed decreased perfusion to a small area of the heart. You did not require a cardiac cath or any stents but received medications to help protect the heart. - You were found to have muscular pain of your left shoulder that is not believed to be related to your heart. - You were found to have a UTI and we gave you an antibiotic for it WHAT SHOULD I DO WHEN I GO HOME? - You should continue to take your medications as prescribed. - You should attend the appointments listed below. - Weigh yourself every morning, call your doctor at ___ if your weight goes up more than 3 lbs in 2 days or 5lbs in 1 week. - 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: 162 pounds. You should use this as your baseline after you leave the hospital. We wish you the best! Your ___ Care Team Followup Instructions: ___
19571473-DS-8	19,571,473	24,327,584	DS	8	2170-07-12 00:00:00	2170-07-12 09:53:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: celecoxib / codeine / hydrochlorothiazide / naproxen / Sulfa / Tramadol HCL Attending: ___ Chief Complaint: following fall from standing Major Surgical or Invasive Procedure: none History of Present Illness: Pt.is a ___ year old male with pmhx significant for prior chronic lower spine deformities s/p vertebroplasty, bradycardia s/p pacemaker placement, BPH, and DM who presents as a transfer from a nursing facility to ___ following a GLF while attempting to go to the bathroom -LOC,- nausea/vomiting, unwitnessed. Pt. states he pivoted with his back toward the toilet while using his walker fell backward hitting his upper back and right subscapular. He sustained left x2 left elbow abrasions and multiple right posterio-lateral rib fractures ___. Of note patient has had prior falls in the past with prior fractures. He endorses right sub scapular pain and pain in the lower T-spine region. Pt. endorses continued pain prior rib fx. following falls, mild SOB(currently on 4L n/c denies fevers/chills, headache, or n/v. Past Medical History: BPH DM GERD HTN Spinal Stenosis Past Surgical History: Vertebroplasty Appendectomy Btl Hernia Repairs Cataract Surgery Social History: ___ Family History: None on File Physical Exam: Physical Exam (WNL or list findings): Head: ( ) WNL Eyes: ( )WNL ENT: ( )WNL Neck: ( )WNL Respiratory: ( )WNL Cardiovascular ( )WNL Chest: ( )WNL GI: ( )WNL Genitourinary: ( )WNL Lymphatic: ( )WNL Musculoskeletal: ( )WNL Skin: ( )WNL Neurologic: ( )WNL Psychiatric: ( )WNL Pertinent Results: ___ 07:21AM BLOOD WBC-11.1* RBC-3.32* Hgb-10.1* Hct-30.2* MCV-91 MCH-30.4 MCHC-33.4 RDW-13.2 RDWSD-43.9 Plt ___ ___ 06:11AM BLOOD WBC-8.7 RBC-3.27* Hgb-9.9* Hct-29.7* MCV-91 MCH-30.3 MCHC-33.3 RDW-13.5 RDWSD-44.9 Plt ___ ___ 10:30AM BLOOD WBC-9.3 RBC-3.13* Hgb-9.6* Hct-28.8* MCV-92 MCH-30.7 MCHC-33.3 RDW-13.7 RDWSD-46.5* Plt ___ ___ 12:38AM BLOOD Neuts-85.8* Lymphs-6.5* Monos-6.6 Eos-0.1* Baso-0.2 Im ___ AbsNeut-12.56* AbsLymp-0.95* AbsMono-0.96* AbsEos-0.01* AbsBaso-0.03 ___ 11:06AM BLOOD Neuts-90.2* Lymphs-4.3* Monos-4.1* Eos-0.0* Baso-0.2 Im ___ AbsNeut-15.14* AbsLymp-0.72* AbsMono-0.68 AbsEos-0.00* AbsBaso-0.04 ___ 04:55AM BLOOD Neuts-87.2* Lymphs-5.3* Monos-6.3 Eos-0.0* Baso-0.2 Im ___ AbsNeut-13.77* AbsLymp-0.83* AbsMono-1.00* AbsEos-0.00* AbsBaso-0.03 ___ 07:21AM BLOOD Plt ___ ___ 06:11AM BLOOD Plt ___ ___ 10:30AM BLOOD Plt ___ ___ 07:21AM BLOOD Glucose-139* UreaN-19 Creat-0.9 Na-139 K-4.2 HCO3-22 AnGap-15 ___ 06:11AM BLOOD Glucose-121* UreaN-22* Creat-0.8 Na-141 K-4.0 Cl-103 HCO3-20* AnGap-18 ___ 10:30AM BLOOD Glucose-120* UreaN-24* Creat-0.9 Na-138 K-3.8 Cl-102 HCO3-22 AnGap-14 ___ 04:55AM BLOOD ALT-57* AST-81* AlkPhos-66 TotBili-0.6 ___ 04:55AM BLOOD Lipase-32 ___ 07:21AM BLOOD Calcium-8.4 Phos-2.5* Mg-2.0 ___ 06:11AM BLOOD Calcium-8.3* Phos-3.2 Mg-1.9 ___ 10:30AM BLOOD Calcium-8.2* Phos-3.1 Mg-1.8 ___ ct abd/pelvis: 1. Numerous minimally displaced posterolateral rib fractures involving the right sixth through eleventh ribs, most notably including a comminuted mildly displaced fracture involving the posterior right eighth rib and a mildly displaced fracture involving the posterior right eleventh rib. 2. No abdominopelvic hematoma. No solid organ laceration. 3. Subtle cortical irregularity involving the right inferior pubic ramus, suggestive of nondisplaced fracture. 4. Multilevel compression deformities involving the T12 through L4 vertebral bodies with associated vertebroplasty changes, likely chronic though correlation with prior imaging is recommended. 5. Numerous cystic lesions throughout the pancreas, with the largest in the distal pancreatic body measuring up to 2.4 cm. Recommend correlation with prior imaging if available, otherwise recommend dedicated MRCP follow-up in 6 months to assess for stability and further characterization. Brief Hospital Course: Rehab stay expected to be less than 30 days ___ year old male s/p vertebroplasty, bradycardia s/p pacemaker placement, BPH, and DM following fall from standing rt. rib fx ___ and pulmonary contusions. On HD1, an epidural was placed and diet was advanced. On HD2, the patient was txf to the floor on a regular diet. ___ was consulted. On HD2, the epidural dose was increased. By HD4, the epidural was capped, PO pain meds were started, and the foley was taken out. On HD5, due to an inability to void, a foley was placed and will be left in on discharge. On ___ the patient was discharged to a rehab facility in good condition with a foley in place. Foley to be discontinued at rehab facility Medications on Admission: Medications: Metformin, Timilol,Hydralazine,MVI,Metoprolol ER. Fluticasone, Finasteride,Prazosin, Tylenol, Ranitidine, Docusate, Latanoprost Discharge Medications: 1. Docusate Sodium 100 mg PO BID 2. Finasteride 5 mg PO QHS 3. HydrALAZINE 100 mg PO TID 4. Losartan Potassium 50 mg PO DAILY 5. Metoprolol Succinate XL 50 mg PO DAILY 6. Prazosin 2 mg PO QHS 7. QUEtiapine Fumarate 25 mg PO QHS 8. Simvastatin 10 mg PO QPM 9. Timolol Maleate 0.5% 1 DROP RIGHT EYE BID Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Right ___ rib fractures and pulmonary contusions Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. ___, You were admitted to the hospital after a fall and you sustained multiple right-sided rib fractures as well as a bruising of your lungs. You had an epidural placed by the Acute Pain Service to help you achieve better pain control so you could take deep breaths. The epidural was later removed and you were started on oral pain medication. Your pain is now better controlled and you are breathing more comfortably. The physical therapists have worked with you and recommend discharge to rehab so you may continue to regain your strength. You are now ready to be discharged from the hospital. Please note the following discharge instructions: * Your injury caused right-sided rib fractures which can cause severe pain and subsequently cause you to take shallow breaths because of the pain. * You should take your pain medication as directed to stay ahead of the pain otherwise you won't be able to take deep breaths. If the pain medication is too sedating take half the dose and notify your physician. * Pneumonia is a complication of rib fractures. In order to decrease your risk you must use your incentive spirometer 4 times every hour while awake. This will help expand the small airways in your lungs and assist in coughing up secretions that pool in the lungs. * You will be more comfortable if you use a cough pillow to hold against your chest and guard your rib cage while coughing and deep breathing. * Symptomatic relief with ice packs or heating pads for short periods may ease the pain. * Narcotic pain medication can cause constipation therefore you should take a stool softener twice daily and increase your fluid and fiber intake if possible. * Do NOT smoke * If your doctor allows, non-steroidal ___ drugs are very effective in controlling pain ( ie, Ibuprofen, Motrin, Advil, Aleve, Naprosyn) but they have their own set of side effects so make sure your doctor approves. * Return to the Emergency Room right away for any acute shortness of breath, increased pain or crackling sensation around your ribs (crepitus). Followup Instructions: ___
19571959-DS-18	19,571,959	23,410,939	DS	18	2138-03-27 00:00:00	2138-03-28 18:58:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / codeine / lactose Attending: ___. Chief Complaint: syncope Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ old woman with a PMHx notable only for hyperlipidemia who was in her USOH for the last 2 weeks when she began to feel intermittent chest pain/"fluttering" and difficulty breathing. She originally attributed this to panic attacks/anxiety given the recent loss of her husband. 2 days PTA, she had been on a road trip from ___, in the car for long periods of time, when she began to feel short of breath and was noticably "hyperventilating". When she was getting out of her car at her sister's driveway after a 9+ hour trip, she reports syncopizing but denies any head trauma. She felt extremely weak and SOB and then syncopized a second time once she was inside the house. Upon waking up 30 minutes later, she was brought to ___ where a CTA showed a submassive pulmonary embolus, extensive b/l upper and lower lobe PE, and a saddle emboli in the main pulmonary arteries bilaterally. She was given lovonox at OSH and transferred to ___ for evaluation of catheter-directed lysis. In the MICU, she was given 10 mg IV tPA as bolus followed by 40 mg infusion over 2 hours based on criteria from the MOPETT trial. She has never had a similar episode with clotting. She has no hx of estrogen replacement therapy. She denies ___ edema or orthopnea. In the ED, initial vital signs were: T97.9 P92 BP101/71 R18 O2 sat 99% 4L. - Labs were notable for trop 0.06, BNP 6989, plt 107, INR 1.2, d-dimer of 3828 - Studies performed include: Lower extremity dopplers which revealed occlusive acute thrombus within the right gastrocnemius vein. No DVT in the left lower extremity. EKG: Sinus tachycardia HR 108. Left axis deviation. Poor R wave progression. ST elevation in v2-V4. No signs of S1T3Q3. Otherwise wnl. ECHO: Normal left ventricular chamber size with low normal systolic function primarily due to septal interaction from RV pressure/volume overload. Moderately dilated right ventricle with significant systolic dysfunction based on fractional area change and relative preservation of apical function suggestive of acute PE ___ Sign). Trivial pericardial effusion. On arrival to the MICU, vital signs were stable. She denied any dyspnea while at rest with nasal cannula. In the MICU, she has been having DOE with associated hyperventilation. Review of Systems: (+) per HPI (-) fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, abdominal pain, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: Hyperlipidemia Breast Augmentation Surgery MRSA+ chin and forehead infection ACL repair Social History: ___ Family History: Mother- ___, T2DM Sister- ___ + ___ Cancer, ___ Denies any family hx of clotting. Physical Exam: PHYSICAL EXAM ON ADMISSION: ============================= Vitals: 83 104/67 97% on 4L GENERAL: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear NECK: supple, JVP not elevated, no LAD LUNGS: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema SKIN: no rashes NEURO: CN2-12 grossly intact PHYSICAL EXAM ON DISCHARGE: ============================= Vitals: 98.4 92/55 68 16 97% RA General: Well-appearing woman in NAD. Appears younger than age. HEENT: Normocephalic, EOMI, PERRL. Neck: Supple. No LAD noed. Lungs: CTA bilaterally CV: RRR, normal S1/S2. no m/r/g. Abdomen: Soft, non tender, nondistended. Bowel sounds slightly hyperactive Ext: Warm, well perfused, 2+ pulses b/l. No edema or swelling. Neuro: AAOx3. CNII-XII are in tact. Strength is ___ in b/l upper and lower extremities. Pertinent Results: LABS ON ADMISSION: =================== ___ 12:49AM BLOOD WBC-7.4 RBC-3.67* Hgb-11.6 Hct-34.6 MCV-94 MCH-31.6 MCHC-33.5 RDW-12.8 RDWSD-44.4 Plt ___ ___ 12:49AM BLOOD Neuts-78.3* Lymphs-15.3* Monos-5.8 Eos-0.0* Baso-0.3 Im ___ AbsNeut-5.82 AbsLymp-1.14* AbsMono-0.43 AbsEos-0.00* AbsBaso-0.02 ___ 12:49AM BLOOD ___ PTT-31.4 ___ ___ 12:49AM BLOOD Glucose-115* UreaN-10 Creat-1.0 Na-137 K-3.4 Cl-104 HCO3-22 AnGap-14 ___ 12:49AM BLOOD cTropnT-0.06* ___ 12:49AM BLOOD CK-MB-4 proBNP-___* IMAGING: ========== Lower extremity US ___: PRELIM Occlusive acute thrombus within the right gastrocnemius vein, a deep vein. No Preliminary ReportDVT in the left lower extremity. ECHO ___: Normal left ventricular chamber size with low normal systolic function primarily due to septal interaction from RV pressure/volume overload. Moderately dilated right ventricle with significant systolic dysfunction based on fractional area change and relative preservation of apical function suggestive of acute PE. Trivial pericardial effusion. ECHO ___: Focused study. Mild to moderate hypokinesis of the right ventricle. Low-normal left ventricular systolic function. Normal pulmonary artery systolic pressure. Compared with the prior study (images reviewed) of ___, the right ventricular function has improved. The right ventricular cavity size has normalized. The pulmonary artery systolic pressure is lower. Brief Hospital Course: ___ who presents with submassive pulmonary embolus in the setting of recent long car trip. #PULMONARY EMBOLUS/DVT: Provoked in the setting of long car trip. Pt is up to date on breast/cervical cancer screenings, but needs colonoscopy. She has had negative stool occult testing. Has had 4 prior miscarriages attributed to abnormal uterus. No recent weight loss, change in bowel habits to suggest colon cancer. Submassive based on elevated troponins and BNP. Hemodynamically stable, though had RV strain on echo, elevated trop, and BNP. Cardiology consulted for evaluation of need for catheter-directed thrombolysis. She receievd systemic anti-coagulation with IV heparin as well as half dose tPA according to MOPPETT trial. She was discharged on ___ on Rivaroxaban for anti-coagulation. Repeat echocardiogram before discharge showed normal RV size with mild-mod hypokinesis. #THROMBOCYTOPENIA: Likely consumptive in setting of massive pulmonary embolus. Coags normal making DIC/TTP unlikely. Platelets trended TRANSITIONAL ISSUES: - Continue Xarelto 15 mg BID for total course of 21 days (until ___ then switch to Xarelto 20mg daily - She should f/u with her PCP ___ ___ days, PCP should continue to trend platelet count - Her PCP may consider doing a more formal workup of possible coagulopathy, in particular anti-phospholipid syndrome given hx of recurrent miscarriage - She should f/u with her appt with Dr. ___ within ___ days. - She will need colonoscopy as part of routine health maintenance Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Simvastatin 20 mg PO QPM 2. temazepam 30 mg oral QHS Discharge Medications: 1. Simvastatin 20 mg PO QPM 2. temazepam 30 mg oral QHS 3. Rivaroxaban 15 mg PO BID RX rivaroxaban [___] 15 mg (42)- 20 mg (9) 1 tablets(s) by mouth twice a day Disp #1 Dose Pack Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Submassive pulmonary embolus with right ventricular strain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted to the hospital here at ___ because you were found to have a submassive pulmonary embolism. You were also found to have right ventricular strain in your heart from the embolism. In the MICU you were given tPA, a thrombolysing agent. You were also started on a heparin drip. You were transferred to the medicine floor and transitioned to Xarelto. We were able to transition you off oxygen and you were breathing well while walking. Your ECHO also showed improvement/near recovery of your right ventricular strain. It was felt that you were well enough to go home. You will need to continue xarelto 15mg BID for 19 more days (end date ___. You will then take xarelto 20mg daily indefinitely. Please follow-up with your PCP regarding your pulmonary embolism and a potential predisposition to coagulation. Please also follow-up with Dr. ___ regarding your right ventricular strain. You will also need a colonoscopy as part of routine health maintenance. It was a pleasure taking care of you, Your ___ Care Team Followup Instructions: ___
19572217-DS-11	19,572,217	21,825,136	DS	11	2188-11-11 00:00:00	2188-11-12 12:14:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Shortness of Breath Major Surgical or Invasive Procedure: none History of Present Illness: ___ y/o male with significant smoking history and recent diagnosis of CAP who presents with shortness of breath. Patient initially presented to PCP approximately one week prior with cough, initially dry but gradually productive, and SOB. He was initially seen on ___ at his PCP's office and was noted to have a lingular infiltrate on CXR and so was started on Avalox and an albuterol inhaler. He represented to his PCP today when he did not improve. His PCP subsequently referred him to the ED when he was noted to be hypoxic on routine vitals. He reports that he has been using his inhaler > ___ times/day without relief. He has smoked 1 ppd since the age of ___ (except for a few years when he quit) but has recently lost his appetite for cigarettes. He also notes poor appetite and difficulty keeping up with fluid losses. He also reports significant exhaustion. He denies any fevers or chills, CP, abdominal pain, dysuria, or hematuria. . On arrival to the ED his initial VS were 98.4 92 124/79 20 100% 4L NC. A CXR revealed a left perihilar opacity. He was started on CTX and Azithromycin as well as given Methylprednisolone 125 mg IV once and nebs. His vital signs at transfer were 98po,77,16,120/76,98 % on ___ np. . On arrival to the floor, the patient reports as above and is feeling somewhat improved. Past Medical History: 1. Hypercholesterolemia, without current treatment 2. Colonic Adenoma 3. Prostate Cancer: treated with brachytherapy years ago 4. h/o Hematuria: none at present time Social History: ___ Family History: No significant family history Physical Exam: ADMISSION PHYSICAL EXAM: VS - 98.4, 120/70, 108, 22, 93% on RA GENERAL - comfortable appearing, lying back in bed, NAD HEENT - MMM, OP clear NECK - supple, no thyromegaly, no JVD, no carotid bruits LUNGS - unlabored respirations, decreased BS at left base with egophony, diffuse wheezing HEART - PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN - NABS, soft/NT/ND, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength ___ throughout, gait not assessed . DISCHARGE PHYSICAL EXAM: VS: 96.3 (97.8) 146/92 (130-161/80-105) 93 (82-101) 20 94%RA, ambulatory sat 91-93%RA Gen: Comfortable, black male, looks stated age, seated on bed HEENT: MMM, EOMI, clear orophyarnx Neck: Supple, no cervical LAD, no carotid bruits, JVP at clavicle Lungs: Breathing comfortably without accessory muscle use, +end-expiratory wheeze at left lung base CV: RRR, normal S1/S2, no MRG Abd: Soft, normoactive bowel sounds, non-tender, non-distended Extr: WWP, no pitting edema, right calf slightly larger than left, no TTP, no erythema or tenseness, 2+ distal pulses NEURO: Awake, A&Ox3, CNs II-XII grossly intact, moving all extremities, gait not assessed Pertinent Results: ADMISSION LABS: ___ 03:10PM BLOOD WBC-4.9 RBC-4.05* Hgb-12.1* Hct-37.3* MCV-92 MCH-29.8 MCHC-32.4 RDW-13.0 Plt ___ ___ 03:10PM BLOOD Neuts-63.9 ___ Monos-3.5 Eos-1.6 Baso-0.8 ___ 03:10PM BLOOD Glucose-114* UreaN-10 Creat-0.7 Na-139 K-3.5 Cl-102 HCO3-29 AnGap-12 . RELEVANT LABS: ___: UA negative . DISCHARGE LABS: ___ 06:10AM BLOOD WBC-7.9 RBC-4.03* Hgb-12.2* Hct-37.2* MCV-93 MCH-30.3 MCHC-32.8 RDW-13.1 Plt ___ ___ 06:10AM BLOOD Glucose-109* UreaN-12 Creat-0.7 Na-141 K-3.9 Cl-103 HCO3-30 AnGap-12 ___ 06:10AM BLOOD Calcium-8.8 Phos-3.4 Mg-2.0 . MICROBIOLOGY: ___: Urine Legionella antigen: negative ___: Blood culture, no growth to date ___: Blood culture, no growth to date . IMAGING: ___: EKG Sinus rhythm. Poor R wave progression. No previous tracing available for comparison. . ___: Chest x-ray FINDINGS: Frontal and lateral views of the chest are obtained. Left ___- and infra-hilar opacity is worrisome for infection. No pleural effusion or pneumothorax is seen. The lungs are relatively hyperinflated, suggesting chronic obstructive pulmonary disease. The cardiac and mediastinal silhouettes are unremarkable. IMPRESSION: Left ___- and infra-hilar consolidation worrisome for infection. Recommend followup to resolution to exclude underlying lesion. . ___: Lower extremity ultrasound Normal flow in the left common femoral vein. Grayscale and Doppler sonograms of the right common femoral, femoral, and popliteal veins were performed. There is normal compressibility, flow, and augmentation. The peroneal vein and the PTV showed normal compressibility. IMPRESSION: No evidence of DVT. Brief Hospital Course: Mr. ___ is a ___ year old gentleman, with a PMH of tobacco abuse and prostate cancer treated with brachytherapy, who was admitted with persistent respiratory symptoms and hypoxia after outpatient treatment for CAP with moxifloxacin, with presentation most consistent with COPD exacerbation. . . ACTIVE ISSUES: # COPD Exacerbation: Patient's clinical picture, with subacute dyspnea, cough and diffuse wheezing on exam, were concerning for COPD exacerbation, given his extensive smoking history. He was treated with standing albuterol/ipratropium nebulizers, a 5-day course of azithromycin and a 5-day prednisone burst. The patient felt much improved after initiation of treatment, with maintained oxygen saturations on ambulation. . # Community-Acquired Pneumonia: Patient had recent treatment for presumed CAP with empiric moxifloxacin. CXR on admission showed some evidence of left perihilar consolidation. Urine Legionella antigen was negative. Blood cultures are negative to date. It was possible that underlying pneumonia that was not yet fully treated was contributing to patient's symptoms. During this hospitalization, he was treated empirically with ceftriaxone, which was transitioned to cefpodoxime at the time of discharge. He was also administered flu and pneumococcal vaccines. . # Right lower extremity enlargement: On exam, patient was noted to have right lower leg larger than left. Given his initial hypoxia, initial tachycardia and dyspnea (Wells Score for PE 3, with intermediate risk), there was concern for DVT and possible PE. Ultrasound of lower extremities revealed no DVT. Patient's right leg may be larger due to right-sided dominance. . . CHRONIC ISSUES: # Prostate cancer: s/p brachytherapy treatment, asymptomatic. . . TRANSITIONAL ISSUES: # Recommend follow up chest x-ray after resolution of symptoms (6 weeks) to re-evaluate left ___- and infra-hilar consolidation. Medications on Admission: - Tylenol ___ PO PRN insomnia - Multivitamin PO daily Discharge Medications: 1. azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 3 days: Please take one pill on ___ and ___. Disp:3 Tablet(s) Refills:0 2. prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) for 3 days: Please take 40 mg on ___ and ___. Disp:6 Tablet(s) Refills:0 3. cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) for 11 doses: Please take two pills in the evening on ___. Please take two pills twice daily on ___ and ___. Disp:22 Tablet(s) Refills:0 4. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation q6 hours PRN as needed for shortness of breath or wheezing. Disp:1 nebulizer Refills:0 5. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: ___ puffs Inhalation q4 hours PRN as needed for shortness of breath or wheezing. Disp:1 inhaler Refills:0 6. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig: One (1) puff Inhalation every six (6) hours as needed for shortness of breath or wheezing. ___ MDI* Refills:0 Discharge Disposition: Home Discharge Diagnosis: Primary diagnoses: COPD exacerbation Community acquired pneumonia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure to participate in your care here at ___ ___. You were admitted with shortness of breath, which we believed was most consistent with an exacerbation of chronic obstructive pulmonary disease. You improved with oral steroids and nebulizer treatments. Since there was also concern for pneumonia that had not been treated fully, we continued antibiotics as well. You should complete your course of azithromycin and cefpodoxime after you leave the hospital. Please note, the following changes have been made to your medications: - START azithromycin 250 mg by mouth daily, on ___ and ___ - START cefpodoxime 200 mg by mouth twice a day, through ___ - START prednisone 40 mg by mouth daily, on ___ and ___ - START albuterol nebulizer, ___ puffs every 4 hours as needed for shortness of breath or wheezing - START ipratropium nebulizer every 6 hours as needed for shortness of breath or wheezing Please continue all of your other medications as you had prior to your hospitalization. It is important that you follow up with your primary care physician at the appointment that has been made for you (details below). Wishing you all the best! Followup Instructions: ___
19572399-DS-14	19,572,399	25,843,956	DS	14	2119-07-16 00:00:00	2119-07-17 23:32:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: ___ spray Attending: ___. Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: Colonoscopy History of Present Illness: Patient is a ___ with abdominal for the past 5 days. It began as a burning epigastric pain and was associated with nausea, with no emesis. Of note, she has had this epigastric pain before, for which she reportedly had upper endoscopies in ___ and ___. She states that they showed "mild gastritis". She recently finished a course of pantoprazole for this. She was seen at ___ on ___ where she had a normal pelvic ultrasound. She was observed overnight with improvement in her symptoms and discharged with dx of gastritis. However, yesterday she started having cramping lower abdominal pain. Pain is non-radiating. She had two loose bowel movements, and with the second one, she noticed blood on the tissue. Did not notice if there was any mucus associated with the stool. Her family history is significant for a cousin who has ___. She states that she has had a colonscopy in ___ and was diagnosed with colitis. She does not remember the details. She traveled to ___ in the summer. No other recent travel history. No recent antibiotic use. In the ED, initial vitals were T97.5, P82, BP 113/63 RR16 O2Sat 97%RA. On exam, had LUQ and RLQ tenderness with palpation with no rebound. Guaiac was negative. Labs showed WBC 4.7, H/H 12.3/38.4, unremarkable chem-7 and LFTs, and lactate 0.9. Patient was given flagyl and cipro after blood and urine cultures were collected. CT abdomen/pelvis showed mild wall thickening and fat stranding along mid transverse ___ suggesting colitis. Also had possible separate inflammatory thickening along splenic flexure and rectum, raising possibility skip lesions. Mild fat stranding along ___. CT also showed enhancing mass in liver. On the floor, she continued to feel nauseated. She had one episode of emesis shortly after arrival, nonbloody. Tolerating POs. Review of systems: (+) Per HPI, headache. (-) 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, no heartburn. Denies arthralgias or myalgias. Past Medical History: asthma depression migraine headaches gastritis Social History: ___ Family History: Mother: healthy Father: ___ cancer, blood cancer (doesn't know what type) Cousin: ___ disease Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T:98.2 BP:100/67 P:82 R:16 O2:100% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear. No oral lesions noted Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, Marked epigastric tenderness with palpation. Mid-lower abdominal tenderness with palpation. bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: No rash Neuro: AOx3. CN2-12 intact. DISCHARGE PHYSICAL EXAM: VS: Temperature:97.9 Blood pressure:110-122/56-67 Heart ___ Respiratory rate:20 Oxygen saturation:100 on room air Bowel movements (yesterday evening):350cc liquid green/brown stools General: comfortable, no acute distress, alert Cardiac: regular rate and rhythm with no murmurs, gallops, or rubs Lungs: breathing comfortably, lungs clear to auscultation bilaterally with no wheezes, rhonchi, or rales Abdomen: soft, non-distended, normoactive bowel sounds, mild epigastric tenderness to palpation Extremities: warm and well perfused with no clubbing, cyanosis, or edema; right arm phlebitis site has less erythema and decreased tenderness to palpation Pertinent Results: ADMISSION LABS: ___: WBC-4.7 RBC-4.14* Hgb-12.3 Hct-38.4 MCV-93# MCH-29.8# MCHC-32.2 RDW-13.3 Plt ___ Neuts-53.8 ___ Monos-4.8 Eos-1.4 Baso-0.3 ___ PTT-28.9 ___ Glucose-92 UreaN-13 Creat-1.0 Na-140 K-3.7 Cl-106 HCO3-24 AnGap-14 ALT-12 AST-22 AlkPhos-48 TotBili-0.3 Albumin-4.2 Lipase-38 Lactate-0.9 HCG-<5 ___: CRP-4.7 STUDIES: CT abdomen/pelvis ___: 1. Findings consistent with colitis including possible skip lesions although the most definitive area of inflammatory involvement is within the mid transverse ___. 2. Reticular appearance to the hepatic parenchyma, of uncertain significance, but hepatic inflammation may potentially explain this appearance. Correlation with liver function tests is recommended. 3. Enhancing mass in the dome of the right lobe of the liver. Differential considerations include focal nodular hyperplasia or adenoma although the lesion is indeterminate. Evaluation with multiphasic CT or preferably MR is recommended. 4. Anterior sacroiliac erosions, which may indicate a history of inflammatory sacroiliitis, which may additionally support concern for underlying inflammatory bowel disease. MRI liver ___: 2.4 segment VIII hepatic lesion demonstrates imaging features most consistent with focal nodular hyperplasia. H pylori Antibody: negative Micro: stool culture ___: C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. (Reference Range-Negative). FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER FOUND. FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA FOUND. FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___: NO E.COLI 0157:H7 FOUND. DISCHARGE LABS ___: WBC-4.3 RBC-4.10* Hgb-12.3 Hct-37.1 MCV-91 MCH-30.1 MCHC-33.2 RDW-13.5 Plt 284 Glucose-70 UreaN-13 Creat-0.8 Na-137 K-3.8 Cl-100 HCO3-20* AnGap-21* ALT-41* AST-49* AlkPhos-58 TotBili-0.5 Calcium-9.7 Phos-3.7 Mg-1.9 Brief Hospital Course: Ms. ___ is a ___ year old female with a history of OCP use and prior episode of colitis who presented with persistent abdominal pain, nausea, and self-limited bloody diarrhea. She was found to have possible colitis on CT scan and visually normal mucosa on colonoscopy. ACTIVE ISSUES ------------- # Abdominal pain/diarrhea/nausea: Patient presented with both burning epigastric pain, lower abdominal cramping, severe nausea, and diarrhea with blood. Per patient report, pelvic ultrasound was normal as outside hospital. CT scan in the ___ ED showed colitis with possible skip lesions. She was initially started on IV ciprofloxacin and metronidazole, but these were discontinued due to low suspicion for infectious etiology as Ms. ___ remained afebrile with no leukocytosis. Nausea was controlled with lorazepam PRN, ondansetron PRN, and prochlorperazine PRN. During hospitalization, she did not have any further episodes of diarrhea. She was evaluated the GI team, who felt, given the long-standing nature of her symptoms and history of colitis, inpatient colonoscopy was indicated. The colonoscopy was performed on ___ which showed visually normal mucosa. However, biopsies were taken and results are pending. During hospital course, patient's abdominal pain slowly improved. She was also started on pantoprazole daily with good effect. # Hepatic lesion: CT scan with contrast showed a 21 x 18 mm enhancing mass in the right lobe of the liver, likely focal nodular hyperplasia or adenoma. Given history of oral contraceptive use and association with hepatic adenomas, OCP was held during hospitalization. MRI liver was performed which showed that the lesion was consistent focal nodular hyperplasia. Oral contraceptive pill (Amethyst) were restarted upon discharge. # Increased anion gap: On ___, patient developed anion gap metabolic acidosis with HCO3 20. UA was positive for ketones. Acidosis was felt to be due to starvation ketoacidosis since patient had been on clear liquid diet for about two days because of prep for colonoscopy. INACTIVE ISSUES --------------- # Migraine: Patient was continued on home topiramate. Transitional Issues: - GI at ___ will call the patient with the results of colonic biopsies - She has a lesion in the liver consistent with focal nodular hyperplasia - Her LFTs were mildly elevated with AST 49 and ALT 41 on discharge. She should have these followed-up at discharge. - Follow up pending H. pylori antibody test with primary care doctor Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Topiramate (Topamax) 50 mg PO BID 2. Amethyst (levonorgestrel-ethinyl estrad) 90-20 mcg oral daily Discharge Medications: 1. Topiramate (Topamax) 50 mg PO BID 2. Pantoprazole 40 mg PO Q24H RX pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:*0 3. Amethyst (levonorgestrel-ethinyl estrad) 90-20 mcg oral daily Discharge Disposition: Home Discharge Diagnosis: Primary: abdominal pain, focal nodular hyperplasia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were seen at ___ for your abdominal pain. We did a CAT scan of you abdomen and found inflammation of your ___ as well as a small lesion in your liver. Our gastroenterology doctors saw ___ you were here and performed a colonoscopy to better visualize your ___. The colonoscopy was normal upon visualization. Biopsies were taken and the results of these are still pending. The GI team will call you with the results of the biopsies. We also did an MRI of your liver to take a closer look of the liver lesion. Prelimarily, it looks like "focal nodular hyperplasia". This is a benign condition and does not need treatment. Since it is not a hepatic adenoma, you can continue to take oral contraceptive pills. You need to follow up with the gastroenterology doctors in ___ ___. You have an appointment scheduled with them on ___. Please call ___ at ___ to leave a fax number for your discharge paper work so that we can send it to your GI doctor. It has been a pleasure taking care of you and we wish you all the best. Your ___ care team Followup Instructions: ___
19572399-DS-15	19,572,399	28,354,308	DS	15	2120-06-07 00:00:00	2120-06-08 11:39:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ___ Allergies: hurricane spray Attending: ___. Chief Complaint: Abdominal Pain; Change in Bowel Movements Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a pleasant ___ year old college student with five year history of recurrent abdominal pain and intermittent bloody diarrhea with unclear etiology followed by Dr. ___ presents with one week of fatigue and abdominal pain similar to prior episodes. This past week, Ms. ___ reports that she developed recurrent abdominal pain, that was crampy and associated with nausea and fatigue. She reports that she has barely eaten during this time. It is primarily epigastric, but also diffuse across the lower abdomen. Pt has not vomited. Normal BM without hematochezia or melena. Pt endorses subjective fevers/chills. Past Medical History: asthma depression migraine headaches gastritis Social History: ___ Family History: Mother: healthy Father: ___ cancer, blood cancer (doesn't know what type) Cousin: ___ disease Physical Exam: ADMISSION PHYSICAL: Vitals: 97.9 127/77 76 18 100RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear. No oral lesions noted Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, Marked epigastric tenderness with palpation. Mid-lower abdominal tenderness with palpation. bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: No rash Neuro: AOx3. CN2-12 intact DISCHARGE PHYSICAL: Vitals: 97.9 107/57 77 16 100% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear. No oral lesions noted Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, Marked epigastric tenderness with palpation. Mid-lower abdominal tenderness with palpation. bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: No rash Neuro: AOx3. CN2-12 intact. Pertinent Results: PERTINENT LABS: ___ 07:52PM URINE HOURS-RANDOM ___ 07:52PM URINE UCG-NEGATIVE ___ 07:52PM URINE COLOR-Yellow APPEAR-Hazy SP ___ ___ 07:52PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-MOD ___ 07:52PM URINE RBC-2 WBC-7* BACTERIA-FEW YEAST-NONE EPI-11 ___ 07:52PM URINE MUCOUS-RARE ___ 06:30PM GLUCOSE-87 UREA N-13 CREAT-0.9 SODIUM-138 POTASSIUM-3.8 CHLORIDE-106 TOTAL CO2-21* ANION GAP-15 ___ 06:30PM estGFR-Using this ___ 06:30PM ALT(SGPT)-13 AST(SGOT)-21 ALK PHOS-62 TOT BILI-0.2 ___ 06:30PM LIPASE-28 ___ 06:30PM ALBUMIN-4.0 ___ 06:30PM CRP-3.0 ___ 06:30PM WBC-5.7 RBC-3.46* HGB-10.3* HCT-31.4* MCV-91 MCH-29.8 MCHC-32.8 RDW-12.5 RDWSD-40.9 ___ 06:30PM NEUTS-33.1* LYMPHS-55.6* MONOS-9.6 EOS-0.9* BASOS-0.4 IM ___ AbsNeut-1.88 AbsLymp-3.14 AbsMono-0.54 AbsEos-0.05 AbsBaso-0.02 ___ 06:30PM PLT COUNT-304 PERTINENT IMAGING: IMPRESSION: 1. No acute intra-abdominal process. 2. Unchanged hyper enhancing lesion in the liver previously characterized as an FNH SPECIFICALLY: URINARY: The kidneys are of normal and symmetric size with normal nephrogram. There is no evidence of focal renal lesions or hydronephrosis. There is no perinephric abnormality. GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. The ___ and rectum are within normal limits. The appendix is not visualized and there appear to be surgical clips at the base of the cecum likely reflecting prior appendectomy. . PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The uterus is of normal size and enhancement. There is no evidence of adnexal abnormality bilaterally. DISCHARGE LABS: ___ 07:20AM BLOOD WBC-4.5 RBC-3.43* Hgb-10.1* Hct-31.0* MCV-90 MCH-29.4 MCHC-32.6 RDW-12.4 RDWSD-40.6 Plt ___ ___ 07:20AM BLOOD Glucose-91 UreaN-7 Creat-0.9 Na-139 K-3.7 Cl-106 HCO3-22 AnGap-15 ___ 07:10AM BLOOD ALT-9 AST-18 LD(LDH)-130 AlkPhos-57 TotBili-0.3 ___ 07:20AM BLOOD Calcium-9.0 Phos-3.3 Mg-2.0 Brief Hospital Course: This is a ___ year old female with past medical history of recurrent abdominal pain of unclear etiology despite workup including cross-sectional imaging and colonoscopy, admitted ___ with 1 week of worsening abdominal pain associated with nausea, subsequently improving without intervention, able to tolerate regular PO intake, seen by GI and recommended for outpatient upper endoscopy, able to be discharged home on trial of dicyclomine #ABDOMINAL PAIN - patient initially reported diarrhea during the week prior to her presentation in addition to abdominal pain; after admission patient had no additional episodes of diarrhea; initially abdominal pain was described as epigastric as well as in her bilateral lower quadrants; she was treated conservatively with NPO and symptom control with subsequent diet advancement. She was seen by the GI consult service who recommended inpatient versus outpatient endoscopy. Patient opted for outpatient. She was able to advance her diet and was able to be discharged with plan for close outpatient follow up with Dr. ___. Hpylori pending at discharge # HIGH RISK BEHAVIOR / Unprotected Sex - Patient reported recent unprotected intercourse. She was counseled on importance of use of condoms. She was asymptomatic. G/C swab pending at discharge *TRANSITIONAL ISSUES* - Patient to schedule follow-up endoscopy with Dr. ___ ___ gastroenterology Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Topiramate (Topamax) 75 mg PO BID 2. Amethyst (levonorgestrel-ethinyl estrad) 90-20 mcg oral DAILY 3. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain 4. Duloxetine 60 mg PO DAILY 5. eletriptan HBr 40 mg oral DAILY:PRN migraine 6. frovatriptan 2.5 mg oral Q2H:PRN migraine Discharge Medications: 1. Amethyst (levonorgestrel-ethinyl estrad) 90-20 mcg oral DAILY 2. Duloxetine 60 mg PO DAILY 3. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain 4. Topiramate (Topamax) 75 mg PO BID 5. DiCYCLOmine 10 mg PO ONCE MR1 Duration: 1 Dose RX dicyclomine 20 mg 1 tablet(s) by mouth BID PRN Disp #30 Tablet Refills:0 6. Docusate Sodium 100 mg PO BID RX docusate sodium [Colace] 100 mg 2 capsule(s) by mouth daily as needed Disp #30 Capsule Refills:0 7. eletriptan HBr 40 mg oral DAILY:PRN migraine 8. frovatriptan 2.5 mg oral Q2H:PRN migraine 9. Ondansetron 8 mg PO Q8H:PRN nausea RX ondansetron 8 mg 1 tablet(s) by mouth q8h as needed Disp #30 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Abdominal Pain High risk sexual behavior Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. ___, You were admitted to the ___ for recurrence of your well known abdominal pain and nausea. While admitted you were seen by both Internal ___ and Gastroenterology teams. Your pain and nausea were managed medically. Follwing an evaluation by the Gastroenterology team it was determined that you would be best cared for, as long as you could tolerate meals, by being discharged from the hospital with close follow up with Dr. ___. As discussed we will attempt to schedule an appointment for you for this ___. You should only drink clear liquids starting at midnight tonight. The gastroenterology team will contact you by noon tomorrow to confirm or reschedule an appointment for you with Dr. ___. If you have not heard from them by noon you should call the operator at ___ @ ___ and ask for the "Gastroenterology Fellow on call." They will clarify any schedule moving forward. Medication changes: 1. You should continue all of your home medications. 2. We have provided a prescription for ondansetron (zofarn) 8mg. You can take this ___ every 8 hours up to three times a day. You should NOT take this medication more than 3 times a day. 3. Colace (docusate) 200mg daily as needed for constipation 4. Dicyclomine 20mg twice daily as needed for abdominal pain. It was a pleasure taking care of you, Ms. ___. Best, Your ___ Deaconess ___ and ___ Teams. Followup Instructions: ___
19572399-DS-16	19,572,399	29,241,924	DS	16	2120-07-01 00:00:00	2120-07-01 15:33:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: hurricane spray / lidocaine Attending: ___. Chief Complaint: Epigastric abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ with a PMHx of chronic abdominal pain, who presents with continued/worsened abdominal pain. Pt has had a ___ hx of abdominal pain and intermittent bloody diarrhea, followed by Dr. ___. Pt was recently admitted (___) for this abdominal pain. Pt had reported diarrhea prior to admission but this was not noted during admission. Pt was treated conservatively with pain control. She opted for outpatient endoscopy and was discharged on Oxycodone. Outpatient endoscopy was performed ___ and results were remarkable only for chronic, inactive gastritis. Pt describes her pain as epigastric (where pain is burning), radiating to bilateral lower quadrants (where pain is more cramping), unchanged with BM but worsened with food, improved w upright posture, associated with nausea and occasionally bloody diarrhea. In the ED, initial VS: 97.8, 82, 148/78, 16, 100%RA. Labs were remarkable for AST 51, UA with RBCs, 6 epis and few bacteria. Pelvic exam was unremarkable. Prelim read of pelvic US was unremarkable. Pt received Zofran 4mg IV x 2, Morphine 5mg IV x 2 and was admitted for further evaluation. On ROS, pt reported vaginal bleeding but denies fever, chills, recent travel, rashes or joint swelling. 10point ROS otherwise negative. On interview, pt reports continued severe abd pain. Past Medical History: # Chronic abdominal pain # Asthma # Depression # Migraine headaches # Gastritis Social History: ___ Family History: Father: ___ cancer MGM: blood cancer (doesn't know what type) Maternal cousin: ___ disease Physical Exam: Admission PE VS: 97.8, 122/74, 71, 18, 100%RA General: Alert, oriented, mild discomfort; thin pale HEENT: Sclera anicteric, MMM, oropharynx clear. No oral lesions 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, Abdomen: Soft, +epigastric tenderness with palpation. Mid-lower abdominal tenderness with palpation. Bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: No rash Neuro: AOx3. CN2-12 intact; strength symmetric and intact Discharge PE: VS: 97., 122/68, 72, 18, 100%RA General: NAD, resting comfortably HEENT: Sclera anicteric, MMM, oropharynx clear. No oral lesions Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs or gallops Abdomen: Soft, +epigastric tenderness with palpation. Mid-lower abdominal tenderness with palpation. Bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: No rash Pertinent Results: ___ 04:20PM BLOOD WBC-6.9 RBC-3.83* Hgb-11.1* Hct-34.2 MCV-89 MCH-29.0 MCHC-32.5 RDW-13.1 RDWSD-41.9 Plt ___ ___ 04:20PM BLOOD Neuts-49.8 ___ Monos-6.6 Eos-0.6* Baso-0.4 Im ___ AbsNeut-3.44 AbsLymp-2.93 AbsMono-0.46 AbsEos-0.04 AbsBaso-0.03 ___ 04:20PM BLOOD Glucose-82 UreaN-13 Creat-0.8 Na-136 K-5.1 Cl-103 HCO3-22 AnGap-16 ___ 04:20PM BLOOD ALT-16 AST-51* AlkPhos-58 TotBili-0.4 ___ 04:20PM BLOOD Albumin-4.2 Calcium-9.6 Phos-3.3 Mg-2.1 Imaging: CT AP ___: IMPRESSION: 1. No acute intra-abdominal process. 2. Unchanged hyper enhancing lesion in the liver previously characterized as an FNH MRI Abdomen ___: IMPRESSION: 2.4 segment VIII hepatic lesion demonstrates imaging features most consistent with focal nodular hyperplasia. Pathology ___: Antral mucosa with chronic inactive gastritis. Duodenal and colonic mucosa wnl. CT AP ___: IMPRESSION: 1. Findings consistent with colitis including possible skip lesions although the most definitive area of inflammatory involvement is within the mid transverse ___. 2. Reticular appearance to the hepatic parenchyma, of uncertain significance, but hepatic inflammation may potentially explain this appearance. Correlation with liver function tests is recommended. 3. Enhancing mass in the dome of the right lobe of the liver. Differential considerations include focal nodular hyperplasia or adenoma although the lesion is indeterminate. Evaluation with multiphasic CT or preferably MR is recommended. 4. Anterior sacroiliac erosions, which may indicate a history of inflammatory sacroiliitis, which may additionally support concern for underlying inflammatory bowel disease. EGD ___: Impression: Normal mucosa in the esophagus Normal mucosa in the stomach. Cold forceps biopsies were performed for histology at the stomach antrum to rule out HP. Normal mucosa in the duodenum. Cold forceps biopsies were performed for histology to rule out IBD. Otherwise normal EGD to third part of the duodenum Recommendations: Follow-up with Dr. ___ as previously scheduled. Clear liquid diet when awake, then advance diet as tolerated. Follow up with pathology reports. Please call Dr. ___ office ___ in 7 days for the pathology results. Further management will depend on pathology results. Colonoscopy ___: Findings: Mucosa: Normal mucosa was noted in the whole ___ and the terminal ileum. Random ___ biopsies were performed for histology to rule out microscopic colitis. Impression: Normal mucosa in the whole ___ (biopsy); Otherwise normal colonoscopy to cecum and terminal ileum Brief Hospital Course: Assessment and Plan: Ms. ___ is a ___ with a PMHx of chronic abdominal pain, who presents with continued abdominal pain. # Abdominal Pain: Pt presents with continued chronic abdominal pain. DDx broad and includes IBD (given findings on CTAP from ___ though recent colonoscopy/EGD not supportive of this and prior CS in ___ showed only prominent lymphoid aggregate on bx). Enometriosis and PUD in ddx as well, though less likely. Other considerations include abdominal migraine. UHCG negative. TSH, CRP, lactate, TTG, IgA normal. Patient initially reported she was very symptomatic and requested a GI consult but then reported her pain improved, wanted to eat and wanted to be discharged. Given that there were no concerning findings on work-up and that her symptoms were unchanged from prior she was discharged with outpatient GI follow-up. Counselled her on importance of continued outpatient care for this chronic issue and importance of avoiding opioids for her chronic abdominal pain. Recommended that she obtain a PCP in the area to help coordinate her care. - F/U ESR - Trial of ___ diet - Trial of Bentyl and PPI - Cont duloxetine - F/u with GI as outpatient # AST elevation: due to hemolyzed blood, normalized on repeat. # Migraines: - Cont topiromate # Vaginal bleeding: Patient menstruating, urinalysis showing blood but no flank or groin pain, likely due to menstruation. - Recommend repeat urinalysis as outpatient when not menstruating. # Transitional: Liver lesion previously noted most cw FNH, f/u with PCP. # Code Status: Full Code # HCP: Mother # FEN: ___ diet # DVT PPx: Ambulation Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amethyst (levonorgestrel-ethinyl estrad) 90-20 mcg oral DAILY 2. Duloxetine 60 mg PO DAILY 3. Topiramate (Topamax) 75 mg PO BID 4. frovatriptan 2.5 mg oral Q2H:PRN migraine 5. Ondansetron 8 mg PO Q8H:PRN nausea Discharge Medications: 1. Duloxetine 60 mg PO DAILY 2. Topiramate (Topamax) 75 mg PO BID 3. Amethyst (levonorgestrel-ethinyl estrad) 90-20 mcg oral DAILY 4. frovatriptan 2.5 mg oral Q2H:PRN migraine 5. Ondansetron 8 mg PO Q8H:PRN nausea 6. DiCYCLOmine 20 mg PO QID RX dicyclomine 20 mg 1 tablet(s) by mouth four times a day Disp #120 Tablet Refills:0 7. Pantoprazole 40 mg PO Q24H RX pantoprazole 40 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 Discharge Disposition: Home Discharge Diagnosis: Chronic abdominal pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for worsening of your abdominal pain. There were no concerning findings and you were able to eat a normal diet without increased pain, nausea or vomiting.. It is very important that you set up a primary care physician in the area to help manage your symptoms and continue following with GI as an outpatient. Followup Instructions: ___
19572643-DS-19	19,572,643	23,188,885	DS	19	2166-04-20 00:00:00	2166-04-21 13:22:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Syncope Major Surgical or Invasive Procedure: None. History of Present Illness: Patient is a ___ yo woman with a history of triple negative breast CA recently diagnosed earlier this month at ___. Received dose dense Adriamycin and Cytoxan on ___ (C1D1) developed nausea, poor PO intake and vomiting soon after. She has had substantial retching and lightheadedness since her infusion the day before. She took multiple doses of her PRN antiemetics (compazine, zofran, ativan) without substantial effect. Earlier today was standing at home with her family and collapsed, caught by husband with regaining of consciousness soon after. She was referred to ED by oncology where she was given IV fluids, electrolyte repleation and antiemetics. CT head without evidence of metastatic disease. Of note she denies any frequent passage of loose stools. Past Medical History: PAST ONCOLOGIC HISTORY -___: patient self-palpated lump in right breast. She monitored it over several weeks and when it did not resolve saw her PCP who ordered diagnostic imaging. -___: work-up at ___ with ___ and ___ revealed mass in upper outer quadrant measuring 3.4cm, there was no lymphadenopathy on right or left side. Biopsy revealed grade 2, IDC, ER equivocal (1% weakly positive), PR negative, HER2-neu negative. Breast MRI on ___ identified in the right breast at 12 o'clock measuring 23 mm x 25 mm x 24 mm. There are enhancing irregular linear bands extending towards the nipple from the dominant mass for approximately 2 cm, with several satellite lesions in the anterior aspect of the enhancing bands, measuring approximately 6 mm each. The total AP dimension of the abnormality is approximately 45 mm. The abnormality is contained within the upper half of the breast, without extension below the nipple line. The distance to the nipple from the most anterior aspect of the satellite lesion is approximately 26 cm. Several non-pathologically enlarged right axillary nodes. The left breast was clean. Patient wishes for breast-conserving therapy and met with Dr. ___ on ___ to discuss neoadjuvant chemotherapy including parrticipation in INFORM trial. -___: BRCA testing negative. patient started on neoadjuvant chemotherapy with dose-dense adriamycin & cytoxan PAST MEDICAL HISTORY: -HTN on HCTZ -Breast biopsy ___ with hyperplasia but no known atypia, although we do not have a path report. S -Chronic lumbar/siatic pain -Mitral valve prolapse in her ___ Social History: ___ Family History: Family history is significant for an identical twin sister who was diagnosed with ovarian cancer at age ___ and then developed a sarcoma on her nose that was excised at age ___ Her mother was diagnosed with breast cancer at age ___ and then had a bilateral ulcerating lesion in the other breast at the end of her life but it was not worked up because she had Alzheimer's disease at that point and passed away at age ___. Her paternal uncle developed colon cancer at ___ and passed away at age ___. There is a paternal aunt who they are not sure had any cancer, but that aunt's daughter, her first cousin, developed breast cancer at ___. Physical Exam: VS: T 98.5 BP 140/78 HR 84 RR 16 O2 94% RA GENERAL: NAD HEENT: NC/AT, EOMI, MMM CARDIAC: RRR, normal S1 & S2 LUNG: clear to auscultation ABD: Soft, NT/ND, no rebound or guarding EXT: No lower extremity pitting edema NEURO: Alert and oriented, no focal deficits. SKIN: Warm and dry, without rashes Pertinent Results: ___ 06:26PM BLOOD WBC-12.4# RBC-3.85 Hgb-11.1* Hct-30.6* MCV-80* MCH-28.8 MCHC-36.3 RDW-11.9 RDWSD-34.5* Plt ___ ___ 06:26PM BLOOD Glucose-128* UreaN-17 Creat-0.7 Na-124* K-2.8* Cl-86* HCO3-25 AnGap-16 ___ 06:26PM BLOOD Calcium-9.0 Phos-4.1 Mg-1.9 ___ 08:03AM BLOOD Glucose-94 UreaN-7 Creat-0.5 Na-138 K-3.6 Cl-105 HCO3-28 AnGap-9 ___ 08:03AM BLOOD Calcium-8.7 Phos-2.1* Mg-1.8 Head CT: No acute intracranial abnormality. White matter changes which can be seen in setting of chronic small vessel disease. MRI would be more sensitive for the detection of intracranial metastases. EKG:Sinus rhythm. Diffuse T wave flattening. Otherwise, normal ECG. Compared to the previous tracing of ___ there is probably no change. Brief Hospital Course: ___ yo w/ newly diagnosed triple negative breast CA admitted with syncope 1 day after initiation of dose dense adriomycin and Cytoxan. # Syncope: - She had an episode of syncope after not eating or drinking anything all day due to nausea. The cause of her syncope is likely related to dehydration. She was monitored on telemetry and a head CT and both were unremarkable. Of note she does have a cardiology appointment later this month due to the side effect of chemotherapy and her age but there was not an indication for an urgent cardiology evaluate while inpatient as there was no indication that he syncope was cardiac in nature. # Possible UTI: - Had boderline UA in the ED but had no symptoms and the urine culture was negative. She was started on ceftriaxone in the ED but this was stopped. Of note she did have an elevated WBC but this was likely a result of the neulasta she received. #Breast Cancer - Received chemotherapy the day prior to admission. This was likely the cause of her nausea. Her nausea was treated with zofran, compazine, and ativan. Electrolytes were replaced as needed. She was also discharged with a prescription of oral electrolyte replacement to complete this. # Hyponatremia: - Her hyponatremia on admission was likely due to volume depletion and resolved with IV hydration. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ondansetron 8 mg PO Q8H:PRN nausea 2. Prochlorperazine 10 mg PO Q6H:PRN nausea 3. Lorazepam 0.5 mg PO Q4H:PRN nausea/anxiety 4. Ibuprofen 400 mg PO Q8H:PRN pain 5. Calcium Carbonate 500 mg PO DAILY 6. Hydrochlorothiazide 50 mg PO DAILY Discharge Medications: 1. Calcium Carbonate 500 mg PO DAILY 2. Lorazepam 0.5 mg PO Q4H:PRN nausea/anxiety 3. Ondansetron 8 mg PO Q8H:PRN nausea 4. Prochlorperazine 10 mg PO Q6H:PRN nausea 5. Famotidine 20 mg PO BID:PRN Dyspepsia 6. Hydrochlorothiazide 50 mg PO DAILY 7. Neutra-Phos 1 PKT PO TID Duration: 1 Day RX potassium & sodium phosphates [Phos-NaK] 280 mg-160 mg-250 mg 1 packet by mouth three times a day Disp #3 Packet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Breast Cancer Syncope Nausea Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admited after you passed out. This was likely due to dehydration from the nausea you had and because you had not been eating or drinking. Followup Instructions: ___
19572730-DS-18	19,572,730	26,424,307	DS	18	2153-05-08 00:00:00	2153-05-21 08:43:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Facial swelling, pain and fever Major Surgical or Invasive Procedure: None History of Present Illness: HISTORY OF PRESENT ILLNESS: This is a ___ M PMhx HIV intermittently compliant w HAART, presenting w 2d worsening L facial swelling. Patient reports that 2d prior to admission he noticed worsening pain over L submandibular area, spreading to L face, associated w mild erythema and swelling; reports + associated L molar pain; denies associated fevers/chills. Symptoms progressed over 2 days prompting patient to present to ___ ED for further evaluation. . On presentation to ED, vital signs were 98.9 148 ___ 97%. Labs were notable for WBC 12.8 (72%N), lactate 2.0. CT neck w contrast showed subcutaneous stranding and edema of the left submandibular soft tissues. Patient was seen by ___ who recommended admission. Patient was given IV cefepime and flagyl, but left AMA prior to admission @ 1400. Patient subsequently spiked a fever at home and returned @ 1730. Vitals at that time were 101.1 127 115/71 16. Patient was admitted to medicine for further management. Access was 20g R arm x1. . On arrival to the floor, patient was comfortable, reported mild facial pain. He denied any difficulty breathing, swallowing. Vitals were 97.5 104/68 93 24 98%RA. . REVIEW OF SYSTEMS: (+) per HPI (-) chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, nausea, vomiting, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: HIV on HAART (last CD4 in ___ was 191) HCV (untreated) Genital HSV Schizophrenia Social History: ___ Family History: Question of mental illness in mother. Physical Exam: PHYSICAL EXAM ON ADMISSION: VS: 97.5 104/68 93 24 98%RA GENERAL: well appearing, marked L-sided facial swelling HEENT: PERRL, EOMI; L-facial edema and erythema extending from L preauricular inferiorly to L anterior cervical, most tender in area of submandibular gland; no focal fluctuance or palpable fluid collections; able to open mouth ___ way, oropharynx clear without erythema/exudate, poor dentition NECK: supple, as above LUNGS: CTA bilat, no wheezing/stridor, good air movement HEART: RRR, no MRG ABDOMEN: NABS, soft/NT/ND EXTREMITIES: WWP, no edema, 2+ radial and DP pulses bilaterally NEURO: A&Ox3, moving all extremities PHYSICAL EXAM ON DISCHARGE: Afebrile, vital signs stable. Significantly decreased left facial swelling and erythema involving the anterior cervical and submandibular area. Able to open mouth fully. No oral lesions, poor dentition. Lungs clear, RRR with no murmur. R thumb with healing blisters from burns (cigarette lighter). Pertinent Results: LABS: ___ 01:20PM WBC-12.8# RBC-4.97 HGB-15.3 HCT-42.5 MCV-86 MCH-30.8 MCHC-36.0 RDW-14.4 ___ 01:20PM NEUTS-72.1* ___ MONOS-6.8 EOS-0.3 BASOS-0.2 ___ 01:20PM GLUCOSE-118* UREA N-11 CREAT-1.2 SODIUM-132* POTASSIUM-3.6 CHLORIDE-102 TOTAL CO2-18* ANION GAP-16 ___ 02:00PM LACTATE-2.0 MICROBIOLOGY: Blood culture x1 - pending on discharge IMAGING: CT neck ___ IMPRESSION: Subcutaneous inflammtion of the left masticator space and submandibular soft tissues with reactive level 1 cervical adenopathy. Probable primary cause may be periodontal disease of multiple mandibular teeth. No focal abscess or drainable fluid collection. The study and the report were reviewed by the staff radiologist. Brief Hospital Course: ___ year old male with h/o HCV, HIV intermittently compliant w HAART, presenting worsening L facial edema and pain found to have periodontal disease and R thumb pain. Periodontal disease: He presented to the ED with worsening left facial/cervical erythema and edema and fever. He was able to protect his airway. DDx included odontogenic infection, peritonsilar abcess, sialolithiasis, ludwigs angina, retropharyngeal abcess, parotitis. His exams was consistent with a tooth infection, sialolith, submandibular infection/adenopathy. CT scan showed subcutaneous inflammation of the left masticator space and submandibular soft tissues with reactive level 1 cervical adenopathy. Probable primary cause maybe periodontal disease of multiple mandibular teeth. No focal abscess or drainable fluid collection. CBC showed leukocytosis and thrombocytopenia. Blood cultures were sent and results were pending on discharge. ___ recommended IV Unasyn until discharge and tooth extraction once the infection had resolved. His pain was treated with 1 dose of IV dilaudid and PO Tylenol and viscous lidocaine (magic mouthwash). Upon discharge, he had markedly reduced left facial edema with pain aggravated by mastication and brushing teeth. The erythema on his neck was resolving. He was instructed to report directly to a follow-up appointment with Oral Surgery clinic at ___ ___ ___ floor) on ___ at 4:00pm. R thumb pain: prior to admission, he sustained four small areas of burns to his thumb with a cigarette lighter. Exam showed mild erythema, three 3-5mm sized closed crusted lesions on volar surface of thumb. Full ROM. No evidence of active infection, however if any infection, should be covered by Unasyn. His pain was controlled by PO Tylenol. CHRONIC ISSUES: HIV infection: he was previously on several HAART regimens complicated by noncompliance. His last CD4 count was performed on ___ and was 191, no Viral load obtained due to insufficient sample. We did not initiate HAART treatment during admission. Social work consultant provided counseling regarding barriers to compliance. He was continued on bactrim PO. Access to healthcare/compliance: He has significant problems with self-care and attending his appointments. He was provided with a T pass. With assistance from social work, arrangements were made for ___ The Ride and PT1 status application for future assistance with transportation to appointments. He declined to talk further with social work about any other problems that he did not believe pertained to this admission. HCV infection: no current treatment Thrombocytopenia: stable with platelets 200s -> 114 -> 143. Schizophrenia/depression/anxiety: treated with home doses of Zyprexa and Prozac. Drug Use: recent meth use. Social work consult was obtained for evaluation, counseling and resources for cessation. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. OLANZapine 25 mg PO HS 2. Fluoxetine 20 mg PO DAILY 3. Sulfameth/Trimethoprim SS 1 TAB PO DAILY Discharge Medications: 1. OLANZapine 25 mg PO DAILY 2. Maalox/Diphenhydramine/Lidocaine 15 mL PO QID:PRN mouth pain 3. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain RX oxycodone 5 mg 1 tablet(s) by mouth three times a day Disp #10 Tablet Refills:0 4. Docusate Sodium 100 mg PO BID RX docusate sodium 100 mg 1 tablet(s) by mouth once a day Disp #7 Tablet Refills:0 5. Senna 1 TAB PO BID:PRN constipation RX sennosides 8.6 mg 1 tablet by mouth once a day Disp #7 Tablet Refills:0 6. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 7 Days RX amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by mouth every twelve (12) hours Disp #14 Tablet Refills:0 7. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 8. Fluoxetine 20 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Periodontal infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure taking care of you during your admission to the ___. You were admitted to the Medicine service for evaluation and management of your left facial swelling, pain, redness and fever. We performed blood tests which showed evidence of an infection. We also did a CT scan of your face and neck and this showed that you have a tooth infection and evidence of an infection around the jaw near the infected tooth. During your admission, you were given antibiotics to treat the infection. Your swelling decreased significantly. You also had some pain with eating and brushing your teeth. We treated the pain with oral pain medications and vicous lidocaine (magic mouth wash). You were seen by the Oral Maxillofacial surgeons who recommend removal of the damaged tooth after the infection has resolved. Please follow-up with the Oral Surgeon by going directly to your appointment at the ___ located in the ___ Building at ___ floor at 4:00pm. On the second day of your admission, the swelling and redness in your face and neck were significantly improved. You were able to eat a regular diet of food during your admission. Please continue to eat and drink regularly at home. You also had pain in your right thumb. We found four areas of blisters that had crusted over. You were able to move your fingers wihtout difficulty. There was no evidence of an active infection in your thumb. We treated your pain with oral pain medication. You are being discharged with oral antibiotics and oral Oxycodone. Please take them as instructed so your face swelling and pain will get better. If the pain, swelling and redness gets worse or you get a fever or you cannot swallow your saliva or you have severe pain with eating and swallowing, please call your doctor immediately and come to the emergency department. If you have difficulty getting to the emergency department due to weather conditions, please call ___ for transportation to the hospital by ambulance. Followup Instructions: ___
19572730-DS-19	19,572,730	20,608,047	DS	19	2153-09-12 00:00:00	2153-09-13 12:56:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: chest pain, cough Major Surgical or Invasive Procedure: none History of Present Illness: ___ y/o male with HIV (CD4 ___ on HAART who presented with left sided chest discomfort, cough and sputum production. Patient states that for approximately ___ days prior to presentation he has been experiencing what he describes as a "burning sensation" in the left chest which is worse with inspiration, range of motion of the trunk as well as coughing. States that he has had cough productive of whitish sputum. He denies fevers or chills, nausea, vomiting, abdominal pain and diarrhea. He denies being on Bactrim prophylaxis. In the ED, initial vs were: 99.0 101 116/76 20 100% RA. Labs were remarkable for a d-dimer of 1439. A CTA was performed which showed no acute aortic pathology or pulmonary embolus but innumerable millimetric scattered peripheral nodules and ground glass opacities were noted which were suggestive of infection. He was also noted to have an acute fracture of his 6th rib. He was given a dose of ceftriaxone and azithromycin as well as albuterol and morphine. Past Medical History: HIV on HAART dx ___ CD4 in ___ was 191) genotype: 98S 356K 15V 37N has been on atazanovir, ritonovir, turvada, compliance issues HCV (untreated) Ia, Hep A,B immune Genital HSV Schizophrenia g/o molluscum h/o genital herpes h/o thrush h/o syphili ___, treated h/o genital HPV Social History: ___ Family History: FAMILY HISTORY: Question of mental illness in mother. Physical Exam: PE: 98.9 99/65 85 18 96%RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, dry mouth and tongue, oropharynx clear no thrush Neck: supple, JVP not elevated, no LAD chest: tender LL ribs Lungs: Rhonchi heard on the right with crackles at the base, no wheezes, quiet breath sounds CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: no rashes Neuro: CN2-12 intacts, ___ strength both upper and lower extremity on d/c vitals wnl and exam unchanged, scant wheeze on lung exam Pertinent Results: admission labs ___ 06:00PM BLOOD WBC-4.2 RBC-5.02 Hgb-15.5 Hct-43.6 MCV-87 MCH-30.9 MCHC-35.6* RDW-14.4 Plt ___ ___ 08:00AM BLOOD WBC-3.8* RBC-4.63 Hgb-14.8 Hct-40.1 MCV-87 MCH-32.0 MCHC-36.9* RDW-14.2 Plt ___ ___ 06:00PM BLOOD Neuts-63.5 ___ Monos-8.0 Eos-1.0 Baso-0.6 ___ 08:00AM BLOOD Neuts-52.9 ___ Monos-10.7 Eos-1.8 Baso-0.8 ___ 06:00PM BLOOD Plt ___ ___ 08:00AM BLOOD ___ PTT-31.6 ___ ___ 06:00PM BLOOD Glucose-84 UreaN-9 Creat-1.0 Na-135 K-3.3 Cl-100 HCO3-27 AnGap-11 ___ 06:00PM BLOOD ALT-38 AST-30 LD(LDH)-210 AlkPhos-76 TotBili-0.4 ___ 06:00PM BLOOD D-Dimer-143___* ___ 06:09PM BLOOD Lactate-0.9 d/c labs ___ 10:00AM BLOOD WBC-3.1* RBC-4.34* Hgb-13.6* Hct-37.7* MCV-87 MCH-31.3 MCHC-36.1* RDW-14.4 Plt ___ ___ 10:00AM BLOOD Neuts-51.6 ___ Monos-12.0* Eos-1.0 Baso-0.2 ___ 10:00AM BLOOD Plt ___ ___ 10:00AM BLOOD WBC-3.1* Lymph-35 Abs ___ CD3%-90 Abs CD3-971 CD4%-13 Abs CD4-143* CD8%-70 Abs CD8-763* CD4/CD8-0.2* ___ 08:00AM BLOOD Glucose-82 UreaN-9 Creat-1.1 Na-137 K-3.8 Cl-106 HCO3-25 AnGap-10 ___ 08:00AM BLOOD Glucose-82 UreaN-9 Creat-1.1 Na-137 K-3.8 Cl-106 HCO3-25 AnGap-10 ___ 06:00PM BLOOD ALT-38 AST-30 LD(LDH)-210 AlkPhos-76 TotBili-0.4 ___ 08:00AM BLOOD Calcium-8.3* Phos-3.4 Mg-2.0 ___ 06:00PM BLOOD D-Dimer-143___* CTA IMPRESSION: 1. Acute lateral 6th rib fracture. 2. Mild bronchial wall thickening with subtle areas of bronchial mucoid impaction, mild peripheral areas of tree in ___ opacities suggestive of atypical infection such as MAC. 3. No acute aortic pathology or pulmonary embolus. Brief Hospital Course: ___ y/o male with HIV (CD4 ___ poor compliance with HAART who presented with left sided chest discomfort, cough and sputum production. #Cough: Appears to be chronic in nature per ___ records this has been going on for months rather than 3 days per pt. He was given guaifenasin and tesslon pearls. Spoke with radiologist about the read on the CTA and it showed no PE, little medistinal lymph node proiminance, bronchial wall thickening was started on azitromycin for 5 d course for possible underlying CAP vs pertussis. He had some wheeze on second hospital day and was given inhalers and sent home on fluticasone, abuterol prn. #Rib fracture: believed to from coughing so much. He was given advil, tylenol, oxycodone and ultram for pain while here #HIV: Last CD4 was 191 h/o non-compliance. We continued rionovir boosted atazanovir and truvada, Bactrim prophylaxis. Social work was consulted. sent off for cd4, vl, genotype, phenotype #Schizophrenia: Pt with flat affect. His home meds: Zyprexa 20 and Klonipin TID were continued #Hep C: type Ia, has never been treated. He is hep A,B immune TRANSITIONAL ISSUES: []f/u CD4, HIV VL, genotype, phenotype ][f/u fungal cultures []f/u blood cultures []f/u pertussis Medications on Admission: The Preadmission Medication list is accurate and complete. 1. OLANZapine 20 mg PO DAILY 2. Maalox/Diphenhydramine/Lidocaine 15 mL PO QID:PRN mouth pain 3. Docusate Sodium 100 mg PO BID 4. Senna 1 TAB PO BID:PRN constipation 5. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 6. Fluoxetine 60 mg PO DAILY 7. Atazanavir 300 mg PO DAILY 8. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY 9. RiTONAvir 100 mg PO DAILY 10. ClonazePAM 1 mg PO TID 11. ValACYclovir 1000 mg PO DAILY:PRN outbreak Discharge Medications: 1. Atazanavir 300 mg PO DAILY 2. ClonazePAM 1 mg PO TID 3. Docusate Sodium 100 mg PO BID 4. Fluoxetine 60 mg PO DAILY 5. OLANZapine 20 mg PO DAILY 6. RiTONAvir 100 mg PO DAILY 7. Senna 1 TAB PO BID:PRN constipation 8. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY 9. Maalox/Diphenhydramine/Lidocaine 15 mL PO QID:PRN mouth pain 10. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 11. ValACYclovir 1000 mg PO DAILY:PRN outbreak 12. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN Cough RX codeine-guaifenesin 100 mg-10 mg/5 mL ___ mL by mouth every six (6) hours Disp #1 Bottle Refills:0 13. Benzonatate 100 mg PO TID RX benzonatate 100 mg 1 capsule(s) by mouth three times a day Disp #90 Capsule Refills:0 14. Acetaminophen 650 mg PO Q6H:PRN pain Please stagger this medication with ibuprofen to decrease inflammation RX acetaminophen 650 mg 1 tablet extended release(s) by mouth every six (6) hours Disp #120 Tablet Refills:0 15. Ibuprofen 400 mg PO Q6H:PRN pain Please stagger this medication with acetaminophen to decrease inflammation RX ibuprofen 400 mg 1 tablet(s) by mouth every six (6) hours Disp #120 Tablet Refills:0 16. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain RX tramadol 50 mg 1 tablet(s) by mouth every four (4) hours Disp #180 Tablet Refills:0 17. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN Pain RX oxycodone 10 mg 1 tablet(s) by mouth twice a day Disp #12 Tablet Refills:0 18. Azithromycin 250 mg PO Q24H Duration: 4 Days RX azithromycin 250 mg 1 tablet(s) by mouth daily Disp #4 Tablet Refills:0 19. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheeze RX albuterol sulfate 90 mcg 2 puffs IH every four (4) hours Disp #1 Inhaler Refills:0 20. Fluticasone Propionate 110mcg 2 PUFF IH BID RX fluticasone [Flovent HFA] 110 mcg/actuation 2 puff IH twice a day Disp #2 Inhaler Refills:*0 Discharge Disposition: Home Discharge Diagnosis: primary: rib fracture, cough secondary: HIV positive Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You came to the hospital because you had a cough and chest pain. You had imaging done which showed a rib fracture and we think the rib fracture is from your coughing. We started you on treatment for a lung infection with azithromycin which you will take for 4 more days. We treated your pain with advil, tylenol, tramadol and oxycodone. You can continue these medications after you leave the hospital. - advil and tylenol can be taken three times a day to decrease inflammation - tramadol and oxycodone will help with the pain as needed You had some wheeze on your exam and we gave you inhalers to start taking. It is important you use a spacer and rinse your mouth after the inhalers because it can cause thrush, which you have had before. It is VERY important you take your medications every day, in particular your HIV medications and bactrim! Please follow up with Dr ___ below for appointment details) Followup Instructions: ___
19572730-DS-23	19,572,730	23,565,832	DS	23	2159-12-28 00:00:00	2159-12-28 14:57:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: ___ Attending: ___. Chief Complaint: admitted with Dysphagia Major Surgical or Invasive Procedure: Lumbar puncture on ___ Bone marrow bx ___ History of Present Illness: Mr ___ is a ___ year old man with h/o MALT, Kaposi's, HIV (on ART), HCV and h/p PE (___), schizophrenia (c/b by meth-abuse) who was directed to present to the ED for admission by ___ heme/onc after an urgent referral was sent to heme/onc by PCP for care of his newly diagnosed esophageal plasmablastic lymphoma. Patient initially presented to ___ ED on ___ w dysphagia ___ large esophageal mass. Mass was biopsied via endoscopy during visit. Pt has received previous tx for ___'s sarcoma at ___ heme/onc. Records from ___ ED visit and path report have been faxed to ___ heme/onc. Per patient he was asked to come here by his PCP (who followed up with ___ for biopsy results) for immediate treatment given aggressive nature of mass. Per heme onc evaluation, on arrival, patient notes that he has had dysphagia for several weeks. When he eats solid food and feels like it gets stuck in his chest. No pain at present. Denies fevers or chills. No change in vision or hearing. No headache. No new rashes, lesions, wounds. No change in bowel or bladder function. No focal neurologic deficits. Per ED, patient felt overall okay and wanted to go home but was told by his PCP to go to the ER for further evaluation. He reports has had dysphagia for several weeks. He is able to tolerate liquids and smoothies. Worsening discomfort with solid foods. Notes occasional nausea and vomiting when he eats solid food and feels like it gets stuck in his chest. Patient reports some weight loss, currently weighs 165 pounds (weighed 158 pounds ___ per OMR). Denies fevers or chills. No change in vision or hearing. No headache. No new rashes, lesions, wounds. No change in bowel or bladder function. No focal neurologic deficits. In the ED - Initial vitals: 96.9 96 137/84 17 97% RA - Exam notable for: no abnormal findings - Labs notable for + CBC: WBC 4.4 Hgb 9.5 Plt 320 + Chem 10: Na 140 K 4.0 Creat 1.2 + UA negative + Uric acid 9.6 + ALT 9, AST 18, Alkphos 132, LDH 352, T bili 0.3 - Patient was given clonazepam in the ED - Seen by Hemeonc in ED who recommended admission for elevated uric acid level for further evaluation and management. - Transfer vitals: 82 129/80 18 100% RA Past Medical History: Marginal zone lymphoma Kaposi's sarcoma on LUE Iron deficiency anemia HCV (untreated) Meth use HIV on HAART dx ___ HCV (untreated) Ia, Hep A,B immune Genital HSV Schizophrenia g/o molluscum h/o genital herpes h/o thrush h/o syphilis ___, treated h/o genital HPV Schizophrenia - overall stable h/o OCD, depression, anxiety; r/o panic disorder h/o polysubstance use - esp stimulants Social History: ___ Family History: Question of mental illness in mother. - No history of clotting disorders Physical Exam: ADMISSION 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 with white lesions on tongue consistent with thrush, no erythema or exudate CV: Heart regular, no murmur, no S3, no S4. No JVD. RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, non-distended, non-tender to palpation. Bowel sounds present. No HSM GU: No suprapubic fullness or tenderness to palpation MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs 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 DISCHARGE EXAM ===================== 24 HR Data (last updated ___ @ 1100) Temp: 98.5 (Tm 99.0), BP: 104/68 (94-107/51-73), HR: 99 (88-99), RR: 16 (___), O2 sat: 100% (95-100), O2 delivery: RA GENERAL: Alert and in no apparent distress EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without white lesions on tongue, no erythema/exudate CV: Heart regular, no murmur, no S3, no S4. No JVD. RESP: Lungs clear to auscultation with good air movement bilaterally. No wheezes, rales or rhonchi. Breathing is even and non-labored. GI: Abdomen soft, non-distended/non-tender. +bowel sounds present. No HSM MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs. Tenderness on palpation of left lumbar area. 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 Pertinent Results: ADMISSION LABS =================== ___ 07:37PM BLOOD WBC-4.4 RBC-4.42* Hgb-9.5* Hct-33.6* MCV-76* MCH-21.5* MCHC-28.3* RDW-20.3* RDWSD-55.4* Plt ___ ___ 07:37PM BLOOD Neuts-70.6 Lymphs-18.3* Monos-9.9 Eos-0.5* Baso-0.2 Im ___ AbsNeut-3.13 AbsLymp-0.81* AbsMono-0.44 AbsEos-0.02* AbsBaso-0.01 ___ 07:37PM BLOOD Plt ___ ___ 06:10AM BLOOD ___ PTT-28.9 ___ ___ 06:10AM BLOOD Ret Aut-2.1* Abs Ret-0.09 ___ 07:37PM BLOOD Glucose-108* UreaN-10 Creat-1.2 Na-140 K-4.0 Cl-100 HCO3-25 AnGap-15 ___ 07:37PM BLOOD ALT-9 AST-18 LD(LDH)-352* AlkPhos-132* TotBili-0.3 ___ 07:37PM BLOOD Lipase-20 ___ 07:37PM BLOOD Albumin-4.3 UricAcd-9.6* ___ 06:10AM BLOOD Calcium-8.8 Phos-3.8 Mg-2.0 UricAcd-9.3* IMAGING STUDIES ==================== U/S ___: Non-occlusive thrombus within the left subclavian and axillary veins, adjacent to the PICC line CT CHEST ___: Relatively unchanged appearance of a known esophageal mass compared to prior study. New lytic lesions along the thoracic spine, concerning for new foci of lymphoma. New thrombus noted adjacent to the tip of the left PICC. No evidence of new pneumonia. CT A/P ___: There are numerous small, newly appreciated lytic osseous lesions predominantly located in the pelvic, but also located in the partially imaged spine. A large circumferential mass in the distal thoracic esophagus is partially imaged, not appreciably changed since the most recent prior examination. Splenomegaly measures 16.4 cm. DISCHARGE LABS ================= ___ 06:25AM BLOOD WBC-5.9 RBC-3.71* Hgb-8.3* Hct-28.3* MCV-76* MCH-22.4* MCHC-29.3* RDW-20.1* RDWSD-50.8* Plt ___ ___ 06:25AM BLOOD Neuts-59 Bands-2 ___ Monos-8 Eos-0* ___ Metas-2* Myelos-3* Promyel-1* NRBC-1.0* Other-3* AbsNeut-3.60 AbsLymp-1.30 AbsMono-0.47 AbsEos-0.00* AbsBaso-0.00* ___ 06:25AM BLOOD Plt Smr-NORMAL Plt ___ ___ 01:03PM BLOOD WBC-3.4* Lymph-26 Abs ___ CD3%-89 Abs CD3-784 CD4%-13 Abs CD4-118* CD8%-72 Abs CD8-640 CD4/CD8-0.18* ___ 06:10AM BLOOD Ret Aut-2.1* Abs Ret-0.09 ___ 06:25AM BLOOD Glucose-107* UreaN-11 Creat-1.0 Na-141 K-4.3 Cl-102 HCO3-21* AnGap-18 ___ 06:25AM BLOOD ALT-10 AST-8 LD(LDH)-253* AlkPhos-109 TotBili-0.2 ___ 06:25AM BLOOD Albumin-3.8 Calcium-8.8 Phos-3.6 Mg-2.0 UricAcd-4.7 ___ 07:37PM BLOOD Lipase-20 ___ 01:03PM BLOOD calTIBC-309 Ferritn-16* TRF-238 ___ 06:10AM BLOOD Hapto-206* ___ 05:50PM BLOOD CMV IgG-POS* CMV IgM-NEG CMVI-Generally EBV IgG-POS* EBNA-NEG EBV IgM-NEG EBVI-Infection TOX IgG-NEG TOX IgM-NEG TOXI-No antibod ___ 06:10AM BLOOD Vanco-15.5 ___ 01:03PM BLOOD HBV VL-NOT DETECT HCV VL-NOT DETECT Brief Hospital Course: ASSESSMENT AND PLAN: Mr ___ is a ___ year old male with a history of MALT, Kaposi's sarcoma on LUE, HIV (on HAART dx ___, HCV (untreated), syphilis, gential HPV and HSV and history of PE ___, was previously on rivaroxoban), schizophrenia (c/b by meth-abuse) with newly diagnosed esophageal plasmablastic lymphoma who originally presented with dysphagia and found to have an esophageal mass. He now initiated C1 DA-EPOCH (___) and IT MTX (___) c/b febrile neutrapenia. ACUTE/ACTIVE CONDITIONS ========================== #ESOPHAGEAL PLASMABLASTIC LYMPHOMA: #ENCOUNTER FOR CHEMOTHERAPY: Presented to ___ ED with dysphagia, biopsy found to be esophageal plasmablastic lymphoma. Notably, he had MALT on last admission in ___ where there was concern of transformation based on PET imaging. He unfortunately rarely followed up with outpatient. HBV/HCV VL negative. CD4 count 118, but HIV VL negative. For staging, TTE wnl and CT torso c/w esophageal malignancy and local nodes, possible focus within T2 vertebral body. On ___, patient underwent an LP with IT MTX (no evidence of CNS involvement). Plan to re-stage status post nadir after cycle 1 per his primary oncologist (CT Torso/Neck). CT Torso obtained in the setting of LBP workup showed stable esophageal mass and new lytic lesions along the thoracic spine and pelvic region (unclear significance at just received C1 treatment). EBV viral load from ___ significantly lower at 8948 ? benefit from Rituxan, prior EBV VL ___ elevated at ___ (continue to trend outpatient). Continue acyclovir/bactrim for infectious prophylaxis. Filagristim from D6 until counts recovery: ___. Per speech and swallow evaluation ___, safe for thin liquids and regular solids from an oropharyngeal perspective. Today is D5 of his regimen. He has appointment with Dr. ___ on ___. #FEBRILE NEUTROPENIA: Resolved. First FN spike ___ ___ in setting of chills & generalized fatigue ___ progressed to cough & thrush. Had significant thrush vs. leukoplakia. ENT consulted ___ but would require a bx but as patient was neutropenic at that point, procedure was deferred. Also, noted for worsening productive cough on ___, given persistent fevers and history of heavy vape use (high risk for invasive fungal infection), a CT chest was obtained which showed no evidence of pneumonia. Prior to CT, patient was briefly started on posaconazole (received loading dose ___. However, with negative CT results, posaconazole was discontinued on ___ and treatment with micafungin was initiated (D1: ___ instead. Fluconazole discontinued ___ with initiation of posaconazole, now on micafungin as above. Off micafungin (D1: ___ as well cefepime (D1: ___ as no source identified and culture data negative. Also, off vancomycin (D1: ___ as counts recovering and no evidence of gram positive infection. Blood and urine cultures, NGTD. Monitor for recrudescence of fever outpatient. #LOW BACK PAIN: Resolving since ___. Noted since bone marrow biopsy ___. CT negative for fluid collection, abscess, hematoma or other etiology of back pain. ? likely neupogen-related. Continue to monitor and trend pain. #LUE PICC-ASSOCIATED THROMBUS: Incidental finding on CT A/P ___ obtained in s/o LBP workup. C/f a fibrin tail initially. However, a dedicated U/S on ___ showed a non-occlusive thrombus within the left subclavian and axillary veins, adjacent to the PICC line. Patient has been on prophylaxis dosing of lovenox on admission, changed to Lovenox 70mg BID on ___ then proceeded with rivaroxban 15mg BID ___ (x 21 days, then 20mg daily) to make amenable for disposition planning. ___ removed ___. Consider repeat U/S in ___ weeks to evaluate for resolution. #THROMBOYCTOPENIA/NEUTROPENIA: Likely due to recent EPOCH. Overall, counts are recovering. No active bleeding. No infection identified as above, off neupogen since ___. Trend CBC outpatient. CHRONIC/STABLE/RESOLVED CONDITIONS ====================================== #IRON DEFICIENCY ANEMIA: Stable. Likely multi-factorial in setting of anemia of chronic disease vs. myeloablative chemotherapy vs. lymphoma itself. Iron studies c/w iron deficiency anemia. -Continue to trend and transfuse for Hgb<7 -Consider GI consult if persists post nadir (e.g. known Kaposi's sarcoma could be bleeding in gut) -IV iron administration ___ #ANXIETY: #HISTORY OF PSYCHOSIS: #SCHIZOPHRENIA: #IVDA: Patient is very anxious about treatment and receiving chemotherapy. Continues to ask for Ativan or other benzodiazepines. Trying to avoid too many benzos that will sedate him. Per psych, patient is taking more clonazepam than RX'd (Rx is for 1mg BID). Further, per the outpatient psychiatry provider, patient may be having active auditory hallucinations and using benzos to quiet those voices. -Continues on olanzapine 5mg with breakfast, lunch standing in addition to 20mg qHS to help with anxiety -Continue clonazepam, decreased to 1mg BID ___ per psych #HIV: On Bictegrav-Emtricit-Tenofov Ala 1 TAB PO DAILY #CONSTIPATION: Resolved. Patient has had intermittent constipation in the past week with a BM every ___ days. Concern for constipation given risk with vincristine; therefore, received standing bowel regimen inpatient but discontinued prior to discharge. #HISTORY OF PE, Segmental: Patient reports that he has stopped taking rivaroxaban ___ years ago. PE dx ___ #HISTORY OF METH ABUSE: SW/PSYCH following #GERD: Continue PPI daily. CORE MEASURES ================= #Lines/Tubes/Drains: PICC removed ___. #Contacts/HCP: Per OMR; Father ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild 2. ClonazePAM 1 mg PO TID 3. Nicotine Lozenge 4 mg PO Q1H:PRN cigarette craving 4. OLANZapine 20 mg PO QHS 5. Omeprazole 40 mg PO BID 6. bictegrav-emtricit-tenofov ala 50-200-25 mg oral DAILY Discharge Medications: 1. Acyclovir 400 mg PO BID 2. Allopurinol ___ mg PO DAILY 3. Nicotine Patch 14 mg/day TD DAILY 4. Rivaroxaban 15 mg PO BID take with food 5. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 6. ClonazePAM 1 mg PO BID 7. OLANZapine 5 mg PO DAILY anxiety 8. OLANZapine 5 mg PO DAILY:PRN anxiety 9. bictegrav-emtricit-tenofov ala 50-200-25 mg oral DAILY 10. Nicotine Lozenge 4 mg PO Q1H:PRN cigarette craving 11. OLANZapine 20 mg PO QHS 12. Omeprazole 40 mg PO BID Discharge Disposition: Home Discharge Diagnosis: PRIMARY =============== Diffuse Large B Cell Plasmablastic Lymphoma Encounter for chemotherapy Febrile Neutropenia SECONDARY =============== MALT Kaposi's Sarcoma HIV Hepatitis C Schizophrenia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure taking care of you at ___! WHY WAS I ADMITTED TO THE HOSPITAL? - You were admitted to the hospital after biopsy results from your esophageal mass showed plasmablastic lymphoma. WHAT HAPPENED WHILE I WAS IN THE HOSPITAL? - You started on EPOCH chemotherapy on ___. - You developed a fever while your counts were low. We treated you with antibiotics and you are now ready to be discharged WHAT SHOULD I DO WHEN I GO HOME? - Please take all your medications as prescribed. - Please follow-up with your doctor as noted in your discharge paperwork. We wish you the best, Your ___ care team Followup Instructions: ___
19572730-DS-28	19,572,730	22,299,417	DS	28	2160-03-23 00:00:00	2160-03-23 15:15:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Geodon Attending: ___. Chief Complaint: cough, sore throat Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ year old male with Plasmablastic Lymphoma engulfing the esophagus (diagnosed via biopsy at ___ on ___, Stage IV with involvement of the bone marrow, numerous osseous sites, and spleen, cytogenetics with t 8;14) and Inversion 18 on FISH, status-post da-EPOCH x 5 cycles with Bortezomib added from C2 onwards and prophylactic IT methotrexate x 5 doses) as well as history of extranodal Marginal Zone Lymphoma of the Salivary Gland (treated with anti-HIV therapy alone), HIV on HAART (diagnosed ___, history of genital HSV, Molluscum Contagiosum, and Syphilis), EBV viremia (improving with anti-neoplastic therapy), Pulmonary Embolism (previously treated with Rivaroxaban), Kaposi Sarcoma on Left Upper extremity, Iron Deficiency Anemia of uncertain etiology, HCV (untreated), Schizophrenia, left upper extremity PICC- associated thrombosis (diagnosed ___, status-post PICC removal and now on Rivaroxaban), and recent Influenza B infection requiring treatment with Tamiflu now presenting with cough, rhinorrhea, and sore throat found to have pneumonia on CXR and referred to the ED for further management. Notably, patient was recently admitted from ___ for C5 da-EPOCH and Bortezomib that was complicated by development of influenza B. Patient left the hospital on ___ against medical advice prior to improvement of his respiratory status in the setting of his influenza B infection. He was discharged on Tamiflu 75mg BID for 5 total days (D1 of therapy ___. Double dosing was deferred after discussion with ID via phone. In the ED: -Initial vital signs were notable for: Temp. 97.0, HR 68, BP 141/105, RR 20. 100% RA -Exam notable for: Diffuse rhonchi with some wheezing heard in the left upper lobe -Labs were notable for: WBC 6.9, Hg 6.9, platelets of 46 with normal renal function, lactate, and UA. Hg improved to 8.2 after 1 unit pRBC transfusion. -Studies performed include: CXR showed increased opacification of the bilateral mid and lower lung zones, concerning for pneumonia and a trace right pleural effusion. -Patient was given: 75 mg daily Tamiflu, IV cefepime and vancomycin in addition to other home medication regimen, and ___ IVF. Xarelto not given while in the emergency department. Vitals on transfer: Temp. 98.4, HR 85, BP 100/65 RR 20, 95% 3L NC Upon arrival to the floor, he reports persistent cough and chest congestion. Feels a little better. Has some shortness of breath but not severe. No new symptoms. Review of Systems:(+) Per HPI. Denies fever, chills, rigors, night sweats, headache, vision changes, rhinorrhea, congestion, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria or hematuria. Past Medical History: Past Medical History: - Plasmablastic Lymphoma, as above - Extranodal Marginal Zone Lymphoma of the salivary gland (treated with anti-HIV therapy alone) - HIV on HAART (diagnosed ___, history of genital HSV, Molluscum Contagiosum, and Syphilis) - Pulmonary Embolism (previously treated with Rivaroxaban) - Kaposi Sarcoma on Left Upper extremity - Iron Deficiency Anemia of uncertain etiology - HCV (untreated, Genotype 1a) - Schizophrenia - Left upper extremity PICC-associated thrombosis (status-post PICC removal, on Rivaroxaban) g/o molluscum h/o genital herpes h/o thrush h/o syphilis ___, treated h/o genital HPV h/o OCD, depression, anxiety; r/o panic disorder h/o polysubstance use - esp stimulants Hematologic/Oncologic History: - ___: Presents to ___ ED with dysphagia. - ___: Biopsy of esophageal mass at ___ reveals Diffuse Large B Cell Lymphoma consistent with Plasamblastic Lymphoma. MYC is positive by IHC in 80% of cells, ___ is positive. Ki67 is 95%. The neoplastic cells are negative for CD20. - ___: PCP follows up biopsy results from ___ and directs the patient to come immediately to the ___ ED for admission and institution of therapy. - ___: Bone Marrow Biopsy reveals a mildly hypocellular bone marrow with maturing trilineage hematopoiesis and low-level involvement by recently-diagnosed lambda-restricted Plasmablastic Lymphoma. Cytogenetics reveal the presence of t(8;14) and Inversion 18 on karyotype, as well as t(8;14) by FISH. DNMT3A exon 10 splice donor loss mutation with variant allele frequency 11%. - ___: Staging CT Torso reveals a large esophageal mass in continuity with a few satellite nodules, a small new lucency in the T2 vertebral body, possible focus of lymphoma, and mild splenomegaly. The final staging is Stage IV, given involvement of bone marrow, osseous sites, and spleen. - ___: LVEF 55-60%. - ___: C1D1 da-EPOCH, dose level 1, uncapped vincristine. - ___: Dose 1 prophylactic intrathecal Methotrexate. - ___: CT chest shows relatively unchanged appearance of a known esophageal mass compared to prior study, new lytic lesions along the thoracic spine, concerning for new foci of lymphoma, new thrombus noted adjacent to the tip of the left PICC, and no evidence of new pneumonia. - ___: CT abdomen shows numerous small, newly appreciated lytic osseous lesions predominantly located in the pelvis, but also located in the partially imaged spine, and splenomegaly measures 16.4 cm. - ___: Left UENIs demonstrate nonocclusive thrombus within the left subclavian and axillary veins, adjacent to the PICC line. Theraepeutic enoxaparin initiated, transitioned to Rivaroxban at the time of discharge. - ___: Discharged to home. Admission also complicated by febrile neutropenia, treated empirically with Vancomycin, Cefepime, and Posaconazole. - ___: Dose 2 prophylactic intrathecal Methotrexate. CSF analysis reveals 1 WBC (93% lymphs, 7% monos), 0 RBCs, TProt 36, Gluc 57, FISH negative for IgH/MYC rearrangement, flow cytometry normal. - ___: Admitted for C2D1 da-EPOCH/Bortezomib, dose level -1, uncapped vincristine. - ___: C2D4 Bortezomib. - ___: Discharged to home. - ___: C2D8 Bortezomib. - ___: C2D11 Bortezomib. - ___: Dose 3 prophylactic intrathecal Methotrexate. - ___: Admitted for C3D1 - ___: Admitted for C4 D1 - ___: Admitted for C5D1 Social History: ___ Family History: Question of mental illness in mother. - No history of clotting disorders Physical Exam: Admission Exam =============== 24 HR Data (last updated ___ @ 1606) Temp: 97.9 (Tm 97.9), BP: 126/81, HR: 95, RR: 18, O2 sat: 94%, O2 delivery: RA GEN: sitting upright, NAD NEURO: A&Ox3. HEENT: No conjunctival pallor or icterus. MMM. Significant thrush on tongue. NECK: Supple. No LAD LYMPH: No cervical or supraclavicular LAD CV: Nl rate, regular rhythm. No MRG. LUNGS: Coughing during exam with wheezing throughout left lung field and crackles on RLB. Otherwise, with fair aeration ABD: ND, nl bowel sounds, NT, no HSM. EXT: WWP. No ___ edema. SKIN: No rashes, lesions, petechiae, purpura ecchymoses. LINES: PIV C/D/I DISCHARGE EXAM: SEE FLOW SHEET FOR VITALS GEN: sitting upright, NAD NEURO: A&Ox3. HEENT: No conjunctival pallor or icterus. MMM. Significant thrush on tongue. NECK: Supple. No LAD LYMPH: No cervical or supraclavicular LAD CV: Nl rate, regular rhythm. No MRG. LUNGS: Diffuse inspiratory and expiratory wheezes, scattered rhonchi. ABD: ND, nl bowel sounds, NT, no HSM. EXT: WWP. No ___ edema. SKIN: No rashes, lesions, petechiae, purpura ecchymoses. LINES: PIV C/D/I Pertinent Results: Admission Labs ___ 02:59PM BLOOD WBC-1.5* RBC-2.43* Hgb-7.0* Hct-21.7* MCV-89 MCH-28.8 MCHC-32.3 RDW-19.1* RDWSD-63.7* Plt Ct-85* ___ 02:59PM BLOOD Neuts-93.4* Lymphs-4.6* Monos-1.3* Eos-0.0* Baso-0.0 Im ___ AbsNeut-1.42* AbsLymp-0.07* AbsMono-0.02* AbsEos-0.00* AbsBaso-0.00* ___ 02:59PM BLOOD Plt Ct-85* ___ 02:59PM BLOOD Glucose-96 UreaN-15 Creat-0.8 Na-135 K-4.0 Cl-98 HCO3-23 AnGap-14 ___ 02:59PM BLOOD ALT-16 AST-12 LD(___)-212 AlkPhos-65 TotBili-0.2 ___ 07:28PM BLOOD Lactate-0.7 Discharge labs ___ 05:52AM BLOOD WBC-1.1* RBC-3.19* Hgb-9.1* Hct-27.5* MCV-86 MCH-28.5 MCHC-33.1 RDW-16.0* RDWSD-50.4* Plt Ct-37* ___ 05:52AM BLOOD Neuts-42 ___ Monos-24* Eos-1 Baso-0 Atyps-1* AbsNeut-0.46* AbsLymp-0.36* AbsMono-0.26 AbsEos-0.01* AbsBaso-0.00* ___ 05:52AM BLOOD Glucose-102* UreaN-9 Creat-0.9 Na-139 K-4.0 Cl-103 HCO3-22 AnGap-14 ___ 05:52AM BLOOD ALT-9 AST-8 LD(LDH)-143 AlkPhos-84 TotBili-0.3 ___ 05:52AM BLOOD Albumin-3.9 Calcium-8.6 Phos-2.9 Mg-1.7 Imaging: CXR: ___ IMPRESSION: Increased opacification of the bilateral mid and lower lung zones, concerning for pneumonia. Trace right pleural effusion. Brief Hospital Course: Mr. ___ is a ___ year old male with history of well-controlled HIV, anxiety, schizophrenia and Plasmablastic Lymphoma engulfing the esophagus s/p cycle 5 of da-EPOCH and Bortezomib complicated by influenza B infection requiring treatment with Tamiflu presenting with cough, rhinorrhea, and sore throat found to have healthcare associated pneumonia in the setting of antecedent influenza B infection admitted for further management. ACUTE CONDITIONS =============================== #INFLUENZA B INFECTION: #HCAP: Developed on most recent admission (___) in the setting of acute respiratory symptoms. Was initiated on Tamiflu x5 days now with CXR c/f pnuemonia after recent influenza infection. Initiated on HCAP coverage with cefepime and vancomycin, expect counts to be nadiring at this point following his chemotherapy, see below. Hemodynamics are stable though with elevated lactate to 2.1 that improved after repeat. -Continue Tamiflu 75mg BID (D1 ___ x10D -Initially treated with vancomycin/cefepime (D1: ___ De-escalated to Levaquin 750 mg ___. Important to patient to be home for holiday therefore discharged with close follow up (lab/vital sign check ___ a.m. and clinic appt on ___. Instructed to return to ED if febrile. -Will check strep p pending. urine legionella negative. -Fungal markers ___ negative -F/U Bcx and Ucx - MRSA screen pending. #PLASMABLASTIC LYMPHOMA: #LEFT TONGUE BASE SOFT TISSUE SWELLING: Patient underwent PET s/p 3C of da-EPOCH on ___ which showed continued FDG update of base of tongue (SUV 11.5) and unchanged appearance of esophageal involvement. Plan to continue DA-EPOCH/Bortezomib x 6 cycles with intrathecal chemoprophylaxis (last done on ___ followed by radiation. ENT consulted in the past in regards to base of tongue avidity and currently holding on biopsy PND EOT PET results per primary oncologist. Patient is currently day 9 of C5 DA-EPOCH + Bortzemib. Received Pegfilgrastim outpatient on ___ -Continue infectious prophylaxis: Acyclovir and Bactrim -Continue Allopurinol for TLS prevention #ORAL CANDIDIASIS: Mostly on tongue. Continues on fluconazole, added topical therapy with nystatin suspension (D1: ___ #EBV VIREMIA: Elevated EBV serum viral load. Most likely a disease marker given that plasmablastic Lymphoma is ___ positive. level was 914 on ___. Most recent level < 200 copies/ml on ___ CHRONIC/STABLE/RESOLVED CONDITIONS =========================================== #IRON DEFICIENCY ANEMIA: Multi-factorial in s/o anemia of chronic disease vs. myeloablative chemotherapy vs. lymphoma itself. Iron studies consistent with iron deficiency anemia. Occult GI blood loss is the presumed etiology. However, if persistent, will require ___ for both diagnostic and therapeutic purposes -Transfuse for Hgb <7 #ANXIETY: #HISTORY OF PSYCHOSIS: #SCHIZOPHRENIA: #IVDA: History of anxiety around treatment and receiving chemotherapy. Psych evaluated in the past and recommended increasing clonazepam 1mg TID, olanzapine 20mg qhs/olanzaprine 5mg daily PRN when on steroids. #LUE PICC-ASSOCIATED THROMBUS: Incidental finding on CT A/P ___. U/S on ___ showed a non-occlusive thrombus within left subclavian and axillary veins, adjacent to the PICC line. Patient was on lovenox initially but changed to rivaroxban. -Holding rivaroxaban for now with thrombocytopenia. #HISTORY OF PE, Segmental: Patient reports that he had stopped taking rivaroxaban ___ years ago. PE dx ___, now on rivaroxaban again, holding on admission ___ borderline TCP. #HIV: On Bictegrav-Emtricit-Tenofov Ala 1 TAB PO DAILY. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acyclovir 400 mg PO Q12H 2. Allopurinol ___ mg PO DAILY 3. Bictegrav-Emtricit-Tenofov Ala 1 TAB PO DAILY 4. ClonazePAM 1 mg PO BID 5. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line 6. Nicotine Lozenge 4 mg PO Q2H:PRN nicotine cravings 7. OLANZapine 20 mg PO QHS 8. OLANZapine 5 mg PO DAILY:PRN anxiety 9. Omeprazole 20 mg PO DAILY 10. Rivaroxaban 20 mg PO DAILY 11. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 12. Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - First Line 13. Escitalopram Oxalate 10 mg PO DAILY 14. Fluconazole 200 mg PO Q24H 15. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing 16. OSELTAMivir 75 mg PO BID Discharge Medications: 1. GuaiFENesin ___ mL PO Q6H:PRN cough 2. LevoFLOXacin 750 mg PO DAILY 3. Nystatin Oral Suspension 5 mL PO QID 4. Acyclovir 400 mg PO Q12H 5. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing 6. Allopurinol ___ mg PO DAILY 7. Bictegrav-Emtricit-Tenofov Ala 1 TAB PO DAILY 8. ClonazePAM 1 mg PO BID 9. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line 10. Escitalopram Oxalate 10 mg PO DAILY 11. Fluconazole 200 mg PO Q24H 12. Nicotine Lozenge 4 mg PO Q2H:PRN nicotine cravings 13. OLANZapine 20 mg PO QHS 14. OLANZapine 5 mg PO DAILY:PRN anxiety 15. Omeprazole 20 mg PO DAILY 16. Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - First Line 17. OSELTAMivir 75 mg PO BID 18. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 19. HELD- Rivaroxaban 20 mg PO DAILY This medication was held. Do not restart Rivaroxaban until your counts recover. Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary ======================= Pneumonia Influenza B infection MALT----Esophageal Plasmablastic Lymphoma Pancytopenia Oral Candidiasis SECONDARY =============== ___'s Sarcoma HIV Hepatitis C Schizophrenia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were admitted with a cough, sore throat following recent flu diagnosis. You were found to have pneumonia and was admitted for further treatment. You received IV antibiotics with significant improvement in your symptoms. Since you have improved, we think you are medically ready for discharge. Please continue to take all of your medications as prescribed. Your appointment with Dr. ___ is as listed. It was an absolute pleasure taking care of you. Sincerely, Your ___ TEAM Followup Instructions: ___
19573410-DS-10	19,573,410	28,239,588	DS	10	2150-01-04 00:00:00	2150-01-04 10:56:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Codeine / Demerol / Sulfa (Sulfonamide Antibiotics) / Morphine / Biaxin / Augmentin / Cortisporin / Latex / adhesive tape / chlorathiladone / tramadol / Lyrica Attending: ___. Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ who presents 8 days following lap gastric band removal with adhesiolysis. She reports that her abdominal pain never subsided postoperatively, and she states that this worsened some since last night (x24 hours). She also endorses associated constipation x8 days. She denies nausea, vomiting, diarrhea, fevers, chills. She reports that up until 12 noon today (8 hours ago) she was eating vegetable soups and shepards pie at home without issue. She describes the pain as present in the left lower quadrant with some radiation to her lower back on the left. Past Medical History: anemia degenerative disk disease celiac disease gout T2DM HLD HTN hypothyroidism interstitial cystitis obesity psoriasis hx of c diff PSH: lap gastric band ___ hysterectomy Social History: ___ Family History: NC Physical Exam: DISCHARGE PHYSICAL EXAM: Gen: NAD, AxOx3 Card: RRR, no m/r/g Pulm: CTAB, no respiratory distress Abd: Soft, ND, minimally TTP, no rebound or guarding Wounds: c/d/i Ext: No edema, warm well-perfused Pertinent Results: CT A/P ___: 1. Status post lap band removal without evidence of gastric perforation. 2. Small amount of fluid in the region of the gastrohepatic recess. 3. Small subacute appearing hematoma in the anterior body wall 4. Supraumbilical small bowel containing hernia, uncomplicated, Richter's type. Barium swallow ___: 1. No evidence of leak or obstruction. 2. Tertiary contractions without dilatation or evidence of obstruction of the distal esophagus is suggestive of mild esophageal dysmotility. ___ 06:07AM BLOOD WBC-11.1* RBC-3.41* Hgb-9.0* Hct-30.3* MCV-89 MCH-26.4 MCHC-29.7* RDW-16.1* RDWSD-52.6* Plt ___ ___ 06:07AM BLOOD Glucose-173* UreaN-26* Creat-1.3* Na-140 K-4.6 Cl-100 HCO3-26 AnGap-14 Brief Hospital Course: Ms. ___ is a ___ woman who presented with abdominal pain in the setting of uncomplicated laparosopic gastric band removal surgery on ___. Given small perigastric fluid collection on CT A/P, a barium swallow was performed. The study was normal and exonerated underlying leak. Her small fluid collection on imaging likely represents normal post-surgical change and her abdominal pain was assessed to be incisional pain alone. She responded to reassurance. Pt verbalized that she will f/u with her PCP ___ 24 hours of discharge. She will confirm that her furosemide and valsartan dosing is appropriate given her baseline CKD and recent fluctuant diet. Outpatient cardiology was recommended given concern for possible tachybrady syndrome noted on telemetry (asymptomatic, HD stable); she declined inpatient consultation despite discussion of the risks. She also has chronic back pain and will discuss with her PCP if outpatient orthopedic consultation is warranted. She will f/u with bariatric surgeon Dr. ___ week. No medication changes were made this admission. Medications on Admission: 1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze 2. Allopurinol ___ mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Docusate Sodium 100 mg PO DAILY:PRN Constipation - Second Line 5. DULoxetine 120 mg PO DAILY 6. Furosemide 40 mg PO DAILY 7. Glargine 100 Units Q12H Insulin SC Sliding Scale using novolog InsulinMax Dose Override Reason: home dosing 8. Levothyroxine Sodium 125 mcg PO DAILY 9. PredniSONE 7 mg PO DAILY 10. Senna 8.6 mg PO DAILY:PRN Constipation - First Line 11. Valsartan 320 mg PO DAILY Discharge Medications: 1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze 2. Allopurinol ___ mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Docusate Sodium 100 mg PO DAILY:PRN Constipation - Second Line 5. DULoxetine 120 mg PO DAILY 6. Furosemide 40 mg PO DAILY 7. Glargine 100 Units Q12H Insulin SC Sliding Scale using novolog InsulinMax Dose Override Reason: home dosing 8. Levothyroxine Sodium 125 mcg PO DAILY 9. PredniSONE 7 mg PO DAILY 10. Senna 8.6 mg PO DAILY:PRN Constipation - First Line 11. Valsartan 320 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Post-op incisional abdominal pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You came in for evaluation of abdominal pain. Imaging studies exonerated more concerning causes of your pain like infection or leak. We suspect your pain is most likely consistent with normal postoperative pain from your gastric band removal on ___. You are now safe to go home. Please plan to follow up with Dr. ___ on ___. We also recommend follow up with cardiology for possible irregular heart rhythm (tachybrady syndrome). Dr. ___ is a cardiologist who might be able to see you (his office is at ___. We also recommend follow up with orthopedic surgeon Dr. ___ back pain (his number is ___. Followup Instructions: ___
19573527-DS-9	19,573,527	29,648,826	DS	9	2178-11-14 00:00:00	2178-11-14 16:01:00	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 burning/pain Major Surgical or Invasive Procedure: Endoscopy History of Present Illness: ___ with history of essential thrombocytosis, CAD s/p CABG (___), HTN, GERD who presented to ___ for further workup of post-MVA pain who was found to have new anemia and new onset substernal chest pain with ST changes on EKG. He has had intermittent burning epigastric pain for several months. His burning epigastric pain resolves after he takes omeprazole. He denies any black or bloody stool, but on presentation to ___ today was found to have a new anemia ___ down from ___ in ___ and heme positive stool. A rectal exam also showed BRBPR. He had a troponin of 0.01, was given Protonix Maalox and viscous lidocaine. He then apparently abruptly complained of severely burning chest pain became diaphoretic and then had mild changes to inferior leads. He was transferred to ___ given possibility of STEMI. Of note, patient receives all his care at ___. His cardiologist, can't recall name, is also at ___ and he had a follow-up visit with him about 2 weeks ago. A bedside ECHO at that time did not show any abnormalities according to the patient. He also underwent a c-scope earlier this year which according to him was normal. In the ED, initial VS were: 98.0 94 156/79 18 98% RA Exam notable for: Nontender abdomen, 1+ bilateral edema, and guaiac positive brown stool ECG: NSR @ 83bpm, NA, NI, Q waves inferiorly, STD I,aVL, sub-mm STE in III, V1. Concave T wave in V2, V3. TWI I, II, aVL, V4-V6. Suspected LVH Labs showed: Hgb 7.8, Thrombocytosis to 454, BUN elevated to 24, Trop <0.01 On arrival to the floor, patient reports he is having ___ burning chest pain which he insists is not similar to his prior cardiac episodes. He has had this pain for 5 days, relieved by his omeprazole but then returns in within a half an hour. Denies SOB, fevers, chills, nausea, vomiting, hematochezia, or melena. Reports chronic constipation for which he has to strain. Past Medical History: Angioplasty ___ at the ___. Coronary disease-status post micro-infarction in ___ with stents placed in ___ and cardiac bypass performed in ___ HTN since the ___' HLD GERD Essential Thrombocytosis on hydrea Social History: ___ Family History: No FH of DMII or heart disease Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VS: 97.7 PO 126 / 71 86 18 95 RA GENERAL: NAD HEENT: AT/NC, EOMI, PERRL, MMM NECK: supple, no LAD, no JVD HEART: RRR, S1/S2, grade III holosystolic blowing murmur best heard at the LSB LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, mild TTP in the LUQ, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: +1 pitting edema in the ___ up to the mid-shins NEURO: A&Ox3, moving all 4 extremities with purpose SKIN: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE PHYSICAL EXAM: ======================== Temp: 98.0 PO BP: 179/79 HR: 78 RR: 18 O2 sat: 98% O2 delivery: RA GENERAL: NAD HEENT: AT/NC, EOMI, PERRL, MMM NECK: supple, no LAD, no JVD HEART: RRR, S1/S2, III/VI holosystolic blowing murmur best heard at the LSB LUNGS: CTAB, breathing comfortably ABDOMEN: nondistended, obese, nontender, no rebound/guarding EXTREMITIES: +1 pitting edema in the ___ up to the mid-shins NEURO: A&Ox3, moving all 4 extremities with purpose SKIN: warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: ADMISSION LABS: =============== ___ 07:47PM BLOOD WBC-4.6 RBC-1.97* Hgb-7.8* Hct-23.0* MCV-117* MCH-39.6* MCHC-33.9 RDW-15.9* RDWSD-64.3* Plt ___ ___ 12:48AM BLOOD WBC-4.9 RBC-1.72* Hgb-7.1* Hct-20.4* MCV-119* MCH-41.3* MCHC-34.8 RDW-15.0 RDWSD-63.4* Plt ___ ___ 07:47PM BLOOD Neuts-60.0 ___ Monos-7.4 Eos-0.4* Baso-0.6 NRBC-0.4* Im ___ AbsNeut-2.77 AbsLymp-1.29 AbsMono-0.34 AbsEos-0.02* AbsBaso-0.03 ___ 07:47PM BLOOD Plt ___ ___ 07:47PM BLOOD Glucose-174* UreaN-24* Creat-0.6 Na-144 K-4.5 Cl-106 HCO3-25 AnGap-13 ___ 07:47PM BLOOD ALT-12 AST-15 AlkPhos-57 TotBili-0.3 ___ 07:47PM BLOOD cTropnT-<0.01 ___ 12:48AM BLOOD CK-MB-2 cTropnT-<0.01 ___ 07:47PM BLOOD Albumin-3.7 Calcium-8.6 Phos-2.5* Mg-1.8 ___ 12:48AM BLOOD calTIBC-208* VitB12-272 Hapto-76 Ferritn-173 TRF-160* ___ 07:47PM BLOOD Lactate-1.8 DISCHARGE LABS: =============== ___ 06:55AM BLOOD WBC-6.3 RBC-2.76* Hgb-9.6* Hct-28.6* MCV-104* MCH-34.8* MCHC-33.6 RDW-25.6* RDWSD-88.1* Plt ___ ___ 12:40PM BLOOD Glucose-245* UreaN-14 Creat-0.7 Na-141 K-4.0 Cl-105 HCO3-21* AnGap-15 IMAGING: ======== U/S: No evidence of deep venous thrombosis in the left lower extremity veins. EGD: Large blood clot and fresh blood was noted in the fundus. An oozing Dieulafoy lesion was seen in the fundus/cardia. Electrocautery was successfully applied for hemostasis. Brief Hospital Course: ___ with history of CAD s/p CABG (___), HTN, GERD who presented to ___ for further workup of post-MVA pain who was found to have new anemia and concern for gastrointestinal bleed. # Macrocytic Anemia: Patient had baseline hgb ___ and presented with hgb 7.8, macrocytic. No megaloblastic changes likely from Hydrea though acute drop in heme positive stool was felt to be due to a GI bleed. He had a normal colonoscopy ___ NSAID though PCP concerned he may get salicylates through OTC supplements. No evidence of hemolysis on labs and CT negative for RP bleed. He ultimately underwent EGD which showed a bleeding dieulafoy's lesion which was cauterized. He was discharged on PPI therapy in conjunction with H2 blocker. His blood counts improved; he did receive several blood transfusions while hospitalized but ultimately his counts stabilized post procedure. # CAD # Substernal Chest Pain # Transient ST depressions Presented with acute onset epigastric & substernal pain described as burning started 5 days prior to initial presentation. Troponins were negative, EKG changes mostly old however had some transient ST depressions in V4/5 while at ___ resolved by the time of arrival. Ultimately felt unlikely plaque rupture or significant likely demand based in the setting of new anemia. Trops remained negative at ___. His burning chest pain was ultimately attributed to a GI source as it improved with the above GI intervention. He was seen by cardiology on this admission and no acute intervention was necessary. # HTN Normotensive on arrival, notably anemic, concern for large volume blood loss so initially BP meds held. Ultimately restarted without issue. Lisinopril was held during day of procedure. Notably patient says he is not compliant with his medications takes and when he feels he needs them, sometimes lower doses because he thinks he is too many medications. CHRONIC ISSUES: ================ # Essential Thrombocytosis chronically on Hydrea, lower dose than he has been in the past. Baseline MCV 115. Discussed with outpatient ___, were comfortable with holding Hydrea with close follow-up to restart. ==================== TRANSITIONAL ISSUES: ==================== #CODE: Full (presumed) #CONTACT: Next of Kin: ___ Relationship: WIFE Phone: ___ DISCHARGE HEMOGLOBIN: 9.6/28.6 [ ] Restart Hydrea. [ ] Please refer patient for ___ Gastroenterology follow up as appropriate [ ] Discussion with patient about importance of BP control with consistent medication adherence [ ] Evaluation of home supplements / over the counters for salicylates. [ ] Please recheck CBC for H/H within 1 week. [ ] Consider initiation of another anti-hyperglycemic or uptitrating metformin as he required significant insulin while inpatient. [ ] While chest burning was attributed to GI symptoms this admission, given transient non-specific changes on EKG prior to transfer from ___ and his coronary history can consider stress test as outpatient. [ ] After 8 weeks of therapy (end ___ please consider reducing and discontinuing PPI as tolerated and as you feel clinically appropriate. [ ] Follow up with primary care team regarding pain management for left leg discomfort. Time spent: 50 minutes Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Omeprazole 20 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Potassium Chloride 10 mEq PO BID 4. Atorvastatin 40 mg PO QPM 5. ___ (docusate sodium) 100 mg oral BID:PRN 6. Lisinopril 40 mg PO DAILY 7. NIFEdipine (Extended Release) 120 mg PO DAILY 8. Furosemide 20 mg PO DAILY 9. MetFORMIN (Glucophage) 500 mg PO DAILY 10. Viagra (sildenafil) 100 mg oral PRN 11. Vitamin D 1000 UNIT PO DAILY 12. Hydroxyurea 1500 mg PO DAILY 13. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain - Severe 14. Metoprolol Succinate XL 200 mg PO DAILY Discharge Medications: 1. Pantoprazole 40 mg PO Q12H RX pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:0 2. Ranitidine 150 mg PO BID RX ranitidine HCl 150 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:0 3. Atorvastatin 80 mg PO QPM RX atorvastatin 80 mg 1 tablet(s) by mouth at bedtime Disp #30 Tablet Refills:*0 4. Aspirin 81 mg PO DAILY 5. ___ (docusate sodium) 100 mg oral BID:PRN 6. Furosemide 20 mg PO DAILY 7. Lisinopril 40 mg PO DAILY 8. MetFORMIN (Glucophage) 500 mg PO DAILY 9. Metoprolol Succinate XL 200 mg PO DAILY 10. NIFEdipine (Extended Release) 120 mg PO DAILY 11. Omeprazole 20 mg PO DAILY 12. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain - Severe 13. Potassium Chloride 10 mEq PO BID 14. Viagra (sildenafil) 100 mg oral PRN 15. Vitamin D 1000 UNIT PO DAILY 16. HELD- Hydroxyurea 1500 mg PO DAILY This medication was held. Do not restart Hydroxyurea until your doctors ___ to do so Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: CAD s/p CABG Acute Upper GI Bleed Anemia Hypertension Essential Thrombocytosis Type II Diabetes Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure taking care of you at ___. WHY DID YOU COME TO THE HOSPITAL? - You went to ___ because you had burning in your chest. - They noticed your blood counts were very low and they were also worried about your heart, so you were transferred to ___. WHAT HAPPENED WHILE YOU WERE HERE? - You were evaluated by the heart doctors. ___ do not think the chest pain is from your heart. - You were given some extra blood since you had lost so much. - Cameras were used to look into your stomach which showed an area of bleeding, which was treated endoscopically. WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL? - Please continue to take all of your medications as directed, and follow up with all of your doctors. Again, it was a pleasure taking care of you! Sincerely, Your ___ Team Followup Instructions: ___
19573671-DS-7	19,573,671	25,670,414	DS	7	2139-02-01 00:00:00	2139-02-01 19:56:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Latex / lisinopril / finasteride Attending: ___ Chief Complaint: Abdominal Pain, Fatigue Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ yo man with a histroy of nonischemic cardiomyopathy with an ejection fraction of approximately 20% to 30%, Paroxysmal atrial fibrillation on coumadin, ventricular tachycardia and ventricular fibrillation, ___ dual-chamber ICD s/p syncopal episode, VT ablation ___ who presents with three months of worsening fatigue, epigastric pain, belching/flatuluance and abnormal liver tests thought to be secondary to cardiac cirrhosis versus an infiltrative illness. Of note, this is a patient of Dr. ___. He was last seen by Dr. ___ in ___. At that visit the patient was too noted to have a three month history of decreased appetite, nausea and midepigastric pain that seemed to begin after having gone to ___ in ___. Dr. ___ an upper endoscopy which was unrevealing other than mild gastritis. The patient also had an ultrasound that was notable for borderline normal hepatic parenchyma but was otherwise unremarkable. At that visit he was also noted to have multiple soft and bad smelling stools as well as liver test notable for ALT 50 AST 113 AlkPhos 327 TotBili 1 The patient was started on Creon for suspected pancreatic insufficiency and plan was made to trend his LFT as an outpatient for 2 weeks. At this time Dr. ___ the patients history to be most consistent with either cardiac cirrhosis versus an infiltrative illness. Liver biopsy was deferred at this time as the patient is on Coumadin. Per Dr. ___ the patient need for warfarin, biopsy would need to be done through his jugular vein. The patient was set up with outpatient lab work for LFT which did infarct downtrend however remained elevated. The patient presented to the ED with ___ weeks of fatigue, weakness, cool arms and a tremor worse when the palms are extended. There is no fever, chills, chest pain, shortness of breath, nausea or vomiting. No blood in the stool or black stool. In the ED, initial vitals: T 97.3 HR59 BP 123/57 RR16 O2100% - Exam notable for: - Asterixis bilaterally - CN III-XII intact - Strength ___ in upper and lower extremities with drift in bilateral legs after 8 seconds. - CTAB - RRR - Mildly distended abdomen with mild tenderness in RUQ - Labs notable for: Lactate 2.4 ALT 42 AST 103 ALK PHOS 207 Alb 3 Lipase 130 NA 134 K 4 BUN 29 CR 1.4 WBC 13.7 HGB:12.9 HCT 38.3 INR 2 UA Bland - Imaging notable for: CXR: Liver GB US: 1. Absent flow within the portal vein, consistent with portal veinthrombosis. 2. Cirrhotic liver with findings of hypertension including splenomegaly and small volume ascites. No evidence of focal hepatic lesion. - Pt given: Lactulose 30ml Albumin 25% (12.5g / 50mL) 12.5 g Upon arrival to the floor, the patient reports that he had been feeling in his otherwise good health when he began to feel weak. he denies having any sick contact of feeling fevering. He reports that his abdominal pain is not out of proportion to his baseline. He and his wife agree that he has been a little more confused lately. He has, however, reported a ___ LB unintentional weight loss over the past ___ months. Past Medical History: Hypertension Hyperlipidemia Non-ischemic cardiomyopathy with systolic CHF (EF ~20%) Paroxysmal atrial fibrillation NSVT Syncope ___ s/p ICD placement ___ Recently (___) treated for cellulitis of hand 1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension 2. CARDIAC HISTORY: -CABG: NA -PERCUTANEOUS CORONARY INTERVENTIONS: NA -PACING/ICD: s/p ___ ___ ___ placement ___ Social History: ___ Family History: No family history of early MI, otherwise non-contributory Physical Exam: ADMISSION PHYSICAL ================== VITALS: afebrile, stable General: AAOX3 HEENT: Sclerae slightly icteric, MMM, oropharynx clear, CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Obese, no fluid wave appreciated , non-tender, bowel sounds present, no organomegaly, no rebound or guarding Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: Warm, dry, no rashes or notable lesions. Neuro: CNII-XII intact, ___ strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally. Flapping tremor DISCHARGE PHYSICAL ================== VITALS: ___ 0734 Temp: 97.4 PO BP: 112/70 HR: 63 RR: 18 O2 sat: 99% O2 delivery: Ra General: NAD HEENT: Anicteric sclerae, MMM, oropharynx clear CV: RRR, normal S1 + S2, no murmurs, rubs, gallops, or thrills Lungs: CTAB, no wheezes, rales, rhonchi Abdomen: Obese, no fluid wave appreciated, non-tender, bowel sounds present, no organomegaly, no rebound or guarding Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or lower extremity edema Skin: Warm, dry, no rashes or notable lesions Neuro: AAOx3, no asterixis, moving all 4 extremities with purpose Pertinent Results: ADMISSION LABS ============== ___ 12:30PM BLOOD WBC-13.7* RBC-4.20* Hgb-12.9* Hct-38.3* MCV-91 MCH-30.7 MCHC-33.7 RDW-14.3 RDWSD-47.7* Plt ___ ___ 12:30PM BLOOD Neuts-78.7* Lymphs-11.4* Monos-8.4 Eos-0.7* Baso-0.5 Im ___ AbsNeut-10.77* AbsLymp-1.56 AbsMono-1.15* AbsEos-0.09 AbsBaso-0.07 ___ 12:30PM BLOOD ___ PTT-38.2* ___ ___ 12:30PM BLOOD Glucose-141* UreaN-29* Creat-1.4* Na-134* K-4.5 Cl-97 HCO3-18* AnGap-19* ___ 12:30PM BLOOD ALT-42* AST-103* AlkPhos-207* TotBili-1.2 ___ 12:30PM BLOOD Lipase-130* ___ 07:14AM BLOOD GGT-321* ___ 12:30PM BLOOD Albumin-3.0* ___ 04:36PM BLOOD Ammonia-64* ___ 01:27PM BLOOD Lactate-2.4* ___ 12:00PM URINE Color-Straw Appear-Clear Sp ___ ___ 12:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG PERTINENT RESULTS ================= ___ 07:14AM BLOOD calTIBC-264 Ferritn-79 TRF-203 ___ 07:14AM BLOOD HBsAg-NEG HBsAb-POS HBcAb-POS* ___ 07:14AM BLOOD Smooth-POSITIVE* ___ 07:14AM BLOOD ___ ___ 12:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG ___ 07:14AM BLOOD HCV Ab-NEG MICRO ===== Urine Culture ___: No Growth Blood Culture ___: Pending- No Growth to Date STUDIES ======= Liver Ultrasound ___. Absent flow within the portal vein, consistent with portal vein thrombosis. 2. Cirrhotic liver with findings of hypertension including splenomegaly and small volume ascites. No evidence of focal hepatic lesion. CXR PA and LAT ___ The lung volume is small exaggerating bronchovascular markings. No focal consolidation to suggest pneumonia. No pulmonary edema. No pleural effusion or pneumothorax. Moderate cardiomegaly persists. The mediastinal silhouette is unchanged. Left-sided pacer with its leads terminating in the right atrium and right ventricles is in unchanged position. No pneumonia. TTE ___ The left atrium is moderately dilated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is mildly dilated. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is low normal (LVEF 50%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). 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: Suboptimal image quality. Left ventricular cavity dilation with low normal global systolic function. No valvular pathology or pathologic flow identified. Incresaed PCWP. Compared with the prior study (images reviewed) of ___, left ventricular function is improved. The heart rate is now much slower. CT Abd/Pelvis (Triple phase) w/ Contrast ___. Cirrhotic liver with splenomegaly. No lesions meeting OPTN 5 criteria for hepatocellular carcinoma. 2. No evidence of portal or hepatic vein thrombosis. 3. Prominent retroperitoneal and mesenteric lymph nodes may be reactive. 4. Atrophic left kidney. DISCHARGE LABS ============== ___ 07:55AM BLOOD WBC-9.3 RBC-3.90* Hgb-11.8* Hct-35.6* MCV-91 MCH-30.3 MCHC-33.1 RDW-14.4 RDWSD-47.8* Plt ___ ___ 07:55AM BLOOD ___ PTT-33.2 ___ ___ 07:55AM BLOOD Glucose-196* UreaN-20 Creat-1.2 Na-133* K-4.5 Cl-99 HCO3-21* AnGap-13 ___ 07:55AM BLOOD ALT-42* AST-85* AlkPhos-180* TotBili-1.3 Brief Hospital Course: Mr. ___ is a ___ yo man with complicated cardiac history notable for HFrEF EF 20% to 30% previously and now improved to 50%, paroxysmal atrial fibrillation on Coumadin, and ventricular tachycardia(s/p ICD), who presented with three months of worsening fatigue, epigastric pain, belching/flatulence and abnormal liver tests, with new evidence of cirrhosis and portal vein thrombosis. ACUTE/ACTIVE ISSUES: ==================== # Cirrhosis The patient had evidence of cirrhosis on abdominal ultrasound on ___. There is also evidence of small volume ascites on that ultrasound. The etiology of his cirrhosis was thought most likely to be cardiac in nature given his history of heart failure with reduced ejection fraction. The patient was also noted to have a moderate to heavy drinking history. However, the patient reported that he was drinking much less presently. PSC and PBC were also on the differential as the patient had evidence of elevated alkaline phosphatase on his liver function tests. However, these were thought to be unlikely given the patient's age. Autoimmune hepatitis was also considered but again, was thought to be less likely given the patient's age and gender. The patient was screened for viral hepatitis and was noted to have a history of hepatitis B infection and negative hepatitis C antibody. Other autoimmune workup was also sent for to further evaluate for these etiologies but were either pending or negative at the time of discharge as notated in the lab section of the summary. Patient was continued on lactulose to prevent hepatic encephalopathy and was titrated to 34 bowel movements daily. The patient cirrhosis was thought to be well compensated during this hospitalization. # Portal Vein Thrombosis Patient was noted to have evidence of PVT on ultrasound on ___. Patient was therapeutic on warfarin when he developed PVT. On chart review, has been therapeutic on warfarin with INR between ___ consistently. He was therefore started on a heparin gtt. Patient underwent triple phase CT to further evaluate the portal vein thrombus and evaluate for any possible malignancy on ___ but no abnormalities were seen. There is also no evidence of portal vein thrombosis on his CT scan. The patient's heparin drip was discontinued and he was reinitiated on his home dose of warfarin prior to discharge. # Normocytic anemia The patient was noted to have ongoing normocytic anemia since ___ without evidence of iron deficiency. His recent EGD was only notable for mild gastritis and colonoscopy demonstrated diverticula and polyps in ___. The patient did have guaiac positive brown stools but no signs of active bleeding. The patient's hemoglobin remained stable during his hospitalization and there is no evidence of active bleeding even on anticoagulation. # HFrEF Patient had a known history of non ischemic cardiomyopathy. TTE in ___ showed EF ___ with severe TR but a repeat TTE demonstrated LVEF of 50% with minimal TR but with increased PCWP. on exam, the patient was euvolemic without evidence of lower extremity edema. His work lungs were clear to auscultation. After resolution of his acute kidney injury, the patient was restarted on Lasix and lisinopril however at a different dosage than previously as notated in the medication section of the summary. # Paroxysmal atrial fibrillation (Chads VASC 2) Patient presented with a known history of paroxysmal atrial fibrillation. He had been maintained on Coumadin with a goal INR of ___. On review of OMR flow sheet, the patient had exceptional INR control. However, INR may have been artificially elevated in setting of new diagnosis of cirrhosis and patient could have been inadequately anticoagulated. The patient's metoprolol succinate 100 mg daily was fractionated to metoprolol tartrate 25 mg every 6 hours for better control during his hospital stay. His warfarin was initially held and he was started on a heparin drip. Once his CT scans showed no evidence of portal vein thrombosis, the patient's heparin drip was discontinued and he was restarted on his home dose of warfarin. # Hypertension The patient was on losartan, furosemide, spironolactone and metoprolol at home. Patient was noted to be normotensive throughout hospitalization. His metoprolol succinate was fractionated for better control during his hospital stay. His antihypertensive medications were slowly restarted after resolution of his acute kidney injury. # ___ on CKD stage III (Solitary functioning Kidney) - Resolved Patient had a known history of a solitary functioning kidney and known chronic kidney disease stage III with a baseline creatinine around 1.1. On presentation, the patient was found to have a creatinine of 1.4. This is thought to be likely prerenal in the setting of abdominal pain and decreased p.o. intake. The patient was given gentle fluids and his ___ resolved. His diuretics and his losartan were initially held in that setting to prevent further kidney injury. CHRONIC ISSUES: =============== # Ventricular Tachycardia s/p ICD placement Patient was seen for device check most recently in ___. The device battery was noted to have ___ years left at that time. TRANSITIONAL ISSUES: ==================== [ ] Restarted warfarin at 1mg daily as before, recommend rechecking INR and adjusting for goal INR ___. [ ] ___ screening: Will need abdominal ultrasound every 6 months to screen for hepatocellular carcinoma [ ] Repeat Labs: Recommend rechecking CBC, chemistry 10 panel, LFTs, INR on ___ office visit [ ] Losartan: Recommend rechecking renal function and restarting losartan as appropriate for CKD and hypertension [ ] Recommend continuing Lasix 20mg and Spironolactone 50mg if renal function is at baseline # Code status: Full Code (confirmed) # Health care proxy/emergency contact: Wife ___ Daughter ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Losartan Potassium 50 mg PO DAILY 2. Rosuvastatin Calcium 40 mg PO QPM 3. Spironolactone 12.5 mg PO DAILY 4. Warfarin 1 mg PO DAILY16 5. Furosemide 80 mg PO DAILY 6. Metoprolol Succinate XL 100 mg PO DAILY 7. Amiodarone 200 mg PO DAILY Discharge Medications: 1. Lactulose 30 mL PO TID RX lactulose 10 gram/15 mL (15 mL) 30 mL by mouth twice a day Disp #1 Bottle Refills:0 2. Furosemide 20 mg PO DAILY RX furosemide 20 mg 1 tablet(s) by mouth daily Disp #5 Tablet Refills:0 3. Spironolactone 50 mg PO DAILY RX spironolactone [Aldactone] 50 mg 1 tablet(s) by mouth once a day Disp #5 Tablet Refills:0 4. Amiodarone 200 mg PO DAILY 5. Metoprolol Succinate XL 100 mg PO DAILY 6. Rosuvastatin Calcium 40 mg PO QPM 7. Warfarin 1 mg PO DAILY16 RX warfarin [Coumadin] 1 mg 1 tablet(s) by mouth once a day Disp #5 Tablet Refills:0 8. HELD- Losartan Potassium 50 mg PO DAILY This medication was held. Do not restart Losartan Potassium until you discuss with your primary care doctor Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses ================= Cirrhosis Portal vein thrombosis Acute kidney injury Secondary Diagnoses =================== Heart failure with reduced ejection fraction Paroxysmal atrial fibrillation Normocytic Anemia Hypertension Ventricular tachycardia status post ICD placement Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure taking care of you in the hospital! Why was I admitted to the hospital? -You came to the hospital because you had abdominal pain and fatigue What happened while I was admitted to the hospital? -You were found to have liver cirrhosis -You were also found to have a blood clot in your liver vein -You had an ultrasound of your heart that showed it was healthier than before -You had a CT scan of your abdomen that did not show any abnormalities other than your liver cirrhosis -Your lab numbers were closely monitored and you were given medications What should I do after I leave the hospital? -Please continue taking all of your medications as prescribed, details below -Keep all of your appointments as scheduled - Weigh yourself every morning, before you eat or take your medications. Call your doctor if your weight changes by more than 3 pounds - Please stick to a low salt diet and monitor your fluid intake - Seek medical attention if you have new or concerning symptoms We wish you the very best! Your ___ Care Team Followup Instructions: ___
19573671-DS-9	19,573,671	21,384,945	DS	9	2139-05-18 00:00:00	2139-05-21 15:41:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Latex / lisinopril / finasteride / amiodarone Attending: ___. Chief Complaint: Acute on chronic HFrEF Major Surgical or Invasive Procedure: None History of Present Illness: ___ y/o M PMH, HF with recovered EF (20% --> 50%), ventricular tachycardia and ventricular fibrillation, s/p ___ dual-chamber ICD placement, VT ablation ___, admission in ___ for new diagnosis undifferentiated cirrhosis p/w worsening exertional dyspnea, orthopnea, decreased exercise tolerance, abdominal distension and pedal edema. Decreased ET and dyspnea started two weeks ago, patient noticed that he could only walk 3 stairs at a time (baseline 20 stairs) and 2 pillow orthopnea (baseline 0 pillows). Pt was hospitalized here 4 weeks ago for hepatic encephalopathy and ___. He was started on Lactulose and rifaximin with improvement in his mental status. For his cirrhosis, diuretics were held and he was given albumin. He was thought to be euvolemic on discharge so he was sent home off of diuretics. He did not receive a para as no tappable pocket was noted. No varices on EGD ___. He had a RUQUS which was concerning for PVT, however this finding was similar to prior on admission in ___ when a subsequent CT exonerated PVT. He was initially started on Heparin for fear of a Coumadin failure, however this was ultimately DC'ed and his home warfarin was continued. He had ___ on admission with Cr 1.6. With albumin, his renal function did not improve and this was thought to be his new baseline. Diuretics and ACE were held on discharge for this reason. For his heart failure, his TTE noted recovered EF as above to 50%, his Lasix and spironolactone were held, he was continued on his beta blocker. Discharge weight was 168. Since that time, the patient was seen by hepatology at which point he was started back on Lasix 20mg PO, spironolactone 50PO daily (from Lasix 80mg PO daily prior to recent admission.) In the ED, initial VS were: 71 100/62 18 100% RA Exam notable for: Bibasilar crackles, ascites, hepatojugular reflux and 3+ pitting edema. ECG: Labs showed: ___: 36.6 PTT: 39.7 INR: 3.4 11.4 > 9.0/26.5 < 134 proBNP: 3429 ALT: 50 AP: 191 Tbili: 3.0 Alb: 3.4 AST: 116 CK: 117 MB: 2 123 / 90 / 33 ---------------< 123 5.0 / ___ / 2.3 Trop-T: <0.01 URINE: ========= UreaN:468 Na:<20 Phos:44.1 Osmolal:260 Osms:265 Imaging showed: LIVER OR GALLBLADDER US : Pending DUPLEX DOP ABD/PEL LIMI: Pending CXR: No acute cardiopulmonary process. Consults: Hepatology Renal Patient received: Nothing Transfer VS were: 68 107/62 18 100% RA On arrival to the floor, patient reports continued exercise intolerance and edema, but no other symptoms at this time. Explains that when at rest, his breathing feels at baseline, but that when he takes even a few steps he becomes short of breath. No chest pain at this time, no other sx. Past Medical History: Hypertension Hyperlipidemia Non-ischemic cardiomyopathy with systolic CHF (EF ~20%) Paroxysmal atrial fibrillation NSVT Syncope ___ s/p ICD placement ___ Recently (___) treated for cellulitis of hand 1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension 2. CARDIAC HISTORY: -CABG: NA -PERCUTANEOUS CORONARY INTERVENTIONS: NA -PACING/ICD: s/p ___ ___ ___ placement ___ Social History: ___ Family History: No family history of early MI, otherwise non-contributory Physical Exam: ADMISSION EXAM ======================= VS: 97.5 PO 102 / 69 L Sitting 63 18 99 Ra GENERAL: NAD, stiting comfortably at edge of bed. Speaking in full sentences. HEENT: AT/NC, anicteric sclera, MMM NECK: supple, no LAD. CV: Regular rhythm with normal S1, paradoxically split S2. No appreciable murmur. PULM: CTAB, no wheezes, rales, rhonchi, somewhat diminished at left base. GI: Tense, distended abdomen, no appreciable ascites on exam. No tenderness to palpation. No peritoneal signs. EXTREMITIES: 2+ pitting edema to knees bilaterally. PULSES: 2+ radial pulses bilaterally NEURO: Alert and oriented x 3, moving all 4 extremities with purpose, face symmetric. No asterixis. DERM: warm and well perfused, no excoriations or lesions, no rashes. No stigmata of end stage liver disease. DISCHARGE EXAM ======================= 24 HR Data (last updated ___ @ 1106) Temp: 97.3 (Tm 98.5), BP: 99/63 (94-99/57-64), HR: 63 (63-69), RR: 20 (___), O2 sat: 100% (97-100), O2 delivery: Ra Fluid Balance (last updated ___ @ 1032) Last 8 hours Total cumulative -5ml IN: Total 420ml, PO Amt 420ml OUT: Total 425ml, Urine Amt 425ml Last 24 hours Total cumulative 555ml IN: Total 1380ml, PO Amt 1380ml OUT: Total 825ml, Urine Amt 825ml Weight: 73.4 kg Admission weight: 82.7 kg GENERAL: NAD, sitting comfortably on chair. Speaking in full sentences. HEENT: AT/NC, anicteric sclera, MMM NECK: supple, no LAD. JVP ___, improved CV: Regular rhythm without appreciable murmur. PULM: CTAB, no wheezes, crackles. GI: Soft, mild distension, no fluid wave, non-tender EXTREMITIES: No lower extremity edema bilaterally, warm PULSES: 2+ radial pulses bilaterally NEURO: Alert and oriented x 3, moving all 4 extremities with purpose, face symmetric. DERM: warm and well perfused, no excoriations or lesions, no rashes. No stigmata of end stage liver disease. Pertinent Results: ADMISSION LABS ========================= ___ 07:53PM GLUCOSE-152* UREA N-35* CREAT-2.1* SODIUM-126* POTASSIUM-4.0 CHLORIDE-91* TOTAL CO2-20* ANION GAP-15 ___ 07:53PM CALCIUM-9.0 PHOSPHATE-4.1 MAGNESIUM-2.3 ___ 07:53PM WBC-11.3* RBC-3.13* HGB-9.0* HCT-26.9* MCV-86 MCH-28.8 MCHC-33.5 RDW-17.1* RDWSD-53.4* ___ 07:53PM PLT COUNT-139* ___ 05:31AM GLUCOSE-136* UREA N-33* CREAT-2.1* SODIUM-122* POTASSIUM-5.4 CHLORIDE-90* TOTAL CO2-17* ANION GAP-15 ___ 05:31AM CALCIUM-8.7 PHOSPHATE-3.6 MAGNESIUM-2.3 IRON-42* ___ 05:31AM calTIBC-289 FERRITIN-43 TRF-222 ___ 03:39AM OSMOLAL-265* ___ 03:39AM URINE OSMOLAL-260 ___ 12:50AM URINE BLOOD-SM* NITRITE-NEG PROTEIN-30* GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG ___ 12:50AM URINE RBC-<1 WBC-3 BACTERIA-FEW* YEAST-NONE EPI-0 ___ 11:50PM ALT(SGPT)-50* AST(SGOT)-116* CK(CPK)-117 ALK PHOS-191* TOT BILI-3.0* ___ 11:50PM cTropnT-<0.01 ___ 11:50PM CK-MB-2 proBNP-3429* ___ 11:50PM CK-MB-2 proBNP-3429* ___ 11:50PM ALBUMIN-3.4* ___ 11:50PM WBC-11.4* RBC-3.10* HGB-9.0* HCT-26.5* MCV-86 MCH-29.0 MCHC-34.0 RDW-17.1* RDWSD-53.1* ___ 11:50PM ___ PTT-39.7* ___ DISCHARGE LABS ========================= ___ 06:55AM BLOOD WBC-12.3* RBC-3.21* Hgb-9.3* Hct-28.4* MCV-89 MCH-29.0 MCHC-32.7 RDW-17.6* RDWSD-55.3* Plt ___ ___ 06:55AM BLOOD ___ PTT-42.6* ___ ___ 06:55AM BLOOD Glucose-169* UreaN-53* Creat-2.4* Na-134* K-4.3 Cl-95* HCO3-23 AnGap-16 ___ 06:55AM BLOOD ALT-80* AST-132* AlkPhos-219* TotBili-2.1* ___ 06:55AM BLOOD Calcium-9.1 Phos-2.9 Mg-2.0 IMAGING ========================= CXR ___ Left-sided pacemaker with its leads terminating in the right atrium and right ventricle is unchanged. The lung volume is small, exaggerating bronchovascular markings. No focal consolidation or pulmonary edema. No pleural effusion or pneumothorax. Moderate cardiomegaly is unchanged. No acute osseous abnormalities. IMPRESSION: No acute cardiopulmonary process. ABDOMINAL U/S WITH DUPLEX ___ IMPRESSION: 1. Patent but reversal of flow in the main portal vein, left portal vein, and right anterior portal vein. Posterior branch of the right portal vein is not well seen. 2. Cirrhotic liver with sequela portal hypertension including splenomegaly and small volume ascites. RENAL U/S ___ 1. No hydronephrosis seen within the right kidney. Known atrophic Left kidney, not visualized on today's exam. 2. Trace ascites. TTE ___ The left atrial volume index is moderately increased. The right atrium is mildly enlarged. There is normal left ventricular wall thickness with a moderately increased/dilated cavity. There is SEVERE global left ventricular hypokinesis. The visually estimated left ventricular ejection fraction is 20%. Left ventricular cardiac index is low normal (2.0-2.5 L/min/m2). There is no resting left ventricular outflow tract gradient. No ventricular septal defect is seen. Tissue Doppler suggests an increased left ventricular filling pressure (PCWP greater than 18mmHg). Normal right ventricular cavity size with normal free wall motion. 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 diameter is normal. The aortic valve leaflets (3) appear structurally normal. There is no aortic valve stenosis. There is no aortic regurgitation. The mitral valve leaflets are mildly thickened with no mitral valve prolapse. There is mild to moderate [___] mitral regurgitation. The tricuspid valve leaflets appear structurally normal. There is moderate to severe [3+] tricuspid regurgitation. The estimated pulmonary artery systolic pressure is borderline elevated. In the setting of at least moderate to severe tricuspid regurgitation, the pulmonary artery systolic pressure may be UNDERestimated. There is a trivial pericardial effusion. IMPRESSION: Moderately dilated left ventricle with severe global hypokinesis. Top normal right ventricular size with normal systolic function. Likely moderate to severe tricuspid regurgitation accounting for shadowing from the right ventricular lead. Brief Hospital Course: SUMMARY: ___ y/o M PMH, HFref (EF 20 % on ___ echo), HTN, DM2, Afib, recently diagnosed cirrhosis here for worsening exertional dyspnea with volume overloaded exam (weight 182 from 168 on previous discharge) and associated ___ and hyponatremia. Likely ___ to CHF exacerbation in setting of under-diuresis in outpatient setting, concern for R>L sided failure in setting of significant JVP and ___ edema with clear chest x-ray and clinical lack of orthopnea. ACUTE ISSUES: =============== #Acute on chronic heart failure with recovered EF: Patient is known to have CHF for several decades with most recent documented EF of 50% on ___, believed to be non-ischemic in etiology. Patient presented with volume overload and dyspnea with labs notable for elevated BNP, Na of 121, and hemoglobin of 9.0 (reduced from baseline). Weight on admission was 82.7 kg, increased from 68 kg at time of most recent discharge in ___. Significant JVP and lower extremity edema as well as limited ascites suggestived of volume overload ___ to CHF rather than decompensated cirrhosis. In setting of clear chest x-ray and limited orthopnea on presentation, heart failure believed to be R>L. Unknown precipitating factor for excacerbation, however, patient home PO diuresis was recently d/ced in previous hospitalization. Patient was managed with IV Lasix boluses with improving volume exam and transitioned to discharge regimen of PO torsemide 100 on achievement of euvolemia. Repeat TTE demonstrated EF 20% although suspect that last TEE read of 50% was overestimation rather than this representing newly reduced function. Patient was maintained on metoprolol as well as trialed on hydralazine and Imdur for afterload reduction, however, they were d/ced for concern for decreased renal perfusion in setting of ___. At time of discharge, patient was asymptomatic and ambulating comfortably. ___ for CRT in outpatient setting. ___ on CKD (Solitary functioning kidney): ___ on admission 2.3 from baseline of 1.5-1.6. Believed to be cardiorenal in etiology, given the absence of signs of decompensated cirrhosis. Renal ultrasound ruled out obstruction. Cr initially downtrended with diuresis, however was stable at level of 2.4 at time of discharge. #Ventricular Tachycardia s/p ICD placement: Patient has V-tach s/p ablation with most recent episode most recently in ___ VT @ 151 bpm, ATP x 3 failed, 20j shock. Patient had been transitioned off of amiodarone in setting of cirrhosis 2 months prior to admission, however had increased NSVT/ectopy on telemetry throughout hospital course as well as documentation suggesting increased pacing requirement from most recent interrogation. In consultation with EP and hepatology, patient was restarted on amiodarone 200 mg regimen during hospitalization, which was tolerated without any acute documented hepatic adverse reaction. #Leukocytosis Patient had intermittent mild WBC elevation to from ___ over course of hospitalization without fever or other localizing infectious symptoms. Chest x-ray and UA showed no signs of infection and patient blood cultures from day of admission were only positive in one tube for gram positive bacilli, believed to be likely contaminant. Received no treatment over course of hospitalization and white count on discharge was stable at 12.6. #Hyponatremia: Most likely hypervolemic hyponatremia. Urine lytes supported sodium avid, decreased effective circulating volume in setting of heart failure. Improved with diuresis from 121 on admission to 134 on discharge without complication. CHRONIC ISSUES: #Cirrhosis: Recent diagnosis of cirrhosis in ___ ___/p and ultrasound concerning for cirrhotic liver, ascites, splenomegaly. Most likely etiology was cardiac in nature given history of HFrEF, however patient also has documented history of remote alcohol use. Synthetic hepatic function impaired with supratherapeutic INR on admission and baseline thrombocytopenia, however, no signs of decompensated liver disease at this time without bleeding, encephalopathy, or ascites. Mild T bili elevation during hospital course deemed to be secondary to congestive hepatopathy rather than cirrhosis and patient maintained on home rifaxamin and lactulose regimens. #Anemia: Hemoglobin of 9 on admission, decreased from baseline ___ six months prior. Patient was found to be guaic positive, concern for possible chronic GI bleed, however, no gross blood, melena, or anemic symptoms suggsetive of acute bleed. EGD/Colonoscopy 6 months ago showed no upper or lower bleed. Patient was initiated on IV iron (250 mg x 4 doses) during inpatient stay and hemoglobin uptrended without transfusion. #Thrombocytopenia: Stable from baseline, likely ___ to synthetic liver dysfunction vs sequestration of platelets in setting of splenomegaly. #Paroxysmal atrial fibrillation (Chads VASC 2) #Coagulopathy: Supratheraptic INR (3.7) on admission likely ___ synthetic liver dysfunction. Warfarin initially held, however, INR remained within therapeutic range on 1 mg daily regimen during hospitalization and will be discharged on ___ mg alternating regimen. TRANSITIONAL ISSUES: [] Planned follow up with electrophysiology for consideration of upgrade to CRT. [] Recommend repeat CBC at follow up visit. Noted to have leukocytosis to ___ without s/sx infection. [] Continue to follow INR with goal ___. Reduced warfarin dosing from 1.5 to ___ in setting of supratherapeutic INR on admission. [ ] DISCHARGE WEIGHT: 73.4 kg [ ] DISCHARGE DIURETIC: Torsemide 100 [ ] DISCHARGE ANTICOAGULATION: Warfarin 1 mg/0.5 mg alternatine [ ] FOLLOW UP LABORATORY TESTING: INR, CBC [ ] MEDICATION CHANGES: [ ] NEW: Torsemide 100 mg, Amiodarone 200 mg [ ] STOPPED: Losartan, Lasix, spirnolactone [ ] CHANGED: Warfarin 0.1 mg/0.5 mg Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Rosuvastatin Calcium 40 mg PO QPM 2. Warfarin 1.5 mg PO 5X/WEEK (___) 3. Rifaximin 550 mg PO BID 4. Furosemide 20 mg PO DAILY 5. Losartan Potassium 50 mg PO DAILY 6. Metoprolol Succinate XL 100 mg PO DAILY 7. Spironolactone 50 mg PO DAILY 8. Warfarin 1 mg PO 2X/WEEK (MO,TH) 9. Lactulose 15 mL PO TID Discharge Medications: 1. Amiodarone 200 mg PO DAILY RX amiodarone 200 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 2. Torsemide 100 mg PO DAILY RX torsemide 100 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 3. Lactulose 15 mL PO TID 4. Warfarin 0.5 mg PO 3X/WEEK (___) 5. Warfarin 1 mg PO 4X/WEEK (___) RX warfarin 1 mg ___ tablet(s) by mouth Daily Disp #30 Tablet Refills:0 6. Metoprolol Succinate XL 100 mg PO DAILY 7. Rifaximin 550 mg PO BID 8. Rosuvastatin Calcium 40 mg PO QPM 9. HELD- Losartan Potassium 50 mg PO DAILY This medication was held. Do not restart Losartan Potassium until told to do so by your doctor 10. HELD- Spironolactone 50 mg PO DAILY This medication was held. Do not restart Spironolactone until told to do so by your doctor 1. Amiodarone 200 mg PO DAILY RX amiodarone 200 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 2. Torsemide 100 mg PO DAILY RX torsemide 100 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 3. Lactulose 15 mL PO TID 4. Warfarin 0.5 mg PO 3X/WEEK (___) 5. Warfarin 1 mg PO 4X/WEEK (___) RX warfarin 1 mg ___ tablet(s) by mouth Daily Disp #30 Tablet Refills:0 6. Metoprolol Succinate XL 100 mg PO DAILY 7. Rifaximin 550 mg PO BID 8. Rosuvastatin Calcium 40 mg PO QPM 9. HELD- Losartan Potassium 50 mg PO DAILY This medication was held. Do not restart Losartan Potassium until told to do so by your doctor 10. HELD- Spironolactone 50 mg PO DAILY This medication was held. Do not restart Spironolactone until told to do so by your doctor Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSES ================= Acute on chronic systolic heart failure Dilated cardiomyopathy Cirrhosis Ventricular tachycardia s/p ICD placement CKD Secondary diagnoses =================== Anemia Thrombocytopenia Paroxysmal afib 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 was I here? - You came to the hospital because you were having shortness of breath and leg swelling. - This was due to a weak heart, called heart failure. What was done while I was here? - You were given medications to help remove the extra fluid. - You were seen by the liver and kidney doctors to help with your cirrhosis and kidney disease. - Your shortness of breath resolved and the swelling greatly improved. What should I do when I get home? - Please take all of your medications as prescribed. - Please go to all of your appointments as listed below. - Weigh yourself every morning, call MD if weight goes up more than 3 lbs. Your weight on discharge is: 73.4 kg (161.82 lb). We wish you all the best, Your ___ Care Team Followup Instructions: ___
19573990-DS-7	19,573,990	21,684,886	DS	7	2169-04-19 00:00:00	2169-08-10 14:52:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: Sulfa(Sulfonamide Antibiotics) Attending: ___ Chief Complaint: fall from bike Major Surgical or Invasive Procedure: None History of Present Illness: ___ with no significant PMH presenting as transfer from OSH s/p bike accident. Patient was in bike race and went over handle bars at low speed down a hill. + LOC for ___ seconds, ___ amnesia. Seen at ___ where CT head, C-spine and chest showed evidence of C7/T1 transfer fractures as well as ribs fractures with mediastinal fluid. On arrival to ___ 15. Past Medical History: none Family History: Non-contributory Physical Exam: On arrival to ___: HR: 70 BP: 118/76 Resp: 9 O(2)Sat: 98 Normal Constitutional: No acute distress HEENT: Normocephalic, atraumatic, Pupils equal, round and reactive to light, Extraocular muscles intact. Pupils ___ bilaterally. Oropharynx within normal limits. Cervical collar in place. No hemotympanum. Chest: Clear to auscultation. Chest wall nontender to compression. No crepitus Cardiovascular: Regular Rate and Rhythm, Normal first and second heart sounds Abdominal: Soft, Nontender, Nondistended Pelvic: No tenderness to pelvic compression GU/Flank: No costovertebral angle tenderness Extr/Back: Left posterior shoulder abrasion and contusion. Peripheral pulses 2+ and equal bilaterally. Skin: No rash, Warm and dry Neuro: Speech fluent. Following commands appropriately. MAE Psych: Normal mood, Normal mentation Pertinent Results: CT C-SPINE W/O CONTRAST Study Date of ___ 4:56 ___ Acute, nondisplaced fractures of the left transverse processes of C7 and T1, as well as the posterior left second rib. CT HEAD W/O CONTRAST Study Date of ___ 5:09 ___ Normal CT of the head. CT CHEST W/O CONTRAST Study Date of ___ 5:09 ___ IMPRESSION: 1. Non-displaced fracture of the right manubrium with underlying small anterior hematoma. Given that the hematoma appears larger on the subsequently taken chest radiograph, a contrast-enhanced study is recommended for reevaluation. 2. Non-displaced fracture of the posterior left second rib, and displaced fractures of the posterior left third and fourth ribs. 3. Trace loculated left pneumothorax. PELVIS (AP ONLY) Study Date of ___ 6:00 ___ No fracture. SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA LEFT Study Date of ___ 6:00 ___ Posterior left rib fractures as seen on chest CT. No other fracture visualized. Widening of the acromioclavicular joint worrisome for AC joint separation. No dislocation. CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of ___ 6:23 ___ IMPRESSION: 1. Very minimal interval enlargement of the anterior mediastinal hematoma, which arises from the manubrial fracture. There is no evidence of vascular injury. 2. Otherwise unchanged study, with small loculated left pneumothorax as well as left rib fractures in the posterior second, third, and fourth ribs. CHEST (PORTABLE AP) Study Date of ___ 5:25 AM IMPRESSION: 1. Left posterior third and fourth rib fractures are again seen. The manubrial fracture cannot be appreciated on the plain film study. There is minimal superior mediastinal widening which is consistent with the known mediastinal hematoma. Lungs are clear without evidence of focal airspace consolidation, pleural effusions, or pneumothorax. Cardiac contours are stable. ___ 04:35PM WBC-16.2* RBC-5.01 HGB-13.9* HCT-41.7 MCV-83 MCH-27.7 MCHC-33.3 RDW-13.0 ___ 04:35PM NEUTS-89.1* LYMPHS-7.5* MONOS-2.7 EOS-0.1 BASOS-0.5 ___ 04:35PM PLT COUNT-234 ___ 04:35PM ___ PTT-27.6 ___ ___ 04:35PM GLUCOSE-108* UREA N-19 CREAT-1.2 SODIUM-141 POTASSIUM-4.0 CHLORIDE-100 TOTAL CO2-29 ANION GAP-16 Brief Hospital Course: Upon admission on ___, imaging revealed an acute minimally displaced fracture to the transverse processes of C7-T1, left posterior rib fractures to ribs ___, and a right manubrial fracture with a small anterior mediastinal hematoma. Due to concern for both neurologic and cardiac status he was initially admitted to the ICU overnight. He was followed with serial EKG's which remained stable. He remained neurologically intact, and was quickly advanced to a regular diet which he tolerated very well. He was transferred out to the floor on ___. At time of transfer, pain was well controlled with a PCA, he was ambulating minimally, taking in regular food, and voiding appropriately. On ___ the PCA was discontinued and he was started on oral pain medications. Toradol was added for additional pain control. Incentive spirometry and pulmonary toileting were encouraged. He remained without respiratory compromise with adequate oxygen saturations on room air. Occupational therapy performed a cognitive evaluation given the loss of consciousness at the accident who determined the patient to have no cognitive defecits. Orthopedics was consulted for concern for left AC joint separation seen on x-ray who recommended passive ROM twice weekly with outpatient ___ and no activity restrictions. Follow up was scheduled with orthopedics for 4 weeks from discharge. Medications on Admission: None Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain 2. Docusate Sodium 100 mg PO BID 3. Senna 1 TAB PO BID:PRN constipation 4. Outpatient Physical Therapy Diagnosis: Left AC joint separation Passive ROM exercises twice weekly 5. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain RX hydromorphone 2 mg ___ tablet(s) by mouth every three hours Disp #60 Tablet Refills:*0 6. Ibuprofen 400 mg PO Q6H:PRN pain Take with food. Discharge Disposition: Home Discharge Diagnosis: s/p bicycle accident Injuries: 1. C7-T1 minimally displaced transverse process fractures 2. Non-displaced fracture of the right manubrium with underlying small anterior hematoma 3. Non-displaced fracture of the posterior left second rib, and displaced fractures of the posterior left third and fourth ribs 4. Small loculated left pneumothorax 5. Left AC joint separation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital after a bicycle accident. You sustained breaks in the bony processes in a couple of your vertebrae which are stable injuries and require no intervention. You sustained an injury to your left should for which you were seen by the orthopedic doctors who recommended outpatient physical therapy. You have no restrictions to the shoulder and should follow up in the ___ clinic in 4 weeks. You sustained rib fractures which can cause severe pain and subsequently cause you to take shallow breaths because of the pain. You should take your pain medicine as as directed to stay ahead of the pain otherwise you won't be able to take deep breaths. If the pain medication is too sedating, take half the dose and notify your physician. Pneumonia is a complication of rib fractures. In order to decrease your risk you must use your incentive spirometer 4 times every hour while awake. This will help expand the small airways in your lungs and assist in coughing up secretions that pool in the lungs. You will be more comfortable if you use a cough pillow to hold against your chest and guard your rib cage while coughing and deep breathing. Symptomatic relief with ice packs or heating pads for short periods may ease the pain. Do NOT smoke. Return to the ED right away for any acute shortness of breath, increased pain or crackling sensation around your rips (crepitus). Narcotic pain medication can cause constipation. Thefore you should take a stool softener twice daily and increase your fluid and fiber intake if possible. If your doctor allows, non steriodal ___ drugs are very effective in controlling pain (i.e. Ibuprofen, Motrin, Advil, Aleve, Naprosyn) but they have their own set of side effects so make sure your doctor approves. Followup Instructions: ___
19574468-DS-5	19,574,468	27,287,656	DS	5	2174-08-27 00:00:00	2174-08-27 08:46:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Dyspnea on exertion, chest pressure Major Surgical or Invasive Procedure: Coronary artery bypass grafting times five(LIMA-LAD, SVG->Diag, Ramus, OM, RCA, ___ stapling, and atrial clot removal ___ History of Present Illness: ___ with history of AFib (not on rate control, also declined anticoagulation) who is referred to the ED from Urgent Care due to progressive dyspnea and reported "new anterolateral MI" on his EKG (compared to his last EKG which was from ___. He has apparently also been having intermittent chest tightness since early ___ for which his Atrius cardiologist, Dr. ___, ___ ordered a p-MIBI although this has not yet been done. He describes his chest tightness as occasional chest discomfort that is substernal and non-radiating. It lasts a few hours at a time, is not associated with exertion, and resolves on its own although last time he took Tylenol which seemed to help. Currently he is chest pain free. Of note he also was seen by his PCP the first week of this month for non-productive cough and SOB for which he had a CXR done that showed bilateral effusions. His PCP dx PNA and treated him with levofloxacin for a 10 day course from ___. He states that initially that seemed to help but over the last week he has noticed worsening of his dyspnea on exertion and endorses new onset orthopnea. He otherwise denies diarrhea, consitpation, nasal congestion and rhinitis, ___ edema. He is not on O2 at home and is normally very active (runs/exercises regularly). In the ED, initial vitals were T 97.8, BP 145/96, RR 16, HR 120 (ranged 118-152 in ED), O2Sat 93%RA. - CXR showed large left pleural effusion, small R pleural effusion, enlarged heart. ROS: as per HPI, otherwise a 12-point ROS is negative. Past Medical History: - Atrial fibrillation - Hypertension - Low grade Fibroid Sarcomas s/p resection x3 (Two surgeries through nose at the ___ from approx. ___ to ___ performed by Dr. ___ (Otolaryngology). Major surgery at ___ in ___ for removal of the recurring sarcoma which had invaded the brain cavity. Performed by Dr. ___ (neurosurgeon) and Dr. ___ (Otolaryngology)). - macular degeneration, right eye (injections Q6-8 weeks) - thyroid nodule Social History: ___ Family History: H/o DM on mother's side. No family history of cardiovascular disease Physical Exam: PHYSICAL EXAM ON ADMISSION: =========================== Vitals - 97.8, 127/77, 109, 20, 92% RA GEN: well appearing man in NAD HEENT: PERRL, EOMI, sclera anicteric, MMM, no cervical LAD CV: Irregular rate and rhythm, normal S1/S2 no S3/S4 or murmurs. JVD ~9 mmHg PULM: bibasilar crackles, no wheezing ABD: soft, flat, nontender to palpation and non distended. No HSM, normal bowel sounds. EXT: WWP, trace to 1+ pitting edema bilaterally, no cyanosis. SKIN: no rash Neuro: CN II-XII grossly intact, alert and oriented X4 Discharge Exam: VS: T 98.6 HR 101 AFib BP 108/76 RR 20 O2 sat 93% RA WT 68.5kg Pre-op WT 72kg Gen: no acute distress Neuro: Alert and oriented x3, non-focal exam CV: irreg-irreg, no murmur, sternum stable-incision clean dry and intact Pulm: clear, diminished in bases Abdm: soft, non tender, non distended, + bowel sounds Ext: left leg EVH incision site clean dry and intact. no edema Pertinent Results: TTE ___: ------------- The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is at least 15 mmHg. There is mild (non-obstructive) focal hypertrophy of the basal septum. The left ventricular cavity is moderately dilated. Overall left ventricular systolic function is severely depressed (LVEF= 25 %) with global hypokinesis and akinesis of the septum, anterior and apical segments. The basal to mid lateral wall has preserved function. No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. Right ventricular chamber size is normal with mild global free wall hypokinesis. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is a very small pericardial effusion. There are no echocardiographic signs of tamponade. ___ Cardiac catheterization Dominance: Right * Left Main Coronary Artery The LMCA is normal. * Left Anterior Descending The LAD has 95% ___ and 70% mid stenoses. Mild collaterals to distal vessel. D1 has 60% ___ stenosis. * Circumflex The Circumflex has 70% ___ stenosis. * Ramus The Ramus has 95% ___ stenosis. * Right Coronary Artery The RCA has 60% ostial stenosis Echocardiographic Measurements TEE ___: Left Ventricle - Ejection Fraction: 20% to 30% >= 55% Findings LEFT ATRIUM: Moderate ___. Definite thrombus in the ___. RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV. No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thickness. Mildly dilated LV cavity. Severely depressed LVEF. RIGHT VENTRICLE: Mild global RV free wall hypokinesis. AORTA: Normal ascending aorta diameter. Normal descending aorta diameter. Simple atheroma in descending aorta. No thoracic aortic dissection. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Mild (1+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR. ___ VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. Mild PR. GENERAL COMMENTS: Written informed consent was obtained from the patient. A TEE was performed in the location listed above. I certify I was present in compliance with ___ regulations. The patient was under general anesthesia throughout the procedure. No TEE related complications. Results were personally reviewed with the MD caring for the patient. Conclusions Pre-CPB: The left atrium is moderately dilated. A definite thrombus is seen in the left atrial appendage. The thrombus appears to occupy most of the appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity is mildly dilated. Overall left ventricular systolic function is severely depressed (LVEF= 25 %). The distal half of the LV appears to be nearly akinetic while the basal half contracts. There is mild global free wall hypokinesis of the RV. There are simple atheroma in the descending thoracic aorta. No thoracic aortic dissection is seen. The aortic valve leaflets (3) are mildly thickened. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. ___ was notified in person of the results at time of study. Post-CPB: The patient is on epi and norepi infusions. The RV systolic function is mildly depressed to borderline normal on epinephrine. The LV systolic function remains severely depressed with similar regional wall motion abnormalities as prebypass. The LVEF is approximately 25%. The left atrial appendage clot is no longer seen and the left atrial appendage appears to have been ligated. The MR remains mild. Other valvular function remains unchanged. There is no evidence of aortic dissection. Admission Labs: ___ 04:53PM ___ PTT-30.6 ___ ___ 04:53PM PLT COUNT-270 ___ 04:53PM WBC-8.6 RBC-5.31 HGB-16.0 HCT-48.5 MCV-91 MCH-30.1 MCHC-33.0 RDW-13.6 RDWSD-45.8 ___ 04:53PM TSH-1.6 ___ 04:53PM proBNP-6202* ___ 04:53PM cTropnT-0.17* ___ 04:53PM GLUCOSE-96 UREA N-15 CREAT-1.0 SODIUM-138 POTASSIUM-4.4 CHLORIDE-102 TOTAL CO2-17* ANION GAP-23* ___ 05:07PM LACTATE-2.2* ___ 06:51PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG ___ 06:51PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 06:30AM BLOOD %HbA1c-5.4 eAG-108 Discharge Labs: ___ 06:17AM BLOOD WBC-10.3* RBC-3.84* Hgb-11.7* Hct-34.8* MCV-91 MCH-30.5 MCHC-33.6 RDW-13.3 RDWSD-43.8 Plt ___ ___ 06:17AM BLOOD Plt ___ ___ 06:17AM BLOOD ___ PTT-29.3 ___ ___ 04:36AM BLOOD ___ ___ 06:17AM BLOOD Glucose-87 UreaN-29* Creat-0.9 Na-137 K-3.8 Cl-99 HCO3-25 AnGap-17 ___ 04:36AM BLOOD Mg-2.1 Radiology Report CHEST (PA & LAT) Study Date of ___ 5:28 ___ Final Report Sternotomy. Cardiac enlargement. No pulmonary edema. Normal pulmonary vascularity. These tiny left pleural effusion, similar to prior. Chest tubes have been removed. No right pneumothorax. The small bilateral pleural effusions, more prominent. Bibasilar opacities, likely atelectasis. Stable right rib fractures. Minimal retrosternal air, in keeping with recent surgery. IMPRESSION: Stable tiny left apical pneumothorax. Small pleural effusions. Mild bibasilar atelectasis. Cardiomegaly. ___, MD electronically signed on ___ ___ 5:58 ___ Brief Hospital Course: ___ year old architect with past medical history most notable for atrial fibrillation (not anticoagulated), who presents with weeks of worsening dyspnea on exertion and intermittent chest pain not associated with exertion, found to have multivessel disease and new diagnosis of heart failure with reduced ejection fraction (LVEF = 25%) from ischemic cardiomyopathy with evidence of apical akinesis. Patient presented with weeks of worsening dyspnea on exertion and intermittent chest pain, EKG with rate 100s, a-fib, left axis deviation, T-wave inversions in I, aVL, V3-6 with 1mm ST elevation in V3 and elevated troponin to 0.3 concerning for NSTEMI. He was started on heparin gtt, atorvastatin, aspirin, and metoprolol on admission, and received cardiac catheterization on ___, which revealed a right dominant system with multivessel disease (95% ___ and 70% mid LAD, 60% ___ D1, 70% ___, 95% ___ ramus, and RCA 60% ostial). Cardiac surgery was consulted for CABG evaluation. Postoperative course: Mr. ___ was brought to the Operating Room on ___ where he underwent CABGx5(LIMA->LAD, SVG->Diag, Ramus, OM, ___ stapling and atrial clot removal. Overall he tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found him extubated, alert and oriented and breathing comfortably. He was neurologically intact and hemodynamically stable. He was started on Coumadin and Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. He was seen in consultation by the electrophysiology service for evaluation for ICD given his low ejection fraction. He will follow with electrophysiology in 3 months. By the time of discharge on post-operative day six he was ambulating freely, the wound was healing and pain was controlled with oral analgesics. He was discharged to home in good condition with appropriate follow up instructions. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 5 mg PO DAILY 2. Aspirin 325 mg PO DAILY 3. coenzyme Q10 unknown oral DAILY 4. Vitamin B Complex 1 CAP PO DAILY 5. Vitamin D 1000 UNIT PO DAILY 6. Vitamin E 400 UNIT PO DAILY 7. Fish Oil (Omega 3) 1000 mg PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO/PR Q4H:PRN pain or temperature >38.0 2. Docusate Sodium 100 mg PO BID RX docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #60 Capsule Refills:0 3. Lisinopril 2.5 mg PO DAILY RX lisinopril 2.5 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:1 4. Metoprolol Succinate XL 75 mg PO BID RX metoprolol succinate [Toprol XL] 25 mg 3 tablet(s) by mouth twice a day Disp #180 Tablet Refills:1 5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain: moderate/severe RX oxycodone 5 mg ___ tablet(s) by mouth every six (6) hours Disp #75 Tablet Refills:0 6. Ranitidine 75 mg PO DAILY RX ranitidine HCl 75 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:1 7. Senna 17.2 mg PO BID:PRN constipation 8. ___ MD to order daily dose PO DAILY dose to be prescribed by ___ clinic RX warfarin [Coumadin] 2 mg as directed tablet(s) by mouth once a day Disp #90 Tablet Refills:0 9. Aspirin EC 81 mg PO DAILY RX aspirin 81 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:1 10. coenzyme Q10 1 ? oral DAILY resume pre-op schedule 11. Atorvastatin 80 mg PO QPM 12. Fish Oil (Omega 3) 1000 mg PO DAILY 13. Vitamin B Complex 1 CAP PO DAILY 14. Vitamin D 1000 UNIT PO DAILY 15. Vitamin E 400 UNIT PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary: Coronary artery disease-s/p CABG ___ ligation Secondary: - Atrial fibrillation - Hypertension - Low grade Fibroid Sarcomas s/p resection x4 - Macular Degeneration, right eye (injections Q6-8 weeks) - Thyroid nodule - Coronary artery disease Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Oxycodone and Tylenol Incisions: Sternal - healing well, no erythema or drainage Leg/Left - healing well, no erythema or drainage. Edema none Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for one month or while taking narcotics. Driving will be discussed at follow up appointment with surgeon-when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call cardiac surgery office with any questions or concerns ___. Answering service will contact on call person during off hours* Followup Instructions: ___
19574468-DS-6	19,574,468	29,806,429	DS	6	2174-09-03 00:00:00	2174-09-03 13:55:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: syncope Major Surgical or Invasive Procedure: Thoracentesis ___ Device Brand: ___ Model: Inogen ICD / Serial No. ___ Date of Implant: ___ Cardiac catheterization ___ History of Present Illness: ___ year old male well known to service was discharged this am home after CABG ___ of note is post operative course was noted for arrhythmia and electrophysiology was consulted. He was in rate controlled atrial fibrillation at discharge with history of atrial fibrillation and ventricular ectopy. His betablockers were adjusted he continued on his Coumadin for anticoagulation and was discharged home this am. After arriving home he was sitting on the couch and wife found him slumped over which she had just left room few minutes prior did not think it was very long. He was noted to be shaking and not responding to her briefly then woke up confused. Wife states that he remained on the couch and did not fall and hit anything. EMS was called and he was brought into the emergency room. In the emergency room he had self limited runs of VT and on initial evaluation he was awake, alert and oriented. During the time in the ED he developed further runs of VT with concern for polymorphic EP was called, he required defibrillation in ED resulting in conversion after single shocks. He was give IV magnesium sulfate and Amiodarone 300 mg IV bolus. He did not require intubation and was awake although groggy and moving all extremities. He was transferred to the ___ for ongoing management. Past Medical History: - Atrial fibrillation - Hypertension - Low grade Fibroid Sarcomas s/p resection x3 (Two surgeries through nose at the ___ from approx. ___ to ___ performed by Dr. ___ (Otolaryngology). Major surgery at ___ in ___ for removal of the recurring sarcoma which had invaded the brain cavity. Performed by Dr. ___ (neurosurgeon) and Dr. ___ (Otolaryngology)). - macular degeneration, right eye (injections Q6-8 weeks) - thyroid nodule Social History: ___ Family History: H/o DM on mother's side. No family history of cardiovascular disease Physical Exam: Pulse:109 Resp:20 O2 sat: 94/RA B/P Left: 123/95 Height:72" Weight:72.6 kg General: No acute distress while resting on stretcher Skin: Dry [x] Sternal incision healing no erythema or drainage Left EVH healing no erythema or drainage HEENT: PERRLA [x] EOMI [x] Chest: Lungs clear except diminished bilateral Heart: RRR [] Irregular [x] Murmur none Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds +[x] Extremities: Warm [x], well-perfused [x] Edema none Neuro: Alert and oriented x3 no focal deficits Pulses: Femoral Right: 2+ Left: 2+ DP Right: 1+ Left: 1+ ___ Right: 2+ Left: 1+ Radial Right: 2+ Left: 2+ Pertinent Results: ___ Cardiac catheterization Coronary Anatomy Dominance: Right * Left Main Coronary Artery The LMCA is normal * Left Anterior Descending The LAD has subtotal proximal occlusion. The distal vessel fills via the LIMA graft with no significant disease. The ___ Diagonal fills via a SVG with no significant distal disease * Circumflex The Circumflex has ostial and proximal 70% stenosios. The distal vessel fills from the SVG with no significant disease. * Ramus The Ramus has a long segment of 90% disease. The distal vessel fills from the SVG with no significant distal disease * Right Coronary Artery The RCA has proximal 80% stenosis. The distal vessel fills from the SVG with no significant distal disease LIMA-LAD is normal SVG-OM is normal SVG-ramus is normal SVG-diagonal is normal SVG-RCA is normal and fills retrograde to the ostium ECHO ___ The left atrium is elongated. The right atrium is markedly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is moderate to severe regional left ventricular systolic dysfunction with hypokinesis of the basal anteroseptum and akinesis of the anterior wall and apical left ventricle. The remaining segments contract normally (LVEF = 34%). No masses or thrombi are seen in the left ventricle. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size is normal with mild free wall hypokinesis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Regional left ventricular dysfunction c/w CAD (LAD territory), with moderate to severely reduced ejection fraction. Mild right ventricular free wall hypokinesis. Mild mitral regurgitation. Mild pulmonary hypertension CXR: ___ s/p Thorocentesis In comparison with the study of ___, there has been a left thoracentesis with removal of a substantial amount of pleural fluid. No evidence of post procedure pneumothorax. Otherwise, little change except for removal of the right IJ catheter. Hazy opacification at the right base is consistent with small pleural effusion and underlying compressive atelectasis. CXR ___ In comparison with the study of ___, the dual channel pacer device is unchanged. Continued substantial enlargement of the cardiac silhouette in this patient with intact midline sternal wires after CABG procedure. The opacification at the right base has improved. This could reflect decreasing atelectasis and pleural effusion, though this also could merely be a manifestation of a more erect position of the patient. ___ 04:36AM BLOOD WBC-10.1* RBC-3.74* Hgb-11.3* Hct-33.9* MCV-91 MCH-30.2 MCHC-33.3 RDW-13.2 RDWSD-43.1 Plt ___ ___ 06:17AM BLOOD WBC-10.3* RBC-3.84* Hgb-11.7* Hct-34.8* MCV-91 MCH-30.5 MCHC-33.6 RDW-13.3 RDWSD-43.8 Plt ___ ___ 02:40AM BLOOD WBC-13.3* RBC-3.96* Hgb-12.1* Hct-35.7* MCV-90 MCH-30.6 MCHC-33.9 RDW-12.9 RDWSD-42.6 Plt ___ ___ 05:54AM BLOOD Glucose-88 UreaN-20 Creat-0.9 Na-136 K-4.1 Cl-102 HCO3-22 AnGap-16 ___ 04:00AM BLOOD K-4.1 ___ 06:17AM BLOOD Glucose-87 UreaN-29* Creat-0.9 Na-137 K-3.8 Cl-99 HCO3-25 AnGap-17 ___ 06:03AM BLOOD WBC-13.8* RBC-4.06* Hgb-12.3* Hct-36.6* MCV-90 MCH-30.3 MCHC-33.6 RDW-13.2 RDWSD-43.1 Plt ___ ___ 06:03AM BLOOD ___ ___ 06:03AM BLOOD Glucose-89 UreaN-22* Creat-1.0 Na-136 K-4.4 Cl-100 HCO3-23 AnGap-17 ___ 06:03AM BLOOD Mg-1.9 Brief Hospital Course: He was discharged from hospital in the morning of ___, was at home restinf on couch when he had syncopal episode. Wife called EMS and he was brought into the emergency room. In the emergency room he had short run of non sustqained ventricular tachycardia. Then he had further episodes that were sustained requiring defibrillation. He received Magnesium and amiodarone in the emergency and was admitted to intensive care unit for monitoring. He continued to have ventricular tachycardia that was sustained and required chest compressions with lidocaine bloused and started on drip. He was electively intubated prior to being taken to the cath lab for cardiac catheterization which vessels were patent. He returned to the intensive care unit was started on inotrope and pressors and continued on amiodarone and lidocaine drips. TEE demonstrated a significant decrease in his EF to 10% from 25%. Repeat ECHO was done on ___ with resolution of EF to 34%. He was weaned off all vasopressors and intropes and started on po Amiodarone and Mexilitine per EP recommedations. He was extubated the next morning and kept in the CVICU over the weekend until he could receive his ICD. He has one episode of VT after his ICD was placed in the cath lab shocking him once. No other VT noted. He was started back on his Coumadin and on ___ he was transferred to the step down unit for further transition. PA/Lateral CXR shows significant left pleural effusion. Interventional Pulmonology was consulted for thorocentesis, which was done ___ draining 1400 ml. Post CXR clear bilateral lung fields. He was evaluated by physical therapy with recommendation for rehab due to deconditioning and was discharged to ___ on ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 5 mg PO DAILY 2. Aspirin 325 mg PO DAILY 3. Vitamin B Complex 1 CAP PO DAILY 4. Vitamin D 1000 UNIT PO DAILY 5. Vitamin E 400 UNIT PO DAILY 6. Fish Oil (Omega 3) 1000 mg PO DAILY 7. coenzyme Q10 unknown oral DAILY Discharge Medications: 1. Acetaminophen 325-650 mg PO Q4H:PRN Pain - Mild 2. Amiodarone 400 mg PO BID on mexiletine and amiodarone per Cardiology 3. Atorvastatin 80 mg PO QPM 4. Furosemide 20 mg PO DAILY Duration: 2 Weeks 5. Lisinopril 5 mg PO DAILY 6. Magnesium Oxide 800 mg PO DAILY 7. Metoprolol Succinate XL 50 mg PO DAILY 8. Mexiletine 150 mg PO Q8H on mexiletine and amiodarone per Cardiology 9. Potassium Chloride 10 mEq PO DAILY Sliding Scale Duration: 2 Weeks 10. Ranitidine 150 mg PO DAILY 11. ___ MD to order daily dose PO DAILY16 next INR ___ for further dosing 12. Aspirin 81 mg PO DAILY 13. Vitamin B Complex 1 CAP PO DAILY 14. Vitamin D 1000 UNIT PO DAILY 15. HELD- coenzyme Q10 unknown oral DAILY This medication was held. Do not restart coenzyme Q10 until discussed with outpatient cardiologist 16. HELD- Fish Oil (Omega 3) 1000 mg PO DAILY This medication was held. Do not restart Fish Oil (Omega 3) until discussed with outpatient cardiologist 17. HELD- Vitamin E 400 UNIT PO DAILY This medication was held. Do not restart Vitamin E until discussed with outpatient cardiologist 18.Outpatient Lab Work please check bmp and magnesium in 3 days to evaluate electrolytes 19.medications please note patient is on mexilitine and amiodarone for arrhythmia - he will follow up with Dr ___ please do not adjust and if holding please contact amiodarone will be reevaluated at follow up with Dr ___ ___ Disposition: Extended Care Facility: ___ Discharge Diagnosis: Ventricular tachycardia arrest s/p internal defibrillator Pleural effusion s/p thoracentesis Secondary diagnosis s/p CABG ___ ligation Atrial fibrillation Hypertension Low grade Fibroid Sarcomas s/p resection x4 Macular Degeneration, right eye (injections Q6-8 weeks) Thyroid nodule Coronary artery disease Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait deconditioned Incisional pain managed with acetaminophen Incisions: ICD Left subclavian dressing intact Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. Edema none Discharge Instructions: Please wash daily but you can not shower from 1 week from ICD placement ___, please wash sternal and leg incision daily the ICD site is not to be washed until directed by cardiology - no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month from cardiac surgery standpoint however due to arrhythmia you will need clearance from Dr ___ you can discuss at follow up No lifting more than 10 pounds for 10 weeks from CABG surgery however with ICD Wound care - If your wound becomes reddened, swollen, more painful, or develops drainage from the site, call your MD or the nurses at the device clinic (___) as you should be evaluated in the office urgently. The site may be slightly uncomfortable for a few days and you may require Tylenol as needed. Frequently there are steri-strips on the site which should be allowed to fall off with time and not be pulled off. Once you are able to shower (after your 1 week device clinic appointment), do not allow water to directly contact the steri-strips; just let it rinse over the wound. Activity - Activities involving the arm near the device will not be allowed for ___ weeks, including reaching, golf, tennis, and swimming. You will not be able to lift more than 5 pounds for ___ weeks. After this, you have only a few restrictions in activities to avoid things that could interfere with your device. You may not have MRI (magnetic resonance imaging), and arc welding is not allowed. Microwaves are ok. You may use cellphones and remote controls and other electronic devices, but these must be held at least one foot from the ICD. You will be given instructions about walking through security gates or being scanned with security wands. Please call cardiac surgery office with any questions or concerns ___. Answering service will contact on call person during off hours Followup Instructions: ___
19574468-DS-7	19,574,468	21,164,602	DS	7	2176-02-20 00:00:00	2176-02-20 14:34:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: episodes of R hand symptoms Major Surgical or Invasive Procedure: None. History of Present Illness: Neurology at bedside for evaluation after code stroke activation/consult within: 5 minutes Time (and date) the patient was last known well: 5 days ago (24h clock) ___ Stroke Scale Score: 2 t-PA given: No LKW 5 days agoThrombectomy performed: [] Yes [] No --- If no, reason thrombectomy was not performed or considered: I was present during the CT scanning and reviewed the images instantly within 20 minutes of their completion. The NIHSS was performed: Date: ___ Time: 13:oo (within 6 hours of patient presentation or neurology consult) ___ Stroke Scale score was : 2 1a. Level of Consciousness: 0 1b. LOC Question: 0 1c. LOC Commands: 0 2. Best gaze: 0 3. Visual fields: 0 4. Facial palsy: 0 5a. Motor arm, left: 0 5b. Motor arm, right: 2 6a. Motor leg, left: 0 6b. Motor leg, right: 0 7. Limb Ataxia: 0 8. Sensory: 0 9. Language: 0 10. Dysarthria: 0 11. Extinction and Neglect: 0 REASON FOR CONSULTATION: R hand/arm weakness and heaviness/tingling, episodic HPI: Mr. ___ is a ___ gentleman with a past medical history significant for atrial fibrillation on Coumadin and aspirin, hypertension, low-grade fibroid sarcomas status post multiple resections (the last being 8 weeks ago at ___, frequently the sarcomas have invaded the brain cavity. He also has a history of macular degeneration in the right eye and thyroid nodule. He presents to the emergency department today for episodic right hand and arm heaviness, weakness, and tingling that has been ongoing for the past ___ days. Briefly, the patient states that 8 weeks ago he underwent removal of a right frontal sarcoma that was initially thought to be a meningioma, however on pathology it returned as sarcoma. He had the surgery done at ___ without complication. Prior to the surgery he had to be off his Coumadin for 5 days, did not use any bridging medications. After surgery, the patient was resumed on his Coumadin and since then he has not missed any doses. His INRs have been between 2 and 3 except for this week when his INR was elevated to 3.3. He has never been subtherapeutic. Since the surgery the patient has been doing very well until about 4 days ago when he noticed the following: he was standing up but does not remember exactly what he was doing when suddenly his right hand felt very heavy and he had mild tingling. The heaviness spread to all 5 fingers and up his arm circumferentially to just below the elbow over a span of 1 minute. The hand and arm continued to feel very weak with mild tingling and he felt that it was very difficult to coordinate any movements with the right hand. This entire episode lasted between 5 and 10 minutes and then completely resolved. After this, the patient was able to move and use the hand normally. This then occurred again the next day while the patient was working on the computer. Since onset, this has occurred daily but at different times during the day. This morning, the patient awoke at 7 AM and was able to shower and get ready normally. After breakfast, he went into his office and tried to send an email. He was able to log into the computer, type in his password and was about to send an email when suddenly the episode occurred again. His wife was in the room with him and did not notice any facial droop, no confusion, no difficulty with language or pronunciation, and the patient denies any spread of the symptoms up his arm to his face or down his leg. After about 10 minutes the symptoms resolved. As this was now the fifth time that this occurred the patient and his wife decided to come to the ER for further evaluation. The patient currently feels well and the symptoms have not returned. He does finds that moving his right hand feels slightly more cumbersome compared to the left which is new. He denies any other symptoms. On neuro ROS, the pt denies headache, loss of vision, blurred vision, diplopia, dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or hearing difficulty. Denies difficulties producing or comprehending speech. No bowel or bladder incontinence or retention. Denies difficulty with gait. On general review of systems, the pt denies recent fever or chills. No night sweats or recent weight loss or gain. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Denies rash. Past Medical History: - Atrial fibrillation - Hypertension - Low grade Fibroid Sarcomas s/p resection x3 (Two surgeries through nose at the ___ from approx. ___ to ___ performed by Dr. ___ (Otolaryngology). Major surgery at ___ in ___ for removal of the recurring sarcoma which had invaded the brain cavity. Performed by Dr. ___ (neurosurgeon) and Dr. ___ (Otolaryngology)). - macular degeneration, right eye (injections Q6-8 weeks) - thyroid nodule Social History: ___ Family History: H/o DM on mother's side. No family history of Neurologic disease Physical Exam: ADMISSION Physical Exam: Vitals: Temperature 98.1, HR 80, BP 133/68, 98% on RA General: awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: supple Pulmonary: breathing comfortably on room air Cardiac: RRR, nl Abdomen: soft, NT/ND Extremities: warm, well perfused Skin: no rashes or lesions noted Neurologic: -Mental Status: Alert, oriented x self, date, location. Able to relate history without difficulty. Attentive, able to name ___ backward without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Pt was able to name both high and low frequency objects. Able to read without difficulty. Speech was not dysarthric. Able to follow both midline and appendicular commands. Pt was able to register 3 objects and recall ___ at 5 minutes. There was no evidence of apraxia or neglect. -Cranial Nerves: II, III, IV, VI: L pupil 4-->2, R pupil 3--->2. EOMI without nystagmus. Normal saccades. VFF to confrontation. Fundoscopic exam revealed no papilledema, exudates, or hemorrhages. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. Pronation of R arm with upward drift. Slower with finger tap on the R, diffiuclty with touching each finger to his thumb on the R compared to left (patient right handed). No orbiting noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 5 ___ ___ 5 5 5 5 5 5 R 5 ___ ___ 5 5 5 5 5 5 -Sensory: No deficits to light touch, pinprick, cold sensation, diminished vibration in toes <6 seconds, intact proprioception throughout. No extinction to DSS. -DTRs: Bi Tri ___ Pat Ach L 2 2 2 3 1 R 2 2 2 3 1 Plantar response was withdrawal/vs. upgoing bilaterally. -Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF or HKS bilaterally. -Gait: Good initiation. Narrow-based, normal stride and arm swing. Able to walk in tandem without difficulty. Romberg absent. ======================================================== DISCHARGE PHYSICAL EXAM: General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM Pulmonary: Breathing comfortably, no tachypnea nor increased WOB Cardiac: skin warm, well-perfused. Abdomen: soft, ND Extremities: Symmetric, no edema. Neurologic: -Mental Status: Alert, oriented x 3. Attentive. No dysarthria or aphasia. Able to follow both midline and appendicular commands. -Cranial Nerves: PERRL. VFF to confrontation. EOMI intact. Facial sensation intact to light touch. Facial muscles symmetric. Hearing intact to conversation. Palate elevates symmetrically. ___ strength in trapezii bilaterally. Tongue protrudes in midline and moves briskly to each side. -Motor: Normal bulk, tone throughout. No drift. No adventitious movements, such as tremor, noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 5 ___ ___ 5 5 5 5 5 5 R 5 ___ ___ 5 5 5 5 5 5 -Sensory: Proprioception intact b/l. Intact to LT throughout. -DTRs deferred. -Coordination: Slightly slower FNF on right. No dysmetria on FNF or HKS bilaterally. -Gait deferred. Pertinent Results: ___ 12:00PM BLOOD WBC-7.0 RBC-4.07* Hgb-12.4* Hct-38.0* MCV-93 MCH-30.5 MCHC-32.6 RDW-13.2 RDWSD-44.6 Plt ___ ___ 08:38AM BLOOD WBC-7.3 RBC-4.19* Hgb-12.9* Hct-38.5* MCV-92 MCH-30.8 MCHC-33.5 RDW-12.9 RDWSD-43.1 Plt ___ ___ 12:00PM BLOOD ___ PTT-33.1 ___ ___ 08:38AM BLOOD ___ ___ 12:00PM BLOOD Glucose-113* UreaN-19 Creat-1.0 Na-139 K-5.0 Cl-104 HCO3-23 AnGap-12 ___ 12:00PM BLOOD ALT-23 AST-32 AlkPhos-87 TotBili-0.6 ___ 07:30AM BLOOD ALT-22 AST-25 AlkPhos-83 TotBili-0.8 ___ 12:00PM BLOOD Lipase-31 ___ 12:00PM BLOOD cTropnT-<0.01 ___ 07:30AM BLOOD Calcium-8.2* Phos-4.2 Mg-2.1 Cholest-103 ___ 07:30AM BLOOD %HbA1c-5.5 eAG-111 ___ 07:30AM BLOOD Triglyc-54 HDL-51 CHOL/HD-2.0 LDLcalc-41 ___ 07:30AM BLOOD TSH-1.0 ___ 12:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG ___ 06:19PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG ___ 06:19PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG Imaging: ___ ___, CTA head/neck: 1. The patient is status post bicoronal craniotomy for right frontal mass resection and sinus surgery as described detail above. 2. Heterogenous left frontoparietal subdural hematoma with hyperdense components that are likely acute/subacute hemorrhage that measures 1.3 cm in greatest diameter. There is a mass effect and midline shift that cannot be exactly quantified due to postsurgical changes in the anterior fossa. 3. Heterogeneous amorphous calcifications are seen at the surgical bed in the frontal region, the possibility of packing surgical material, versus residual mass are considerations, correlation with prior exams is advised. RECOMMENDATION(S): Prior CT head or MRI brain examinations may help to determine the evolution left frontoparietal subdural hematoma and frontal extra-axial fluid collection. ___ CT with contrast IMPRESSION: 1. The 7.1 cm anterior frontal extra-axial fluid collection is unchanged in size. Adjacent dural enhancement is nonspecific and may be postsurgical. However, a superimposed infectious process cannot be excluded. 2. Unchanged left frontal parietal subdural hematoma. 3. Re-demonstration of heterogeneous calcifications in the frontal surgical bed, which may represent postsurgical change, surgical material versus or residual disease. 4. No new acute intracranial abnormality. ___ EEG read: No epileptiform activity. One typical event captured, no electrographic correlate. Brief Hospital Course: Mr. ___ was admitted with ___ min episodes of paresthesia in R hand and forearm. Workup revealed a bifrontal and L frontoparietal subdural fluid collection, likely SDH. ASA and Coumadin were held. SDH was stable on repeat imaging. No significant vascular abnormalities on CTA head/neck. CT with contrast did not show clear evidence of infection of this subdural fluid collection, though infection could not be completely ruled out. Given that he has not fevered nor had any other infectious s/s, this was felt to be less likely and he was not treated with antibiotics. ASA 81 was restarted on the day of discharge. Coumadin will be held with plan for PCP to ___ in ___ weeks. If subdural collection is stable, it would be reasonable to restart therapeutic anticoagulation at that time. We recommend consideration of apixaban rather than Coumadin, as there may be slightly lower hemorrhage risk, though the evidence is not clear. Defer final decision to PCP and ___. He was monitored with cvEEG and one typical spell was captured, which showed no EEG correlate. Though focal seizure cannot be ruled out, given the timecourse of symptoms, suspect that they are more likely due to cortical spreading depression. Therefore, he was not started on AED. =================================== Transitional Issues: [ ] PCP: refer to ___ Neuro urgently. [ ] Neuro: consider AED therapy if he develops a more broad spread of this sensory phenomenon or if he has a GTC or event with alteration of awareness. [ ] PCP: repeat ___ in ___ weeks [ ] PCP/Neuro: If ___ stable, consider restarting anticoagulation Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 80 mg PO QPM 2. Metoprolol Succinate XL 50 mg PO DAILY 3. Warfarin Dose is Unknown PO Frequency is Unknown 4. Aspirin 81 mg PO DAILY 5. coenzyme Q10 0 unknown oral unknown 6. Magnesium Oxide 400 mg PO Frequency is Unknown Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 80 mg PO QPM 3. coenzyme Q10 0 unknown oral Frequency is Unknown Continue your prior home dose of this medicine 4. Magnesium Oxide 400 mg PO DAILY 5. Metoprolol Succinate XL 50 mg PO DAILY 6. HELD- Warfarin Dose is Unknown PO Frequency is Unknown This medication was held. Do not restart Warfarin until repeat CT is done and you have discussed this with your Primary care physician ___ Neurologist Discharge Disposition: Home Discharge Diagnosis: subdural hematoma Numbness 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 episodes of tingling in your right hand. On a CT scan we found that there is a collection of blood between he brain and the skull, something called a 'subdural hematoma'. Part of the subdural hematoma is near your surgical mesh, but another part goes further back along the left side of your head. The brain is the part of your body that controls and directs all the other parts of your body, and changes on the left side of the brain affect the right side of the body. We think that the subdural hematoma is causing some fluctuating changes in the brain called cortical spreading depression, which is causing your symptoms. We did an EEG to find out whether or not this could be a type of seizure, and we captured one of the episodes on EEG, and there was no sign of seizure. However, this does not completely rule out the possibility of seizure. In order to prevent future bleeding in or around the brain, we need to change your blood thinner plan in the short term. We are changing your medications as follows: Continue aspirin 81 mg daily STOP Coumadin (aka warfarin). 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 Weigh yourself every morning, call MD if weight goes up more than 3 lbs. Sincerely, Your ___ Neurology Team Followup Instructions: ___
19575238-DS-11	19,575,238	26,270,211	DS	11	2114-04-28 00:00:00	2114-04-28 10:46:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Abd pain Major Surgical or Invasive Procedure: ___: Laparascopic cholecystectomy History of Present Illness: ___ M w/ ~48 hrs RUQ pain. The patient states his pain began suddenly on ___, and has been persistent since. He has had no nausea/vomiting. He has had fevers and chills at home. He has tolerated a regular diet without difficulty, and has been having normal bowel movements, no color change. He has not ever had previous similar symptoms. Past Medical History: Past Medical History: Prostate CA s/p ChemoXRT, DMII, HTN, Glaucoma, HL, NASH Past Surgical History: None Social History: ___ Family History: noncontributory Physical Exam: Vitals: 101.6 98.2 ___ 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. Moderately distended, tender RUQ, ___. Ext: No ___ edema, ___ warm and well perfused Pertinent Results: LABS: ___ 05:34AM BLOOD WBC-15.6* RBC-4.42* Hgb-12.3* Hct-36.1* MCV-82 MCH-27.8 MCHC-34.0 RDW-12.8 Plt ___ ___ 05:34AM BLOOD Plt ___ ___ 05:34AM BLOOD Glucose-115* UreaN-14 Creat-0.8 Na-140 K-3.5 Cl-103 HCO3-24 AnGap-17 ___ 05:34AM BLOOD ___ 05:34AM BLOOD ALT-75* AST-73* AlkPhos-88 TotBili-1.0 ___ 05:34AM BLOOD Lipase-12 ___ 05:34AM BLOOD Calcium-7.5* Phos-2.9 Mg-1.7 ___ 06:28AM BLOOD WBC-17.5* RBC-4.59* Hgb-12.6* Hct-37.3* MCV-81* MCH-27.4 MCHC-33.7 RDW-12.8 Plt ___ PTT-32.7 ___ Glucose-107* UreaN-11 Creat-0.9 Na-136 K-3.6 Cl-100 HCO3-24 AnGap-16 ALT-71* AST-47* AlkPhos-94 TotBili-1.4 Calcium-8.3* Phos-2.1* Mg-1.7 ___ 06:00PM BLOOD WBC-21.3# RBC-5.26 Hgb-14.5 Hct-43.5 MCV-83 MCH-27.5 MCHC-33.3 RDW-12.9 Plt ___ Neuts-84.0 Lymphs-8.8* Monos-6.6 Eos-0.4 Baso-0.2 ___ PTT-31.3 ___ Glucose-175* UreaN-15 Creat-0.9 Na-137 K-4.2 Cl-97 HCO3-24 AnGap-20 ALT-101* AST-77* AlkPhos-111 TotBili-1.5 Lipase-19 Albumin-4.0 Calcium-8.8 Phos-2.3* Mg-1.8 Lactate-2.9* IMAGING: ___ CHEST (PA & LAT): IMPRESSION: Limited, negative. ___ LIVER OR GALLBLADDER US (SINGLE ORGAN): IMPRESSION: 1. Gallbladder sludge without evidence of cholecystitis. 2. Echogenic liver compatible with diffuse steatosis. More serious forms of liver disease including cirrhosis and fibrosis cannot be excluded on the basis of this study. ___ CT ABD & PELVIS WITH CONTRAST: IMPRESSION: Preliminary Report: Mild gallbladder wall edema and pericholecystic stranding. These findings can be seen in acute cholecystitis. However, other conditions such as hepatitis may mimic this appearance. Given the equivocal ultrasound for acute cholecystitis, a HIDA scan may be helpful to confirm gallbladder inflammation. Brief Hospital Course: Mr. ___ was admitted on ___ under the acute care surgery service with a 2-day history of right upper quadrant abdominal pain. A liver/gallbladder ultrasound suggested 'sludge without evidence of cholecystitis' and 'echogenic liver compatible with diffuse steatosis'. A follow-up Abd/Pelvic CT scan suggested 'mild gallbladder wall edema and pericholecystic stranding', therefore, the patient was placed on bowel rest, given intravenous antibiotics and taken to the operating room and underwent a laparoscopic cholecystectomy. Please see operative report for details of this procedure. He tolerated the procedure well and was extubated upon completion. He we subsequently taken to the PACU for recovery. He was transferred to the surgical floor hemodynamically stable. His vital signs were routinely monitored and he remained afebrile and hemodynamically stable. He was initially given IV fluids postoperatively, which were discontinued when he was tolerating PO's. His diet was advanced on the morning of ___ to regular, which he tolerated without abdominal pain, nausea, or vomiting. He did, however, has constipation, and his belly became distended. To this end, a KUB was ordered, and it showed large bowel ileus. For this he was given rectal suppositories and enemas, which were effective in inducing bowel movements. As such, his distention subsided. From a genitourinary perspective, he was voiding adequate amounts of urine without difficulty. He was encouraged to mobilize out of bed and ambulate as tolerated, which he was able to do independently. His pain level was routinely assessed and well controlled at discharge with an oral regimen as needed. On ___, he was discharged home with scheduled follow up in ___ clinic on ___. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. MetFORMIN (Glucophage) 1000 mg PO DAILY 2. Simvastatin 40 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. GlyBURIDE 5 mg PO DAILY 5. Lisinopril 20 mg PO DAILY 6. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES TID Discharge Medications: 1. MetFORMIN (Glucophage) 1000 mg PO DAILY 2. Simvastatin 40 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Lisinopril 20 mg PO DAILY 5. GlyBURIDE 5 mg PO DAILY 6. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES TID 7. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain RX oxycodone 5 mg ___ tablet(s) by mouth every ___ hours Disp #40 Tablet Refills:0 8. Docusate Sodium 100 mg PO BID 9. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 4 Days RX amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by mouth every 12 hours Disp #10 Tablet Refills:0 10. Senna 1 TAB PO BID:PRN constipation Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: gangrenous cholecystitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with the hospital due to abdominal pain related to inflammation of your gallbladder. You subsequently underwent removal of your gallbladder, recovered in the hospital and are now preparing for discharge to home with the following instructions: ACTIVITY: o Do not drive until you have stopped taking pain medicine and feel you could respond in an emergency. o You may climb stairs. o You may go outside, but avoid traveling long distances until you see your surgeon at your next visit. o Don't lift more than ___ lbs for 4 weeks. (This is about the weight of a briefcase or a bag of groceries.) This applies to lifting children, but they may sit on your lap. o You may start some light exercise when you feel comfortable. o You will need to stay out of bathtubs or swimming pools for a time while your incision is healing. Ask your doctor when you can resume tub baths or swimming. HOW YOU MAY FEEL: o You may feel weak or "washed out" for a couple of weeks. You might want to nap often. Simple tasks may exhaust you. o You may have a sore throat because of a tube that was in your throat during surgery. o You might have trouble concentrating or difficulty sleeping. You might feel somewhat depressed. o You could have a poor appetite for a while. Food may seem unappealing. o All of these feelings and reactions are normal and should go away in a short time. If they do not, tell your surgeon. YOUR INCISION: o Tomorrow you may shower and remove the gauzes over your incisions. Under these dressing you have small plastic bandages called steri-strips. Do not remove steri-strips for 2 weeks. (These are the thin paper strips that might be on your incision.) But if they fall off before that that's okay). o Your incisions may be slightly red around the stitches. This is normal. o You may gently wash away dried material around your incision. o Avoid direct sun exposure to the incision area. o Do not use any ointments on the incision unless you were told otherwise. o You may see a small amount of clear or light red fluid staining your dressing or clothes. If the staining is severe, please call your surgeon. o You may shower. As noted above, ask your doctor when you may resume tub baths or swimming. YOUR BOWELS: o Constipation is a common side effect of narcotic pain medications. If needed, you may take a stool softener (such as Colace, one capsule) or gentle laxative (such as milk of magnesia, 1 tbs) twice a day. You can get both of these medicines without a prescription. o If you go 48 hours without a bowel movement, or have pain moving the bowels, call your surgeon. PAIN MANAGEMENT: o It is normal to feel some discomfort/pain following abdominal surgery. This pain is often described as "soreness". o Your pain should get better day by day. If you find the pain is getting worse instead of better, please contact your surgeon. o You will receive a prescription for pain medicine to take by mouth. It is important to take this medicine as directed. o Do not take it more frequently than prescribed. Do not take more medicine at one time than prescribed. o Your pain medicine will work better if you take it before your pain gets too severe. o Talk with your surgeon about how long you will need to take prescription pain medicine. Please don't take any other pain medicine, including non-prescription pain medicine, unless your surgeon has said its okay. o If you are experiencing no pain, it is okay to skip a dose of pain medicine. o Remember to use your "cough pillow" for splinting when you cough or when you are doing your deep breathing exercises. If you experience any of the following, please contact your surgeon: - sharp pain or any severe pain that lasts several hours - pain that is getting worse over time - pain accompanied by fever of more than 101 - a drastic change in nature or quality of your pain MEDICATIONS: Take all the medicines you were on before the operation just as you did before, unless you have been told differently. If you have any questions about what medicine to take or not to take, please call your surgeon. Followup Instructions: ___
19575335-DS-10	19,575,335	26,965,280	DS	10	2164-10-16 00:00:00	2164-10-17 15:37:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Codeine / Narcotic Analgesic & Non-Salicylate Comb / adhesive tape / morphine / Bactrim / Penicillins / Oxycodone / acetaminophen Attending: ___ Chief Complaint: left leg pain Major Surgical or Invasive Procedure: none History of Present Illness: This is an ___ woman with complex PMH including IDDM, CAD s/p MIx2 and CABG x4, distant TIA/CVA s/p bilat CEA stent placement, severe PVD not amenable to vascular interventions on Plavix who p/w left lower extremity pain. She reports one day of left lower extremity pain which she described as burning severe pain. She noted that her left first toe looked not well about 3 days ago. Denies any drainage from the toe. Denies any fevers at home. Also denies chills, nausea, vomiting, chest pain, shortness of breath, new numbness, or weakness. She was thus brought to the ED by her daughter. In the ED, initial vitals: 97.5 95 153/49 20 100% RA - Labs were significant for FSG 452, Cr 1.1, lactate 3.5, WBC 11.4 with 73%PMN - Xray of the foot showed concern for osteomyelitis of distal left great toe - Evaluated by vascular who noted she has no revascularization options. - Evaluated by podiatry who noted patchy area of erythema on the medial thigh, superficial collection of purulent material, concerning for paronychia of L ___ toe. They performed local debridement at the bedside and recommended cipro/vanc as well as wound care and WBAT L heel in surgical shoe. - Patient was given IV cipro, IV vanc, 10 units regular insulin, and 500cc NS Vitals prior to transfer: 98.9 67 128/67 19 100% RA On the floor, patient has no complaints. Notes her foot is not particularly painful. Denies any chest pain or shortness of breath. She does have pain in her lower leg, however, and it is tender when it is touched. ROS: as noted in HPI, otherwise 10-point ROS is negative Past Medical History: # bradycardia s/p pacemaker placement ___ at ___ # DM II c/b peripheral neuropathy and retinopathy, followed at ___ # Asthma # CAD s/p MI x 2 ___, s/p stent placement and CABG x 4 # Peripheral Vascular disease: followed by Dr. ___. # carotid artery stenosis s/p b/l CEA ___ # abdominal aneurysm # H/o shingles # Pneumonia ___ PAST SURGICAL HISTORY: # Right & Left carotid endarterectomy. R at ___ ~ ___, L at ___ ~ ___. # s/p laser eye surgery # s/p hysterectomy # s/p CABG x 4 # s/p RAA repair ___ # s/p amputation L third toe Social History: ___ Family History: Mother and Father with MI (father died at young age) Physical Exam: ADMISSION EXAM: VS: T 97.7 BP 182/61 HR 78 RR 16 O2 99% RA GEN: Alert, lying in bed, no acute distress HEENT: MMM, anicteric sclera, no conjunctival pallor, oropharynx clear NECK: Supple without LAD PULM: Clear, no wheeze, rales, or rhonchi COR: RRR, normal S1/S2, III/VI systolic murmur throughout precordium, radiating to the carotids ABD: Soft, NT ND, normal BS EXTREM: On the hallux of the left foot there is a 3mm deep ulcer where the toenail should be with some surrounding erythema, no drainage, there are chronic venous stasis changes throughout the left lower extremity and some of the right lower extremity. There is a black eschar on the distal portion of the hallux of the right foot that is nontender to palpation without any surrounding erythema. NEURO: AAOx3, CN II-XII tested and intact, moved all extremities, there is sensation to light touch in both feet up the ankles DISCHARGE EXAM: VS: T 97.7 BP 129/56 HR 62 RR 16 O2 99% RA GEN: Lying in bed, no acute distress HEENT: MMM, anicteric sclera, no conjunctival pallor NECK: Supple PULM: Clear, no wheeze, rales, or rhonchi COR: RRR, normal S1/S2, III/VI systolic murmur throughout precordium, radiating to the carotids ABD: Soft, normal BS, non-tender, no rebound, no gaurding EXTREM: Left foot is dressed and bandaged. NEURO: Moving all extremities Pertinent Results: ADMISSION LABS: ================================================== ___ 03:36AM BLOOD WBC-11.4* RBC-4.26 Hgb-12.4 Hct-37.4 MCV-88 MCH-29.1 MCHC-33.2 RDW-12.3 RDWSD-39.4 Plt ___ ___ 03:36AM BLOOD Neuts-72.5* Lymphs-17.8* Monos-6.8 Eos-1.7 Baso-0.8 Im ___ AbsNeut-8.23* AbsLymp-2.02 AbsMono-0.77 AbsEos-0.19 AbsBaso-0.09* ___ 03:36AM BLOOD ___ PTT-29.4 ___ ___ 03:36AM BLOOD Glucose-507* UreaN-25* Creat-1.1 Na-136 K-5.1 Cl-99 HCO3-24 AnGap-18 ___ 06:11AM BLOOD Calcium-9.0 Phos-4.0 Mg-2.1 ___ 03:36AM BLOOD CRP-43.3* ___ 03:36AM BLOOD Lactate-3.5* DISCHARGE LABS: ================================================== ___ 06:40AM BLOOD WBC-10.2* RBC-3.94 Hgb-11.3 Hct-34.6 MCV-88 MCH-28.7 MCHC-32.7 RDW-12.3 RDWSD-39.7 Plt ___ ___ 06:40AM BLOOD Glucose-102* UreaN-25* Creat-1.1 Na-140 K-4.4 Cl-107 HCO3-26 AnGap-11 ___ 06:40AM BLOOD Calcium-8.6 Phos-3.7 Mg-2.1 MICROBIOLOGY: ================================================== ___ blood culture NGTD ___ 7:01 am SWAB Source: L hallux. GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. WOUND CULTURE (Final ___: ENTEROBACTER AEROGENES. SPARSE GROWTH. This organism may develop resistance to third generation cephalosporins during prolonged therapy. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. For serious infections, repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used. STAPHYLOCOCCUS, COAGULASE NEGATIVE. SPARSE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROBACTER AEROGENES \| CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED. IMAGING: ================================================== ___ foot xray: IMPRESSION: 1. Osteomyelitis of the distal phalanx of the great toe. 2. Erosion of the distal tuft of the fifth distal phalanx, which may also reflect osteomyelitis. ___ ultrasound left leg: IMPRESSION: No evidence of deep venous thrombosis in the left lower extremity veins. Brief Hospital Course: ___ yo woman w/ hx of IDDM, PVD, CAD, peripheral neuropathy, and chronic foot ulcers p/w lower extremity pain concerning for left great toe osteomyelitis as well as hyperglycemia. # left hallux osteomyelitis: Patient with history of chronic foot ulcers, diabetes, and PVD who presented with left foot pain and imaging concerning for osteomyelitis. Seen by vascular surgery in the ED who noted she no longer has vascular options. Seen by podiatry who were concerned for left great toe paronychia and cellulitis so performed local debridement and removal of left first toenail. Podiatry surgery offered, but patient declined amputation. ___ showed no evidence of DVT. Patient initially treated with IV vancomycin, PO cipro/flagyl. ID consulted and recommended a 6 week course of cipro/flagyl (day 1: ___. # Diarrhea: Patient developed diarrhea on antibiotics, which resolved prior to cdiff testing. ___ remained non-elevated. ___: Creatinine increased to 1.3 from 1.1 on ___. Past records indicate baseline creatinine may be 1.1 - 1.3 range. Could also be pre-renal given acute infection and related poor PO intake. Given patient's age, eGFR is 40-50 and she likely has underlying CKD. #IDDM/hyperglycemia: Patient p/w BG of 500s. Likely exacerbated in the setting of active infection, but patient does not clearly understand how she takes her Humalog at home. ___ consulted and agreed with inpatient ISS + lantus management. #HTN:: Home Lasix held for creatinine bump to 1.3 on ___. Creatinine stable now x 2 days and lasix was restarted. Home amlodipine and losartan were continued. CHRONIC ISSUES: #CAD: Continued on ASA, Plavix, atorvastatin, metoprolol #PVD: Per vascular surgery, patient is not a candidate for any operative management. Contined on ASA/Plavix. #Asthma: Continued on home albuterol prn #Neuropathy: Continued on home lyrica Transitional issues: ====================== - close monitoring of blood glucose recommended - 6 weeks antibiotics, day 1: ___, last day: ___ - daily dressing changes with betadine and dry gauze Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Losartan Potassium 12.5 mg PO DAILY 2. Pregabalin 75 mg PO TID 3. Metoprolol Succinate XL 50 mg PO DAILY 4. Amlodipine 10 mg PO DAILY 5. Atorvastatin 20 mg PO QPM 6. liraglutide 1.2 mg subcutaneous DAILY 7. Furosemide 30 mg PO DAILY 8. Multivitamins 1 TAB PO DAILY 9. Clopidogrel 75 mg PO DAILY 10. Omeprazole 20 mg PO BID 11. Aspirin 325 mg PO DAILY 12. Glargine 33 Units Bedtime Humalog 7 Units Breakfast Humalog 7 Units Lunch Humalog 7 Units Dinner Discharge Medications: 1. Amlodipine 10 mg PO DAILY 2. Aspirin 325 mg PO DAILY 3. Atorvastatin 20 mg PO QPM 4. Clopidogrel 75 mg PO DAILY 5. Furosemide 30 mg PO DAILY 6. Losartan Potassium 12.5 mg PO DAILY 7. Metoprolol Succinate XL 50 mg PO DAILY 8. Multivitamins 1 TAB PO DAILY 9. Omeprazole 20 mg PO BID 10. Ciprofloxacin HCl 500 mg PO/NG Q12H RX ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve (12) hours Disp #74 Tablet Refills:0 11. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H RX metronidazole 500 mg 1 tablet(s) by mouth every eight (8) hours Disp #111 Tablet Refills:0 12. liraglutide 1.2 mg SUBCUTANEOUS DAILY 13. Outpatient Lab Work Please perform WEEKLY labs: ESR, CRP Fax results to: ___, attn: Dr. ___ code: ___ 14. Glargine 33 Units Bedtime Humalog 10 Units Breakfast Humalog 10 Units Lunch Humalog 10 Units Dinner Insulin SC Sliding Scale using HUM Insulin 15. Pregabalin 75 mg PO QHS Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY: left hallux osteomyelitis +enterobacter SECONDARY: type 2 diabetes mellitus, uncontrolled peripheral vascular disease, severe CAD s/p CABG HTN hyperlipidemia 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. ___, It was a pleasure caring for you during your stay at ___ ___. You were admitted for foot pain and were found to have an infection in the bone of your toe, likely due to a chronic ulcer in your toe. You elected to not have surgery and to treat your infection with antibiotics. You should continue your antibiotics as directed by your infectious disease doctors. ___ metronidazole (flagyl) through ___ Continue ciprofloxacin through ___ Please take care, Your ___ Team Followup Instructions: ___
19575335-DS-12	19,575,335	24,735,489	DS	12	2165-09-13 00:00:00	2165-09-14 11:09:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Codeine / Narcotic Analgesic & Non-Salicylate Comb / adhesive tape / morphine / Bactrim / Penicillins / Oxycodone / acetaminophen Attending: ___. Chief Complaint: R shin blister, L ___ toe ulcer, fever, SOB Major Surgical or Invasive Procedure: None. History of Present Illness: ___ with IDDM with peripheral neuropathy, recurrent foot infections, hx of L great toe osteomyelitis, PVD, HLD, CAD s/p CABG, bilateral carotid endarterectomy, AAA s/p surgery ___, AICD, right third toe amp who presented to ___ with right shin blister, left second toe with purulent drainage, and fever that started yesterday. Returned from ___ on ___. Presented to ___ with a day of cough and some SOB. Had WBC 13.7, Lactate 1.6, Initial T-103 w/ AMS, after Tylenol T-99.5, A&O X4, HR 64, RR18, BP 106/30, O2 96% RA, left toe possible osteo, left foot Doppler pulse, right foot palpable pulse, C-Xray- RLL opacity, given IV Zosyn and Vanco. Flu swab negative. MRSA positive. Transferred to ___ since vascular surgery care at ___. ___ the ED, initial vitals: 98.6 99 125/93 16 98RA - Exam notable for: Right lower anterior leg flat blister with surrounding erythema. left ___ toe amputated. left ___ toe with black discoloration and purulent drainage. RRR. Crackles bilaterally. NTND abd. AAOx3. - Labs notable for: WBC 13.7, flu negative, UA negative - Imaging notable for: ___: CXR pneumonia. Possible osteoarthritis on toe XR. No nec fasciitis on leg XR. - Patient given: zosyn - Seen by vascular surgery: recs: No acute vascular surgery interventions necessary tonight. Recommend admission to medicine for pneumonia and cellulitis of the right shin ___ prior blister at that location. Left ___ toe ulceration with slight drainage noted. Will need repeat ABI/PVR/arterial duplex of the left foot prior to any consideration for intervention. - Vitals prior to transfer: 99.3 122/88 16 99NC On arrival to the floor, pt reports no fever, chills, chest pain, nausea. Past Medical History: # bradycardia s/p pacemaker placement ___ at ___ # DM II c/b peripheral neuropathy and retinopathy, followed at ___ # Asthma # CAD s/p MI x 2 ___, s/p stent placement and CABG x 4 # Peripheral Vascular disease: followed by Dr. ___. # carotid artery stenosis s/p b/l CEA ___ # abdominal aneurysm # H/o shingles # Pneumonia ___ PAST SURGICAL HISTORY: # Right & Left carotid endarterectomy. R at ___ ~ ___, L at ___ ~ ___. # s/p laser eye surgery # s/p hysterectomy # s/p CABG x 4 # s/p RAA repair ___ # s/p amputation L third toe Social History: ___ Family History: Mother and Father with MI (father died at young age) Physical Exam: ADMISSION PHYSICAL EXAM: ========================= Vitals: 98.3 PO 121 / 55 70 20 97 2L NC General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, neck supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Right lower leg blister over shin with mild surrounding erythema. left ___ toe with black discoloration, left foot dopplerable, R palpable pulse Neuro: A&Ox3. Grossly intact. DISCHARGE PHYSICAL EXAM: ========================= VS - 97.4 120 / 64 60 18 94 ra General: Somewhat altered with brief episodes of loss of awareness, starting to redevelop headache, daughter relied upon for accurate history HEENT: sclera anicteric, pinpoint pupils equally round and reactive 2-->1, mild crusting of eyes, dry mucus membranes, oropharynx clear Neck: no LAD, neck supple, JVP not elevated CV: Systolic murmur with clear S1/2, regular rate and rhythm, no rubs or gallops Lungs: Bibasilar crackles R>L, mild end expiratory wheezes with initial auscultation Abdomen: Soft, NT, ND; BS present; no rebound, guarding, or organomegaly Ext: RLE 6cm diameter erosion over shin with erythematous base, LLE ___ digit with black necrotic discoloration Neuro: A&Ox3, poor historian, fluctuating mood; ___ strength ___ ___ on dorsiflexion; sensation intact ___ ___ b/l Pertinent Results: ADMISSION LABS: ================ ___ 01:20PM BLOOD WBC-9.9 RBC-3.41* Hgb-10.0* Hct-31.4* MCV-92 MCH-29.3 MCHC-31.8* RDW-12.8 RDWSD-42.8 Plt ___ ___ 01:20PM BLOOD ___ PTT-29.1 ___ ___ 01:20PM BLOOD Glucose-334* UreaN-24* Creat-1.2* Na-136 K-4.8 Cl-103 HCO3-21* AnGap-17 ___ 01:20PM BLOOD ALT-26 AST-41* LD(LDH)-275* CK(CPK)-57 AlkPhos-146* TotBili-0.7 ___ 01:20PM BLOOD Albumin-3.0* Calcium-7.8* Phos-3.2 Mg-1.8 ___ 03:20PM BLOOD CRP-145.4* DISCHARGE LABS: ================ ___ 06:00AM BLOOD WBC-8.6 RBC-3.54* Hgb-10.2* Hct-32.2* MCV-91 MCH-28.8 MCHC-31.7* RDW-12.4 RDWSD-41.1 Plt ___ ___ 06:00AM BLOOD Glucose-349* UreaN-19 Creat-1.1 Na-140 K-4.9 Cl-102 HCO3-27 AnGap-16 ___ 06:00AM BLOOD Calcium-8.8 Phos-3.1 Mg-2.0 MICRO: ======== ___ 6:10 pm SWAB Source: L foot . GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. ___ PAIRS AND SINGLY. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). SMEAR REVIEWED; RESULTS CONFIRMED. WOUND CULTURE (Final ___: ENTEROBACTER AEROGENES. MODERATE GROWTH. This organism may develop resistance to third generation cephalosporins during prolonged therapy. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. For serious infections, repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used. MIXED BACTERIAL FLORA. This culture contains mixed bacterial types (>=3) so an abbreviated workup is performed. Any growth of P.aeruginosa, S.aureus and beta hemolytic streptococci will be reported. IF THESE BACTERIA ARE NOT REPORTED, THEY ARE NOT PRESENT ___ this culture. Work-up of organism(s) listed discontinued (excepted screened organisms) due to the presence of mixed bacterial flora detected after further incubation. SENSITIVITIES: MIC expressed ___ MCG/ML _________________________________________________________ ENTEROBACTER AEROGENES \| CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S ANAEROBIC CULTURE (Preliminary): RESULTS PENDING. Blood Cultures ___ and ___: No growth to date. IMAGING: ======== TTE ___: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is low normal (LVEF = 50%) secondary to hypokinesis of the inferior septum and inferior free wall. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Doppler parameters are most consistent with Grade II (moderate) left ventricular diastolic dysfunction. Right ventricular chamber size and free wall motion are normal. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis (valve area 1.2-1.9cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. A mitral valve annuloplasty ring is present. The mitral annular ring appears well seated with normal gradient. Trivial mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] [Due to acoustic shadowing, the severity of tricuspid regurgitation may be significantly UNDERestimated.] There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of ___, mild aortic stenosis now present. CXR ___: 1. No evidence of pneumonia. 2. Interval development of increased central vascular congestion with moderate pulmonary edema. Stable mild to moderate cardiomegaly. 3. Mild bibasilar opacities, most consistent with atelectasis. Foot xray ___: Chronic osteomyelitis of the distal phalanx of the left first digit. No radiographic evidence of acute osteomyelitis of either foot. If there is however clinical concern for osteomyelitis, further evaluation with MRI or bone scintigraphy is recommended. Arterial duplex left foot ___: Increased peak systolic velocity at the distal left SFA measuring 271 cm/sec, increased from the prior study and likely indicating underlying stenosis. DISCHARGE LABS: ================ ___ 06:00AM BLOOD WBC-8.6 RBC-3.54* Hgb-10.2* Hct-32.2* MCV-91 MCH-28.8 MCHC-31.7* RDW-12.4 RDWSD-41.1 Plt ___ ___ 06:00AM BLOOD Glucose-349* UreaN-19 Creat-1.1 Na-140 K-4.9 Cl-102 HCO3-27 AnGap-16 ___ 06:00AM BLOOD Calcium-8.8 Phos-3.1 Mg-2.0 ___ 06:00AM BLOOD %HbA1c-10.2* eAG-246* ___ 03:20PM BLOOD CRP-145.4* Brief Hospital Course: ___, with a PMHx notable for T2DM c/b peripheral neuropathy, venous stasis ulcers, L hallux chronic osteomyelitis s/p LLE angioplasty and stent, PVD, CAD s/p CABGx4, PNA ___, levofloxacin course), and RLE ___ digit amp, who was transferred from ___ with LLE second digit necrosis and infection, Enterobacter bacteremia and RLE cellulitis. #Enterobacter bacteremia: Patient febrile with leukocytosis on admission. Blood cultures from ___ positive for pan-sensitive Enterbacter. Repeat surveillance cultures with no growth to date. Presumed source is infected L second toe. Podiatry and ID consulted; recommend removal of toe for source control. Patient refusing amputation at this time despite multiple conversations regarding risks of not having toe removed which include recurrence of bacteremia. Patient also has pacemaker which is concerning ___ setting of bacteremia. She was treated with Zosyn (___), Ceftazidime (___), Vancomycin (___), Cipro (___-). Patient discharged on Cipro/Doxycycline for ongoing suppressive therapy for toe infection for at least six weeks or until decision can be made regarding amputation. Patient should follow up with Podiatry and Vascular Surgery to continue discussing toe removal. Patient scheduled for outpatient angiogram on ___ to improve vascularization of L lower extremity. # RLE Cellulitis: Patient febrile with leukocytosis on presentation. Patient 6x2cm tender RLE shin erosion with previous fluid filled bulla present for 5 days prior to admission that has ruptured. Patient also with ocean water exposure ___ the ___ concern for Vibro exposure, treated with Doxycycline. Discharged on Cipro/Doxycycline. # LLE hallux osteomyelitis: Chronic LLE hallux osteomyelitis. No external evidence of active infection/drainage. Has completed a 8 week course of IV antibiotics over the past 3 months. Evidence of persistent osteo on X-ray. Also with elevated ESR/CRP. S/p LLE angioplasty and stent ___ the setting of T2DM. Per ID only definitive treatment would be amputation of the digit. Patient will undergo LLE angio with vascular surgery on ___ with plan for revascularization. # Pulmonary edema ___ HFpEF: Described to have RLL opacity on CXR ___ ___ (___) also with hypoxia. Repeat CXR ___ with evidence of bilateral pleural infiltrates. Satting ___ high ___ and weaning O2. ProBNP of 4608. Dry weight 140 (___). Continue Torsemide 10mg daily and Metoprolol XL. TTE showed LVEF 50% c/w prior with mild aortic stenosis. On home Torsemide 10mg daily Metoprolol 50mg XL. Discharge weight 66.91 kg. #DM: Patient with longstanding history of DM. On home Lantus 38 units qHs and insulin sliding scale. Patient with low morning blood glucose, decreased Lantus to 35 units. HbA1c 10.2. # asthma: albuterol neb # Atrial fibrillation: Not on anticoagulation, rate controlled with Metoprolol. # PVD: continue Plavix, management of ulcer as above # CAD s/p CABG: continue aspirin, Plavix, atorvastatin, metoprolol # HLD: continue atorvastatin # HTN: continue home antihypertensives # GERD: continue omeprazole Transitional Issues: ===================== -Discharge weight 66.91 kg. -Discharge CRP 145.4 -Discharged on Ciprofloxacin (day 1: ___ and Doxycycline (day1: ___- for suppressive therapy for at least 6 weeks per ID recommendation, possible end date of ___ -Continue discussions about left toe amputation as patient is at continued risk for recurrent infection due to inadequate source control -Follow-up with vascular surgery and podiatry following discharge -Plan for left lower extremity angiogram on ___ to determine if vascular surgery is an option for improved blood flow to the limb -Continue outpatient management of diabetes. HbA1c 10.2. Decreased home lantus to 35 units nightly given episode of hypoglycemia. -Code: Full -Contact: -- Name of health care proxy: ___ -- Relationship: daughter -- Phone number: ___ (h) -- Cell phone: ___ (c) Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ondansetron 4 mg PO Q8H:PRN nausea 2. Losartan Potassium 12.5 mg PO DAILY 3. Pregabalin 75 mg PO TID 4. Metoprolol Succinate XL 50 mg PO DAILY 5. amLODIPine 10 mg PO DAILY 6. Carbamide Peroxide 6.5% 5 DROP BOTH EARS 1X/WEEK (MO) 7. Atorvastatin 20 mg PO QPM 8. Glargine 38 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 9. Torsemide 10 mg PO DAILY 10. Multivitamins 1 TAB PO DAILY 11. Clopidogrel 75 mg PO DAILY 12. Omeprazole 20 mg PO BID 13. Aspirin 325 mg PO DAILY 14. Vitamin D ___ UNIT PO 1X/WEEK (MO) 15. Ascorbic Acid ___ mg PO BID 16. Albuterol Inhaler 1 PUFF IH Q6H:PRN SOB, wheezing Discharge Medications: 1. Ciprofloxacin HCl 500 mg PO Q12H 2. Doxycycline Hyclate 100 mg PO Q12H 3. Polyethylene Glycol 17 g PO DAILY:PRN constipation 4. Glargine 35 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 5. Albuterol Inhaler 1 PUFF IH Q6H:PRN SOB, wheezing 6. amLODIPine 10 mg PO DAILY 7. Ascorbic Acid ___ mg PO BID 8. Aspirin 325 mg PO DAILY 9. Atorvastatin 20 mg PO QPM 10. Carbamide Peroxide 6.5% 5 DROP BOTH EARS 1X/WEEK (MO) 11. Clopidogrel 75 mg PO DAILY 12. Losartan Potassium 12.5 mg PO DAILY 13. Metoprolol Succinate XL 50 mg PO DAILY 14. Multivitamins 1 TAB PO DAILY 15. Omeprazole 20 mg PO BID 16. Ondansetron 4 mg PO Q8H:PRN nausea 17. Pregabalin 75 mg PO TID 18. Torsemide 10 mg PO DAILY 19. Vitamin D ___ UNIT PO 1X/WEEK (MO) Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS: Cellulitis Sepsis SECONDARY DIAGNOSIS: Pulmonary edema Acute-on-chronic diastolic heart failure Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. ___, You came to ___ with an infection of your toe. You refused to have your toe removed despite it being infected, and so you will be on a course of antibiotics. It is very important you take these antibiotics every single day. Please ensure you follow up with your primary care doctor, vascular surgery team, and the infectious disease doctors. It has been a pleasure caring for you, and we wish you all the best. Your ___ Team Weigh yourself every morning, call MD if weight goes up more than 3 lbs. Followup Instructions: ___
19575803-DS-12	19,575,803	25,067,645	DS	12	2186-10-08 00:00:00	2186-10-08 12:59:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Severe abdominal pain Major Surgical or Invasive Procedure: ___: PROCEDURE: Ultrasound guided diagnostic paracentesis. . ___: PROCEDURE: Ultrasound-guided drainage of a peritoneal fluid collection. . ___: PROCEDURE: 1. Left iliac vein and IVC venogram. 2. Infrarenal Denali IVC filter deployment. 3. Post-filter placement venogram. . ___: CT-guided exchange of the existing 8 ___ catheter for a 12 ___ catheter, and placement of a new ___ pigtail catheter into the collection in the right pelvis. History of Present Illness: The patient is a ___ yo male with recent whipple on ___ presents with abdominal pain after being discharged yesterday morning. Since being discharged the pt has developed increasing pain along the incision sites that he refers is ___, Sharp & Constant. Alleviated with Tylenol and worsened with positioning. Patient refers associating the pain with weakness, mild nausea without vomiting, constipation and inability to take PO. Pt also notes urinary retention that resolved with foley placemnt. Denies fevers. Pt presented to OSH and had leukocytosis to 19.9, lactate of 6, lipase of 186, and CT scan of chest which revealed no PE (but bilateral lobe atelectasis) and CT abd which revealed post operative changes with sub hepatic and pelvic fluid. Past Medical History: CAD s/p ___ Hypertension Irritable bowel syndrome Lumbar radiculopathy Status post appendectomy Social History: ___ Family History: Father died in ___ of MI Sister with CAD Physical Exam: DISCHARGE PHYSICAL EXAM: General: resting comfortably in NAD HEENT: EOMI, PERRL, anicteric Neck: supple, no LAD Chest: CTAB, no respiratory distress Heart: RRR Abdomen: minimal ttp RUQ, no guarding, no rebound, no rigidity, ___ drain x1 in place with serosanguineous output Neuro: alert and oriented x3 Extremities: no edema Pertinent Results: Per ___ Brief Hospital Course: The patient s/p Whipple procedure on ___ for PNET was readmitted to the HPB Surgical Service on the next day after discharge with increased abdominal pain, PO intolerance and urinary retention. Admission labs were noticeable for leukocytosis, elevated transaminase, patient was afebrile. In ED patient developed wide complex tachycardia, which was treated with IV Metoprolol. NGT tube was placed with large bilious output. OSH CT scan revealed sub hepatic and pelvic fluid collections. ___ was consulted for possible drainage. Patient was started on Vanc/Zosyn, which were changed to Vanc/Ceftaz/Flagyl later. On ___, patient underwent CT, which demonstrated ascites associated with peritonitis (please see Radiology report for details). On ___ patient underwent US-guided peritoneal fluid drainage with drain placement. He was started on TPN secondary to NPO status and severe malnutrition. Patient was started on Octerotite as ascites fluid had high amylase concerning for pancreatic fistula. On ___ patient was noticed to have bilateral ___ swelling, Doppler revealed bilateral ___ DVTs. Patient was started on Heparin drip, which was changed to therapeutic Lovenox later. On ___, patient had an episode of tachycardia, tachypnea and hypoxia concerning for PE, he was transferred to the ICU and Heparin gtt was started. CTA chest revealed bilateral pulmonary emboli. Hematology was consulted as his platelets were low and he was considered high risk for HIT. Per Hematology, heparin was stopped and argatroban drip started. ___ was consulted for IVC filter. On ___, IVC filter was placed. Patient also underwent exchange and upsize of excising midline drain and new pelvic drain was placed. Fluid cultures were positive for SERRATIA MARCESCENS. On ___, patient underwent surveillance UE Doppler, which revealed left jugular vein DVT and bilateral cephalic veins DVTs. Patient was transferred to the floor, NPO with NGT, TPN, Vanc/Ceftaz/Flagyl, argatroban gtt and Octerotide. ID was consulted on ___, and patient was transitioned to Cefepime per ID recommendations. On ___, NGT and Foley catheter were discontinued. He was voiding with no issues. Patient's diet was advanced to clears on ___ and was well tolerated, TPN was started to cycle, patient's abdominal pain continued to improve. On ___, the HIT panel came back negative so the patient was started on Warfarin. On ___ the patient had an episode of hypotension with sinus tachycardia, which was treated with fluid bolus and resolved. On ___, the argatroban drip was discontinued, as patient's INR was therapeutic on Warfarin. ___ drains output continued to decrease. On ___ patient underwent abdominal CT scan, which demonstrated near complete resolution of the fluid collections (please see radiology report). Patient's diet advanced to fulls after the scan. On ___, the abdominal drain was removed (now has one remaining drain), patient tolerated full liquid diet, he received ___ normal TPN. On ___, patient's diet was advanced to regular low fat and TPN was discontinued. He was awaiting disposition to a rehabilitation facility. A bed became available on ___ so he was discharged to the facility. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. He will follow up with Dr. ___ in clinic with repeat scan at that time to determine whether or not his remaining drain will be removed. He will need to schedule follow up with Hematology as an outpatient regarding his hyper coagulable work up. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Metoprolol Succinate XL 25 mg PO DAILY 2. Lisinopril 2.5 mg PO DAILY 3. Simvastatin 40 mg PO QPM 4. Aspirin 81 mg PO DAILY 5. Cetirizine 10 mg PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 2. CefePIME 2 g IV Q12H 3. Docusate Sodium 100 mg PO BID 4. Insulin SC Sliding Scale Fingerstick q6h Insulin SC Sliding Scale using REG Insulin 5. Octreotide Acetate 100 mcg SC Q12H Take this medication for 3 days (two times daily), reduce to once daily for 3 days, then discontinue 6. TraMADol 50-100 mg PO Q6H:PRN Pain - Moderate 7. Aspirin 81 mg PO DAILY 8. Cetirizine 10 mg PO DAILY 9. Lisinopril 2.5 mg PO DAILY 10. Metoprolol Succinate XL 25 mg PO DAILY 11. Simvastatin 40 mg PO QPM Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: 1. Pancreatic neuroendocrine tumor s/p Whipple 2. Intra abdominal abscess 3. Pancreatitis 4. Bilateral deep vein thrombosis of the lower extremities 5. Bilateral segmental pulmonary emboli involving upper lobes 6. Severe malnutrition. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. ___, You were admitted to the surgery service at ___ for evaluation of abdominal pain and leukocytosis. You were found to have intra abdominal fluid collection (abscess). You underwent ___ drainage of the abscess and were started on antibiotics. Your recovery was complicated by pulmonary emboli and bilateral ___ DVTs. You were started on anticoagulation therapy and IVC filter was placed. You were provided with TPN for nutrition during hospitalization, which was weaned off after you tolerated regular diet. You are now safe to return home to complete your recovery with the following instructions: . Please ___ Dr. ___ office at ___ or Office RNs at ___ if you have any questions or concerns. . General Drain Care: Please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever). If the drain is connected to a collection container, please note color, consistency, and amount of fluid in the drain. ___ the doctor, ___, or ___ nurse if the amount increases significantly or changes in character. Be sure to empty the drain frequently. Record the output, if instructed to do so. Wash the area gently with warm, soapy water or ___ strength hydrogen peroxide followed by saline rinse, pat dry, and place a drain sponge. Change daily and as needed. Keep the insertion site clean and dry otherwise. Avoid swimming, baths, hot tubs; do not submerge yourself in water. Make sure to keep the drain attached securely to your body to prevent pulling or dislocation. . PICC Line: Please monitor the site regularly, and ___ your MD, nurse practitioner, or ___ Nurse if you notice redness, swelling, tenderness or pain, drainage or bleeding at the insertion site. ___ your MD or proceed to the Emergency Room immediately if the PICC Line tubing becomes damaged or punctured, or if the line is pulled out partially or completely. DO NOT USE THE PICC LINE IN THESE CIRCUMSTANCES.Please keep the dressing clean and dry. Contact your ___ Nurse if the dressing comes undone or is significantly soiled for further instructions. . Followup Instructions: ___
19575935-DS-6	19,575,935	23,277,716	DS	6	2176-03-05 00:00:00	2176-03-05 13:35:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: latex Attending: ___. Chief Complaint: Suicide Ideations, nausea/vomiting, abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old female with a self-reported a psychiatric history of bipolar disorder, alcohol use disorder, and medical history of cirrhosis and recurrent pancreatitis, who presents to the ___ ED due to worsening depression with SI. On the floor she denies SI but states that she knew that if she didn't come in it would get there. She states that she is a chicken and couldn't handle the pain of tryijng to take her own life. Her first husband tried to commit suicide which made her angry and she would never do that to her sons. She has had recurrent bouts of pancreatitis. She had an MRI of her pancreas done at ___ ___ in ___ but was not told what it showed. She had a RUQ US at ___ yesterday. In ER: (Triage Vitals:0, 97.8, 92 , 190/99, 16, 95% RA ) Meds Given: PO Potassium Chloride 40 mEq IVF 1000 mL NS 1000 mL IVF 1000 mL NS 1000 mL PO/NG Diazepam 5 mg PO/NG Diazepam 5 mg IVF 1000 mL NS 1000 mL Radiology Studies:None- RUQ US performed on ___ consults called: psychiatry . PAIN SCALE: ___ location:+ epigastric -> back REVIEW OF SYSTEMS: CONSTITUTIONAL: No fevers/chills, weight loss HEENT: [X] All normal RESPIRATORY: [X] All normal CARDIAC: [X] All normal GI: + nausea without emesis GU: [X] All normal SKIN: [X] All normal MUSCULOSKELETAL: [X] All normal NEURO: [X] All normal ENDOCRINE: []+ fatigue, staying in bed for 3 days of the past week HEME/LYMPH: [X] All normal PSYCH: [+] per HPI All other systems negative except as noted above Past Medical History: Cirrhosis Recurrent pancreatitis HTN Hepatitis C Social History: ___ Family History: Her mother had HTN and both her sisters had HTN. One sister had breast cancer. MGF died of heart disease at age ___. Physical Exam: Physical Exam on Admission: Vitals: T 97.5 P 74 BP 146/96 RR 18 SaO2 97% on RA GEN: NAD, comfortable appearing HEENT: ncat anicteric MMM CV: s1s2 rr no m/r/g RESP: b/l ae no w/c/r ABD: +bs, soft, NT, ND, no guarding or rebound EXTR:no c/c/e 2+pulses DERM: no rash NEURO: face symmetric speech fluent PSYCH: calm, cooperative = = = = = = = = ================================================================ Physical Exam on Discharge: T: 97.9 BP 124/81, P 60, RR 18 O2 94% RA Gen: Alert, sitting up in bed, appears comfortable. HEENT: Anicteric sclera, MMM, oropharynx clear. Neck: Supple, JVP not elevated, no LAD CV: RRR, normal S1 + S2, no murmurs, rubs, gallops Lungs: CTAB Abdomen: soft, mild diffuse tenderness, no rebound. +BS Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis. Skin: No rashes, no jaundice. MSK: No obvious muscle atrophy. Neuro: AAOx3, non-focal, 2+ reflexes bilaterally, Pertinent Results: Labs on Admission: ___ 05:08PM BLOOD UreaN-16 Creat-1.0 Na-139 K-3.3 Cl-100 HCO3-26 AnGap-16 ___ 05:08PM BLOOD ALT-47* AST-58* AlkPhos-117* TotBili-0.8 ___ 05:08PM BLOOD Lipase-291* ___ 05:08PM BLOOD Albumin-4.5 Calcium-11.1* Cholest-175 ___ 05:08PM BLOOD Triglyc-49 HDL-97 CHOL/HD-1.8 LDLcalc-68 ___ 05:08PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-POSITIVE HAV Ab-POSITIVE IgM HAV-NEGATIVE ___ 05:08PM BLOOD ___ 05:08PM BLOOD HCV Ab-POSITIVE* ___ 05:08PM BLOOD LIVER FIBROSIS PANEL-PND = = = = = ================================================================ Labs on Discharge: ___ 06:10AM BLOOD WBC-1.9* RBC-3.16* Hgb-9.1* Hct-26.9* MCV-85 MCH-28.8 MCHC-33.8 RDW-14.6 RDWSD-45.7 Plt ___ ___ 06:10AM BLOOD Plt ___ ___ 06:10AM BLOOD Glucose-93 UreaN-9 Creat-0.6 Na-142 K-3.6 Cl-108 HCO3-28 AnGap-10 ___ 06:10AM BLOOD ALT-30 AST-42* AlkPhos-97 Amylase-124* TotBili-0.5 ___ 06:10AM BLOOD Calcium-9.2 Phos-2.2* Mg-1.9 = = = = = ================================================================ Studies/Clinical Imaging: MRCP: ___ IMPRESSION: 1. Nodular hepatic contours concerning for cirrhosis. No concerning focal hepatic lesions. Sequela of portal hypertension with mild splenomegaly and recannulized umbilical vein. Trace perihepatic ascites. 2. Mild dilatation of the central intrahepatic bile ducts as well as, focal obstructing lesion or stone identified. 3. Cholelithiasis without evidence of cholecystitis. 4. Left adrenal adenoma. Abdominal U/S: ___ FINDINGS: LIVER: The hepatic parenchyma appears within normal limits. The contour of the liver is smooth. There is no focal liver mass. The main portal vein is patent with hepatopetal flow. There is no ascites. BILE DUCTS: There is no intrahepatic biliary dilation. The CBD is dilated measuring 1.0 cm. GALLBLADDER: A non shadowing and mobile echogenic focus measures 0.5 cm within the gallbladder lumen, possibly sludge or alternatively a stone. There is no gallbladder wall edema, thickening, or pericholecystic fluid. PANCREAS: Imaged portion of the pancreas appears within normal limits, without masses or pancreatic ductal dilation, with portions of the pancreatic tail obscured by overlying bowel gas. SPLEEN: Normal echogenicity, measuring 16.4 cm. KIDNEYS: The right kidney measures 9.9 cm. The left kidney measures 11.0 cm. Normal cortical echogenicity and corticomedullary differentiation is seen bilaterally. There is no evidence of masses, stones, or hydronephrosis in the kidneys. RETROPERITONEUM: Visualized portions of aorta and IVC are within normal limits. IMPRESSION: 1. Splenomegaly without a focal lesion. 2. Nonshadowing mobile echogenic stone within the gallbladder. No evidence of cholecystitis. MRCP ___: IMPRESSION: 1. Mild dilatation of the central intrahepatic bile ducts as well as common bile duct with no focal obstructing lesion or stone identified. 2. Heterogeneous signal of the pancreas with subtle peripancreatic stranding compatible with sequelae of pancreatitis. 3. Nodular hepatic contours. No concerning focal hepatic lesions. Mild splenomegaly and recanalized umbilical vein. Trace perihepatic ascites. 4. Cholelithiasis without evidence of cholecystitis. 5. Left adrenal adenoma. 6. Small nodule in the right lower lobe, which can be further evaluated with dedicated chest imaging. Brief Hospital Course: ___ y/o w/ bipolar disorder, Hep C cirrhosis, recurrent pancreatitis and HTN admitted with suicidal ideation, severe depressive symptoms and abdominal pain, found to have pancreatitis likely ___ ETOH. #Acute Pancreatitis: At the time of admission, Ms. ___ endorsed abdominal pain and that she recently drank ETOH on the day prior to admission (100 proof Vodka, 2 shots). Her blood alcohol level was 81 and her Lipase was 204. This was likely secondary to alcoholic pancreatitis. We also considered the possibility of an obstructive etiology, although her Tbili and alk phos level remained normal. She had an RUQ ultrasound that demonstrated CBD dilation to 1.0cm. We obtained an MRCP that showed no obstructing lesion or choledocholithiasis. She did have evidence of cholelithiasis without evidence of cholecystitis. We treated her aggressively with IVFs and made her NPO. After the MRCP procedure, we started to advance her diet to clear liquids, which she tolerated. Her LFTs remained normal, she may passed a stone causing her pancreatitis but alcoholic pancreatitis seems more likely. If episode recurs without alcohol use would recommend evaluation for cholecystectomy. Her diet was advanced to regular and she had minimal pain on discharge. #Suicidal Ideation: At time of admission, patient endorsed having SI, but no plan or intent to harm herself. While on the floor, her mood improved and she denied any recurrent SI/HI. We obtained a psych consultation and they recommended that she be discharged to a dual diagnosis unit. #Bipolar disorder: We continued her home psych meds. #Hep C Cirrhosis/transaminitis: At the time of admission, she had a mildly elevated AST, likely from her hepC/Cirrhosis. We continued her home propranolol and PPI. Patient would like to follow-up in liver clinic for possible treatment in the future. #Coagulopathy: At the time of admission, she had an INR of 1.2. This was likely secondary to her chronic hep C/cirrhosis. We continued to trend her INR during this hospitalization. #ETOH abuse: Patient had a blood ETOH level of 81 on admission, but no evidence of withdrawal. We continued her on ativan 1mg PO PRN CIWA >10. #Pancytopenia: Patient had a new pancytopenia from her normal baseline. This was likely secondary to hemodilution from fluids. We continued to trend her CBC during this hospitalization. Her pancytopenia improved. -Recommend that PCP repeat CBC on next visit. #HTN: We continued her home lisinopril. #GERD: We continued her home PPI. Code: Full Contact: HCP, son ___. Phone: ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Venlafaxine XR 150 mg PO DAILY 2. QUEtiapine extended-release 100 mg PO QHS 3. Oxcarbazepine 300 mg PO BID 4. Multivitamins 1 TAB PO DAILY 5. Lisinopril 10 mg PO DAILY 6. Propranolol 10 mg PO BID 7. Omeprazole 20 mg PO DAILY 8. Potassium Chloride 10 mEq PO DAILY Discharge Medications: 1. Lisinopril 10 mg PO DAILY 2. Multivitamins 1 TAB PO DAILY 3. Omeprazole 20 mg PO DAILY 4. Oxcarbazepine 300 mg PO BID 5. Propranolol 10 mg PO BID 6. QUEtiapine extended-release 100 mg PO QHS 7. Venlafaxine XR 150 mg PO DAILY 8. Acetaminophen 650 mg PO Q6H:PRN pain 9. Potassium Chloride 10 mEq PO DAILY Hold for K > Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Acute pancreatitis Alcohol abuse Suicidal ideation Hep C/Cirrhosis Transaminitis Coagulopathy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for abdominal pain and you were found to have pancreatitis, most likely from alcohol use. You had an ultrasound and MRI of your abdomen which did not show evidence of gallstones. You also had thoughts of wanting to hurt yourself and are being discharged to an inpatient dual diagnosis unit. Followup Instructions: ___
19576216-DS-10	19,576,216	22,787,610	DS	10	2140-07-05 00:00:00	2140-07-05 21:33:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins Attending: ___. Chief Complaint: Failure to thrive Major Surgical or Invasive Procedure: none History of Present Illness: ___ y/o male with PMH of CKD followed by nephrology- stage 4 (Cr at 5.9 in ___, on epo for anemia, Asperbergers, HTN, Venous insufficiency, ruptured varicose vein LLE presents with FTT. Patient lives home with home health aid every day during daytime and is alone at night. For the past two weeks patient has been having difficulty ambulating, increased weakness. He normally sleeps in a reclining chair and has been using his lifeline 3 times a night to call for assistance in sliding him up his chair when he slumps down. He denies any fevers, headaches, cough, SOB, sore throat, chest pain, abdominal pain, diarrhea, urinary symptoms. His meals are prepared for him by home health aid and both he and aid endorse no change in appetite, PO intake or urinary output. In the ED, initial vitals: 97.8, 69, 110/52, 18, 100% RA Labs were significant for K of 4.7. Bicarb 19 with anion gap of 19. BUN 71. Cr 6.2. Phos elevated at 6.2. CBC notable for WBC 11.0 with neutrophil predominance of 82.6%. H/H notable for 8.7/27.0 with plt of 241. UA notable for moderate leukocytes, negative nitrites, protein 30, WBC 26, few bacteria. Imaging showed: ___: CT head No acute intracranial process. ___: CXR PA and LAT: No pneumonia. Given a total of 2.5mg Ativan in ED. 2L NS. cipro 500mcg. Lasix 20mg PO. home metoprolol, ferrous sulfate, sodium bicarb, and calcitriol given. Vitals prior to transfer: 98.2, 65, 123/51, 18, 100% RA Currently on transfer to floor, patient not complaining of any pain. His leg ulcers usually give him pain, though feeling better after recent wound care treatments. No chest pain or shortness of breath. No n/v. No diarrhea or constipation. Feeling anxious. The patient's brother-in-law is at bedside and confirms that the patient appears to be at his baseline. Past Medical History: -CKD stage IV, being evaluated for dialysis -Cognitive impairment -Hypertension -Venous insufficiency -Possible schizophrenia -Ruptured varicose vein in LLE s/p 4 units pRBC transfusion, vein removal in ___ -h/o pneumonia with admission to ___ (___) -h/o Mechanical fall with fractured clavical (___) Social History: ___ Family History: No family history of renal disease, diabetes, hypertension. Mother and father died of Alzheimer's in their ___. No family history of early MIs or sudden cardiac death. Physical Exam: ADMISSION PHYSICAL EXAM: ========================== VS: 98.2 140/57 69 20 99% RA GEN: Alert, lying in bed, oriented to person, ___, Hospital, screaming his answers but denying distress, when asked to lower his voice he says "that's just how my voice is" HEENT: Tacky MM, anicteric sclerae, no conjunctival pallor NECK: Supple without LAD PULM: Diffuse expiratory wheezes in bilateral lung fields, no increased work of breath, good air movement bilaterally COR: RRR (+)S1/S2 no m/r/g ABD: Soft, NT/ND, BS+ no rebound masses or guarding, guaiac negative, good rectal tone (per ED examination) EXTREM: upper extremities warm and well perfused with no lesions lower extremities bilaterally exhibit significant venous stasis changes and tense edema. Right Lower Extremity 3cm bullous lesion on anterolateral shin. LLE demonstrates open shallow ulcer on lateral surface of distal extremity from ankle to knee, healing well with granulation tissue present. NEURO: CN II-XII grossly intact, motor function grossly normal DISCHARGE PHYSICAL EXAM: ========================== VS: 97.7 110s-130s/60s ___ 24 100% RA GEN: Alert, lying in bed, oriented to person, ___, Hospital, screams his answers but denying distress, when asked to lower his voice he says "that's just how my voice is" HEENT: MMM PULM: Diffuse rhonchi, no wheezes or crackles, no increased work of breath, good air movement bilaterally COR: RRR (+)S1/S2 no m/r/g ABD: Soft, NT/ND, BS+ EXTREM: upper extremities warm and well perfused with no lesions lower extremities bilaterally exhibit significant venous stasis changes and tense edema. Right Lower Extremity 3cm bullous lesion on anterolateral shin. LLE demonstrates open shallow ulcer on lateral surface of distal extremity from ankle to knee; left ulcer with weeping. dressing overlying soaked with combination of blood and serosanguous drainage. Pertinent Results: Admission labs: ___ 12:15PM BLOOD WBC-11.0* RBC-2.75* Hgb-8.7* Hct-27.0* MCV-98 MCH-31.6 MCHC-32.2 RDW-12.8 RDWSD-45.4 Plt ___ ___ 12:15PM BLOOD Neuts-82.6* Lymphs-7.3* Monos-7.1 Eos-1.3 Baso-0.5 Im ___ AbsNeut-9.11* AbsLymp-0.80* AbsMono-0.78 AbsEos-0.14 AbsBaso-0.05 ___ 12:15PM BLOOD Glucose-91 UreaN-71* Creat-6.2* Na-141 K-4.7 Cl-103 HCO3-19* AnGap-24* ___ 12:15PM BLOOD Calcium-8.5 Phos-6.2# Mg-2.6 Discharge labs: ___ 05:50AM BLOOD WBC-8.0 RBC-2.45 Hgb-7.9* Hct-24.6* MCV-100* MCH-32.2* MCHC-32.1 RDW-13.1 RDWSD-47.4* Plt ___ ___ 01:27PM BLOOD WBC-9.9 RBC-2.59* Hgb-8.4* Hct-25.6* MCV-99* MCH-32.4* MCHC-32.8 RDW-13.0 RDWSD-46.0 Plt ___ ___ 05:50AM BLOOD Glucose-103* UreaN-61* Creat-5.6* Na-143 K-4.5 Cl-108 HCO3-23 AnGap-17 ___ 05:50AM BLOOD Calcium-9.1 Phos-5.8* Mg-2.4 Imaging/other studies: ___: CXR No pneumonia. ___: CT head No acute intracranial process. Microbiology: ___ 9:30 pm URINE Source: ___. **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. Brief Hospital Course: ___ y/o male with PMH of CKD followed by nephrology- stage 4 (Cr at 5.9 in ___, on epo for anemia, Asperbergers, HTN, venous stasis ulcers presents with FTT, found to have UTI and awaiting dispo to SNF for rehab. #Aspergers: Pt with known dementia/Aspergers. Appears to be at mental baseline per brother-in-law who knows him well. Brother-in-law reports that Ativan was helpful for him in the ED. Never posing any danger to himself or others, just occasionally loud and disturbing to the staff. #UTI: Asymptomatic bactiuria, but given leukocytosis of 11.0 with neutrophil predominance and ?new agitation, started with treated for complicated UTI for 7 day course to be completed on ___. UCx with > 3 species, consistent with contamination. #Hyperphosphatemia: elevated from baseline of 3.0-5.8 up to 6.7. Downtrended during admission back to baseline range. Potassium stable. - Calcium acetate 667 TID with meals for phosphate binding started - low phos diet, low potassium diet #LLE venous stasis ulcers: Wound care consulted. Recs for daily dressing changes in Page 1. ___ recs: Pt is most appropriate for discharge to a rehabilitation facility or home with 24hr assist and home ___. #Anemia: Hematocrit trended down from 27 to 25 during admission. No signs of GI bleeding. Some oozing from lower extremity ulcers at baseline per patient. Recommend recheck later this week at rehab. =============================== Transitional Issues =============================== -started on ciprofloxacin for 7 day course for complicated UTI (last day = ___. -Calcium acetate 667 TID with meals for hyperphosphatemia started -wound care recs for venous stasis ulcers with daily dressing change -Recommend repeat CBC at rehab to ensure stability. Please draw CBC on ___ and contact covering doctor at rehab with results. H/H on discharge was 8.4/25.6. -Niece and brother-in-law reported that Ativan has been helpful for the patient for anxiety, especially with changes in his environment. Added prn Ativan prescription on discharge. -follow up with PCP after discharge from rehab Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Metoprolol Succinate XL 25 mg PO DAILY 2. Calcitriol 0.25 mcg PO DAILY 3. Ferrous Sulfate 325 mg PO DAILY 4. Sodium Bicarbonate 650 mg PO Frequency is Unknown 5. Furosemide 20 mg PO DAILY Discharge Medications: 1. Calcitriol 0.25 mcg PO DAILY 2. Ferrous Sulfate 325 mg PO DAILY 3. Furosemide 20 mg PO DAILY 4. Sodium Bicarbonate 650 mg PO BID 5. Calcium Acetate 667 mg PO TID W/MEALS 6. Ciprofloxacin HCl 250 mg PO Q24H 7. Docusate Sodium 100 mg PO BID Hold for loose stools. 8. Lorazepam 0.5 mg PO Q4H:PRN anxiety 9. Senna 8.6 mg PO BID:PRN constipation Hold for loose stools. 10. Metoprolol Succinate XL 25 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary: UTI FTT Secondary: dementia/Asbergers CKD anemia HTN Venous stasis ulcers FTT Discharge Condition: mental status: Pt with known dementia/Asbergers. Appears to be at mental baseline per brother-in-law who knows him well.Alert, lying in bed, oriented to person, ___, Hospital, intermittently screams his answers but denies distress, when asked to lower his voice he says 'that's just how my voice is' Ambulatory status: ambulates with assistance Discharge Instructions: Dear Mr. ___, You were admitted because you were having difficulty caring for yourself at your home. You were admitted to ___ while a bed search was conducted to find a place at a specialized nursing facility. While in the hospital, you were found to have a urinary tract infection. We treated your urinary tract infection with antibiotics which you should continue until ___. Regarding your left leg varicose vein ulcer, we had wound care see you. They made recommendations for daily dressing changes which will be continued at rehab. We wish you the best, Your ___ primary care team. Followup Instructions: ___
19576216-DS-8	19,576,216	27,675,565	DS	8	2138-03-10 00:00:00	2138-03-12 13:15:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins Attending: ___. Chief Complaint: Elevated Creatinine Major Surgical or Invasive Procedure: none History of Present Illness: ___ with hx of CRI, mental retardation, anemia, who was recently admitted for difficulty walking and started on treatment for prostatitis with cipro, now readmitted with acute on chronic kidney injury, cr 3.6-->6.0. The pt was recently admitted from ___ for inability to walk. He was found to have a boggy/?tender prostate on admission, and +u/a (ucx c/w contamination). Given some concern for prostatitis, the pt was empirically treated with ciprofloxacin (renally dosed at 250mg q24h) for a goal 4wks. Last cr ___. The pt is unclear about exactly what led to his coming to the hospital, but purportedly his labs were checked and he was found to have a cr 6.0 and sent to the ED. In the ED, the pt's vs 98.3 67 140/65 18 98% ra. BUN/Cr 93/6.0, Hct 28 (baseline), K 4.6. u/a with traces blood and trace protein. ulytes demonstrating FeUrea 44%. Prot/cr 0.2. PVR reportedly 155. 1L NS was given. Pt was admitted for workup of acute on chronic kidney injury. On the floor, the pt was 98.1 123/64 66 18 98%RA. He denies any dysuria, frequency, abdominal pain. ___ pain and swelling L>R which is chronic. He stated he was tired and did not want to talk any more. Past Medical History: -CKD stage IV, being evaluated for dialysis -Cognitive impairment -Hypertension -Venous insufficiency -Possible schizophrenia -Ruptured varicose vein in LLE s/p 4 units pRBC transfusion, vein removal in ___ -h/o pneumonia with admission to ___ (___) -h/o Mechanical fall with fractured clavical (___) Social History: ___ Family History: No family history of renal disease, diabetes, hypertension. Mother and father died of Alzheimer's in their ___. No family history of early MIs or sudden cardiac death. Physical Exam: Admission Exam: Vitals: 98.1 123/64 66 18 98%RA General: Alert when awoken from sleep, disinterested in answering questions HEENT: MMM Neck: supple Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, no r/g, no hsm Ext: extensive erythema, venous stasis ulcers and excoriations, +Edema L>R (per pt chronic) Rectal: refused Discharge Exam: Vitals: 98 117/69 72 18 100% RA General: Alert and Oriented x 3. Speaks in a loud voice HEENT: PERRL MMM Neck: supple, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, no r/g, no hsm Ext: extensive erythema, venous stasis ulcers and excoriations, +Edema L>R (per pt chronic) Rectal exam: refused Pertinent Results: ___ 07:05AM BLOOD WBC-7.5 RBC-3.01* Hgb-9.2* Hct-27.0* MCV-90 MCH-30.5 MCHC-34.1 RDW-13.8 Plt ___ ___ 07:15PM BLOOD WBC-10.7# RBC-3.18* Hgb-9.6* Hct-28.0* MCV-88 MCH-30.1 MCHC-34.1 RDW-14.1 Plt ___ ___ 07:05AM BLOOD Plt ___ ___ 07:15PM BLOOD Plt ___ ___ 07:20AM BLOOD Glucose-105* UreaN-72* Creat-4.1* Na-143 K-4.7 Cl-107 HCO3-26 AnGap-15 ___ 07:15PM BLOOD Glucose-101* UreaN-93* Creat-6.0# Na-142 K-4.6 Cl-101 HCO3-23 AnGap-23 ___ 07:20AM BLOOD Calcium-7.6* Phos-5.4* Mg-2.5 ___ 03:21AM BLOOD Calcium-7.2* Phos-5.7*# Mg-2.6 Kidney U/S Minimal fullness of the bilateral renal pelves, without frank hydronephrosis. Simple appearing right renal cortical cysts. Brief Hospital Course: ___ with hx of CRI, mental retardation, anemia, who was recently admitted for difficulty walking and started on treatment for prostatitis with cipro, now readmitted with acute on chronic kidney injury, cr 3.6-->6.0. # Acute on chronic kidney injury: Pt with baseline cr 3.6, found to have asymptomatic increase to 6.0 at ___ following being discharged from the previous hospital admission (___). ___ likely prerenal due to recent decrease PO intake and diarrhea with labs suggestive of intrinsic renal injury as well. Urine sediment was negative for ATN. Renal u/s was negative for hydronephrosis. The patient's furosemide was held throughout the hospitalization and started at a lower dose prior to discharge. With fluids, creatinine improved and at discharge was 4.1. # CKD: The inpatient renal team representing his outpatient nephrologist Dr. ___ recommendations and followed closely throughout the hospitalization. Patient continued on calcitrol and sodium bicarbonate. He will follow up with Chem 10 and albumin lab draws the upcoming ___ and next ___ for surveillance at ___. These labs should be sent to his PCP as well as faxed to Dr. ___ at ___. # Prostatitis: Pt started on cipro x28d in his previous hospitalization for prostatitis. Given that he was asymptomatic, a u/a here in ___ that was normal and concern for potential kidney injury, ciprofloxacin was discontinued at admission and will not be continued at discharge. # Venous stasis ulcers: Chronic. Wound care followed. # HTN: continued home metoprolol. # Anemia: chronic. continued home iron # Transitional issues - Patient's HCP ___ need to make appointment with Dr. ___, by phone at ___ - Patient's HCP ___ also need to call to make an appointment with PCP -___ check daily weights, Chemistry 10 panel with albumin on ___ and ___. Will need these labs drawn qweekly after this. Please fax results to the PCP as well as Dr. ___ at ___ -If albumin still low, please obtain nutrition consult Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ferrous Sulfate 325 mg PO DAILY 2. Furosemide 40 mg PO DAILY 3. Metoprolol Succinate XL 25 mg PO DAILY 4. Sodium Bicarbonate 650 mg PO BID 5. Ciprofloxacin HCl 250 mg PO Q24H 6. Calcitriol 0.25 mcg PO DAILY Discharge Medications: 1. Calcitriol 0.25 mcg PO DAILY 2. Ferrous Sulfate 325 mg PO DAILY 3. Metoprolol Succinate XL 25 mg PO DAILY 4. Sodium Bicarbonate 650 mg PO BID 5. Furosemide 20 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary: - Acute on chronic kidney injury Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. ___, You came in because your creatinine, a blood test that tells us about the function of your kidneys was abnormal. It improved when we gave you fluids. You will be going to ___ for inpatient physical therapy. There you can have your blood drawn so that doctors ___ continue to watch your kidneys. You will follow up with your nephrologist and primary care doctor. It was a pleasure taking care of you. Followup Instructions: ___
19576505-DS-5	19,576,505	29,355,211	DS	5	2165-04-29 00:00:00	2165-05-03 19:34:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: small ___ left temporal bone fracture Major Surgical or Invasive Procedure: Right frontal EVD on ___, removal ___ Insertion of PICC ___ History of Present Illness: Mr. ___ is a ___ yo man who presents following a high speed motor vehicle accident. Patient was apparently driving back to ___ from ___ when his car went off the road traveling at high speeds (?70mph), perhaps because he had fallen asleep. He was found partially ejected through his windshield. He required a 35 minute extracation. Unclear if he was seatbelt restrained. After this he was described as confused and agitated. He was intubated ___ the field (two attempts) and an IO was placed. He was medflighted here after being sedated with etomidate, vec, fentanyl and succ. Past Medical History: unknown Social History: ___ Family History: unknown Physical Exam: PHYSICAL EXAMINATION ON ADMISSION: O: T: Afeb BP: 195/117 HR: 68 O2Sats: 100% Gen: Inutbated and sedated HEENT: Large left scalp hematoma, blood from left ear Neck: ___ hard collar Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and ___. Right calf much larger (chronic per report of wife) ___: (off of propofol for 15 minutes) No eye opening to voice or noxious. No commands. No BTT. Pupils briskly reactive 3 to 2mm. Good corneals. Doll's not attempted due to ETT. Face symmetric. Gag not profound. He occasionally shivers during which time he seems to extensor porture. However, he does convincingly show purposeful withdraw to all extremities to noxious. Toes are down. PHYSICAL EXAMINATION ON DISCHARGE: AAO x 3. Follows commands ___ all 4 extremities. ___ x4. c/o vision being blurry, better when closing one eye or the other, suspect subtle CN deficit. Pertinent Results: Radiology Report MR CERVICAL SPINE W/O CONTRAST Study Date of ___ 10:07 AM 1. Mild interspinous ligament edema from ___ through ___. Anterior longitudinal ligament, posterior longitudinal ligament, and ligamentum flavum appear unremarkable. No evidence for other traumatic injuries. 2. Moderate to severe bilateral neural foraminal narrowing from ___ and ___. ___ CT ___ 1. No acute cervical spine fracture or malalignment 2. Numerous small bilateral cervical and supraclavicular lymph nodes, of unknown etiology. 3. Biapical dependent airspace opacities, likely atelectasis ___ CT Head: 1. No acute intracranial abnormality. 2. Large left parietal scalp subgaleal hematoma, without underlying fracture. 3. Subtle, non - displaced longitudinal - appearing fracture through the mastoid segment of the left temporal bone, with opacification of the left mastoid air cells, but clear middle ear cavity, incompletely characterized. ___ CT Torso: 1. No traumatic injuries to the chest abdomen pelvis. Atelectasis ___ both lungs. 2. Endotracheal tube 2 cm above the carina Right Tib/fib ___: No right tibia or fibula fracture ___ CXR: The endotracheal tube lies 4.1 cm from the carinal angle. The lung fields are clear. No pneumothorax is identified ___ NCHCT: 1. Increased size of large left subgaleal hematoma extending across the midline to the right parietal scalp, with increasing density, likely representing additional bleeding. 2. Small, thin right subdural hematoma along the right temporoparietal convexity, was not visible on the CT performed 12 hours earlier. 3. Evolving right parietal hemorrhagic contusion and trace right parietal subarachnoid blood products are more conspicuous on the current examination. 4. Unchanged ___ longitudinal left temporal bone fracture with partial opacification of the left mastoid and middle ear cavity. ___ CT Head: 1. Stable small right parietal hemorrhagic contusion. 2. Nondisplaced left temporal bone fracture is again noted ___ CT Head: 1. Interval pull back of the right frontal approach extraventricular drain, which now terminates ___ the frontal horn of the right lateral ventricle. 2. Unchanged appearance of anterior parietal lobe parenchymal contusion, with some likely redistributed blood now seen ___ the occipital horn of the right lateral ventricle. 3. Stable appearance of left temporal bone fracture. CHEST (PORTABLE AP) Study Date of ___ 5:09 AM FINDINGS: As compared to the previous radiograph, there is unchanged evidence of mild fluid overload. Retrocardiac atelectasis and bilateral areas of atelectasis are slightly better than on the previous image. However, subtle parenchymal opacities at the left lung bases persist, raising the previously documented suspicion for a developing pneumonia. The lung volumes remain low. The monitoring and support devices are ___ unchanged position. CHEST (PORTABLE AP) Study Date of ___ 5:22 AM IMPRESSION: Bibasilar opacities are unchanged or slightly increased and may represent developing pneumonia. Trace left pleural effusion. BILAT LOWER EXT VEINS Study Date of ___ 8:22 AM IMPRESSION: No evidence of DVT ___ either the right or the left lower extremity. ___ NCHCT: 1. Stable appearance of right parietal hemorrhagic contusion. 2. Small amount of intraventricular blood, stable ___ the right occipital horn of the lateral ventricle and slightly increased ___ the left occipital horn of the lateral ventricle. 3. Interval removal of right frontal ventricular catheter with small amount of hemorrhage along the track. ___ Chest ___: As compared to the previous radiograph, there is improved ventilation of the lung bases, potentially due to a change ___ respiratory pressure. The monitoring and support devices are constant. No pneumothorax, no pleural effusions. Borderline size of the cardiac silhouette without pulmonary edema. ___ Chest ___: As compared to the previous radiograph, no relevant change is seen. The areas of parenchymal opacities, likely atelectatic, at both lung bases, persist. No pleural effusions. Mild cardiomegaly. No pulmonary edema. The monitoring and support devices are constant. ___ CXR: As compared to the previous radiograph, bilateral parenchymal opacities that ___ on the previous image have not substantially changed. The symmetry and distribution of the opacity favors atelectasis over pneumonia. The lung volumes remain low. The monitoring and support devices are constant ___ appearance. No pleural effusions. No pulmonary edema. Unchanged appearance of the cardiac silhouette. ___ BUE dopplers: IMPRESSION: Occlusive DVT ___ the left subclavian vein, paired brachial veins as well as basilic vein ___ the upper arm. ___ CT Chest: 1. No evidence of empyema. 2. Patchy nodular opacities noted ___ the posterior aspect of the right upper lobe associated with a more confluent consolidation ___ the right lower lobe. The constelliation of finding suggest microaspiration and/or pneumonia. ___ CT Head without Contrast: No evidence of new hemorrhage or acute infarction. Calvarial or orbital fractures are largely unchanged from the prior examination. Interval resolution of previously described intraventricular blood and right parietal hemorrhagic contusion. PICC placement ___. The accessed vein was patent and compressible. 2. Right cephalic vein approach double lumen PIC line with tip ___ the low SVC. DISCHARGE LABS ___ 02:52PM BLOOD ___ ___ Plt ___ ___ 05:56AM BLOOD ___ ___ ___ 02:52PM BLOOD ___ ___ ___ 02:52PM BLOOD ___ ___ 10:00 am SPUTUM Source: Endotracheal. *FINAL REPORT ___ GRAM STAIN (Final ___: >25 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI. ___ PAIRS AND CLUSTERS. RESPIRATORY CULTURE (Final ___: Commensal Respiratory Flora Absent. STAPH AUREUS COAG +. HEAVY GROWTH. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. SENSITIVITIES: MIC expressed ___ MCG/ML _________________________________________________________ STAPH AUREUS COAG + \| CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN----------<=0.12 S OXACILLIN------------- 0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S Brief Hospital Course: This is a ___ year old man who was status post MVC intubated and medflighted to the emergency room for further evaluation and treatment. The patient was evaluated by neurosurgery. A NCHCT was performed and was found to be conistent with a large left parietal scalp subgaleal hematoma, without underlying fracture, a Subtle, non - displaced longitudinal - appearing fracture through the mastoid segment of the left temporal bone, with opacification of the left mastoid air cells, but clear middle ear cavity, incompletely characterized. The patient was admitted to the trauma intensive care unit and a repeat NCHCT was performed which showed increased size of large left subgaleal hematoma extending across the midline to the right parietal scalp, with increasing density, likely representing additional bleeding. There was also a small, thin right subdural hematoma along the right temporoparietal convexity, was not visible on the CT performed 12 hours earlier. Further, there was an evolving right parietal hemorrhagic contusion and trace right parietal subarachnoid blood products are more conspicuous on the current examination. On the morning of ___, The patient was on a contiuous precedex and propofol intravenous infusions for sedation. The patient was administered intermittent fentanyl as well. All sedation was stopped for a neurological assessment on morning rounds and the patient's glascow coma exam was 7T. A external ventricular catheter was placed for intercranial pressure monitoring. The patients wife was updated. The patients ICP was 7 and the drain was clamped. A EEG was consistent with temporal epiletiform discharges not seizures, 1 every ___ seconds and the patient was started keppra 750 mg BID per eplilepsy. On ___, the MRI cspine was performed and consistent with interspinous ligamentous injury and the patient hard cervical collar will remain ___ place at all times. a NCHCT was performed and was found to be stable. The external ventric8ular catheter was clamped and intracranial pressures were normal at 7. Tube feedings were started. physical therapy was consulted. The EEG was unchanged and the patients keppra was increased to 1gm BID. The patient was initiated on a course of vancomycin and zosyn for pneumonia. On ___ his EEG was discontinued, a PICC line was inserted, and he remained otherwise stable. ___ the evening his ICP waveform was dampened, and the drain was troubleshot. It was not draining so a STAT head CT was obtained which showed the drain had been withdraw almost out of the ventricle. The EVD was subsequently removed. A new drain was not replaced as he had low ICP's for ther last few days. On ___ he remained stable with a stable neurologic exam and continued antibiotics. The patient had a bowel movement. On ___, lower extremity ultrasounds were performed to rule out deep vein thrombosis were perfromed given the patients prolonged bedrest and right lower extremity edema. This study was negative. The patient continued to be hypertensive and po blood pressure medications were tirtaed up. Sedation was minimized. The patient temperate was 100.8. The patient's exam off propofol for 1 hour, The patient localizes withthe left greater than right bilateral upper extremities and the patient moved lowers on bed to noxious left greater than right. The patients pupils ___ bilateral. On ___, he remained stable ___ the ICU while awaiting family meeting ___. On ___, his exam was stable and her underwent NCHCT to evalaute for any changes. The imaging was stable and he was awaiting family meeting. On ___, his examination remained stable. A family meeting was held and was attended by Dr. ___ his sister were present. It was determined that he would undergo placement of a PEG and Trach. On ___ his exam was brighter and trach and PEG were placed on hold to see if he would be able to be extubated. He was following commands with his feet and was much more interactive. He was started on Naficillin for MSSA PNA. The patient was extubated on ___ and did well. He was started on Levoflox for H.Flu coverage. He continued to be monitored ___ the ICU. He had some fluid boluses for hyponatremia. On ___ he was transferred to the SDU. On ___ ID was consulted for abx guidance. The team was unable to pass a NG tube. On ___ there was some LUE swelling and a doppler study showed + DVT ___ L subclavian, b/l brachial, and partial basilic. He was started on a heparin drip and the PICC line was discontinued. The patient remained stable on ___ and a speech and swallow eval was ordered. On ___, his exam was improved and the PEG was cancelled ___ order to repeat the swallow eval. On evaluation he was advanced to a regular diet with thin liquids. The PEG was cancelled and the patient was put on calorie counts. Patient continued to improve neurologically. Restraints were removed. On the evening of ___, Mr. ___ had fallen out of bed and struck his head. Because he had been receiving anticoagulation, a STAT ___ head CT was obtained. There was no acute change or hemorrhage noted. A posey vest was placed for the patient's safety overnight. On ___, Mr. ___ was taken to the Interventional Radiology suite for insertion of a PICC line. His heparin infusion was held prior to that procedure. On this day, his INR was therapeutic at 2. The patient's mental status waxed and wanted, but he was oriented to person, place and time upon morning assessment. On ___, diarrhea slows down. Only had one loose stool overnight. INR 3.8. Holding warfarin today. On ___ Patient remains stable. INR 1.9. Warfarin dose was restarted at 2.5 daily On ___ Patient remains stable. INR 1.4. Patient was given an additional 2.5 of warfarin on top of daily dose. Daily dose changed to 5mg. On ___ Patient's exam remains stable. INR today 1.7. Nacfillin was discontinued after last dose today. Daily dose of warfarin changed to 3mg. On ___: Patient's exam remains stable. INR today 1.5. Daily dose of warfarin remains at 3mg. ___ continues to work with patient, reports some improvement ___ mobility. On ___, the patient remained stable neurologically. The Coumadin was increased from 3mg to 4mg daily. He continued to ambulate with physical therapy. On ___, the patient remained stable. INR was still low so Coumadin increased to 5 mg daily, and heparin gtt was started for bridging therapy. On ___, the patient remained stable, and progressed with ___ to the point where he was able to be discharged home with 24 hour help. INR was still low so coumadin was increased to 7.5 x 1 on ___, with plan to continue 5 mg daily throughout the weekend. Heparin gtt was discontinued ___ favor of lovenox bridging therapy. PCP was contact and a PCP appointment was made for ___ with an INR check at that time. TRANSITIONAL ISSUES - The patient was started on Coumadin for DVT ___ his L arm. He needs his INR checked ___, ___, and coumadin dose adjusted as needed. He is being discharged on a Lovenox bridge, when INR is at goal of ___ he should stop the Lovenox under direction from his PCP. - F/U with PCP - ___ to control BP, goal normotension. - Consider transitioning off the labetalol ___ the long run given TID dosing Medications on Admission: None Discharge Medications: 1. Outpatient Lab Work INR check on ___ and fax to Dr. ___ at ___ 2. Warfarin 5 mg PO DAILY16 RX warfarin 2.5 mg 2 tablet(s) by mouth daily at 4 ___ Disp #60 Tablet Refills:0 3. Amlodipine 10 mg PO DAILY RX amlodipine 10 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 4. Enoxaparin Sodium 100 mg SC Q12H Start: Today - ___, First Dose: Next Routine Administration Time RX enoxaparin 100 mg/mL ___very twelve (12) hours Disp #14 Syringe Refills:0 5. Lisinopril 20 mg PO DAILY RX lisinopril 20 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 6. Labetalol 600 mg PO TID RX labetalol 300 mg 2 tablet(s) by mouth three times a day Disp #180 Tablet Refills:0 7. Outpatient Physical Therapy outpatient ___ 8. Outpatient Occupational Therapy outpatient OT Discharge Disposition: Home Discharge Diagnosis: Left temporal bone fracture Right parietal contusion Traumatic brain injury Respiratory failure Dysphagia Altered mental status Cervical ligamentous injury Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. ___, It was a pleasure caring for you at ___ ___. You were admitted after a motor vehicle collision with a skull fracture and a small amount of bleeding around your brain. You got physical therapy ___ the hospital because you could not go to rehab, but you improved enough to go home with help from your family. You developed a blood clot while ___ the hospital so you were started on a blood thinner (coumadin) to prevent further clotting. It is important that you get your INR checked outpatient with your primary care physician so they can adjust your dose as needed. When your INR gets to the goal of ___, you will be able to stop your Lovenox, which you are taking as a bridging therapy. Nonsurgical Brain Hemorrhage: -Take your pain medicine as prescribed. -Exercise should be limited to walking; no lifting, straining, or excessive bending. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING New onset of tremors or seizures. Any confusion, lethargy or change ___ mental status. Any numbness, tingling, weakness ___ your extremities. Pain or headache that is continually increasing, or not relieved by pain medication. New onset of the loss of function, or decrease of function on one whole side of your body. Followup Instructions: ___
19576610-DS-5	19,576,610	20,337,199	DS	5	2200-01-07 00:00:00	2200-01-07 17:31:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins Attending: ___. Chief Complaint: fever and weakness Major Surgical or Invasive Procedure: ERCP History of Present Illness: ___ w/ past medical history of gallbladder adenocarcinoma status post bare-metal stent on ___ after presentation for right upper quadrant pain radiating to the back, presenting ___ for fever, cough, nausea, vomiting. Past Medical History: Hypertension Prostate cancer s/p external beam radiation Allergic rhinitis Social History: ___ Family History: No family history of hepatobiliary illness. Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VS: 97.9 ___ P 87 19 98% RA GEN: elderly chronically ill appearing, laying in bed EYES: no scleral icterus HENNT: NCAT, EOMI, dry mucus membranes CV: rrr, no m/r/g, no JVD RESP: ctab ABD: distended, no rebound, no guarding MSK: strength grossly in tact, extremities wwp, no peripheral edema SKIN: no rashes, no jaundice NEURO: A&Ox3 PSYCH: appropriate, conversational DISCHARGE PHYSICAL EXAM: ======================== VITALS: Afebrile and vital signs stable GENERAL: Alert and in no apparent distress EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate CV: Heart regular, no murmur, no S3, no S4. No JVD. RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, non-distended, non-tender to palpation. Bowel sounds present. GU: No suprapubic fullness or tenderness to palpation MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: No rashes or ulcerations noted NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs, sensation to light touch grossly intact throughout PSYCH: pleasant, appropriate affect Pertinent Results: ADMISSION LABS: ================ ___ 11:14AM BLOOD WBC-25.6* RBC-4.19* Hgb-12.8* Hct-37.9* MCV-91 MCH-30.5 MCHC-33.8 RDW-14.5 RDWSD-47.8* Plt ___ ___ 11:14AM BLOOD Neuts-84.1* Lymphs-6.6* Monos-7.2 Eos-0.1* Baso-0.2 Im ___ AbsNeut-21.50* AbsLymp-1.68 AbsMono-1.84* AbsEos-0.02* AbsBaso-0.05 ___ 11:14AM BLOOD ___ PTT-29.2 ___ ___ 11:14AM BLOOD Glucose-176* UreaN-34* Creat-2.0* Na-133* K-4.8 Cl-91* HCO3-24 AnGap-18 ___ 11:14AM BLOOD ALT-106* AST-141* AlkPhos-403* TotBili-1.3 ___ 11:14AM BLOOD Lipase-7 ___ 11:14AM BLOOD cTropnT-<0.01 ___ 11:14AM BLOOD Albumin-3.3* Calcium-9.1 Phos-3.4 Mg-1.5* ___ 06:03PM BLOOD ___ pO2-32* pCO2-61* pH-7.18* calTCO2-24 Base XS--7 ___ 02:20PM BLOOD Lactate-3.7* ___ 06:03PM BLOOD Lactate-6.4* ___ 06:24AM BLOOD WBC-13.2* RBC-4.06* Hgb-11.9* Hct-35.7* MCV-88 MCH-29.3 MCHC-33.3 RDW-14.7 RDWSD-47.9* Plt ___ ___ 07:40AM BLOOD WBC-15.7* RBC-3.91* Hgb-11.5* Hct-34.2* MCV-88 MCH-29.4 MCHC-33.6 RDW-14.7 RDWSD-47.3* Plt ___ ___ 04:31AM BLOOD WBC-16.2* RBC-3.42* Hgb-10.3* Hct-30.4* MCV-89 MCH-30.1 MCHC-33.9 RDW-14.9 RDWSD-47.8* Plt ___ ___ 02:04AM BLOOD WBC-29.2* RBC-3.90* Hgb-11.8* Hct-35.9* MCV-92 MCH-30.3 MCHC-32.9 RDW-14.9 RDWSD-50.1* Plt ___ ___ 04:31AM BLOOD ___ PTT-27.8 ___ ___ 02:04AM BLOOD ___ PTT-28.1 ___ ___ 11:14AM BLOOD ___ PTT-29.2 ___ ___ 07:40AM BLOOD Glucose-93 UreaN-25* Creat-1.0 Na-144 K-3.4* Cl-106 HCO3-27 AnGap-11 ___ 02:04AM BLOOD Glucose-142* UreaN-33* Creat-1.6* Na-135 K-4.4 Cl-101 HCO3-14* AnGap-20* ___ 11:14AM BLOOD Glucose-176* UreaN-34* Creat-2.0* Na-133* K-4.8 Cl-91* HCO3-24 AnGap-18 ___ 04:31AM BLOOD ALT-87* AST-158* LD(LDH)-565* AlkPhos-304* TotBili-0.8 ___ 02:04AM BLOOD ALT-99* AST-176* AlkPhos-327* TotBili-1.4 ___ 11:14AM BLOOD ALT-106* AST-141* AlkPhos-403* TotBili-1.3 ___ 02:04AM BLOOD Lipase-6 ___ 11:14AM BLOOD Lipase-7 ___ 11:14AM BLOOD cTropnT-<0.01 ___ 06:24AM BLOOD Calcium-8.4 Phos-3.3 Mg-1.5* ___ 2:15 pm BLOOD CULTURE *FINAL REPORT ___ Blood Culture, Routine (Final ___: ESCHERICHIA COLI. FINAL SENSITIVITIES. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI \| AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Anaerobic Bottle Gram Stain (Final ___: Reported to and read back by ___ @ 0201 ON ___ - ___. GRAM NEGATIVE ROD(S). Aerobic Bottle Gram Stain (Final ___: GRAM NEGATIVE ROD(S). ERCP ___: no new stents placed. CXR: ___: IMPRESSION: Left-sided central venous catheter projects over the proximal SVC. No acute intrathoracic findings. CT chest: IMPRESSION: 1. No focal consolidation. 2. Multiple sub 4 mm pulmonary nodules are unchanged and likely secondary to a benign process. No new or suspicious pulmonary nodules are identified. 3. Interval progression of chronic bronchitis since ___. CT abd/pelvis IMPRESSION: 1. No evidence of bowel ischemia, bowel obstruction or pneumoperitoneum. No drainable intra-abdominal fluid collections. 2. Significant interval increase in metastatic disease burden throughout the abdomen and pelvis. For example, there has been significant interval increase in size and number of multiple hepatic metastases. Additionally, there is been significant interval increase in size and number of multiple peritoneal implants. The largest measures up to 7.6 cm, previously 2.9 cm inferior to the gallbladder fossa. RuQ u/s: IMPRESSION: 1. The gallbladder remains distended and contains layering sludge and gallstones. Although there is no gallbladder wall edema or specific imaging features for acute cholecystitis, this cannot be excluded on the basis of this examination. 2. Persist mild intrahepatic biliary ductal dilatation as well as dilatation of the common hepatic duct with common bile duct stent in place. 3. Redemonstration of a fundal gallbladder mass invading the adjacent liver parenchyma, although this is better demonstrated on the prior CT. Brief Hospital Course: Mr ___ is an ___ year-old male with metastatic gallbladder adenocarcinoma status post bare-metal stent on ___, on home hospice who presented with fever, nausea, vomiting, abdominal pain, c/f cholangitis s/p ERCP. PLAN ======== # GNR bacteremia/Ecoli # cholangitis # Septic Shock: Presented with fever and hypotension requiring pressors c/f septic shock, started on broad spectrum abx. ERCP w/ clearing of sludge, kept stent in place. Pt improved rapidly after procedure and weaned off pressors. Abx narrowed to IV CTX per pan-sensitive GNR bacteremia, and then to PO ciprofloxacin. LFTs downtrended. Plan for 14 day course of ciprofloxacin. # GOC: Pt on home hospice at time of presentation. After acute infection stabilized, had GOC conversation with patient, HCP, and other family members. Pt expressed that he would like to remain home if possible and would like to avoid any further invasive procedures, including ERCP, central lines. Confirmed DNR/DNI. If however, he has a repeat infection that can be stabilized with noninvasive measures like PO antibiotics, especially at home, he would like those interventions, will need to confirm full capabilities of hospice team. ___ convo documented in OMR. #HTN-pt appears to be on HCTz and metoprolol at home. Unclear if fully taking meds prior to admission. BP 130's-150's off these medications. ___ at home to assist with ongoing assessment of need for meds Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN 2. Hydrochlorothiazide 25 mg PO DAILY 3. Docusate Sodium 100 mg PO BID:PRN constipation 4. Senna 8.6 mg PO BID:PRN Constipation - First Line 5. Metoprolol Succinate XL 25 mg PO DAILY 6. Ondansetron 8 mg PO Q8H:PRN Nausea Discharge Medications: 1. Ciprofloxacin HCl 500 mg PO Q12H RX ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day Disp #22 Tablet Refills:0 2. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN 3. Docusate Sodium 100 mg PO BID:PRN constipation 4. Hydrochlorothiazide 25 mg PO DAILY continue to assess if this medication is needed ongoing 5. Metoprolol Succinate XL 25 mg PO DAILY continue to assess to see if this medication is ongoing 6. Ondansetron 8 mg PO Q8H:PRN Nausea 7. Senna 8.6 mg PO BID:PRN Constipation - First Line Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: cholangitis biliary obstruction metastatic gallbladder cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted for evaluation of infection in your bile ducts and blood. For this, you were initially in the ICU but improved. You were started on antibiotic therapy which you will need to continue for a total of 2 week's time. You will return home with hospice care to help manage your symptoms. Followup Instructions: ___
19577101-DS-7	19,577,101	25,724,914	DS	7	2182-02-24 00:00:00	2182-02-24 17:09:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Major Surgical or Invasive Procedure: None attach Pertinent Results: ADMISSION LABS ___ 11:00AM BLOOD WBC-4.4 RBC-4.52 Hgb-12.8 Hct-41.0 MCV-91 MCH-28.3 MCHC-31.2* RDW-13.1 RDWSD-42.9 Plt ___ ___ 07:23AM BLOOD Glucose-85 UreaN-12 Creat-1.0 Na-145 K-4.7 Cl-107 HCO3-26 AnGap-12 ___ 07:23AM BLOOD Calcium-9.6 Phos-4.0 Mg-2.0 IMAGING: Final Report EXAMINATION: MR HEAD W/O CONTRAST ___ MR HEAD INDICATION: ___ with history of hypothyroidism and vertigo who presented to the ED with dizziness, most likely due to known vestibular neuronitis induced by a viral syndrome. // ?ischemic stroke TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was performed with gradient echo, FLAIR, diffusion, and T2 technique were then obtained. COMPARISON CTA dated ___ FINDINGS: The exam is slightly degraded by motion artifact. Within these confines: There is no evidence of hemorrhage, edema, masses, mass effect, midline shift or infarction. The ventricles and sulci are normal in caliber and configuration. There is a nonspecific focus of T2/FLAIR hyperintensity in the left external capsule without associated diffusion restriction, likely sequelae chronic ischemic disease. The visualized vascular flow voids are grossly preserved. There is mild thickening of the ethmoid air cells and bilateral maxillary sinuses. The mastoid air cells are clear. The globes and orbits are unremarkable. There is no abnormal marrow signal. IMPRESSION: 1. Unremarkable noncontrast brain MRI. No evidence of an acute infarct, intracranial mass, or hemorrhage. Brief Hospital Course: TRANSLATIONAL ISSUES: ====================== [ ] please titrate and discontinue Meclizine as appropriate. was DCd with short course [ ] please consider sleep study, patient concerned about OSA [ ] consider MRI with gad to look for infection, schwannoma, or other nerve damage if symptoms persist. Patient had MRI non-con while hospitalized that was unrevealing. [ ] Please ensure pt completes vestibular ___, patient was given a Rx on DC [ ] Pt was DC'd with Rx for walker # Code status: Full, presumed # Health care proxy/emergency contact: ___ Phone number: ___ ASSESSMENT & PLAN: ===================== ___ yo woman with history of hypothyroidism and with a history of multiple episodes of prior vertigo, believed to be a vestibular neuronitis induced by a viral syndrome, who presented with similar complaints of episodic subacute vertigo. Central causes were ruled out, and this was most likely contributed to known vestibular neuronitis induced by a viral syndrome. ACUTE/ACTIVE PROBLEMS: ====================== # Vestibular Neuronitis/peripheral vestibulopathy Orthostatic vitals were negative. Neurologic exam unremarkable. Notable for absence of nystagmus, skew deviation, dysmetria, ataxia. Notably, symptoms not reproduced by ___ in ED, but did recur when went from supine to sitting after maneuver. Positive head impulse test with ___ consistent with peripheral cause of vertigo. CT head and CTA head/neck are unremarkable for any acute process. MRI of the head without contrast without evidence of acute infarct, intracranial mass, or hemorrhage. Neurology was consulted and agreed with symptomatic control. Discharged on Meclizine and Zofran. Will also receive vestibular physical therapy, was DC'd with Rx. If symptoms not continuing to improve, could consider MRI with contrast of head to look for schwannoma, nerve damage or infection. CHRONIC/STABLE PROBLEMS: ======================== # Hypothyroidism: Continued home levothyroxine 112 mcg # Iron Deficiency Anemia: Resolved in ___. Hgb currently at baseline [x]>30 minutes spent on discharge planning and care coordination on day of discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Levothyroxine Sodium 112 mcg PO DAILY 2. capsaicin 0.1 % topical DAILY:PRN Discharge Medications: 1. Meclizine 25 mg PO TID 2. Ondansetron 4 mg PO Q8H 3. capsaicin 0.1 % topical DAILY:PRN 4. Levothyroxine Sodium 112 mcg PO DAILY 5.Outpatient Physical Therapy ICD-9 code: ___ Patient will need vestibular physical therapy. PCP: Name: ___., Phone: ___ 6.___ ICD 9 Code: ___ PCP: ___, ___ Prognosis: Good Length: 12 months Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSES Vestibular Neuronitis/peripheral vestibulopathy Vertigo SECONDARY DIAGNOSES Hypothyroidism Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. ___, It was a pleasure taking care of you at the ___ ___! WHY WAS I IN THE HOSPITAL? ========================== - You were admitted because you were very dizzy. WHAT HAPPENED IN THE HOSPITAL? ============================== - You had imaging of your brain to rule out a stroke - You were started on mediation to help with your dizziness WHAT SHOULD I DO WHEN I GO HOME? ================================ - Be sure to take all your medications and attend all of your appointments listed below. We wish you the best! Sincerely, Your ___ Team Followup Instructions: ___
19577145-DS-11	19,577,145	24,290,575	DS	11	2175-03-30 00:00:00	2175-03-30 11:38:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ___ Allergies: Sulfa drugs / Penicillins / Levaquin Attending: ___ Chief Complaint: RLE cellulitis Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ man with ___ notable for HFrEF (EF 35%), CAD s/p CABG, afib not on AC for GIB, PPM for primary prevention, PVD c/b venous stasis ulcers, CKD, and severe neuropathy, who presents for further evaluation of RLE wound with associated erythema that progessively worsened after a fall at home. Over the past 1 week, the patient has developed a blister on his the anterior right tibia. Approximately ___ days prior to presentation, pt notes that the blister opened and since that time has been with increased right lower leg redness and swelling. This worsened particularly after he lost his balance at home and fell onto his right leg. Given his worsening symptoms, he initially presented to ___ for further evaluation where he was noted to be afebrile and hemodynamically stable. Cbc/chemistries notable for normal wbc ct, creat 1.5, lactate 2.5. US negative for DVT. He was given 1L NS bolus and vancomycin 1250mg IV x1. Plan was inpatient admission but due to lack of beds at ___, he was transferred to ___ for further evaluation (although he receives most of his care at ___). Upon arrival to the floor, patient affirms the above history. He states that he's been having issues with ___ "blister-like" wounds for some time and recently saw a Vascular Surgeon at ___ that recommended compression stockings, which he has not been able to obtain. He denies any associated fevers or rigors. In regards to his CHF, he states that he has faithfully taken his home torsemide 60mg daily. He denies any associated SOB, DOE, orthopnea, or chest discomfort. Furthermore, he denies any recent weight gain and in fact has lost about 20 lbs over the past several months, which he attributes to intentional dieting. In regards to his falls, the patient states that he has experienced multiple episodes of falls in the past. He is mostly wheelchair bound due to his severe neuropathy, but uses a walker to ambulate to the restroom. He denied any assocaited pre-syncopal symptoms or LOC associated with the fall, but instead states that he simply lost his balance. ROS: Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative. Past Medical History: - CAD s/p MI (CABG ___ - systolic CHF (EF 35%), s/p PPM - documented pAF, not on AC due to hx of GIB (patient denies) - PVD (seen by Vascular Surgery at ___) - HTN - Diabetes Mellitus (diet controlled) - Chronic anemia: - Graves disease s/p treatment; now iatrogenic hypothyroid - BPH, s/p TURP - Peripheral neuropathy - Anxiety/Depression - Mild dementia - recurrent UTIs with associated delirium - G6PD deficiency - OA Social History: ___ Family History: Reviewed and found to be not relevant to this illness/reason for hospitalization. Physical Exam: admit weight: 89.3 kg; 196.9 lb discharge weight: 89.72kg, 197.8 lb GENERAL: pleasant older gentleman NAD. EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate CV: Heart regular, no murmur, no S3, no S4. No JVD. RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, non-distended, non-tender to palpation. Bowel sounds present. No HSM GU: No suprapubic fullness or tenderness to palpation. Scrotum with superficial redness and wet. MSK: well perfused, RLE wound tightly wrapped. SKIN: chronic venous stasis changes noted bilaterally, scattered venous stasis ulcers on both shins. Pertinent Results: ___ 05:53AM BLOOD WBC-7.7 RBC-3.63* Hgb-10.4* Hct-33.4* MCV-92 MCH-28.7 MCHC-31.1* RDW-14.7 RDWSD-49.5* Plt ___ ___ 05:53AM BLOOD Glucose-131* UreaN-35* Creat-1.4* Na-141 K-4.1 Cl-99 HCO3-30 AnGap-12 ___ 2:00 am BLOOD CULTURE *FINAL REPORT ___ Blood Culture, Routine (Final ___: STAPH AUREUS COAG +. Consultations with ID are recommended for all blood cultures positive for Staphylococcus aureus, yeast or other fungi. FINAL SENSITIVITIES. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + \| CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 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. All blood cultures from ___ on are negative TEE CONCLUSION: There is no spontaneous echo contrast or thrombus in the body of the left atrium/left atrial appendage. The left atrial appendage ejection velocity is normal. No spontaneous echo contrast or thrombus is seen in the body of the right atrium/right atrial appendage. The right atrial appendage ejection velocity is normal. There is no evidence for an atrial septal defect by 2D/color Doppler. There is a pacer lead in the RA/RV without any masses attached. Overall left ventricular systolic function is depressed. There are no aortic arch atheroma with complex (>4mm, non-mobile) atheroma in the descending aorta. The aortic valve leaflets (3) appear structurally normal. There are multiple small mobile echodensities (0.3cm, 0.4cm, best seen Clip 26) on the aortic valve (one on LV side and one on aortic side) most c/w Lambl's excrecences (normal variant) or fibrin strands, but given the clinical circumstance, small vegetations cannot be definitively excluded. No abscess is seen. There is no aortic regurgitation. The mitral valve leaflets appear structurally normal with no mitral valve prolapse. No masses or vegetations are seen on the mitral valve. No abscess is seen. There is physiologic mitral regurgitation. The tricuspid valve leaflets appear structurally normal. No mass/vegetation are seen on the tricuspid valve. No abscess is seen. There is physiologic tricuspid regurgitation. Due to acoustic shadowing, the severity of tricuspid regurgitation may be UNDERestimated. There is no pericardial effusion. IMPRESSION: Suboptimal image quality due to patient rotation. There are multiple small linear mobile echodensities (0.3cm x 0.1 cm and 0.4cm x 0.1 cm, best seen Clip 26) on the aortic valve (one on LV side and one on aortic side) most c/w Lambl's excrecences (normal variant) or fibrin strands, but given the clinical circumstance, small vegetations cannot be definitively excluded. No definite other evidence of endocarditis is identified. Depressed left ventricular systolic function. CXR: EXAMINATION: CHEST PORT. LINE PLACEMENT INDICATION: ___ year old man with new line// new right PICC 41 ___ ___ Contact name: ___: ___ TECHNIQUE: AP portable chest radiograph COMPARISON: None FINDINGS: The tip of a right PICC line projects over the mid SVC. A left chest wall dual lead ICD is present. There is pulmonary vascular congestion. The size of the cardiac silhouette is enlarged. No pleural effusion or pneumothorax. Sternotomy wires are present. IMPRESSION: The tip of a right PICC line projects over the mid SVC. No pneumothorax. ___, MD electronically signed on ___ 6:32 ___ Brief Hospital Course: Mr. ___ is a ___ man with ___ notable for HFrEF (EF 35%), CAD s/p CABG, PVD c/b venous stasis ulcers, CKD, and severe neuropathy, a/w RLE cellulitis in the setting of a fall and found to have MSSA baceteremia. Afebrile and HDS on IV vancomycin-->cefazolin, cannot r/o endocarditis ACUTE/ACTIVE PROBLEMS: # RLE traumatic wound with associated cellulitis: # PVD with multiple venous stasis wounds: # Staph aureus bacteremia Patient with known venous stasis blisters and ulcerative lesions. Now presenting with superinfected ulcerative lesion on anterior RLE that worsened following trauma. Per patient, he was recently seen by Vascular Surgeon at ___ just a few weeks ago who recommended compression stockings, which he has not yet obtained. TTE is negative for vegetations. ID consulted, thinks it is better to get TEE as he has PPM. Now that TEE is with some questionable lesions on aortic valve, we are going to need IV abx for 4 weeks - cont cefazolin 2g TID. cx shows MSSA, total of 4 weeks - PICC ordered, will need home infusion pump as wife cannot do TID infusions - Wound care nursing consulted, apprec recs - He saw vascular, no surgical intervention needed - ACE wraps over dressings - Follow-up pending blood cultures - ID following, appreciate recommendations #Groin itching likely fungal, improved -miconazole powder # Acute on Chronic Renal Insufficiency, stable, cr ___ - cont torsemide - strict Is/Os - daily weights - BMP daily # Mechanical Fall: Per patient and history documented in ___ Geriatrics visit, patient with severe neuropathy and gait imbalance resulting in frequent falls, which is likely etiology of recent episode. No concern for syncope. - ___ cleared pt to go home CHRONIC/STABLE PROBLEMS: # systolic CHF (EF 35%) Suspect secondary to CAD/prior MI. Currently appears euvolemic. - cont torsemide - daily weights - strict Is/Os - continue carvedilol # CAD s/p MI, CABG ___ - continue home Imdur - continue home carvedilol - continue home atorvastatin - continue home ASA 81 # pAF: Per patient, only occurred once. Chart indicates he is not on AC due to history of GIB. # HTN: - continue home carvedilol - continue home hydralazine # Chronic anemia: Known history of G6PD deficiency. Unclear baseline. No concern for active bleeding or hemolysis at this time. - continue home iron - avoid sulfa drugs # Graves disease # iatrogenic hypothyroidism - continue home levothyroxin # Peripheral neuropathy: # Anxiety/Depression: - continue buproprion - continue valproex - continue lyrica GENERAL/SUPPORTIVE CARE: # Nutrition/Hydration: heart healthy diet, replete electrolytes PRN # VTE prophylaxis: ___ # Consulting Services: wound nursing, ___ # Contacts/HCP: wife ___ ___, updated today # Code Status/Advance Care Planning: full with limited trial, confirmed with patient. # Disposition: - Anticipate discharge to: Home with services - Anticipated discharge date: likely 1d - Discharge barriers: Home infusion ___ setup ___, MD ___ of Hospital ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Levothyroxine Sodium 50 mcg PO DAILY 2. CARVedilol 12.5 mg PO BID 3. Atorvastatin 20 mg PO QPM 4. BuPROPion 100 mg PO BID 5. Pregabalin 100 mg PO TID 6. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 7. HydrALAZINE 10 mg PO TID 8. Aspirin 81 mg PO DAILY 9. Klor-Con M20 (potassium chloride) 20 mEq oral Q24H 10. Torsemide 60 mg PO DAILY 11. Magnesium Oxide 400 mg PO Frequency is Unknown 12. Multivitamins 1 TAB PO DAILY 13. Ferrous Sulfate 325 mg PO DAILY 14. Divalproex (EXTended Release) 250 mg PO DAILY Discharge Medications: 1. CeFAZolin 2 g IV Q8H RX cefazolin in dextrose (iso-os) 2 gram/100 mL 2 g IV every eight (8) hours Disp #63 Intravenous Bag Refills:0 2. Miconazole Powder 2% 1 Appl TP TID RX miconazole nitrate [Anti-Fungal] 2 % Apply to groin rash as needed three times a day Disp #1 Bottle Refills:*0 3. Magnesium Oxide 400 mg PO BID dyspepsia 4. Aspirin 81 mg PO DAILY 5. Atorvastatin 20 mg PO QPM 6. BuPROPion 100 mg PO BID 7. CARVedilol 12.5 mg PO BID 8. Divalproex (EXTended Release) 250 mg PO DAILY 9. Ferrous Sulfate 325 mg PO DAILY 10. HydrALAZINE 10 mg PO TID 11. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 12. Klor-Con M20 (potassium chloride) 20 mEq oral Q24H 13. Levothyroxine Sodium 50 mcg PO DAILY 14. Multivitamins 1 TAB PO DAILY 15. Pregabalin 100 mg PO DAILY 16. Pregabalin 200 mg PO QHS 17. Torsemide 60 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: RLE cellulitis MSSA bacteremia possible endocarditis Discharge Condition: good, ambulatory with minimal assist. Discharge Instructions: Dear Mr ___, You were admitted to the hospital for R leg cellulitis and bacteremia. To evaluate your heart for possible infection, we performed two echocardiograms, and the results could not completely exclude endocarditis. Therefore, we are going to send you home with 4 weeks of IV antibiotics. Please follow with your PCP, ___, and infectious disease doctor ___ your ___ referral). Your infectious disease appointment should be schedule within 1 week. We will arrange visiting nurse to help you with your antibiotic infusion, your wound care, and PICC line care. It was a pleasure to care for you in ___. Followup Instructions: ___
19577428-DS-19	19,577,428	21,955,621	DS	19	2155-12-17 00:00:00	2155-12-18 17:15:00	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 flank pain Major Surgical or Invasive Procedure: CYSTOSCOPY, URETEROSCOPY, LEFT URETERAL STENT PLACEMENT, FOLEY PLACEMENT History of Present Illness: HISTORY OF PRESENT ILLNESS: Mr. ___ is a ___ male with a history of nephrolithiasis who presents with left flank pain, nausea/vomiting, and a known 5mm left ureteral stone. He reports that he had one prior kidney stone about ___ years ago, which was treated with ureteroscopy and laser lithotripsy. He believes it was also on the left side. He states that about 3 days ago, he had acute onset of left flank pain, which was similar to renal colic he had in the past. He went to urgent care and a CT scan showed a 5 mm calculus within the left upper ureter without significant hydroureteronephrosis. He saw Dr. ___ in clinic yesterday and was given vicodin and started on medical expulsive therapy. He continued to experience left renal colic and reports that today it got worse. He had associated nausea and vomiting. He returned to clinic to see Dr. ___ instructed him to present to ___ for admission. He denies fevers, dysuria, hematuria, frequency, urgency. After receiving pain medication in the ED, he currently feels comfortable. Prior treatments for kidney stones include: [x] Ureteroscopy [] SWL [] PCNL [] 24 hr urine testing [] Medical/dietary management ________________________________________________________________ PAST MEDICAL HISTORY: Problems (Last Verified - None on file): Nephrolithiasis PAST SURGICAL HISTORY: Surgical History (Last Verified - None on file): Ureteroscopy, laser lithotripsy ___ years ago B/l knee surgery Hand surgery ________________________________________________________________ MEDICATIONS: --------------- --------------- --------------- --------------- No active medications as of ___ --------------- --------------- --------------- --------------- ________________________________________________________________ ALLERGIES: -- Allergies (Last Verified ___ by ___: Patient recorded as having no known allergies to drugs _____________________________________________________________ SOCIAL HISTORY: ___ FAMILY HISTORY: [] Nephrolithiasis [] Malignant Hyperthermia [] Renal Cell CA [] Testisa CA [] Prostate CA [] Bladder CA ________________________________________________________________ REVIEW OF SYSTEMS: GENERAL: [x] All Normal [ ] Fever [ ] Chills [ ] Sweats [ ] Fatigue [ ] Malaise [ ] _____ lbs. weight loss/gain over _____ months HEENT: [x] All Normal [ ] Blurred vision [ ] Blindness [ ] Photophobia [ ] Decreased acuity [ ] Dry mouth [ ] Bleeding gums [ ] Oral ulcers [ ] Sore throat [ ] Epistaxis [ ] Tinnitus [ ] Decreased hearing [ ] Other: RESPIRATORY: [x] All Normal [ ] SOB [ ] DOE [ ] Can't walk 2 flights [ ] Cough [ ] Wheeze [ ] Purulent sputum [ ] Hemoptysis [ ] Pain [ ] Other: CARDIAC: [x] All Normal [ ] Angina [ ] Palpitations [ ] Edema [ ] PND [ ] Orthopnea [ ] Other: GI: [x] All Normal [ ] Blood in stool [ ] Hematemesis [ ] Odynophagia [ ] Dysphagia: [ ] Solids [ ] Liquids [ ] Anorexia [ ] Nausea [ ] Vomiting [ ] Reflux [ ] Diarrhea [ ] Constipation [ ] Abd pain [ ] Other: GU: [x] All Normal [ ] Dysuria [ ] Frequency [ ] Hematuria SKIN: [x] All Normal [ ] Rash [ ] Pruritus MS: [x] All Normal [ ] Joint pain [ ] Jt swelling [ ] Back pain [ ] Bony pain NEURO: [x] All Normal [ ] Headache [ ] Visual changes [ ] Sensory change [ ] Seizures [ ] Weakness ENDOCRINE: [x] All Normal [ ] Skin changes [ ] Hair changes [ ] Temp subjectivity HEME/LYMPH: [x] All Normal [ ] Easy bruising [ ] Easy bleeding [ ] Adenopathy PSYCH: [x] All Normal [ ] Mood change [ ] Other: OTHER: ________________________________________________________________ PHYSICAL EXAM: Pain: 2 T: 98.5 HR: 80 BP: 157/81 RR: 18 O2Sat: 95% ra GENERAL: NAD, comfortable, pleasant HEENT: PERRLA, EOMI Neck: No lymphadenopathy RESPIRATORY: CTA B CARDIOVASCULAR: RRR, no MRG GI: S, ND, mild left-sided tenderness to deep palpation Back: mild left CVAT, no R CVAT GU: deferred NEURO: AO X 3, MA4 ext normally, no focal deficits MS: Normal tone, no cyanosis SKIN: No obvious rashes or lesions PSYCHIATRIC: Nl affect, insight, mood ________________________________________________________________ Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct ___ 17:49 12.7* 4.52* 14.5 41.3 91 32.1* 35.1* 13.3 232 DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas ___ 17:49 80.4* 11.0* 7.8 0.7 0.1 BASIC COAGULATION ___, PTT, PLT, INR) Plt Ct ___ 17:49 232 GENERAL URINE INFORMATION Color: straw Appear: clear Sp ___: 1.012 Blood: neg Nitrite: neg Protein: neg Glucose: neg Ketone: neg Bilirub:neg Urobiln: neg pH: 5.5 Leuks: neg Urine cx = pending Cr = pending Imaging: OSH CT abd/pelvis: 5 mm calculus within the left upper ureter without significant hydroureteronephrosis ________________________________________________________________ IMPRESSION/PLAN: ___ with a h/o nephrolithiasis who now presents with left flank pain, nausea/vomiting, and CT scan showing a 5mm proximal left ureteral stone. The patient is currently afebrile and hemodynamically stable. Physical exam is remarkable for mild left-sided abdominal and CVA tenderness. He has a leukocytosis of 12.7, but UA shows no evidence of infection. He will be admitted to urology for left ureteral stent placement given that he has failed medical expulsive therapy and his pain/nausea have been refractory to outpatient medical management. Plan: -Admit to Urology N: tylenol, toradol, oxycodone, dilaudid CV: no issues P: no issues GI: House. NPO after midnight GU: IVF@125. Flomax H: pboots ID: no issues. f/u urine culture E: no issues Added on to OR tomorrow for cystoscopy, left ureteral stent placement Assessment and plan discussed with chief resident, ___, and attending, Dr. ___. ___, MD ___ PGY2 ___ Addendum by ___, MD on ___ at 7:05 pm: Cr is 1.5 so will hold off on toradol. Past Medical History: Nephrolithiasis Ureteroscopy, laser lithotripsy ___ years ago B/l knee surgery Hand surgery Social History: ___ Family History: Non-contributory Physical Exam: NAD WWP No respirtory distress No CVAT bilaterally Abd S, NT, ND Foley catheter in place draining clear yellow urine Pertinent Results: ___ 05:49PM BLOOD WBC-12.7* RBC-4.52* Hgb-14.5 Hct-41.3 MCV-91 MCH-32.1* MCHC-35.1* RDW-13.3 Plt ___ ___ 05:49PM BLOOD Neuts-80.4* Lymphs-11.0* Monos-7.8 Eos-0.7 Baso-0.1 ___ 07:35AM BLOOD Glucose-98 UreaN-12 Creat-1.1 Na-143 K-3.9 Cl-108 HCO___ AnGap-12 Brief Hospital Course: Mr. ___ was admitted to Dr. ___ for nephrolithiasis management with a known left ureteral stone. He underwent cystoscopy and left ureteral stent placement. The patient tolerated the procedure well and recovered in the PACU before transfer to the general surgical floor. See the dictated operative note for full details. Overnight, the patient was hydrated with intravenous fluids and received appropriate perioperative prophylactic antibiotics. Flomax was given for stent discomfort and a 5 day course of Bactrim was started. The patient had a foley catheter after the procedure and was instructed to remove it himself the next day after discharge. At discharge on POD1, patients pain was controlled with oral pain medications, tolerating regular diet, ambulating without assistance. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. This patient is not taking any preadmission medications Discharge Medications: 1. Docusate Sodium 100 mg PO BID RX docusate sodium [Colace] 100 mg ONE capsule(s) by mouth twice a day Disp #60 Capsule Refills:0 2. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain RX oxycodone 5 mg ONE tablet(s) by mouth Q4hrs Disp #40 Tablet Refills:0 3. Tamsulosin 0.4 mg PO DAILY 4. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 5 Days RX sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg ONE tablet(s) by mouth twice a day Disp #10 Tablet Refills:0 5. Bacitracin Ointment 1 Appl TP QID:PRN IRRITATION FROM CATHETER Discharge Disposition: Home Discharge Diagnosis: NEPHROLITHIASIS Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: -You can expect to see occasional blood in your urine and to possibly experience some urgency and frequency over the next month; this may be related to the passage of stone fragments or the indwelling ureteral stent. -The kidney stone may or may not have been removed AND/or there may fragments/others still in the process of passing. -You may experience some pain associated with spasm of your ureter.; This is normal. Take the narcotic pain medication as prescribed if additional pain relief is needed. -Ureteral stents MUST be removed or exchanged and therefore it is IMPERATIVE that you follow-up as directed. -Do not lift anything heavier than a phone book (10 pounds) -You may continue to periodically see small amounts of blood in your urine--this is normal and will gradually improve -Resume your pre-admission/home medications EXCEPT as noted. You should ALWAYS call to inform, review and discuss any medication changes and your post-operative course with your primary care doctor. HOLD ASPIRIN and aspirin containing products for one week unless otherwise advised. -IBUPROFEN (the ingredient of Advil, Motrin, etc.) may be taken even though you may also be taking Tylenol/Acetaminophen. You may alternate these medications for pain control. For pain control, try TYLENOL FIRST, then ibuprofen, and then take the narcotic pain medication as prescribed if additional pain relief is needed. -Ibuprofen should always be taken with food. Please discontinue taking and notify your doctor should you develop blood in your stool (dark, tarry stools) -You MAY be discharged home with a medication called PYRIDIUM that will help with the "burning" pain you may experience when voiding. This medication may turn your urine bright orange. -Colace has been prescribed to avoid post surgical constipation and constipation related to narcotic pain medication. Discontinue if loose stool or diarrhea develops. Colace is a stool softener, NOT a laxative, and available over the counter. The generic name is DOCUSATE SODIUM. It is recommended that you use this medication. -Do not eat constipating foods for ___ weeks, drink plenty of fluids to keep hydrated -No vigorous physical activity or sports for 4 weeks and while Foley catheter is in place. IF YOU ARE DISCHARGED HOME WITH A FOLEY CATHETER: -Please refer to the provided nursing instructions and handout on Foley catheter care, waste elimination and leg bag usage. -Your Foley should be secured to the catheter secure on your thigh at ALL times. *You can remove your own foley ___ evening or ___ morning, by using a 10cc syringe or cutting the balloon port of the foley, which will automatically deflate the balloon and allow you to remove the catheter. -Wear Large Foley bag for majority of time, leg bag is only for short-term when leaving house. Please take Bactrim for 5 days. Followup Instructions: ___
19577479-DS-7	19,577,479	24,041,663	DS	7	2146-01-14 00:00:00	2146-01-14 16:57:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Headache Major Surgical or Invasive Procedure: none History of Present Illness: ___ was found down at the bottom of the ___ station at the base of stairs. The patient states that he drank alcohol, but he does not remember how much. He was repetative during the interview process and smelled of alcohol. He was not able to verbalize any other pain related to his fall. The day after his admission, the patient felt that while he was drinking, he did not think he had enough to cause a fall down the stairs. He stated that he has radiculopathy from an injury during his time in the ___. Frequently, he said he has a foot drop which he thinks contributed to his fall. Social History: ___ Family History: Non-contributory Physical Exam: On admission: AVSS awake, alert, oriented x3 follows commands throughout PERRL, EOMI, FSTM No drift MAE ___ sensation intact to light touch throughout Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. On discharge ***** Pertinent Results: ___ 04:35AM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 04:35AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG ___ 02:50AM GLUCOSE-117* UREA N-7 CREAT-1.0 SODIUM-141 POTASSIUM-3.7 CHLORIDE-103 TOTAL CO2-21* ANION GAP-21* ___ 02:50AM estGFR-Using this ___ 02:50AM CALCIUM-9.3 PHOSPHATE-5.0* MAGNESIUM-2.1 ___ 02:50AM ___-10.4 RBC-5.17 HGB-15.8 HCT-43.8 MCV-85 MCH-30.5 MCHC-36.1* RDW-13.1 ___ 02:50AM NEUTS-63.7 ___ MONOS-5.2 EOS-0.8 BASOS-1.2 ___ 02:50AM PLT COUNT-440 ___ 02:50AM ___ PTT-29.5 ___ ___ ___ 1. Two small foci of intraparenchymal hemorrhage in the superior left parietal lobe; one measures 4 mm (2, 26), and one measures 2 mm (2, 28). There is no significant mass effect. Minimal hyperdensity along the adjacent sulci is equivocal and may be a tiny amount of subarachnoid hemorrhage or just prominence of the cortex. No extra-axial collection. 2. Scalp hematoma and laceration. 3. No fracture. ___ CXR IMPRESSION: No acute cardiopulmonary process. If there is continued clinical concern for an injury to the chest, recommend further evaluation with conventional PA and lateral chest radiographs. ___ repeat NCHCT: (prelim read) 3 mm superior left parietal lobe hyperdensity is now less apparent, which would be typical for the evolution of a small hemorrhage. Brief Hospital Course: The patient was admitted for observation after a traumatic fall resulting in a subarchnoid hemorrage on early in the morning on ___. He was started on Dilantin for seizure prevention and placed on a CIWA scale because of his history of alcohol abuse and current use of alcohol. On ___, he was complaining of headaches which were not being managed well with percocet so he was started on Fioricet. At the time of discharge in the afternoon on ___, the patient was doing well, afebrile with stable vital signs, tolerating a regular diet, ambulating, stable neuro exam and pain was well controlled. Repeat head CT scan was stable. The patient was discharged home on Dilantin for 10 days. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge and the patient expressed readiness for discharge. Medications on Admission: BUPROPION HCL [WELLBUTRIN] - Dosage uncertain - (Prescribed by Other Provider) Discharge Medications: 1. Acetaminophen-Caff-Butalbital ___ TAB PO Q4H:PRN headache RX butalbital-acetaminophen-caff 50 mg-325 mg-40 mg 1 tablet(s) by mouth Q4H:PRN Disp #30 Tablet Refills:0 2. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN pain RX oxycodone 5 mg ___ tablet(s) by mouth Q6H:PRN Disp #30 Tablet Refills:0 3. Phenytoin Sodium Extended 100 mg PO TID PLEASE CONTINUE FOR 10 DAYS ___ RX phenytoin sodium extended 100 mg 1 capsule(s) by mouth three times a day Disp #30 Capsule Refills:*0 Discharge Disposition: Home Discharge Diagnosis: subarachnoid hemorrhage Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Have a friend/family member check your laceration daily for signs of infection. Take your pain medicine as prescribed. Your head laceration was closed with staples, please wait until after they are removed to wash your hair. You may shower before this time using a shower cap to cover your head. Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, or 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 after discussing with your doctor at follow up. You have been prescribed Dilantin (Phenytoin) for anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in ___ days and again in one week. This can be drawn at your PCPs office, but please have the results faxed to ___. PLEASE TAKE DILANTIN FOR A TOTAL OF 10 DAYS. ___. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING New onset of tremors or seizures. Any confusion, lethargy or change in mental status. Any numbness, tingling, weakness in your extremities. Pain or headache that is continually increasing, or not relieved by pain medication. New onset of the loss of function, or decrease of function on one whole side of your body. Followup Instructions: ___
19577642-DS-17	19,577,642	26,100,691	DS	17	2136-12-02 00:00:00	2136-12-04 17:50:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Bactrim / Sulfa (Sulfonamide Antibiotics) / amlodipine / Augmentin / lisinopril / ceftriaxone Attending: ___. Chief Complaint: L flank pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ with PMH of HTN, CAD s/p stents, CKD presenting with L flank pain that started this morning. Pt states pain has been sharp, constant, ___, and located in mid L flank without radiation. Pain associated with nausea and dry heaves. Pt denies dysuria, hematuria, or fever/chills. Pt was seen at ___ office where labs and CT showed ___ (Cr of 3.4 from 2.7 baseline), hyperkalemia, and perinephric stranding suggestive of passed renal stone or pyelonephritis. Pt was not given fluids or pain medication. He reports normal PO intake up until this morning when the pain started. In the ED, initial vitals were: 98.5 83 ___ RA. WBC 12.4, Hgb 11.7, Cr 3.7 (baseline 2.7), initial K 5.8 --> 5.2, bicarb 17, normal LFTs, UA with 2 WBCs and 13 RBCs. CT AP showed L perinephric stranding with moderate hydronephrosis on the L. Also noted sub-mm non-obstructing stone in the lower pole of the left kidney. The patient was given 2L NS, 1g tylenol, 4mg IV zofran. He was receiving 1g IV CTX when he developed wheals. No respiratory complaints. The infusion was stopped and he was given benadryl. Past Medical History: nephrolithiasis BPH Prostatitis GIB most likely due to colonic AVM HTN CKD Anemia Social History: ___ Family History: Reviewed. Not pertinent to this hospitalization Physical Exam: ON ADMISSION: Vitals: 97.7 147/75 64 18 96% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, EOMI, PERRL CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended, no rebound or guarding GU: No foley Back: no CVA tenderness Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII grossly intact ON DISCHARGE: Vitals: 97.7 F, BP 140s/70s, HR ___, RR 18, 96% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, EOMI, PERRL CV: Regular rate and rhythm, II/VI systolic murmur appreciable across upper chest wall Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended, no rebound or guarding GU: No foley Back: no CVA tenderness, no spinal or paraspinal tenderness Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII grossly intact Pertinent Results: ==LABS UPON ADMISSION== ___ 12:50PM BLOOD WBC-10.8* RBC-3.88* Hgb-11.7* Hct-36.4* MCV-94 MCH-30.2 MCHC-32.1 RDW-13.0 RDWSD-44.6 Plt ___ ___ 12:50PM BLOOD Neuts-80.0* Lymphs-12.0* Monos-5.0 Eos-2.0 Baso-0.4 Im ___ AbsNeut-8.61* AbsLymp-1.29 AbsMono-0.54 AbsEos-0.21 AbsBaso-0.04 ___ 12:50PM BLOOD Plt ___ ___ 12:50PM BLOOD UreaN-52* Creat-3.4* Na-139 K-5.8* Cl-104 HCO3-20* AnGap-21* ___ 12:50PM BLOOD ALT-29 AST-35 CK(CPK)-191 AlkPhos-82 TotBili-0.3 ___ 06:50AM BLOOD Calcium-8.9 Phos-4.3 Mg-1.9 ___ 10:23PM BLOOD K-5.2* ___ 08:03PM BLOOD Lactate-1.3 K-5.3* ==LABS UPON DISCHARGE-- ___ 06:50AM BLOOD WBC-8.6 RBC-3.13* Hgb-9.3* Hct-29.1* MCV-93 MCH-29.7 MCHC-32.0 RDW-13.3 RDWSD-45.1 Plt ___ ___ 06:50AM BLOOD Plt ___ ___ 06:50AM BLOOD Glucose-88 UreaN-47* Creat-3.4* Na-141 K-4.9 Cl-112* HCO3-19* AnGap-15 ==OTHER RESULTS== CT ABDOMEN PELVIS: 1. Mild left perinephric fat stranding with moderate amount of hydronephrosis extending into the proximal ureter with some narrowing at the ureteropelvic junction. These findings could be concerning for pyelonephritis in the right clinically setting. 2. A tiny non-obstructing sub-millimeter stone is seen in the lower pole of the left kidney. 3. Diverticulosis of the sigmoid colon without evidence of diverticulitis. Brief Hospital Course: ___ with PMH of HTN, CAD s/p stents, CKD who presented with L flank pain and ___ suggestive of passed stone. ACUTE ISSUES: # L flank pain/Presumed Nephrolithiasis: the pt's flank pain had resolved by the time he arrived to the ED. He was found to have leukocytosis to 12 but otherwise did not meet SIRS criteria. He was afebrile and had stable vital signs. He had been able to tolerate PO intake up until time of admission. CT A/P showed some L perinephric stranding that was suggestive for pyelonephritis in the right context, although the pt did not appear otherwise infected. He was given 1 g IV CTX in the ED but started having wheals, so that was d/c'ed and he was treated with benadryl with resolution of wheals. He was given 3 L NS in total overnight and one dose of IV Cipro on the floor. His blood and urine cultures were still pending at time of discharge. The source of his pain was felt to be related to nephrolithiasis. # ___: The pt's baseline Cr is 2.7, and his creatinine in the ED was 3.4. This was most likely due to obstruction from a stone that had passed by time of evaluation in the setting of CKD. His urine lytes showed a FENa of 3.18% suggestive of ATN superimposed on CKD. Urine microscopy was unfortunately not done because the patient did not stay. He will follow up with his PCP and nephrologist in the outpatient setting, who were in close communication during his hospitalization. # Anemia: the pt has had an extensive outpt workup for anemia. His iron levels were normal after PO supplementation, B12 and folate normal, SPEP normal. He has had several positive guaiac stool cards, negative colonoscopy earlier in ___. Most likely cause is anemia of chronic disease ___ CKD. # HTN: The pt was hypertensive to 217 on arrival to the ED. This was thought to be secondary to pain since his SBP downtrended to the 140s upon arrival to the floor without intervention. *Transitional issues*: - ___: the pt was found to have a Cr to 3.4 on discharge associated with a FeNa of 3.18%. Urine microscopy could not be completed due to the pt's leaving, but should be done in the outpt setting to examine for casts. He should also have his Cr re-checked in a few days to make sure it is trending down. Blood and urine cultures are still pending. - The pt received 1 dose of ceftriaxone and developed wheals that resolved with Benadryl. Ceftriaxone should be listed among the pt's drug allergies. FULL CODE Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Terazosin 2 mg PO QHS 2. Metoprolol Succinate XL 25 mg PO DAILY 3. ipratropium bromide 0.06 % nasal BID:PRN allergy symptoms 4. Rosuvastatin Calcium 40 mg PO QPM 5. Ferrous GLUCONATE 324 mg PO DAILY 6. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY 7. Aspirin 81 mg PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY 3. Metoprolol Succinate XL 25 mg PO DAILY 4. Rosuvastatin Calcium 40 mg PO QPM 5. Terazosin 2 mg PO QHS 6. Ferrous GLUCONATE 324 mg PO DAILY 7. ipratropium bromide 0.06 % nasal BID:PRN allergy symptoms Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Nephrolithiasis Secondary diagnosis: hypertension CKD 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 concern for infection in your kidney. Once on the medical floor, you did not have signs or symptoms of infection, and your pain had resolved. We believe your pain was due to a kidney stone that was passed. You were also found to have an elevated creatinine that improved slightly with fluids, but you should follow up with your doctors to discuss this acute kidney injury. Sincerely, Your ___ team Followup Instructions: ___
19577720-DS-16	19,577,720	20,064,263	DS	16	2152-02-19 00:00:00	2152-02-19 15:38:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: abd pain Major Surgical or Invasive Procedure: none History of Present Illness: ___ yo F with PMH pHTN, CHF, MR, recurrent diuretic refractory ascites requiring regular paracentesis admitted for paracentesis. Pt developed abd pain 2d ago plus N/V. She has also been constipated though she recently passed a small BM yest. Also having fatigue for 1 week and LOA. She has regular paracentesis, last on ___. On arrival to the ED, initial vitals were: 97.7 100 114/63 16 98%. Labs were all unremarkable including CBC, LFTs, CHEM-7, and a diagnostic para. u/a neg. Pt has paperwork indicates she is DNR/DNI and is also Do Not Hospitalize. However, ED had discussion with patient where they recommended admission to the hospital for a therapeutic paracentesis and she agreed to do this if she could be discharged immediately back home. Of note, pt already scheduled for outpt therapeutic para on ___. On arrival to the floor, VS 98.7, 102/52, 120, 20, 97% RA. She is resting comfortable in bed. She appears annoyed to use interpreter phone. ROS: per HPI, plus denies melena, hematpchezia, dysuria, hematemesis, SOB, CP, f/c/s. Past Medical History: 1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension 2. CARDIAC HISTORY: - congenital ASD and pulmonic stenosis s/p pulmonic commissurotomy and closure of atrial septal defect in ___ - ___: cardiac catheterization was complicated by dissection of the left main coronary artery and she was urgently transported to ___ where she underwent coronary artery bypass grafting to the LAD and an obtuse marginal branch with closure of the atrial septal defect and a commissurotomy of the pulmonary valve. Her postoperative course was complicated by respiratory distress syndrome and atrial arrhythmias and she was intubated for several weeks. She was initially treated with procainamide to which she had a reaction and then was given sotalol 120 mg twice daily, but she broke through with atrial arrhythmias. Nevertheless, she was discharged on sotalol. - ___, had two episodes of syncope and she was evaluated by Dr. ___ at the ___ in ___. He raised the possibility either of sotalol-induced torsade or episodes of bradycardia and the sotalol was stopped - CHF, LVEF of 55-60%. Moderate to mod-severe eccentric mitral regurgitation is present, moderate to severe tricuspid regurgitation, estimated PA systolic pressure is ___ mmHg above RA pressure. Severity of TR may affect accuracy of PASP estimate as will Pulmonic stenosis. The pulmonic leaflets are thickened with average peak pressure gradient of 35mmHg Mild-moderate pulmonic stenosis. 3. OTHER PAST MEDICAL HISTORY: - anemia- ___ - admitted with GIB, 3 u PRBC - had colonoscopy and EGD at ___ - Depression - Anemia - Hyperbilirubinemia Social History: ___ Family History: Brother - Hearing Loss; ___ Psych - Depression Cardiac FH is unknown. Physical Exam: ADMISSION EXAM: VS - 98.7, 102/52, 120, 20, 97% RA General: NAD, resting comfortably in bed HEENT: no scleral icterus, OP clear, dry MM Neck: supple, no cervical ___, JVD to jawline CV: rapid, irreg rate, hyperdynamic, ___ sys murmur with heave. Lungs: decreased BS at left base, no rales, wheezing Abdomen: soft, NT/ND. No organomegaly. +BS. GU: no Foley. Ext: WWP, +2 pulses. 2+ pitting edema to hips/anasarca. Neuro: A+Oxhospital, date one day off, and why she was admitted, attentive. CN II-XII grossly intact. Skin: no rashes. DISCHARGE EXAM: Awake and alert but confused. Sitting comfortably in bed in no acute distress with unlabored breathing. Rest of exam deferred. Pertinent Results: ADMISSION LABS: ___ 11:35AM BLOOD WBC-7.1 RBC-4.32 Hgb-11.0* Hct-37.8 MCV-88 MCH-25.6* MCHC-29.2* RDW-15.1 Plt ___ ___ 11:35AM BLOOD Neuts-82.1* Lymphs-9.8* Monos-5.0 Eos-2.4 Baso-0.8 ___ 11:35AM BLOOD ___ PTT-34.9 ___ ___ 11:35AM BLOOD Glucose-93 UreaN-13 Creat-0.9 Na-141 K-4.3 Cl-96 HCO3-34* AnGap-15 ___ 11:35AM BLOOD ALT-10 AST-21 AlkPhos-89 TotBili-1.3 ___ 11:35AM BLOOD Albumin-3.4* ___ 12:00PM BLOOD Lactate-1.4 LABS AT TIME OF DECOMPENSATION: ___ 07:30AM BLOOD Calcium-8.4 Phos-6.6* Mg-2.2 ___ 07:30AM BLOOD Glucose-96 UreaN-17 Creat-1.4* Na-138 K-4.8 Cl-97 HCO3-28 AnGap-18 ___ 07:30AM BLOOD WBC-10.7# RBC-4.01* Hgb-10.2* Hct-35.7* MCV-89 MCH-25.5* MCHC-28.6* RDW-15.1 Plt ___ CXR: Cardiac silhouette is enlarged, with associated massive enlargement of the pulmonary arteries, the latter consistent with known history of pulmonary hypertension. Pulmonary vascular congestion and interstitial edema are similar to the recent radiograph, and small bilateral pleural effusions are also not substantially changed. Right retrocardiac opacity may reflect a combination of atelectasis and effusion, but underlying infectious consolidation is possible in the appropriate clinical setting. Brief Hospital Course: ___ yo F with PMH pHTN, CHF, MR, recurrent ascites requiring regular paracentesis admitted for paracentesis who developed hemodynamic instability, hypoxia, and confusion, made CMO. Pt was DNR/DNI/DNH on arrival to ED but agreed to admission for a therapeutic paracentesis only with plan to discharge after that. Pt confirmed on admission she wanted to leave the hospital as soon as para was performed. This is usually done outpatient for her. The night of admission (before getting para) she became hypoxic and unresponsive and hypotensive to ___. She did not respond to fluid bolus. Family was contacted and after discussion about patient's known wishes to avoid hospitalization in general she was made CMO rather than pursue work up and treatment of her decompensation. Her home medications were stopped and she was put on prn pain medication and scopolamine. Without any further intervention, pt's mental status improved (vitals signs were no longer checked except resp rate), but she was confused. Per discussion with family pt was continued only on medications that contributed to comfort and she would be discharged to hospice. She was put on oxycodone liquid, scopolamine patch, and diuretics were added back as her symptoms of fluid overload were thought to be contributing to discomfort. Para was not pursued (abdomen was not tense), but rather her torsemide was increased to help manage ascites. Pt was discharged to hospice with plan to pursue outpatient para if abdominal distension worsened or became uncomfortable. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Potassium Chloride 10 mEq PO DAILY 2. Escitalopram Oxalate 10 mg PO DAILY 3. Fluticasone Propionate NASAL 2 SPRY NU DAILY 4. Vitamin D 1000 UNIT PO DAILY 5. Acetaminophen 650 mg PO Q6H:PRN pain, fever 6. Bisacodyl 10 mg PR HS:PRN constipation 7. Fleet Enema ___AILY:PRN cpnstipation 8. ClonazePAM 0.5 mg PO QHS:PRN insomnia 9. Metoprolol Tartrate 12.5 mg PO BID 10. Torsemide 10 mg PO DAILY 11. Polyethylene Glycol 17 g PO DAILY 12. Pantoprazole 20 mg PO Q24H 13. TraMADOL (Ultram) 50 mg PO Q8H:PRN pain 14. Senna 2 TAB PO DAILY 15. Scopolamine Patch 1 PTCH TD Q72H 16. Morphine Sulfate (Oral Soln.) 2 mg PO Q1H:PRN agitation, discomfort 17. Morphine Sulfate (Oral Soln.) 4 mg PO Q4H:PRN severe agitation Discharge Medications: 1. ClonazePAM 0.5 mg PO QHS:PRN insomnia 2. Scopolamine Patch 1 PTCH TD Q72H 3. Torsemide 20 mg PO DAILY 4. OxycoDONE Liquid 2.5 mg PO Q4H:PRN agitation, pain, resp distress RX oxycodone 5 mg/5 mL 2.5 mg by mouth every four (4) hours Disp ___ Milliliter Refills:0 Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: decompensated heart failure Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You came to the hospital because you had abdominal pain. You agreed to be admitted to the hospital to have a paracentesis. While you were here you became very sick and your oxygen levels and blood pressure dropped. Your family was called and a decision was made to pursue comfort measures and stop aggressive treatments. You felt a little better before you left, and you were discharged when services were arranged for you to go home with hospice care. Your medications were adjusted to help reduce your abdominal swelling. If the swelling worsens again, it will be arranged for this to be done as an outpatient so you don't have to come back to the hospital, which was what you indicated your wishes to be before you became sick. Followup Instructions: ___
19578000-DS-12	19,578,000	29,887,984	DS	12	2156-09-19 00:00:00	2156-09-19 14:07:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Ampicillin / Penicillins Attending: ___. Chief Complaint: Ruptured infrapatellar aortic aneurysm. Major Surgical or Invasive Procedure: ___ Endovascular abdominal aneurysm repair with Endurant graft History of Present Illness: Ms. ___ is a ___ who presented to ___ with abdominal pain. CT with IV contrast at the OSH demonstrated a large ruptured AAA. At the OSH, she was hypotensive to the 80's but was still mentating. She was ___ transfered to ___ for evaluation and EVAR. Per the patient's daughter she is full code and they are consenting to EVAR. Past Medical History: CAD s/p MI in ___, stent in place Orthostatic hypotension OA Spinal stenosis Anxiety on chronic benzodiazepine Hyperlipidemia L hip replacement L humerus fracture Hard of hearing Social History: ___ Family History: Mother had "dementia," father had renal failure and CHF. Sibling with ?___ disease. Also history of diabetes. Physical Exam: ON ADMISSION: Vitals: 97.2 83 106/61 18 98% NRB GEN: Mentating WD/WN elderly female HEENT: CV: tachycardia PULM: Clear to auscultation b/l ABD: Soft, mildly distended abdomen with palpable AAA. Ext: Mottled bilateral lower extremities. Non-palpable distal pulses. ===================== ON DISCHARGE: VS: T 98, HR 83, BP 168/63, RR 16, SaO2 91% RA Gen: Alert, occasionally somnolent, but arousable. Speech slurred, but able to understand and communicate effectively HEENT: Mostly edentulous, wears dentures. NCAT, EOMI, MMM CV: Regular rate, occasional irregular beat, otherwise, normal S1, S2 PULM: Coarse breath sounds throughout, easy work of breathing on 1L NC ABD: Soft, nontender, nondistended EXT: Warm, mild edema Pulses: ___ L: p/d/p/p R: p/d/p/d Pertinent Results: COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct ___ 07:00AM 14.2 3.03 9.5 28.9 96 31.4 32.8 18.3 265 ___ 07:10AM 13.6 3.10 9.4 29.2 94 30.4 32.2 18.2 261 ___ 05:15AM 12.9 2.97 9.2 27.9 94 30.9 32.9 18.3 228 ___ 04:31AM 8.7 3.05 9.5 27.8 91 31.1 34.2 18.4 163 ___ 04:24AM 8.8 3.31 10.3 29.6 90 31.2 34.9 18.8 142 ___ 06:07AM 10.2 3.50 10.6 30.8 88 30.3 34.4 18.9 106 ___ 12:20AM 30.1 ___ 05:48PM 32.3 ___ 09:08AM 32.6 ___ 03:12AM 13.2 3.43 10.2 29.1 85 29.7 35.0 18.5 101 ___ 12:27AM 27.6 ___ 09:00PM 25.9 ___ 04:00PM 11.3 3.20 9.6 27.2 85 29.9 35.2 18.5 90 ___ 11:58AM 11.9 3.27 9.9 27.9 85 30.3 35.7 18.5 90 ___ 05:19AM 13.7 3.47 10.6 29.6 85 30.5 35.7 18.3 105 ___ 01:25AM 13.4 3.41 10.3 29.1 85 30.2 35.4 18.2 102 ___ 12:05AM 13.2 3.20 10.0 27.2 85 31.3 36.7 18.1 95 ___ 07:50PM 13.8 3.33 9.9 28.6 86 29.9 34.7 18.1 105 ___ 03:50PM 12.9 3.03 9.3 26.4 87 30.8 35.3 18.7 77 ___ 12:55PM 21.6 ___ 12:25PM 14.7 2.51 7.6 21.8 87 30.2 34.6 19.4 86 ___ 08:47AM 19.5 3.48 10.5 29.8 86 30.3 35.4 18.9 85 ___ 03:39AM 24.7 2.63 8.2 24.3 93 31.2 33.7 15.5 146 ___ 12:20AM 12.5 1.75 5.5 17.2 98 31.7 32.3 15.8 106 RENAL & GLUCOSE Glu BUN Cr Na K Cl HCO3 AnGap ___ 07:00AM ___ 141 3.7 100 30 15 ___ 07:10AM 118 28 0.7 141 3.9 ___ 07:45AM 113 29 0.7 142 4.0 ___ 05:15AM 126 35 0.7 144 4.7 ___ 04:00AM 227 34 0.8 144 3.9 ___ 04:31AM 95 26 0.7 145 3.7 ___ 04:24AM 86 19 0.6 145 3.6 ___ 06:07AM 94 21 0.7 144 3.9 115 19 14 ___ 03:12AM ___ 142 3.8 114 17 15 ___ 11:58AM 81 31 0.9 140 3.7 114 18 12 ___ 01:25AM ___ 141 3.7 113 17 15 ___ 03:50PM 151 31 0.9 142 4.3 115 18 13 ___ 12:25PM 141 4.2 114 ___ 08:47AM 171 30 0.7 140 4.6 114 16 15 ___ 03:39AM 149 30 0.7 143 4.4 114 19 14 ___:20AM 155 32 0.7 141 4.3 118 19 8 CHEMISTRY Ca Phos Mg ___ 07:00AM 8.8 3.3 1.7 ___ 07:10AM 8.9 2.9 1.8 ___ 07:45AM 8.8 3.4 1.9 ___ 05:15AM 8.3 3.5 2.0 ___ 04:00AM 8.8 2.5 2.1 ___ 04:31AM 9.1 3.1 2.7 ___ 04:24AM 9.0 3.8 1.7 ___ 06:07AM 9.0 3.9 2.0 ___ 05:48PM 2.1 ___ 03:12AM 8.5 4.2 2.2 ___ 11:58AM 8.4 3.4 2.2 ___ 01:25AM 8.3 3.3 2.3 ___ 03:50PM 7.8 3.7 2.3 ___ 12:25PM 8.2 2.6 ___ 08:47AM 6.9 3.6 1.3 ___ 03:39AM 7.4 3.7 1.4 ___ 12:20AM 1.7 ========================= ___ 3:39 am MRSA SCREEN Source: Nasal swab. FINAL REPORT ___ MRSA SCREEN (Final ___: No MRSA isolated. ========================= ___ 10:37 am URINE Source: Catheter. FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. ========================= C. difficile: *FINAL REPORT ___ C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. (Reference Range-Negative). ========================= ___ CXR IMPRESSION: New triangular region of consolidation in the right upper lung could be infection or infarction. Mild pulmonary edema has worsened, moderate left and small right pleural effusions are stable and left lower lobe atelectasis is unchanged. Heart is normal size. Patient has been extubated. Right jugular line ends in the mid SVC. No pneumothorax ========================= ___ CXR IMPRESSION: There are layering bilateral effusions with increasing consolidation at the bases suggestive of partial lower lobe atelectasis. The more wedge-shaped opacity in the right upper lung on the previous study has resolved. Findings suggest fluctuating but slightly worse pulmonary edema. Overall cardiac and mediastinal contours are stable. Interval removal of right internal jugular central line. No pneumothorax. ========================== ___ CXR IMPRESSION: As compared to ___ radiograph, multifocal airspace consolidation in the right lung has worsened and is concerning for progressive pneumonia and less likely asymmetrical edema or multifocal aspiration. Left retrocardiac atelectasis and or consolidation persists with adjacent small to moderate pleural effusion. Small right pleural effusion is also demonstrated. ========================= SPEECH AND SWALLOW FINAL EVALUATION ___: SUMMARY/IMPRESSION: Ms. ___ was without overt s/sx of aspiration. Given that she had dentures placed and her son was at the bedside she was participatory and tolerated all consistencies. Recommend diet advancement to thin liquids and regular solids, pills whole or crushed in applesauce. Pt will require 1:1 supervision to assist with feeding and encourage PO intake. Support continued nutrition f/u. Silent aspiration cannot be r/o without video swallow. Brief Hospital Course: Ms. ___ is a ___ female who was admitted to ___ ___ from outside hospital for ruptured aortic aneurysm. She was seen in the emergency department and given full code status, emergently brought to the endovascular suite and underwent repair of her ruptured aortic aneurysm via endovascular techniques. For further details, please see Dr. ___ note. She required 4 units of packed red blood cells, 3 units of fresh frozen plasma and 1 unit of platelets. After tight blood pressure control, her transfusion requirements slowed. She was subsequently transferred to the ICU for further management and care. Postoperatively, she had temporary bradycardia to ___, but it improved and the left femoral vein sheath was pulled. Her hematocrit remained stable. She was extubated on postoperative day 2, and she was weaned off vasopressors. Her urine output remained well and she was started on beta-blocker and aspirin. On postoperative day 3, Her hematocrit remained stable, and she was given a bedside evaluation; however, she was unable to cooperate at that time. She remained hemodynamically stable and was subsequently transferred to the floor. Postoperative day 4, she passed the speech and swallow re-evaluation and was advanced to thin liquids and purees. Overnight she experienced tachycardia with premature atrial contractions, and IV metoprolol was given. Physical therapy evaluated her. Postoperative day 5, she was given a dose of lasix with good response and she continued to have PAC's on telemetry. Postoperative day 6, she was acutely tachycardic to 140's. Chest Xray showd wedge shaped opacity in the right upper lung concerning for consolidation vs. infarction. She lost her IV access and was unable to get CT Chest to assess for PE. We discussed with the family that no further surgical interventions will be offered as it is considered unsafe, and they agreed that Ms. ___ will be DNI/DNR. Postoperative day 7, repeat chest x-ray showed resolving wedge opacity, and her metoprolol was increased. Post-operatived days ___, her systolic blood pressure remained stable between 140-160's, occasionally in 170-180's. The medicine team was consulted to optimize her blood pressure regimen. She continues to have episodes of blood-streaked sputum which started at this time. She was diuresed with good effect and her breathing continued to improve. Repeat chest x-ray remained concerning for pneumonia and in the setting of elevated white blood count, she was started on a 10-day course of levaquin. Her mental status improved daily, and she remained hemodynamically stable. On discharge, she was able to converse, although with some dysarthria. She was able to tolerate a regular diet with supervision. She is slightly incontinent, but is able to express need to void. She requires assistance to sit in bed and will need continued rehabilitation. She and her family have been provided appropriate discharge and follow-up instructions. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Klor-Con M20 (potassium chloride) 20 mEq oral BID 2. Aspirin 81 mg PO DAILY 3. Lorazepam 0.5 mg PO BID 4. LeVETiracetam 500 mg PO BID 5. Midodrine 5 mg PO TID 6. Metoprolol Tartrate 12.5 mg PO BID 7. Fludrocortisone Acetate 0.2 mg PO DAILY 8. Donepezil 10 mg PO DAILY 9. Lisinopril 5 mg PO DAILY 10. Sertraline 50 mg PO DAILY 11. Sodium Chloride 500 mg PO NOON 12. Ranitidine 150 mg PO QHS 13. Senna 17.2 mg PO QHS 14. Atorvastatin 10 mg PO MWF 15. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Atorvastatin 10 mg PO MWF 2. Donepezil 10 mg PO DAILY 3. LeVETiracetam 500 mg PO BID 4. Lisinopril 5 mg PO DAILY 5. Lorazepam 0.5 mg PO BID 6. Metoprolol Tartrate 12.5 mg PO BID RX metoprolol tartrate 50 mg 1 tablet(s) by mouth three times a day Disp #90 Tablet Refills:0 7. Ranitidine 150 mg PO QHS 8. Senna 17.2 mg PO QHS 9. Sertraline 50 mg PO DAILY 10. Multivitamins 1 TAB PO DAILY 11. Klor-Con M20 (potassium chloride) 20 mEq oral BID 12. Levofloxacin 750 mg PO DAILY RX levofloxacin 750 mg 1 tablet(s) by mouth DAILY Disp #5 Tablet Refills:*0 13. Docusate Sodium 100 mg PO BID Stop for loose or watery stools. 14. Acetaminophen 650 mg PO Q6H:PRN pain 15. Home Oxygen Dx: Pneumonia Rx: Home oxygen, titrate for oxygen saturation > 90%. 16. Aspirin 81 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ ___ Diagnosis: Ruptured infrapatellar abdominal aneurysm Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive, sometimes lethargic, but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Ms. ___, You were brought emergently to ___ ___ with a ruptured aortic aneurysm. With the information we were given regarding your condition, we took you emergently to the operating room, and you underwent endovascular repair of your ruptured aortic aneurysm. Given your age and diagnoisis, you have recovered well from the procedure and are now ready to be discharged to a acute rehabilitation facility to continue your care and recovery there. Please follow the instructions below: MEDICATIONS: Continue to take aspirin 81 mg (enteric coated) once daily Do not stop Aspirin unless your Vascular Surgeon instructs you to do so. Your Midodrine and Florinef (for orthostatic hypotension) have been held since you have been in the hospital as you have not been mobile enough to require them and you have been mostly hypertensive. When you have regained more mobility, you should follow-up with your primary care doctor to discuss restarting these two medications. You may continue your other medications that you were on before you came into the hospital You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort WHAT TO EXPECT AT HOME: It is normal to have slight swelling of the legs: Elevate your leg above the level of your heart (use ___ pillows or a recliner) every ___ hours throughout the day and at night Avoid prolonged periods of standing or sitting without your legs elevated It is normal to feel tired and have a decreased appetite, your appetite will return with time Drink plenty of fluids and eat small frequent meals It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication ACTIVITIES: You should continue to work with physical therapy, occupational therapy, and speech therapy to continue your rehabilitation. When you go home, you may walk with a walker You may shower (let the soapy water run over groin incision, rinse and pat dry) Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing or band aid over the area that is draining, as needed You should gradually increase your activities and work towards getting stronger and back on your feet No driving CALL THE OFFICE FOR: ___ Numbness, coldness or pain in lower extremities Temperature greater than 101.5F for 24 hours New or increased drainage from incision or white, yellow or green drainage from incisions Bleeding from groin puncture site FOR SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site or incision) Lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. If bleeding stops, call vascular office. If bleeding does not stop, call ___ for transfer to closest Emergency Room. Followup Instructions: ___
19578341-DS-17	19,578,341	28,488,346	DS	17	2203-11-17 00:00:00	2203-11-17 20:38:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: Ibuprofen / metformin Attending: ___ Chief Complaint: dizziness Major Surgical or Invasive Procedure: None History of Present Illness: Neurology at bedside after Code Stroke activation within: 6 mins Time/Date the patient was last known well: 6:30 pm I was present during the CT scanning and reviewed the images within 20 minutes of their completion. ___ Stroke Scale Score: 1 for worse HKS on L. t-PA administered: [] Yes - Time given: __ [x] No - Reason t-PA was not given or considered: NIHSS 1, patient symptoms resolved. INR 1.7 Thrombectomy performed: [] Yes [x] No - Reason not performed or considered: No LVO NIHSS Performed within 6 hours of presentation at: 19:58 NIHSS Total: 1 1a. Level of Consciousness: 0 1b. LOC Question: 0 1c. LOC Commands: 0 2. Best gaze: 0 3. Visual fields: 0 4. Facial palsy: 0 5a. Motor arm, left: 0 5b. Motor arm, right: 0 6a. Motor leg, left: 0 6b. Motor leg, right: 0 7. Limb Ataxia: 1 8. Sensory: 0 9. Language: 0 10. Dysarthria: 0 11. Extinction and Neglect: 0 REASON FOR CONSULTATION: gait instability HPI: Ms. ___ is a ___ woman with history of HTN, diabetes, UC in remission, and prior left parietal ischemic stroke in the setting of nonischemic cardiomyopathy with left ventricle thrombus who was started on coumadin presenting with lightheadedness, vertigo, and gait instability. Patient was in her usual state of health when she was in bed tonight at 6:30 pm. At 6:45, she turned in bed and felt very lightheaded. She is unsure if it was vertigo but eventually agreed to feeling as if she were rocking on a boat. She was worried about whether her legs would have similar symptoms to her previous stroke. So, she stood up and felt like she might fall or pass out. She does not feel as if she were falling to the right, left, forwards, or backwards. She both legs felt weaker than usual but she was able to walk down the stairs with her husband ready to catch her. Patient and her husband did not notice other symptoms. They did not see facial droop, other focal weakness, or numbness/tingling. She was not dysarthric and spoke normally. Her dizziness resolved 20 minutes after arriving in ED. However, the ED staff tried to walk her and she had gait instability, so code stroke was called. Patient was able to walk to the restroom with assistance. Later, patient felt dizzy again upon sitting up and standing. Patient denies recent illness. Her last INR was around 2. Prior to that, she was above 3, so her coumadin needed to be adjusted. She currently takes 6 mg from ___, 4 mg on ___. She reports taking all her medications. She follows with Stroke neurologist, Dr. ___ at ___ and last saw him on ___. Her last UC flare was many years ago. She does not take any medication for UC currently. ROS: On neurological review of systems, the patient denies headache, confusion, difficulties producing or comprehending speech, loss of vision, blurred vision, diplopia, dysarthria, dysphagia, tinnitus or hearing difficulty. Denies focal weakness, numbness, parasthesiae. No bowel or bladder incontinence or retention. On general review of systems, the patient denies recent fever, chills, night sweats, or recent weight changes. Denies cough, shortness of breath, chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. Denies dysuria, or recent change in bowel or bladder habits. Denies arthralgias, myalgias, or rash. Past Medical History: - complex renal cyst detected on ultrasound - 4mm lung nodule req radiographic followup - left parietoccipital ischemic stroke - cardiomyopathy with left ventricule thrombus, most recent ECHO with EF 40-45% - TIAs - diabetes type 2 - ulcerative colitis in remission Social History: Works for ___ as ___ Lives with her husband, daughter, and grandson. Former smoker, quit > ___ years ago No alcohol, no illicit drug use. - Modified Rankin Scale: [x] 0: No symptoms [] 1: No significant disability - able to carry out all usual activities despite some symptoms [] 2: Slight disability: able to look after own affairs without assistance but unable to carry out all previous activities [] 3: Moderate disability: requires some help but able to walk unassisted [] 4: Moderately severe disability: unable to attend to own bodily needs without assistance and unable to walk unassisted [] 5: Severe disability: requires constant nursing care and attention, bedridden, incontinent [] 6: Dead Family History: Mother: CHF, DM Grandmother: heart disease no history of stroke or seizure Physical Exam: ADMISSION EXAM Vitals: T:96.8 HR:98 BP:114/87 RR:16 SaO2: 98% on RA General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx. Neck: Supple. No nuchal rigidity. Pulmonary: Normal work of breathing. Cardiac: RRR, warm, well-perfused. Abdomen: Soft, non-distended. Extremities: No ___ edema. Skin: No rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented to self, ___, date. Able to relate history without difficulty. Attentive, able to name ___ backward without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Able to name both high and low frequency objects. Able to read without difficulty. No dysarthria. Able to follow both midline and appendicular commands. There was no evidence of apraxia or neglect. -Cranial Nerves: II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without nystagmus. Normal saccades. VFF to confrontation. Visual acuity ___ bilaterally. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii bilaterally. XII: Tongue protrudes in midline with good excursions. Strength full with tongue-in-cheek testing. -Motor: Normal bulk and tone throughout. L pronation and drift. No adventitious movements, such as tremor or asterixis noted. [___] L 5 5 5 5 5 5 5* 5 5 5 5 5 R 5 5 5 5 5 5 5* 5 5 5 5 5 IPs were back pain limited. -Sensory: No deficits to light touch, pinprick, temperature, proprioception throughout. Diminished vibratory sense in b/l great toes. No extinction to DSS. Romberg positive. -Reflexes: [Bic] [Tri] [___] [Pat] [Ach] L 2 2 2 0 0 R 2 2 2 0 0 Plantar response was flexor bilaterally. -Coordination: No intention tremor. No dysmetria on FNF bilaterally. Slightly worse HKS on L. -Gait: Dizzy on standing. slow, hesitant, short steps. Able to walk a few steps. +Romberg - calls to L. ================= DISCHARGE EXAM As above, with the following corrections: Head impulse test is POSITIVE with a corrective saccade upon left head turn (suggestive of peripheral vestibulopathy), left parietal drift (upward drift), negative ___ test (though difficult to depress head all the way down due to body habitus). Pt able to ambulate without assistance. Pertinent Results: ___ 06:50AM BLOOD WBC-6.2 RBC-4.11 Hgb-12.0 Hct-36.9 MCV-90 MCH-29.2 MCHC-32.5 RDW-13.3 RDWSD-43.8 Plt ___ ___ 07:30PM BLOOD Neuts-61.3 ___ Monos-5.6 Eos-1.8 Baso-0.9 Im ___ AbsNeut-4.89 AbsLymp-2.39 AbsMono-0.45 AbsEos-0.14 AbsBaso-0.07 ___ 06:50AM BLOOD ___ PTT-26.7 ___ ___ 06:50AM BLOOD Glucose-136* UreaN-13 Creat-1.1 Na-144 K-4.3 Cl-107 HCO3-22 AnGap-15 ___ 06:50AM BLOOD AST-15 ___ 07:30PM BLOOD ALT-21 AST-18 AlkPhos-158* TotBili-0.4 ___ 07:30PM BLOOD Lipase-50 ___ 07:30PM BLOOD cTropnT-<0.01 ___ 06:50AM BLOOD Calcium-9.1 Phos-3.9 Mg-1.8 Cholest-104 ___ 07:30PM BLOOD %HbA1c-6.7* eAG-146* ___ 06:50AM BLOOD Triglyc-96 HDL-37* CHOL/HD-2.8 LDLcalc-48 ___ 06:50AM BLOOD TSH-1.2 ___ 07:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG ___ 07:55PM BLOOD Glucose-182* Creat-1.1 Na-140 K-4.0 Cl-108 calHCO3-23 IMAGING MR head w/o contrast IMPRESSION: 1. No evidence of hemorrhage or recent infarction. 2. Old infarcts involving the left occipital lobe and right centrum semiovale. 3. Left maxillary sinus disease. CTA head/neck 1. No acute infarct or intracranial hemorrhage. 2. Old left occipital lobe and right centrum semiovale infarcts. 3. No stenosis or occlusion of the circle of ___ arteries. 4. No stenosis or occlusion of the cervical arteries. EKG: NSR, LVH, stable from prior in ___ Brief Hospital Course: Ms. ___ is a ___ woman with history of HTN, diabetes, UC in remission, and prior left parietal ischemic stroke in the setting of nonischemic cardiomyopathy with a left ventricle thrombus who is on coumadin presenting with lightheadedness, vertigo, and gait instability. By the time of evaluation in the ED, symptoms had resolved apart from mild gait unsteadiness. Her exam was notable for having a positive head impulse test to the left with a corrective saccade (suggestive of peripheral vestibulopathy), normal mental status, normal cranial nerves, mild left arm parietal drift (likely related to her prior infarct) and a mild left arm sensory ataxia. Her workup was notable for CT head which revealed no acute process, and hypodensities related to old infarcts in the right parietal lobe and left occipital lobe. She had a CTA head/neck which revealed no large vessel occlusion. She had an MRI head which revealed no infarct; there were chronic infarcts involving the left occipital lobe and right centrum semiovale. Given the negative workup and reassuring exam, etiology felt consistent with peripheral vestibulopathy. #Dizziness: Likely secondary to peripheral vestibulopathy, with component of vestibular neuritis vs BPPV. - Given instructions for Epley maneuver to be done at home - Follow up with PCP ___ ___ as scheduled #Subtherapeutic INR: Noted to have subtherapeutic INR and did miss one dose of ___ on ___ while in ED. Home regimen is 6mg daily except for ___ where it is 4mg. In past, when INR has run low she has increased dose to 8mg. After discussion with pharmacy, will recommend 7mg tonight (___) and discussion with ___ clinic tomorrow. - Coumadin 7mg tonight (___) - Please call ___ clinic in AM (closed today for holiday) to ask for recommendations for further dosing. Otherwise, would recommend Coumadin 7mg tomorrow (___) and then resuming to previous regimen. - Follow up with PCP ___ ___ as scheduled Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze 2. Atorvastatin 40 mg PO QPM 3. CARVedilol 25 mg PO BID 4. Fluticasone Propionate NASAL 1 SPRY NU BID 5. Lisinopril 20 mg PO DAILY 6. Spironolactone 25 mg PO DAILY 7. Warfarin 7 mg PO DAILY16 Discharge Medications: 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze 2. Atorvastatin 40 mg PO QPM 3. CARVedilol 25 mg PO BID 4. Fluticasone Propionate NASAL 1 SPRY NU BID 5. Lisinopril 20 mg PO DAILY 6. Spironolactone 25 mg PO DAILY 7. Warfarin 7 mg PO DAILY16 Discharge Disposition: Home Discharge Diagnosis: Peripheral vertigo Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. ___, You were admitted to the hospital with dizziness. Your neurologic examination looked good when you came into the hospital, but we wanted to get an MRI of your brain given that you are at high risk for strokes. We did the MRI of your brain, which fortunately did NOT reveal any new strokes. We did further testing, which revealed signs that the dizziness may be due to the inner ear. You may have something called Benign paroxysmal positional vertigo (BPPV), which we will give you exercises for. We noticed that your INR level for the Coumadin was a little bit low. After discussion with our pharmacists, we will increase your dose from 6mg to 7mg for tonight and tentatively for tomorrow. However, please call the ___ clinic in the morning on ___ to confirm what dose you should take. It was a pleasure taking Followup Instructions: ___
19578416-DS-15	19,578,416	29,833,727	DS	15	2141-09-01 00:00:00	2141-09-04 08:31:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: Penicillins Attending: ___. Chief Complaint: vaginal pain Major Surgical or Invasive Procedure: Foley catheter History of Present Illness: ___ yo G7P7 presents with vaginal pain worsening over last ___ weeks. She noticed worsening dull aching pain in vagina over this time period, noticed a "ball" or "bulge"in vagina over the last several days. This pain seemed worse with voiding and she was recently seen at ___ and diagnosed with pyelo, admitted for IV abx and d/c home on PO cipro on ___. She reports this mass in her vagina was noted during her admission and she was instructed to take ___ baths. She tried ___ bath this morning, which did improve her pain but it returned when she got out. The pain is significant enough to impair her ability to walk and it is intermittently worsened to ___ severe pain by sudden movement. It is better with hot packs and rest. Voiding makes this pain worse, but she denies specific dysuria. No urinary frequency. No blood in urine. No VB. No abnormal vaginal discharge. No fevers. No back pain. No abd pain. Past Medical History: PNC: - ___ ___ by LMP, confirmed by ___ tri US - O+, AbS neg, RPR NR, RI, HBsAg neg, Hep C neg, HIV neg - Increased risk T18 on Quad (1:17) with nml FFS, missed appts for NIPT - CF: negative - electrophoresis: negative prior - presentation to care at ___ - many negative utox - recurrent UTI in pregnancy, all Proteus, most recent culture ___ pan-sensitive, was prescribed cephalexin and just finished them yesterday suggesting not taken as prescribed - US ___ for S>D 3054g, 27%, AFI 15 Ob hx: SVD x6, denies complications incl HTN/Mag, bleeding. largest 7#2 Gyn hx: denies abnl Pap or h/o STIs PMHx: frequent UTIs, current smoker 3cig/day, denies EtOH or drug use, lives with her children, FOB involved and feels safe PSHx: denies Meds: PNV All: PCN -> rash Social History: ___ Family History: noncontributory Physical Exam: General: On initial evaluation, pt appeared to be sleeping but when woken for exam became extremely agitated, crying and crouching on floor, unable to answer questions. After IV toradol and heat pack, was able to rest comfortably on stretcher and tolerate exam. Abd -soft, NT, ND, no r/g Back - no CVAT Pelvic - Normal appearing female external genitalia. Normal appearing urethral meatus. On BME, 3-4 cm mass palpaple on anterior vaginal wall, slightly deviated to pts left side. Mild TTP over mass. Pertinent Results: ___ 04:15AM ___ COMMENTS-GREEN TOP ___ 04:15AM LACTATE-1.3 ___ 04:04AM GLUCOSE-75 UREA N-19 CREAT-1.0 SODIUM-140 POTASSIUM-4.4 CHLORIDE-105 TOTAL CO2-23 ANION GAP-16 ___ 04:04AM estGFR-Using this ___ 04:04AM WBC-9.2 RBC-3.64* HGB-12.1 HCT-38.0# MCV-104# MCH-33.2 MCHC-31.8* RDW-12.7 RDWSD-49.4* ___ 04:04AM NEUTS-60.3 ___ MONOS-7.2 EOS-0.8* BASOS-0.5 IM ___ AbsNeut-5.51 AbsLymp-2.83 AbsMono-0.66 AbsEos-0.07 AbsBaso-0.05 ___ 04:04AM PLT COUNT-311 ___ 01:47AM URINE HOURS-RANDOM ___ 01:47AM URINE GR HOLD-HOLD ___ 01:47AM URINE COLOR-Yellow APPEAR-Cloudy SP ___ ___ 01:47AM URINE BLOOD-LG NITRITE-NEG PROTEIN-300 GLUCOSE-TR KETONE-10 BILIRUBIN-NEG UROBILNGN-2* PH-6.5 LEUK-LG ___ 01:47AM URINE RBC->182* WBC->182* BACTERIA-FEW YEAST-NONE EPI-24 ___ 01:47AM URINE MUCOUS-RARE Brief Hospital Course: On ___, Ms. ___ was admitted to the gynecology service for pain management of a vaginal cyst and recently diagnosed UTI. Her admission course was uncomplicated. Her pain was controlled with pyridium TID, acetaminophen, ibuprofen, oxycodone prn. On hospital day 2, her urine output was adequate so her foley was removed and she was found to have urinary retention. She voided 100cc and had 800cc remaining in bladder scan. Her Foley catheter was replaced and she was instructed in its care. Her diet was advanced without difficulty. By hospital day 2, she was tolerating a regular diet, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled. Medications on Admission: ciprofloxacin Discharge Medications: 1. Acetaminophen ___ mg PO Q6H:PRN pain do not take more than 4000mg total acetaminophen per day RX acetaminophen 500 mg ___ tablet(s) by mouth every six (6) hours Disp #50 Tablet Refills:1 2. Ciprofloxacin HCl 750 mg PO Q12H 3. Ibuprofen 600 mg PO Q6H:PRN pain take with food RX ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #50 Tablet Refills:1 4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain do not drive, please take stool softener while taking RX oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #20 Tablet Refills:0 5. Phenazopyridine 100 mg PO TID Duration: 3 Days RX phenazopyridine 100 mg 1 tablet(s) by mouth three times a day Disp #20 Tablet Refills:0 6. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H please take while urinary catheter is in place to prevent infection RX nitrofurantoin monohyd/m-cryst 100 mg 1 capsule(s) by mouth every twelve (12) hours Disp #8 Capsule Refills:0 Discharge Disposition: Home Discharge Diagnosis: possible Gartner's duct cyst, recent urinary tract infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted to the gynecology service due to vaginal pain with possible Gartner's duct cyst. Your pain has been well controlled on oral pain medication and the team believes you are ready to be discharged home with outpatient follow-up. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. General instructions: Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. *) You were discharged home with a Foley (bladder) catheter and received teaching for it prior to discharge. You were also given a prescription for Macrodantin (nitrofurantoin) antibiotic to prevent a UTI while you have the catheter. Please take as prescribed. You should follow-up in Dr. ___ on ___ for catheter removal. Please call the ___ clinic at ___ for an outpatient follow-up appointment. Followup Instructions: ___
19578538-DS-7	19,578,538	20,616,504	DS	7	2149-04-19 00:00:00	2149-04-20 18:24:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: LLE Cellulitis Major Surgical or Invasive Procedure: ___ line placement History of Present Illness: ___ history of unprovoked LLE DVT on ___ s/p coumadin therapy that presents with persistent erythema/swelling of LLE since last month. Patient presented 4 weeks ago in ___ to the ED and was treated for cellulitis with course of keflex and bactrim. She states that the painful area started as a small spot above her medial malleolus 2 weeks ago, approximately 2 cm by 4 cm. At that time, she was started on PO Keflex and Bactrim. In follow-up with her PCP with she got an ultrasound as an outpatient because although her swelling and redness reduced somewhat after abx (per PCP) there was still a swollen area and a quesiton of drainable collection. US revealed no drainable collection. She presented again to the ED on ___ with persistent cellulitis was observed overnight with IV vancomycin and per ED obs report she improved. She was released from ED with 14 day course of doxycycline and bactrim. A ___ was performed and negative at that time. Overall, she states that she has had no improvement of her LLE redness or swelling since the beginning of her symptoms 1 mo ago. She states that the swelling has now spread to dorsum of left foot. +erythema over back of lower calf. Area is red, hot, swollen, hard, and tender to touch. No drainage, pruritus, f/c. No CP, SOB, abd pain. She has a crackle on the L heal from wearing sandals all day during the summer time. She denies any recent trauma. She denies any recent long plan flights or sitting for long duration; to the contrary she is on her feet for 16 hrs per day as a ___ employee in ___ ___. No CA history. She had a LLE DVT in ___, for which she was treated with Coumadin for ___ months, and then transitioned to baby ASA. LLE DVT was resolved within ___ yr. In the ED, initial vs were: ___ 63 134/79 16 100% Labs were performed: - Lactate 1.5 - A1c is pending - Na 139 K 4.4 Cl 105 HCO3 25 BUN 11 Cr 0.6 Glc 77 Ca 8.6 Mg 1.8 Ph 3.2 - CBC WBC 4.2 Hgb 12.4 Plt 333 Diff 48.7 L 42.3 - Blood culture x 2 obtained She is being admitted to medicine for failed outpatient treatment of cellulitis. Transfer VS were not given. On arrival to the floor, patient reports feeling better with IV vanc and less pain with IV morphine from the ED. REVIEW OF SYSTEMS: Denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. All other 10-system review negative in detail. Past Medical History: - Obesity (BMI 41) - Hysterectomy ___ for fibroid uterus, menorrhagia, and significant anemia requiring IV iron infusion therapy status post supracervical hysterectomy via laparotomy and drainage of bilateral ovarian cysts. - Complete DVT at ___ around ___. At that time, she was discharged with oxycodone, Lovenox and coumadin. Per PCP ___ note, the patient had a hypercoagulable workup at ___ PRIOR to starting Coumadin. Per ___, her screening anticoagulant was negative, AT3 function was normal, Protein C was normal, Protein S was normal, APCR was normal, Prothrombin wild type was normal, Factor II was normal. No Factor V Leiden was ordered Social History: ___ Family History: FAMILY HISTORY: Mother: alive, schizophrenic, seizures, ETOH abuse, HTN, and recent cellulitis Dad: A&W No FHx of blood disorders, no known autoimmune dz No early MI No known early CA No siblings Physical Exam: ADMISSION PHYSICAL EXAM: VS T 98.4 Bp 131/85 HR 66 RR 18 100%RA pain ___ GEN Alert, oriented, no acute distress, obese pleasant woman HEENT NCAT MMM EOMI sclera anicteric, OP clear NECK supple, no JVD, no LAD PULM Good aeration, CTAB no wheezes, rales, ronchi CV RRR normal S1/S2, no mrg ABD soft NT ND normoactive bowel sounds, no r/g EXT WWP 2+ pulses palpable bilaterally, no c/c/e NEURO CNs2-12 intact, motor function grossly normal SKIN LLE swolen dorsum of foot, and calf. Posterior-lateral leg warm, reddish, hard. RLE cooler, no swelling. DISCHARGE PHYSICAL EXAM: VS T 98.3 BP 132/84 HR 72 RR 18 100%RA GEN Alert, oriented, no acute distress, obese pleasant woman HEENT NCAT MMM EOMI sclera anicteric, OP clear NECK supple, no JVD, no LAD PULM Good aeration, CTAB no wheezes, rales, ronchi CV RRR normal S1/S2, no mrg ABD soft NT ND normoactive bowel sounds, no r/g EXT WWP 2+ pulses palpable bilaterally, no c/c/e NEURO CNs2-12 intact, motor function grossly normal SKIN mild LLE swelling on L medial ankle, and calf. Decreased induration of left anterior-medial shin. tender to palpation over swollen indurated areas. Pertinent Results: ___ 11:00AM PLT COUNT-333# ___ 11:00AM NEUTS-48.7* LYMPHS-42.3* MONOS-4.6 EOS-3.7 BASOS-0.7 ___ 11:00AM WBC-4.2 RBC-4.45 HGB-12.4 HCT-37.8 MCV-85 MCH-27.9 MCHC-32.9 RDW-14.9 ___ 11:00AM %HbA1c-5.9 eAG-123 ___ 11:00AM CALCIUM-8.6 PHOSPHATE-3.2 MAGNESIUM-1.8 ___ 11:00AM estGFR-Using this ___ 11:00AM GLUCOSE-77 UREA N-11 CREAT-0.6 SODIUM-139 POTASSIUM-4.4 CHLORIDE-105 TOTAL CO2-25 ANION GAP-13 ___ 11:23AM LACTATE-1.5 IMAGING: CXR ___ for PICC Placement A right PICC line is present -- the tip overlies the cavoatrial junction, possibly over the upper right atrium. Clinical correlation regarding possible retraction by approximately 2 to 2.5 mm is requested. There are low inspiratory volumes. However, the lungs are grossly clear, without CHF, focal infiltrate, or effusion. No pneumothorax is detected. The study and the report were reviewed by the staff radiologist. ___ Ultrasound ___ FINDINGS: The right and left common femoral veins demonstrate symmetric waveforms during the Valsalva maneuver. The left common femoral vein, superficial femoral vein, popliteal vein, and posterior tibial vein demonstrate patency with normal compressibility. There is marked edema within the subcutaneous fat of the calf. Evaluation of the peroneal veins is limited due to patient body habitus, soft tissue edema, and patient discomfort, however one of the peroneal veins does not demonstrate flow, making it difficult to exclude a deep venous thrombus within the calf. No soft tissue fluid collection is identified within the lower extremity or foot. IMPRESSION: 1. Evaluation of peroneal veins is limited due to calf edema and patient body habitus, however one of the peroneal veins does not demonstrate flow for which a calf DVT cannot be excluded. 2. No soft tissue fluid collection within the left lower extremity or foot. ___ Ultrasound ___ COMPARISON: ___. FINDINGS: Grayscale and color and spectral Doppler ultrasound was performed of the left common femoral, superficial femoral, popliteal, posterior tibial veins. There is normal flow, augmentation, and compressibility. On the prior study of ___, there had been nonvisualization of one of the paired peroneal veins. Peroneal veins are again difficult to visualize on this study due to cellulitis and calf edema, although color flow is probably seen within both peroneal veins. IMPRESSION: No evidence of DVT in left lower extremity; peroneal veins not well visualized due to calf swelling and edema although color flow is probably seen. Although peroneal DVT cannot be entirely excluded, probability is less likely than following the prior study where no color flow could be demonstrated in one vein. Brief Hospital Course: ___ with PMH of LLE DVT presented with LLE swelling, redness, tenderness, refractory to outpatient antibiotic therapy for cellulitis. # Lower extremity swelling: The patient's LLE, which was warm, red, hard, and tender to touch, was found to be cellulitis without any drainable collections. Pt was given a high dose of vancomycin 1.5g q12h and ceftriaxone 2g q24h intravenously and improved within a day. Pt's pain associated with cellulitis was improved with 1g TID standing tylenol. # h/o DVT: Initially, DVT could not be excluded since pt has previously had a DVT in LLE. After swelling subsided, repeat lower extremity vascular ultrasounds were obtained which revealed no DVT. # TRANSITION ISSUES: [ ] follow-up electrolytes (BUN, and Cr) to be drawn on ___, s/p antibiotics Medications on Admission: none Discharge Medications: 1. Outpatient Lab Work Dx: ICD-9 682.6, Cellulitis/abscess, leg Please have chem 7 (BUN, Cr) drawn on ___ for monitoring while on antibiotics 2. CeftriaXONE 2 gm IV Q24H day 1 ___ RX ceftriaxone 2 gram 2g IV Q24H Disp #6 Bag Refills:0 3. Vancomycin 1500 mg IV Q 12H ___ RX vancomycin 750 mg Vancomycin IV 1500 mg every twelve (12) hours Disp #24 Bag Refills:0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Cellulitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a pleasure caring for you at ___ in ___. You were admitted because you had a cellulitis in your left leg that was not adequately treated with outpatient antibiotics. We gave you high dose intravenous antibiotics, and your leg swelling decreased significantly. We also performed an ultrasound of your left, which revealed that you did not have a blood clot in your leg. Please continue to take IV antibioitics as outlined below: 1. Ceftriaxone 2g IV Daily for 6 days 2. Vancomycin 1500 mg IV every 12 hours for 6 days Followup Instructions: ___
19579086-DS-11	19,579,086	24,755,721	DS	11	2126-12-27 00:00:00	2127-01-01 08:43:00	Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: hay fever Attending: ___. Chief Complaint: altered mental status Major Surgical or Invasive Procedure: none History of Present Illness: Mr. ___ is a ___ year old man with metastatic melanoma to the lungs, liver and brain s/p Ipilimumab and Cyberknife who presents to the ER with altered mental status. He was admitted from ___ for pre-syncope which was thought to be due to dehydration/hypotension vs. CNS progression vs. hyponatremia. Normal orthostatics. MRI brain showed slight enlargement of right temporal met with persistent surrounding edema (likely the cause of his symptoms) and a new 3mm lesion in the left parietal lobe. Radiation Oncology and Neurosurgery consults did not think he was a candidate for any interventions. He was restarted on steroids was going to see his outpatient oncologist to discuss initiation of Bevacizumab. 2.5 hours after discharge, he has an episode of altered mental status. After lunch, his brother reports that he was unable to locate the car, and then was weak and had to be lowered to the ground (landed on knees but not his head). He was poorly responsive and could not speak for 10 seconds. There was no generalized seizure movements, and the patient remembers the event. He denied any chest pain, palpitations, shortness of breath, lightheadedness, dizziness. The enture episode lasted 2 minutes. EMS was called and brought him to the ER where his mental status was back at baseline. On arrival to the floor, he reports feeling well. His brother is concerned that ___ services ___ vs. ___ should be closely involved as soon as he is ready to be discharged. ROS: He denies F/C/S, dizziness, visual changes, syncope, chest pain, dyspnea, abdominal pain, back pain, constipation, diarrhea, hematochezia, hematuria, other urinary symptoms, parasthesias, or rash. All other ROS were negative. Past Medical History: PAST ONCOLOGIC HISTORY: - ___: biopsy of 4 mm ___ level IV melanoma of the left cheek; wide local excision and sentinel lymph node biopsy of nodes within the tail of the parotid gland w/ pathology revealing no residual melanoma at the primary site or in 2 sentinel lymph nodes. - ___ began adjuvant IFN therapy. Course was c/b hyponatremia requiring hospitalization. - ___ - ___, resumed his therapy w/ normal laboratory data and daily electrolytes and blood draws. completed IFN therapy. - ___: surveillance CT Torso ___ notable for lung nodules, peripancreatic, porta hepatis, and gastrohepatic lymph nodes. - ___ CT-guided lung biopsy of the 1.8-cm RLL lesion. Pathology was (+) for metastatic melanoma. Head/Neck MRI showed an enhancing 6.8 mm lesion in the right frontoparietal lobe c/w metastatic disease, surrounding edema. - ___ initiated Temodar x 5 days. - ___ had 1 Cyberknife treatment to the parietal lesion. - ___ Brain MRI showed increased edema around brain lesion w/ increase in size of lesion. He started on Dexamethasone 4mg QAM. - Temodar continued for 4 cycles, last dose on ___ - ___ brain MRI which showed new sites of metastatic disease in the frontal, parietal & occipital lobes. - ___ Cyberknife to 4 brain metastases - ___ Ipilimumab treatment started - ___ MRI with increase in size of temporal brain lesion, s/p Cyberknife ___ - ___ Week 7 Ipilimumab held due to diarrhea, colonoscopy showed colities, started prednisone. - ___: Cyberknife to right temporal lesion and left frontal lesion. . OTHER MEDICAL HISTORY: Hypertension Depression Social History: ___ Family History: + for prostate cancer. No family history of melanoma. Physical Exam: T 97.1 bp 132/64 HR 67 RR 20 SaO2 99RA GEN: A&O, no acute signs of distress, comfortable. HEENT: Sclerae non-icteric, EOM intact, CNs intact, o/p clear, MMM. Neck: Supple, no thyromegaly. Lymph nodes: No cervical, supraclavicular, or inguinal LAD. CV: S1S2, RRR, no MRG. RESP: CTA. ABD: Soft, non-tender, non-distended, no HSM. EXTR: No edema or calf tenderness, right knee has broken skin with no surrounding rerythema, joint is normal and intact DERM: No rash. Neuro: Strength ___, sensation normal to touch, non-focal. PSYCH: Appropriate and calm. Pertinent Results: ___ 07:21PM LACTATE-2.5* NA+-129* K+-3.9 ___ 05:10PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 05:10PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG ___ 04:37PM LACTATE-4.0* ___ 04:00PM GLUCOSE-141* UREA N-28* CREAT-1.0 SODIUM-123* POTASSIUM-4.6 CHLORIDE-87* TOTAL CO2-18* ANION GAP-23* ___ 04:00PM WBC-16.2* RBC-5.16 HGB-14.7 HCT-41.3 MCV-80* MCH-28.5 MCHC-35.5* RDW-14.6 ___ 04:00PM NEUTS-92.4* LYMPHS-4.2* MONOS-3.0 EOS-0.4 BASOS-0.1 ___ 04:00PM PLT COUNT-543# ___ 05:45AM GLUCOSE-177 UREA N-25* CREAT-0.8 SODIUM-122* POTASSIUM-4.0 CHLORIDE-91* TOTAL CO2-21* ANION GAP-14 ___ 05:45AM CALCIUM-8.4 PHOSPHATE-3.1 ___ 05:45AM WBC-15.3# RBC-4.77 HGB-14.7 HCT-41.0 MCV-81 MCH-30.7 MCHC-38.1* RDW-14.9 ___ 05:45AM PLT COUNT-356 ___ 06:16AM GLUCOSE-170* UREA N-12 CREAT-0.6 SODIUM-125* POTASSIUM-3.5 CHLORIDE-87* TOTAL CO2-22 ANION GAP-20 ___ 06:16AM CALCIUM-8.4 PHOSPHATE-2.9 MAGNESIUM-2.2 ___ 06:16AM WBC-6.1 RBC-4.79 HGB-13.8* HCT-38.1* MCV-80* MCH-28.7 MCHC-36.1* RDW-14.4 ___ 06:16AM PLT COUNT-316 . ___ Head CT w/o Contrast: 1. No acute intracranial process. 2. No change from 4 days earlier with the known right temporal mass and surrounding vasogenic edema. . ___ CXR: Right pulmonary nodules as noted previously, no acute process . ___ MRI BRAIN: IMPRESSION: Slightly larger right temporal metastatic lesion, with persistent vasogenic edema and mild narrowing of the right perimesencephalic cistern. Multiple nodular lesions are again seen in both cerebral hemispheres and a new tiny lesion is noted on the left parietal lobe, measuring approximately 2 x 3 mm in size, with no evidence of mass effect. Close followup with MRI is recommended. . ___ CXR: IMPRESSION: No evidence of pneumonia. . ___ CT HEAD: IMPRESSION: 1. Unchanged right temporal lobe metastasis with surrounding edema and mass effect on the right temporal horn. Hyperdensity of this lesion is suggestive of hemorrhagic products as susceptibility was noted within this lesion on prior MRI. 2. Other tiny enhancing lesions seen on prior MRI are not visualized on the current exam. No new mass lesion noted, but MRI with contrast is recommended for further evaluation. . ___ MRI BRAIN: IMPRESSION: Interval increase in size of right temporal lobe lesion with increased perilesional edema and slight midline shift to the left, compared to the examination from six days ago. The remaining lesions are stable. . ___ CT C/A/P: IMPRESSION: Stable right pulmonary nodules, no new nodules, mass, or adenopathy. No evidence of disease progression. Brief Hospital Course: ASSESSMENT/PLAN: ___ man with metastatic melanoma s/p cyberknife and ipilibumab readmitted for recurrent pre-syncope and transient encephalopathy in setting of progressive brain mets from melanoma. He also reported recent N/V on last admission that is improved on decadron. . # Pre-syncope/encepalopathy: Likely due to CNS progression and hyponatremia. No symptoms to suggest that this is cardiac in origin. Doubt infection but cultures are pending. Recent MRI brain showed slight enlargement of right temporal met with persistent surrounding edema and a new 3mm lesion in the left parietal lobe. The right temporal mass is the likely cause of his symptoms, not the new left parietal lesion. Recent TSH normal. AM cortisol borderline. Cosyntropin stim test on last admission with little improvement in cortisol suggesting adrenal insufficiency. Last ipilibumab given ___, so panhypopit unlikely. Urine culture negative - Continued dexamethasone 4mg PO q6HR. - Continued anti-hypertensives - He is not stable to go home alone, will stay with his sister initially as home hospice is initiated - repeat ___ consult recommends ambulation with walker . # Metastatic melanoma to brain with vasogenic edema: s/p cyberknife and ipilibumab (last given ___, stopped due to colitis). MRI on last admission showed CNS progression. Radiation has already been provided to the right temporal mass, so cannot be repeated and the masses proximity to vessels will result in a high stroke-risk surgery. He is not a candidate for neurosurgery. Primary oncologist, Dr. ___ for outpatient bevacizumab. Palliative care and social work services involved. - Continued dexamethasone. - F/U next week for bevacizumab. . # SIADH and Hyponatremia: Sodium normalized during hospitalization with fluid restriction. Will continue 1.5L fluid restriction per day for SIADH as an outpatient. (with consideration for hyperglycemia from decadron and any recurrence of nausea/vomiting). Reviewed with patient so that he knows he can liberalize intake with high ___ glu or nausea & vomiting. He will have labs drawn two days after discharge as an outpatient and results faxed to Dr. ___ . # Hypertension: Continue outpatient lisinopril, amlodipine, and atenolol unless hypotension recurs. Has been intermittantly hypertensive with steroids. He knows how to monitor himself at home and I have asked him to follow his pressures and contact Dr. ___ they remain persistantly elevated. . # Hyperglycemia: Has been mildly hyperglycemic with steroids. This will make his fluid restriction more difficult. Plan to have labs drawn in 2 days as an outpatient and faxed to Dr. ___. ___ will check his ___ Glu at home. . # URI/cough: CXR negative for acute process on last admission. Symptoms resolved. Follow clinical exam, no need for antibiotics unless he deteriorates. . # N/V: due to vasogenic edema and progressive brain mets. Controlled on current dexamethasone - will continue as outpatient and use anti-emetics PRN. . # Anemia: Chronic, mild, will monitor as outpatient. . # Metabolic acidosis: Mildly elevated lactate on admission. Repeat lactate normal prior to DC. . # FEN: Regular diet. Repleted hypophosphatemia. . # Pain (headache): well controlled, continued oxycodone prn and continue decadron . # GI PPx: PPI and bowel regimen. . # Code status: Full. Medications on Admission: 1. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY. 2. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY. 3. lisinopril 40 mg Tablet Sig: PO DAILY. 4. Zofran ___ PO q8 PRN nausea 5. paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY. 6. dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q6H. Disp:120 Tablet(s) Refills:0 7. pantoprazole 40 mg Tablet, Delayed Release (E.C.) PO Q24H. Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 8. oxycodone 5 mg Capsule Sig: ___ Capsules PO q4HR PRN pain. Disp:40 Capsule(s) Refills:0 9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID. 10. lorazepam 0.5 mg Tablet Sig: ___ Tablets PO q4HR PRN nausea. Disp:20 Tablet(s) Refills:0 11. promethazine 12.5 mg Tablet Sig: ___ Tablets PO q6HR PRN nausea. Disp:20 Tablet(s) Refills:1 Discharge Medications: 1. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). Disp:120 Tablet(s) Refills:0 6. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 7. oxycodone 5 mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for pain. Disp:20 Tablet(s) Refills:0 8. lorazepam 0.5 mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for anxiety, nausea, insomnia. Disp:20 Tablet(s) Refills:0 9. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea. Tablet(s) 10. ondansetron 4 mg Tablet, Rapid Dissolve Sig: ___ Tablet, Rapid Dissolves PO Q8H (every 8 hours) as needed for nausea. Disp:20 Tablet, Rapid Dissolve(s) Refills:0 11. Outpatient Lab Work Dx: Metastatic melanoma, CNS mets, SIADH. Labs: Chem7. When: ___ Please fax results to Dr. ___ at ___. Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Dizziness/presyncope (near fainting). Metastatic melanoma. Brain metastases and edema (swelling). Hyponatremia (low sodium). SIADH (syndrome of inappropriate anti-diuretic hormone)- causes low sodium. Hypertension (high blood pressure) Hyperglycemia (high blood sugar) 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 a second episode of near fainting similar to the episode that you had earlier this week. The spell is likely related to brain swelling from progression of the melanoma tumor in your brain and your low sodium level. You should continue with your increased dose of dexamethasone and keep your scheduled follow up with Dr. ___ consideration of further chemotherapy. You should limit your fluid intake to 1.5 liters daily to prevent your low sodium from getting worse. To help prevent further falls, you should use your rolling walker for stability. Your blood pressure has been intermittantly high from the dexamethasone. You should continue to monitor your blood pressure with you home monitor and contact Dr. ___ office is it remains elevated. The visiting nurses ___ help you follow your blood sugar since this can become elevated from the dexamethasone steroids medication. . Because of these near fainting episodes, YOU SHOULD NOT DRIVE. . The following changes were made to your medications during your last admission: CONTINUE Dexamethasone 4mg every 6 hours CONTINUE Pantoprazole 40 mg daily CONTINUE Oxycodone ___ tablets every 4 hours as needed for pain CONTINUE Lorazepam (ativan) ___ tablets every 4 hours as needed for nausea, anxiety, or insomnia CONTINUE Ondansetron (zofran) ___ every 8 hours as needed for nausea CONTINUE Promethazine (phenergan)1 every 6 hours as needed for nausea. You should use zofran and/or ativan first before you use this drug for nausea. Followup Instructions: ___
19579271-DS-7	19,579,271	20,536,259	DS	7	2194-02-16 00:00:00	2194-02-16 15:32:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: Aspirin Attending: ___ ___ Complaint: Right knee pain and bruising Major Surgical or Invasive Procedure: Right knee aspiration by interventional radiology History of Present Illness: Mr. ___ is a ___ year old male now ___ s/p R TKA with Dr. ___ presents to ___ ED with worsening right knee pain, swelling, and low grade temperatures. Patient states since surgery pain has been ___ throughout with minimal relief. He states his 'bruise' increased in size initially and is now same size. The patient denies any new numbness or tingling distally. He has RSD and thus has some baseline neuropathy. Past Medical History: # HTN # Reflex sympathetic dystrophy # Chronic back pain, previously in a wheelchair fo ___ years, then weaned himself off a heavy narcotics regimen to only MS contin BID # Obesity # OSA, not on CPAP # Anxiety/Depression # Left eye blindness (from trauma/fight) # L4/L5 laminectomy Social History: ___ Family History: Notable for brother who passed away from pancreatic cancer at ___. He has a history of alcohol abuse in his father and asthma in his brother. His mother died of a CVA at age ___. No other family history of cancer. Physical Exam: Gen: appears in mild distress Alert and oriented x 3 CV: RRR Lungs: breathing room air comfortably. Right lower extremity: - Incision closed with staples, closed. - Ecchymosis about the right knee. Not warm to touch but tender. - Significant tenderness to palpation of knee. - ___ fire - SILT SPN/DPN/TN/saphenous/sural distributions - 1+ ___ pulses, foot warm and well-perfused Pertinent Results: ___ 06:04AM BLOOD WBC-6.4 RBC-2.86* Hgb-8.8* Hct-26.3* MCV-92 MCH-30.8 MCHC-33.5 RDW-13.4 RDWSD-45.1 Plt ___ ___ 09:55AM BLOOD WBC-7.0 RBC-2.94* Hgb-9.3* Hct-26.9* MCV-92 MCH-31.6 MCHC-34.6 RDW-13.5 RDWSD-45.1 Plt ___ ___ 09:55AM BLOOD Neuts-76.6* Lymphs-5.9* Monos-14.7* Eos-1.6 Baso-0.6 Im ___ AbsNeut-5.34 AbsLymp-0.41* AbsMono-1.02* AbsEos-0.11 AbsBaso-0.04 ___ 06:04AM BLOOD Plt ___ ___ 09:55AM BLOOD Plt ___ ___ 06:04AM BLOOD Glucose-88 UreaN-18 Creat-1.0 Na-137 K-4.3 Cl-95* HCO3-31 AnGap-15 ___ 09:55AM BLOOD Glucose-119* UreaN-17 Creat-1.1 Na-139 K-4.1 Cl-98 HCO3-30 AnGap-15 ___ 06:04AM BLOOD Calcium-8.6 Phos-4.0 Mg-2.1 ___ 09:55AM BLOOD CRP-165.5* ___ 10:00AM BLOOD Lactate-1.2 Brief Hospital Course: Patient was admitted from the emergency department due to concern for postoperative hematoma. He underwent an ___ guided aspiration of the synovial fluid which did not yield any bacteria on gram stain with 2225 WBC. He was initiated on oral antibiotics to prevent infection of hematoma and ___ was consulted for mobility while in the hospital. At the time of discharge the patient was tolerating a regular diet and feeling well. The patient was afebrile with stable vital signs. The patient's hematocrit was acceptable and pain was adequately controlled on an oral regimen. The operative extremity was neurovascularly intact. The patient's weight-bearing status is weight bearing as tolerated on the operative extremity. He was cleared by ___ to go home with services. He will return at his follow-up visit for staple removal. He will be discharged on 10 days of Keflex. Medications on Admission: 1. Allopurinol ___ mg PO DAILY 2. ClonazePAM 0.5-1 mg PO DAILY PRN anxiety 3. Lidocaine 5% Patch 1 PTCH TD QAM 4. Mirtazapine 30 mg PO QHS 5. Morphine SR (MS ___ 30 mg PO Q12H 6. Morphine SR (MS ___ 15 mg PO NOON 7. Prochlorperazine 25 mg PR Q12H:PRN nausea 8. TraZODone 100 mg PO QHS:PRN insomnia 9. Acetaminophen 1000 mg PO Q8H 10. Docusate Sodium 100 mg PO BID 11. Metoclopramide 10 mg PO BID:PRN Headache 12. Senna 8.6 mg PO BID:PRN constipation 13. Lisinopril 10 mg PO DAILY 14. Vitamin D 1000 UNIT PO DAILY 15. Multivitamins 1 TAB PO DAILY 16. Enoxaparin Sodium 40 mg SC Q24H Start: preadmission dose Discharge Medications: 1. Cephalexin 500 mg PO Q6H 2. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain 3. Enoxaparin Sodium 40 mg SC DAILY 3 additional weeks 4. Acetaminophen 1000 mg PO Q8H 5. Allopurinol ___ mg PO DAILY 6. ClonazePAM 0.5-1 mg PO DAILY PRN anxiety 7. Docusate Sodium 100 mg PO BID 8. Lidocaine 5% Patch 1 PTCH TD QAM 9. Lisinopril 10 mg PO DAILY 10. Metoclopramide 10 mg PO BID:PRN Headache 11. Mirtazapine 30 mg PO QHS 12. Morphine SR (MS ___ 15 mg PO NOON 13. Morphine SR (MS ___ 30 mg PO Q12H 14. Multivitamins 1 TAB PO DAILY 15. Prochlorperazine 25 mg PR Q12H:PRN nausea 16. Senna 8.6 mg PO BID:PRN constipation 17. TraZODone 100 mg PO QHS:PRN insomnia 18. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Postoperative hematoma s/p R TKA Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted for postoperative hematoma along the right knee. You underwent an aspiration by interventional radiology. No infection was found but you should continue to take oral antibiotics as prescribed. 1. Please return to the emergency department or notify your physician if you experience any of the following: severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers greater than 101.5, shaking chills, increasing redness or drainage from the incision site, chest pain, shortness of breath or any other concerns. 2. Please follow up with your primary physician regarding this admission and any new medications and refills. 3. Resume your home medications unless otherwise instructed. 4. You have been given medications for pain control. Please do not drive, operate heavy machinery, or drink alcohol while taking these medications. As your pain decreases, take fewer tablets and increase the time between doses. This medication can cause constipation, so you should drink plenty of water daily and take a stool softener (such as Colace) as needed to prevent this side effect. Call your surgeons office 3 days before you are out of medication so that it can be refilled. These medications cannot be called into your pharmacy and must be picked up in the clinic or mailed to your house. Please allow an extra 2 days if you would like your medication mailed to your home. 5. You may not drive a car until cleared to do so by your surgeon. 6. Please call your surgeon's office to schedule or confirm your follow-up appointment. 7. SWELLING: Ice the operative joint 20 minutes at a time, especially after activity or physical therapy. Do not place ice directly on the skin. You may wrap the knee with an ace bandage for added compression. Please DO NOT take any non-steroidal anti-inflammatory medications (NSAIDs such as Celebrex, ibuprofen, Advil, Aleve, Motrin, naproxen etc). 8. ANTICOAGULATION: Please continue your Lovenox for three (3) weeks to help prevent deep vein thrombosis (blood clots). If you were taking Aspirin prior to your surgery, it is OK to continue at your previous dose while taking this medication. 9. WOUND CARE: Please keep your incision clean and dry. It is okay to shower five days after surgery but no tub baths, swimming, or submerging your incision until after your four (4) week checkup. Please place a dry sterile dressing on the wound each day if there is drainage, otherwise leave it open to air. Check wound regularly for signs of infection such as redness or thick yellow drainage. Staples will be removed by your doctor at follow-up appointment approximately 3 weeks after surgery. 10. ___ (once at home): Home ___, dressing changes as instructed, and wound checks. 11. ACTIVITY: Weight bearing as tolerated on the operative extremity. Mobilize with assistive devices (___) if needed. Range of motion at the knee as tolerated. No strenuous exercise or heavy lifting until follow up appointment. Physical Therapy: WBAT RLE No range of motion restrictions Mobilize frequently Treatments Frequency: Dressing changes as needed Wound checks daily Staples to be removed at postoperative visit ICE Followup Instructions: ___

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