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19579305-DS-8
| 19,579,305 | 21,948,430 |
DS
| 8 |
2159-10-09 00:00:00
|
2159-10-10 07:04:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
? TIA
Major Surgical or Invasive Procedure:
left internal carotid cerebral angiogram on ___ with Dr.
___
___ of Present Illness:
This is a ___ woman with a history of obesity and breast cancer
who presents to the ED as a referral from an urgent care clinic
for neurological evaluation for possible TIA. She provides an
excellent history. She reports that her health has been well
lately, except for a mild cold that she has been struggling with
for a few days. She was at home reading yesterday on the couch
when she got up to go to the kitchen to make some oatmeal,
around
3pm. When she got to the kitchen, she put her hands on the
counter and felt that her right hand felt strange. It was
difficult for her to describe this sensation. She explained that
it appears to move involuntarily with small amplitude twitches,
and mimicked athetotic movements of her right fingers. She said
it felt numb but not insensate. She was able to mix her oatmeal
and she was coordinated but her right hand was slow. She noticed
that she felt foggy and clouded, and described it as a sensation
of being "stunned" and "dizzy". She didn't fall and wasn't
stumbling, but her walk back to the couch was deliberate and
slow. She sat down and started to read her book again, and by
this time her oatmeal was cold. But, she noticed that when she
was reading, she had to read every single word slowly, and her
reading speed was reduced. She could comprehend what was being
written, but had difficulty reading quickly. She went back to
the
kitchen, and when she stared out the window, noticed that the
scene was somewhat blurred by a sensation of leaves and foliage.
She covered one eye at a time, and noted that this obscuration
was only present out of the left eye. There was no double
vision,
headache, left sided symptoms, leg symptoms or burning,
numbness.
She returned to herself in an hour, and only decided to seek
medical attention the next morning. Overnight, there were no
other events. Nothing like this has ever happened before. She
denies any classical risk factors for epilepsy such as previous
head trauma or concussion, previous history of febrile seizures,
history of meningitis/encephalitis or a family history of
epilepsy.
Review of systems is negative unless otherwise noted above. She
denies any urinary symptoms, constipation. No palpitations or a
history of stroke, MI or irregular heart rate. She does say that
for a short period of time last night, she heard a whooshing
sound on her left ear that correlated with her pulse.
Past Medical History:
- Breast cancer: diagnosed in ___, ER/PR positive, Her-2neu
negative. S/p radiation and surgery x 2. In remission as far as
we know (please refer to ___ ONC notes). Per patient, no
previous indications to suggest metastatic disease.
- Ethmoid sinus papilloma: Reported an episode previously of a
left eye visual obscurations and was found on MRI to have this
papilloma that returned benign, treated at Mass Eye and Ear
- BCC x 3 removed from face
- Hypertension
Social History:
___
Family History:
A maternal aunt was diagnosed with breast cancer
in her ___. Maternal aunt was diagnosed with throat cancer in
her ___. Maternal aunt was diagnosed with bladder cancer, who
subsequently died from Alzheimer's disease however in her early
___. Mother had an "benign occipital lobe tumor" and brother
with
schizophrenia. Daughter with ADHD and on treatment.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vital signs were 98.8, 71, 138/81, 12, 99%.
In general, patient is awake, cooperative, pleasant and
in no apparent distress. The patient had a NCAT head without
conjunctival icterus. Mucous membranes were moist and oropharynx
is clear of lesions. Neck was supple without masses or
thyromegaly. Chest examination revealed regular heart sounds
without murmurs, and lungs were clear to auscultation
bilaterally. Belly was soft without focal tenderness, and
extremities were warm and well perfused. Skin examination showed
no rashes or lesions. No neck bruits auscultated.
Neurologically, the patient is awake, alert and oriented x 3.
Able to relate history without difficulty. Attentive, able to
name ___ backward without difficulty. Language is fluent with
intact repetition and comprehension. Normal prosody. There were
no paraphasic errors. Pt. was able to name both high and low
frequency objects on the stroke scale protocol. 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. The pt. had good
knowledge
of current events. There was no evidence of apraxia or neglect.
Cranial nerve examination revealed round, equal and reactive
pupils with full visual fields to confrontation. Fundoscopic
examination revealed sharp disc margins without hemorrhages or
exudates. Extraocular movements were full without dysconjugate
gaze, nystagmus or diplopia per report. Facial sensation intact
to pinprick on the face. There was no facial asymmetry, ptosis
or
facial droop. Hearing is intact to finger-rub bilaterally.
Palate
elevates symmetrically, and the strength of trapezii and SCMs
was
___ bilaterally. Tongue was strong bilaterally without atrophy
or
fasiculations.
Strength examination showed normal bulk, tone throughout. No
pronator drift bilaterally. No adventitious movements, such as
tremor, noted. No asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 5 ___ ___ ___ 5 5
R 5 5 ___ ___ ___ 5 5
The sensory examination revealed no deficits to light touch,
pinprick, cold sensation throughout. No extinction to DSS. No
cortical sensory loss on the right hand. Vibration at great toes
was perhaps slightly diminished at ___ bilaterally.
The reflex examination revealed
Bi Tri ___ Pat Ach
L 3 2 3 2 0
R 3 2 3 2 0
Plantar response: Down
Bedside tests of cerebellar function revealed no intention
tremor, dysdiadochokinesia or dysmetria. Gait was narrow based
and steady without truncal ataxia. Tandem gait was normal.
DISCHARGE PHYSICAL EXAM: Unchanged from admisison.
Pertinent Results:
LABS:
___ 02:35PM BLOOD WBC-7.9 RBC-4.71 Hgb-15.2 Hct-42.3 MCV-90
MCH-32.3* MCHC-36.0* RDW-12.2 Plt ___
___ 02:35PM BLOOD Neuts-62.9 ___ Monos-5.2 Eos-3.1
Baso-1.1
___ 02:35PM BLOOD ___ PTT-31.1 ___
___ 02:35PM BLOOD Glucose-98 UreaN-13 Creat-0.6 Na-142
K-3.9 Cl-98 HCO3-32 AnGap-16
___ 10:30AM BLOOD ALT-24 AST-27 LD(LDH)-210 AlkPhos-53
TotBili-1.0
___ 10:30AM BLOOD Albumin-4.6 Calcium-9.7 Phos-3.7 Mg-2.1
Cholest-182
___ 10:30AM BLOOD Triglyc-83 HDL-55 CHOL/HD-3.3 LDLcalc-110
LDLmeas-121
IMAGING:
CXR ___: IMPRESSION: No acute findings in the chest.
CTA HEAD/NECK ___: IMPRESSION:
1. No evidence of acute intracranial abnormalities. MRI would
be more
sensitive for an acute infarction, if clinically indicated.
2. Abnormal appearance of the distal cervical left internal
carotid artery, with a 3 x 3 mm anterolateral pseudoaneurysm 3
cm proximal to the skull base, luminal irregularity between the
pseudoaneurysm and the skull base, and 99% luminal narrowing 1.5
cm proximal to the skull base. These findings could be
posttraumatic or related to a focal connective tissue
abnormality, such as a variant of fibromuscular dysplasia. The
remainder of the cervical and intracranial arteries appear
unremarkable.
MR HEAD W/O CONTRAST ___: IMPRESSION:
1. No acute infarction.
2. Supratentorial white matter signal abnormalities are likely
sequela of chronic small vessel ischemic disease.
LEFT AND RIGHT COMMON CAROTID ARTERY ANGIOGRAM ___:
FINDINGS:
Left common carotid artery arteriogram: There is a long segment
of stenosis of the left mid/distal cervical internal carotid
artery with irregularity of the wall and 95% stenosis of the
segment with a small anteriorly oriented pseudoaneurysm. These
findings are highly suggestive of dissection. In addition,
there is a relatively slow flow into the intracranial segments
of the internal carotid artery and anterior and middle cerebral
arteries. There is no evidence of crossover flow to indicate a
patent posterior communicating artery when injecting in the
right side. The external carotid artery branches appear within
normal limits.
Right common carotid artery arteriogram: There is normal
appearance of the right external and internal carotid arteries.
There is no evidence of stenosis. The intracranial segments of
the internal carotid arteries are normal. The middle and
anterior cerebral arteries appear normal with normal branching
pattern. In addition, there is flow across the midline at the
level of the anterior cerebral arteries in keeping with a patent
anterior communicating artery. When compared to the left common
carotid arteriogram, there is normal flow throughout the entire
cervical, petrous, cavernous, and supraclinoid segments of the
carotid artery and intracranial branches indicating diminished
flow in the contralateral side due to the more proximal
stenosis. The anterior communicating artery is present. The
external carotid artery branches are normal.
Left vertebral artery arteriogram: There is normal appearance
of the
visualized left vertebral artery, basilar artery, and terminal
branches with normal branching.
IMPRESSION:
1. Long segment stenosis of the left mid/distal cervical
internal carotid artery with irregularity of the wall and
overall 95% stenosis of the segment with a small anteriorly
oriented pseudoaneurysm consistent with dissection.
2. Relatively decreased flow throughout the left hemisphere due
to severe stenosis in the cervical internal carotid artery.
3. No angiographic evidence of patent posterior communicating
arteries.
4. Normal right internal carotid, anterior, and middle cerebral
arteries with a patent anterior communicating artery.
MRI SOFT TISSUES/NECK ___: IMPRESSION:
Limited study due to motion degradation. Moderate nonspecific
inflammation in the left carotid space, as previously
demonstrated by CT angiogram and conventional angiogram, which
may be related to known dissection. No evidence of discrete
mass or abnormal enhancement. Continued long term followup with
CT and CTA of the neck is recommended.
Brief Hospital Course:
___ w hx of breast cancer and HTN presented with left hand
numbness, clumsiness/weakness. Found to have left ICA 99%
stenosis close to skull base on CTA, not amenable to carotid
endarterectomy. Angiogram suggestive of dissection. She has no
history of neck injury or any deep neck softtissue manipulation,
any unusualyoga movements or other strain put onto her neck.
Hospital course as follows:
1) Neuro: Presented with transient, spontaneously improving left
hand numbness, clumsiness/weakness. MRI ___ revealed
sequelae of chronic small vessel ischemic disease, but did not
reveal infarct or hemorrhage. However, CTA on ___ revealed a
99% stenosis of the left internal carotid artery 1.5 cm proximal
to the skull base. Per vascular surgery consult service, this
lesion not amenable to re-vascularization via carotid
endarterectomy (in part given proximity to base of skull).
Angiogram on ___ identifed 95% stenosis and pseudoaneurysm,
suggestive of dissection. An MRI on ___ did not identify
obvious extra-vascular source of compression to cause this
stenosis (e.g. neoplasm). However, this study was limited by
motion degradation and lack of IV contrast, thus plan for MRI
head/neck with and without contrast approximately one week after
discharge. Given her degree of stenosis, she was initiated on
systemic anticoagulation (initially via heparin gtt,
transitioned to enoxaparin 80mg SQ BID shortly before
discharge). She was started on warfarin on ___, with a 10mg
loading dose. She was instructed to continue 5mg of warfarin
daily until reaching a therapeutic INR of 2.0-3.0. Next INR
check to be performed ___. Instructed to follow-up with PCP
office for ___ management (this was verbally communicated
to PCP's office as well). As her presentation was initially
concerning for acute stroke, cholesterol levels were checked,
revealing an LDL of 121. She has been started on atorvastatin
80mg daily.
2) CV: Hx of well-controlled HTN, on only 12.5mg HCTZ at home.
Restarted home anti-hypertensives on ___.
TRANSITIONAL ISSUES:
- ANTICOAGULATION: Patient set up with ___ follow-up
via PCP's office (Dr. ___ as above.
- MRI: MRI with and without contrast tentatively scheduled for
___. This study to be performed to rule-out possibility of
extra-vascular compression leading to her significant left ICA
stenosis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. anastrozole *NF* 1 mg Oral daily
2. Calcium Carbonate 300 mg PO DAILY
3. Hydrochlorothiazide 12.5 mg PO DAILY
Hold for sBP <100, HR <60
4. Vitamin D 400 UNIT PO DAILY
Discharge Medications:
1. anastrozole *NF* 1 mg Oral daily
2. Calcium Carbonate 300 mg PO DAILY
3. Hydrochlorothiazide 12.5 mg PO DAILY
4. Vitamin D 400 UNIT PO DAILY
5. Atorvastatin 80 mg PO DAILY
RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*90
Tablet Refills:*0
6. Enoxaparin Sodium 80 mg SC BID
RX *enoxaparin 80 mg/0.8 mL 80 mg SQ twice a day Disp #*20
Syringe Refills:*0
7. Warfarin 5 mg PO DAILY16
RX *warfarin 2 mg 2.5 tablet(s) by mouth daily Disp #*90 Tablet
Refills:*0
8. Outpatient Lab Work
Lab test: ___
ICD-9: 433.1
Fax results to: Dr. ___, fax ___
Call ___ with questions.
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
- left internal carotid artery stenosis
SECONDARY:
- hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
Thank you for choosing ___ for your medical care. You were
admitted with transient hand numbness and weakness, which has
fortunately resolved. You had several imaging studies of your
brain, including CT, angiogram, and MRI as part of your workup.
These studies revealed a stenosis (narrowing) of a portion of
your left internal carotid artery (one of the arteries which
supplies blood to the brain). The artery is not completely
blocked. This narrowing appears to be caused by a dissection in
the wall of the vessel. This means there is an inappropriate
path where blood is flowing, leading to development of a blood
clot and compression on the vessel. To prevent further
propagation of this clot, you have been started on a new
medication, called warfarin (Coumadin).
Coumadin takes several days to reach its maximum level of
activity. You will need to take an injection drug called Lovenox
(enoxaparin) twice per day while warfarin takes effect. Please
continue to take the remainder of your medications as previously
described.
Please follow-up with your primary care doctor (___)
and the neurology service as below. Dr. ___ will need to
monitor your INR, which is a marker of warfarin activity. It is
important you have your INR checked on ___. Please
contact your PCP's office to arrange this.
You will need to have a follow-up MRI with contrast on ___.
You may call to reschedule this as necessary.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these ___
- sudden partial or complete loss of vision
- sudden loss of the ability to speak words from your mouth
- sudden loss of the ability to understand others speaking to
you
- sudden weakness of one side of the ___
- sudden drooping of one side of the ___
- sudden loss of sensation of one side of the body
- sudden difficulty pronouncing words (slurring of
___
- sudden blurring or doubling of ___
- sudden onset of vertigo (sensation of your environment
spinning around ___
- sudden clumsiness of the arm and leg on one side or sudden
tendency to fall to one side (left or right)
- sudden severe headache accompanied by the inability to stay
awake
It was a pleasure providing you with care during this
hospitalization.
Followup Instructions:
___
|
19579658-DS-10
| 19,579,658 | 28,306,256 |
DS
| 10 |
2116-08-23 00:00:00
|
2116-08-25 14:43:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
heparin
Attending: ___.
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ PMH of ___, scleroderma on etanercept and plaquenil, MDS on
___, bilateral AKA from PVD, HTN, and HLD who presents as a
transfer from ___ ER after presenting for
complaints of SOB worsening over the past two days with elevated
troponin of 0.38 (<0.08) without noted EKG changes and BNP 2653
(<180). Denies any episode of CP or numbness/tingling. Has
baseline orthopnea that has been unchanged, requiring two to
three pillows as she lays down in a hospital bed. Does report
mild relief during episodes when sitting up but that these
episodes resolve after ___ minutes. Had an episode 1 week
prior but has been now occurring last two days in a row with
about 3 episodes. Does not ambulate due to her bilateral AKA
with no DOE reported. Has not noticed in ___ edema and no change
in weight. Denies any upper respiratory sx with no cough. Has
scleroderma that has been progressive and is planned to get
esophageal ballooning for her stenosis this week, but states
that she has not had progressive decline in her breathing,
though no recent PFTs obtained. Did recently see her
rheumatologist with no plans to change her treatment.
ED COURSE
In the ED intial vitals were: 97.9 88 101/62 18 99% RA
EKG: NSR, possible atrial tach, ventricular rate of 89, no acute
ST changes, stable from EKGs available here and in ___ ED
Labs/studies notable for: Trop 0.09, Lactate 3.2
Patient was given: None
Vitals on transfer: 97.9 87 106/61 20 100% RA
On the floor, patient with no specific complaints. Currently,
she is chest pain free with no SOB reported. No palpitations. No
n/v or pain radiating to the chest.
Past Medical History:
1. CARDIAC RISK FACTORS: +hypertension, +dyslipidemia
2. CARDIAC HISTORY:
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
___
Scleroderma with arthritis, GERD, dysphagia and Raynaud's
MDS treated with ___
PVD
Depression
Anxiety
Insomnia
Osteoporosis
RA
Social History:
___
Family History:
Mother with heart failure.
No other family history of early MI, arrhythmia,
cardiomyopathies, or sudden cardiac death; otherwise
non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: 97.7 120/77 86 18 100/RA
GENERAL: Chronically ill appearing, elderly female lying in bed
in NAD. Breathing comfortably. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP of 3 cm above sternal angle.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No murmurs/rubs/gallops. No thrills,
lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: Bilateral AKA. No lower extremity edema.
DISCHARGE PHYSICAL EXAMINATION
GENERAL: Chronically ill appearing, elderly female lying in bed
in NAD. Breathing comfortably. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple with JVP 6cm
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. irregular, normal S1, S2. No murmurs/rubs/gallops. No
heavees, thrills, lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Normal
work of breathing. No crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: Bilateral AKA. No lower extremity edema. Sclerotic
fingers.
Pertinent Results:
ADMISSION LABS
___ 03:00PM BLOOD WBC-3.2* RBC-3.00* Hgb-10.4* Hct-32.5*
MCV-108* MCH-34.7* MCHC-32.0 RDW-19.6* RDWSD-77.1* Plt ___
___ 03:00PM BLOOD Neuts-64 Bands-0 ___ Monos-3* Eos-0
Baso-2* ___ Myelos-0 AbsNeut-2.05 AbsLymp-0.99*
AbsMono-0.10* AbsEos-0.00* AbsBaso-0.06
___ 06:00AM BLOOD ___ PTT-29.8 ___
___ 03:00PM BLOOD Glucose-94 UreaN-20 Creat-0.7 Na-136
K-4.7 Cl-102 HCO3-22 AnGap-17
___ 11:18PM BLOOD CK(CPK)-46
___ 03:00PM BLOOD cTropnT-0.09* ___
___ 11:18PM BLOOD CK-MB-8 cTropnT-0.18*
___ 06:00AM BLOOD CK-MB-9 cTropnT-0.23*
___ 01:10PM BLOOD CK-MB-8 cTropnT-0.15*
___ 06:00AM BLOOD Calcium-9.2 Phos-4.4 Mg-1.8
___ 03:00PM BLOOD VitB12-782 Folate-GREATER TH
___ 01:10PM BLOOD %HbA1c-5.0 eAG-97
___ 03:08PM BLOOD Lactate-3.2*
___ 09:48PM BLOOD Lactate-1.3
___ 06:32AM BLOOD Lactate-1.5
DISCHARGE LABS
___ 07:30AM BLOOD WBC-4.4 RBC-3.03* Hgb-10.4* Hct-32.8*
MCV-108* MCH-34.3* MCHC-31.7* RDW-19.7* RDWSD-76.9* Plt ___
___ 07:30AM BLOOD Glucose-83 UreaN-21* Creat-0.7 Na-135
K-4.6 Cl-102 HCO3-25 AnGap-13
___ 03:00PM BLOOD VitB12-782 Folate-GREATER TH
___ 01:10PM BLOOD %HbA1c-5.0 eAG-97
___ 01:10PM BLOOD Triglyc-78 HDL-46 CHOL/HD-2.3 LDLcalc-45
IMAGING:
___ CT CHEST
FINDINGS: MEDIASTINUM: Heterogeneous appearance of the thyroid
with a nodule measuring 12 x 12 mm. No pathologically enlarged
supraclavicular, axillary, hilar or mediastinal lymph nodes.
HEART AND GREAT VESSELS: The aorta is not aneurysmal and the
main pulmonary artery measures 3.6 cm The heart size is globally
moderate and there is no pericardial effusion. Severe
atherosclerotic calcifications of the thoracic aorta and of the
coronary arteries. Moderate severe calcifications of the aortic
valve and severe of the mitral annulus. Focal attenuation of the
cardiac blood pool can be seen with anemia. PLEURA: There is no
pneumothorax. Small bilateral pleural effusions. LUNGS AND
TRACHEOBRONCHIAL TREE: The airways are patent. He asymmetric
elevation of the left hemidiaphragm with adjacent atelectasis.
No substantial bronchiectasis. No honeycomb formation. No acute
parenchymal consolidation. Subpleural 3 mm nodule in the right
upper lobe (04:55). Scattered calcified granulomas. Mild
centrilobular ground-glass opacity, slightly more pronounced in
the upper lobes, is somewhat non-specific. Given the patulous
esophagus, this may be pneumonitis from recurrent aspiration or
mild atypical infection including viral or bacterial. BONES AND
CHEST WALL: Numerous severe compression deformities involving
multiple vertebral bodies are age indeterminate. Notably, a
moderate compression deformity is seen of T5. More severe
deformities are seen involving T7-T10 (series 602b, image 50),
as well as L1 (series 602b, image 55). Chronic-appearing sternal
fracture with evidence of healing (series 602b, image 60).
Multiple bilateral healing rib fractures are also seen. UPPER
ABDOMEN: Although this study is not designed for the evaluation
of subdiaphragmatic structures, the esophagus is patulous and
fluid-filled throughout its course. The right kidney is
atrophic. The abdominal aorta is also heavily calcified. The
remaining upper abdomen is otherwise unremarkable. IMPRESSION:
Mild centrilobular ground-glass opacity, slightly more
pronounced in the upper lobes, is somewhat non-specific and not
suggestive of scleroderma related ILD. Given the patulous
esophagus, this may be pneumonitis from recurrent aspiration or
mild atypical infection including viral or bacterial, in the
appropriate clinical setting. Moderate to severe cardiomegaly,
severe coronary artery disease, and pulmonary artery
enlargement. Multiple wedge compression fractures, sternal and
healing rib fractures.
___ CTPE
FINDINGS: Good quality examination, with the pulmonary artery
opacifying up to 800 Hounsfield units. There is no evidence of
central, lobar, segmental or subsegmental pulmonary embolism.
The pulmonary artery is dilated however measuring up to 3.5 cm,
which is similar to measurement of the ascending thoracic aorta.
There is a background of moderate to severe atherosclerosis
involving the aorta, and the ascending aorta is ectatic,
measuring up to 3.5 cm. There is moderate to severe
cardiomegaly, with dilatation of all 4 chambers. The left lower
thyroid lobe nodule. There is no evidence of axillary,
mediastinal, or hilar lymphadenopathy. The esophagus is dilated.
Small bilateral pleural effusions no pericardial effusion. The
central tracheobronchial tree is patent. Multifocal areas of
ground-glass opacities are noted diffusely within the lungs,
with relative peripheral sparing, likely related to degree of
inspiration. The right kidney is atrophic. Significant
degenerative changes of the thoracolumbar spine, with vertebral
body compression fractures. There is an old healed sternal
fracture and old healed right rib fractures. IMPRESSION: No
evidence of pulmonary embolism. Dilated esophagus, overall
similar compared to previous, maybe ___ esophagus. There is
contrast extending to the stomach. Diffuse ground-glass
opacities with peripheral sparing, likely related to degree of
inspiration. Moderate to severe cardiomegaly.
___ ECHO
Conclusions
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is ___ mmHg. There is mild symmetric left ventricular
hypertrophy with normal cavity size. Overall left ventricular
systolic function is moderately depressed (LVEF= 35 %). The
right ventricular free wall is hypertrophied. Right ventricular
chamber size is normal with mild global free wall hypokinesis.
The aortic valve leaflets are mildly thickened (?#). Mild (1+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Moderate (2+) mitral regurgitation is seen.
The tricuspid valve leaflets are mildly thickened. There is mild
pulmonary artery systolic hypertension. The end-diastolic
pulmonic regurgitation velocity is increased suggesting
pulmonary artery diastolic hypertension. There is no pericardial
effusion.
IMPRESSION: Moderately depressed global left ventricular
systolic function. Mild aortic regurgitation. Moderate mitral
regurgitation. Mild pulmonary artery systolic and diastolic
hypertension.
Brief Hospital Course:
___ year-old female with medical history of sCHF, scleroderma on
etanercept and plaquenil, MDS, bilateral AKA from PVD, HTN, and
HLD who presents as a transfer from ___ ER after
presenting for complaints of SOB worsening over the past two
days with elevated troponin of 0.38 (<0.08) and BNP 2653.
# Atrial tachycardia: Intermittent episodes of heart rates to
170s. EP consulted and on review of EKG and telemetry, it was
noted that her rhythm was atrial tachycardia with 2:1 conduction
and intermittently flipping into 1:1 conduction with increased
activity resulting in her symptoms. No new ischemic changes. BNP
was 2653 at OSH (ref<180). CXR and CTPE unremarkable for
evidence of significant pulmonary edema. Trop-I of 0.38 (ref
<0.08), repeat here dropped to 0.09 but then increased secondary
to tachycardia-related demand (and then downtrended). She was
rate-controlled with metoprolol and titrated for blood pressure
with no further episodes of tachycardia. The team recommended
initiating anticoagulation to reduce risk of stroke. The patient
had prior heparin-induced thrombocytopenia so the decision was
made to anticoagulate her with apixaban. Cardiology follow-up
arranged.
# Chronic systolic congestive heart failure: ECHO showed LVEF
35% with mild/moderate valvular disease and pulmonary
hypertension (see attached report) unchanged from prior study in
___. Initially diuresed with IV lasix 20mg once on admission
due to concern for pulmonary edema as a cause of her dyspnea
given elevated BNP however imaging and exam did not support
volume overload and atrial tachycardia was felt to be a more
likely source of her symptoms.
# History of DVT: s/p bilateral AKA. Per patient has been on ASA
and Plavix for this reason which were discontinued as patient
was started on apixaban. No history of coronary artery stents.
Allergic to heparin (prior HIT). CTPE done given high risk for
clot given history along with connective tissue disorder and
limited mobility. Negative for pulmonary embolus but did show
spinal compression fractures which the patient stated were old.
# CAD: increased home simvastatin to atorvastatin 80mg, on
beta-blocker.
# Scleroderma: recent report from Opthalmology indicating that
she should discontinue Plaquenil. Held during admission and
arranged Rheumatology follow-up. Speech and swallow evaluated
patient and recommended regular diet with small bites. Continued
PPI.
# Macrocytic Anemia: folate and B12 levels checked without any
evidence of deficiency. Continued on folic acid.
# HTN: continued home lisinopril 2.5mg once daily
# Rheumatoid arthritis: continued home prednisone 5mg daily
# Depression: continued home sertraline
# MDS: continued home lenolidamide
Transitional Issues
====================
# Atrial tachycardia: started on apixaban (discontinued ASA and
plavix) and metoprolol. F/u HR and BP at next visit. pMIBI as an
outpatient for ischemic evaluation.
# Scleroderma: recent Optho recommends stopping Plaquenil so the
medication was held in-house. Would recommend addressing issue
with Rheumatologist.
# Incidental:
- Thyroid nodule noted on CT Chest
- Ensure follow-up with GI for treatment of stenosis that had
been planned this week
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Simvastatin 40 mg PO QPM
2. Aspirin 81 mg PO DAILY
3. Lenalidomide 2.5 mg PO TWICE A WEEK
4. Lisinopril 2.5 mg PO DAILY
5. Pantoprazole 40 mg PO Q24H
6. Lorazepam 1 mg PO QHS:PRN Insomnia
7. Clopidogrel 75 mg PO DAILY
8. Enbrel (etanercept) 50 mg/mL (0.98 mL) subcutaneous 1X/WEEK
9. Hydroxychloroquine Sulfate 200 mg PO BID
10. PredniSONE 5 mg PO DAILY
11. FoLIC Acid 1 mg PO DAILY
12. Metoprolol Succinate XL 12.5 mg PO DAILY
13. Sertraline 50 mg PO DAILY
14. Vitamin D 500 UNIT PO BID
15. TraMADOL (Ultram) 50 mg PO Q6H:PRN Pain
16. Morphine Sulfate (Oral Soln.) 10 mg PO Q4H:PRN Moderate pain
17. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN
Moderate pain
Discharge Medications:
1. Apixaban 2.5 mg PO BID
RX *apixaban [Eliquis] 2.5 mg 1 tablet(s) by mouth once daily
Disp #*30 Tablet Refills:*1
2. FoLIC Acid 1 mg PO DAILY
3. Lisinopril 2.5 mg PO DAILY
4. Lorazepam 1 mg PO QHS:PRN Insomnia
5. Pantoprazole 40 mg PO Q24H
6. PredniSONE 5 mg PO DAILY
7. Sertraline 50 mg PO DAILY
8. Vitamin D 500 UNIT PO BID
9. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*1
10. Enbrel (etanercept) 50 mg/mL (0.98 mL) subcutaneous 1X/WEEK
11. Lenalidomide 2.5 mg PO TWICE A WEEK
12. Morphine Sulfate (Oral Soln.) 10 mg PO Q4H:PRN Moderate pain
13. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN
Moderate pain
14. Metoprolol Succinate XL 12.5 mg PO BID
RX *metoprolol succinate 25 mg 0.5 (One half) tablet(s) by mouth
twice daily Disp #*30 Tablet Refills:*0
15. TraMADOL (Ultram) 25 mg PO Q12H:PRN pain
RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth every 12
hours Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnoses:
Atrial tachycardia
NSTEMI, type 2
Chronic systolic congestive heart failure
Hypertension
Secondary diagnoses:
Scleroderma
Rheumatoid arthritis
MDS
Discharge Condition:
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Discharge Instructions:
Ms. ___,
You were admitted to ___ for evaluation and treatment of your
chest pain and shortness of breath. You were found to have a
arrhythmia that was the cause of your symptoms. You were given
medicine to help control your heart rate (metoprolol) as well as
a medication to thin your blood (apixaban).
It was a pleasure taking care of you during your stay- we wish
you all the best!
- Your ___ Cardiology Team
Followup Instructions:
___
|
19579708-DS-17
| 19,579,708 | 25,584,855 |
DS
| 17 |
2114-10-27 00:00:00
|
2114-11-07 15:03:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
___ Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a healthy ___ year old male who was brought in by
ambulance from his assisted living after he was noted to appear
confused and not his regular self. He reports walking out of his
room and others noticing he looked "bad". For the last 3 weeks
he has had lower back pain which would come and go, he says it
was more dull, sometimes sharp, denies dysuria or increased
urinary frequency. He had no cough, no chest pain, no shortness
of breath, just generalized malaise. He notes no fevers, no sick
contacts, no recent travel.
Past Medical History:
Hypertension
SVT
GERD
Mild cognitive impairment MOCA ___ was ___
(L) cataract ___
Social History:
___
Family History:
Sister may have had cancer late in life
Physical Exam:
VS: 97.5, 143/57, 80, 18, 100% on 2L
Gen: NAD, laying in bed, comfortable
HEENT: AT/NC, no icterus, +pallor
Neck: soft and supple
CV: RRR, no m/g/r
Resp: CTAB, slightly decreased bibasilar breath sounds
GI: +BS, NT, ND
Skin: intact
Neuro: grossly intact, muscle strength equal bilaterally
DISCHARGE
Vitals: afeb x24hr Tc 98.3 164/73 71 18 96% RA
General: AAOx2, comfortable and seen in ___ chair
HEENT: Moist mucous membranes
Neck: supple, no LAD, no JVP elevation
Lungs: Comfortable, no accessory muscle use or retractions,
CTAB, no w/r/r
CV: RRR, normal S1 and S2
Abdomen: NABS, soft, nondistended, nontender. No HSM.
GU: no foley
Ext: Thin extremities, WWP. 2+ peripheral pulses. No edema.
Pertinent Results:
___ 10:20AM BLOOD WBC-6.7 RBC-2.74* Hgb-9.3* Hct-27.7*
MCV-101* MCH-33.9* MCHC-33.5 RDW-17.3* Plt ___
___ 08:10AM BLOOD WBC-13.6*# RBC-2.54* Hgb-8.6* Hct-26.7*
MCV-105* MCH-34.1* MCHC-32.4 RDW-17.2* Plt ___
___ 10:30AM BLOOD WBC-12.4* RBC-2.45* Hgb-8.2* Hct-24.8*
MCV-101* MCH-33.4* MCHC-33.1 RDW-17.3* Plt ___
___ 10:20AM BLOOD Neuts-80* Bands-2 Lymphs-14* Monos-2
Eos-0 Baso-0 Atyps-1* ___ Myelos-0 NRBC-1* Plasma-1*
___ 10:20AM BLOOD Glucose-124* UreaN-40* Creat-2.2* Na-134
K-4.6 Cl-98 HCO3-22 AnGap-19
___ 06:10AM BLOOD Glucose-101* UreaN-42* Creat-2.0* Na-142
K-3.6 Cl-112* HCO3-21* AnGap-13
___ 10:20AM BLOOD CK-MB-3
___ 10:20AM BLOOD cTropnT-0.05*
___ 11:59PM BLOOD CK-MB-6 cTropnT-0.06*
___ 10:20AM BLOOD ALT-27 AST-42* AlkPhos-80 TotBili-0.5
___ 10:20AM BLOOD Albumin-3.2* Calcium-10.4* Phos-3.4
Mg-1.6
___ 10:30AM BLOOD Lactate-2.8*
___ 10:30AM URINE RBC-0 WBC-2 Bacteri-NONE Yeast-NONE
Epi-<1
___ 10:30AM URINE Blood-MOD Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
MICRO
___ 10:40 am BLOOD CULTURE #2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE NEGATIVE.
Beta-lactamse negative: presumptively sensitive to
ampicillin.
Confirmation should be requested in cases of treatment
failure in
life-threatening infections..
Aerobic Bottle Gram Stain (Final ___:
GRAM NEGATIVE ROD(S).
Reported to and read back by ___ ___ ___
9:40AM.
___ Blood culture No Growth
IMAGING
CT HEad
There is no fracture. The mastoid air cells and middle ear
cavities are clear. Minimal soft tissue in the external auditory
canals bilaterally is likely cerumen. There is a small mucous
retention cyst in the left sphenoid sinus, and mild mucosal
thickening in the right maxillary sinus and right frontal sinus.
IMPRESSION:
No evidence of an acute intracranial abnormality.
CXR
The lungs are normally expanded. There are opacities in the
right mid lung and left retrocardiac region, new since CT of
___. There is no large pleural
effusion or pneumothorax. The heart is mildly enlarged.
IMPRESSION:
Right middle lobe and left lower lobe opacities concerning for
multifocal
pneumonia versus aspiration pneumonitis.
Renal Ultrasound
No hydronephrosis. Scant trace of perinephric fluid
incidentally noted at the lower pole of the right kidney.
Brief Hospital Course:
Healthy ___ year old independently living male presents with
confusion, found to have multifocal infiltrate on CXR,
w/elevated creatinine which is unclear if chronic or ___.
# Multifocal pna: Improved with ceftriaxone, transitioned to
cefpodoxime and noted to be afebrile with normal room air
saturation. H flu growing in blood, sensitivities not routinely
run, discharged on ___efpodoxime.
# Delirium: Likely ___ acute illness, excellent supprotive
reorienting care with family and nursing, maximing sleep wake
etc. Doesn't seem constipated, no pain, not retaining urine.
Discaharged ___ oriented to place and month with 24 hr care in
place.
# Renal Insufficiency: Cr up 2.2 from 1.2, likely dehydration
though not improved with 3L NS. Despite fluid resuscitation not
improving; renal u/s negative for obstruction, this may be new
baseline.
# Anemia: Baseline 30, here 27->25 with dilution, pancytopenia
raises concern for bone marrow suppression, electropheresis was
held considering age and question of therapeutic benefit to
quality of life if detected.
TRANSITIONAL ISSUES:
# Resolution of delirium at ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 50 mg PO DAILY
2. Mirtazapine 15 mg PO QHS
3. Metoprolol Succinate XL 25 mg PO DAILY:PRN palpitations
4. Omeprazole 20 mg PO DAILY
5. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Atenolol 50 mg PO DAILY
2. Mirtazapine 15 mg PO QHS
3. Cefpodoxime Proxetil 400 mg PO Q24H
RX *cefpodoxime 200 mg 2 tablet(s) by mouth once daily Disp #*10
Tablet Refills:*0
4. Aspirin 81 mg PO DAILY
5. Metoprolol Succinate XL 25 mg PO DAILY:PRN palpitations
6. Omeprazole 20 mg PO DAILY
Discharge Disposition:
___ With Service
Facility:
___
Discharge Diagnosis:
Pneumonia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure participating in your care at ___
___.
You were admitted with a pneumonia and have improved with
antibiotics. You had some confusion, which is common when very
ill in the hospital, and someone will help you around the house
to stay safe.
Please continue to take cefpodoxime every day until you run out
of tablets.
Followup Instructions:
___
|
19579708-DS-18
| 19,579,708 | 22,450,527 |
DS
| 18 |
2115-02-24 00:00:00
|
2115-02-25 14:55:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Quinolones / Demerol
Attending: ___.
Chief Complaint:
Bilateral Subdural Hematomas.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mr. ___ is a ___ year-old male with history of dementia,
CKD, Anemia, GERD, HTN, and SVT, on Aspirin 81mg, who was
admitted to a nursing facility yesterday after a one-week
history
of failure to thrive. This morning, he was found on the ground
by
nursing staff with a left-sided forehead laceration. EMS was
activated and he was brought to ___ ED. Head CT was performed
and revealed small acute bilateral SDH without significant mass
effect or midline shift. The patient has been confused, and is a
poor historian. He does not recall the events surrounding the
fall. Denies headache or visual changes. History obtained from
ED
& PCP records secondary to patient's confusion.
Past Medical History:
Hypertension
SVT
GERD
Mild cognitive impairment MOCA ___ was ___
(L) cataract ___
Social History:
___
Family History:
Sister may have had cancer late in life
Physical Exam:
PHYSICAL EXAMINATION ON ADMISSION:
O: T 98.7 HR 74 BP 121/60 O2 97% (RA)
Gen: Comfortable, NAD. Thin, frail appearing.
HEENT: Left periorbital ecchymosis with adjacent laceration.
Neck: Supple. Non-tender to palpation. C-Collar in place.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and attentive. Oriented to self only.
Follows intermittent commands. Speech clear but soft, no
dysarthria.
Cranial Nerves:
I: Not assessed
II: Pupils equal, reactive (3->2).
III, IV, VI: No gaze deviation. EOMs grossly intact although not
participating in examination.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Decreased hearing bilaterally.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No pronator drift. Very
tremulous in upper extremities. Strength full power ___
throughout.
Sensation: Grossly intact to light touch.
Toes downgoing bilaterally.
PHYSICAL EXAMINATION ON DISCHARGE:
Expired
Pertinent Results:
Head CT without Contrast: ___
1. Bilateral subdural hematomas without mass-effect.
2. Left orbital lateral wall cortical irregularity with
overlying soft tissue swelling, possibly representing a
nondisplaced lateral orbital wall fracture.
CT C Spine: ___
No evidence for malalignment or fracture.
CT Sinus/Face: ___
1. Interval increase in size of left subdural hematoma, now
measuring 1.6 cm wide, previously 6 mm. New effacement of
adjacent sulci and left lateral ventricle as well as 5 mm
rightward shift of the normally midline structures.
2. Incompletely imaged right subdural hematoma appears grossly
stable.
3. New intraventricular extension of hemorrhage into the left
lateral
ventricle and increased subarachnoid blood within the left
quadrigeminal plate cistern.
4. Fracture of the left lateral orbital wall and left-sided
periorbital
hematoma, unchanged.
CT Head without Contrast: ___
1. Increased size of the right subdural hematoma.
2. The left subdural hematoma is difficult to compare to the CT
sinus from approximately the 8 hr prior, but appears grossly
unchanged, with extension into the left lateral ventricle and
quadrigeminal plate cistern.
3. Rightward shift of normally midline structures is decreased,
now measuring 2 mm (previously 5 mm).
ADMISSION LABS
========================
___ 09:20AM BLOOD WBC-5.3# RBC-2.30* Hgb-8.1* Hct-22.9*
MCV-100* MCH-35.1* MCHC-35.3* RDW-16.7* Plt Ct-91*
___ 09:20AM BLOOD Glucose-112* UreaN-56* Creat-3.2*# Na-138
K-4.2 Cl-102 HCO3-19* AnGap-21*
___ 01:58AM BLOOD Calcium-9.5 Phos-6.4*# Mg-1.9 Iron-24*
___ 09:48AM BLOOD Lactate-2.9*
Brief Hospital Course:
The patient was admitted to the trauma ICU for close monitoring
on the day of admission, ___. He underwent a CT of the
orbits which showed an increase in the size of the left SDH with
shift and IVH. He received 1 pack of platelets with Lasix. The
medicine service were consulted for CKD and for the syncopal
event. No neurosurgical intervention.
On ___, the patient's neurologic examination remained stable.
His Hct was 18.1 and he received 1-unit of pRBCs. A repeat Hct
was 21.0. He underwent a repeat non-contrast head CT which
showed stable ___
Patient also developed pneumonia which was treated with
azithromycin and ceftriaxone initially for 4 days and stopped
after family decided on hospice care given lack of
responsiveness and his goals of care. He also developed acute
kidney injury which resolved with fluids. His mental status was
altered, responsive but unable to hold a conversation or follow
instructions.
After discussion with his family (daughters), it was decided to
make him DNR/DNI and also transition to hospice care with no
desire for ICU transfer and made CMO.
He passed away on ___ at 7:30AM
# TRANSITIONAL ISSUES
===========================
- Expired on ___ at 7:30am
Medications on Admission:
Aspirin 81mg PO daily
Prilosec 20mg PO daily
Anusol-HC 25mg PR BID
Atenolol 50mg PO daily
Metorolol 12.5mg PO PRN palpitations
Remeron 15mg PO daily
Centrum 1 tablet PO daily
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary diagnosis:
Bilateral Subdural Hematoma
Intraventricular Hemorrhage
Acute kidney injury
Altered Mental status
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Mr ___,
You were admitted after a fall which caused you to have a bleed
in your head. You also were treated for a pneumonia. Your mental
status did not improve after hospitalization and after
discussion with your family, you were made DNR/DNI and evaluated
by hospice care and made comfort measures only.
(Mr ___ passed away on ___ AM at 7:30Am in the hospital.)
It was a pleasure being part of your care.
Your ___ team
Followup Instructions:
___
|
19580035-DS-4
| 19,580,035 | 29,360,610 |
DS
| 4 |
2145-08-03 00:00:00
|
2145-08-11 15:51:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
left ankle pain
Major Surgical or Invasive Procedure:
___: Open reduction internal fixation, left ankle.
History of Present Illness:
___ yo Female who was walking today when she twisted her left
ankle. No head strike or LOC. Unable to ambulate. Brought to OSH
where xrays showed left bimall ankle fx/dislocation. Was
relocated and splinted and tx to ___ for further evaluation.
Stable upon arrival.
Past Medical History:
lumbar fusion x 3 ___. She reports that after
her ___ back surgery she had a left foot drop
Hep C
Depression/Anxiety
Social History:
___
Family History:
nc
Physical Exam:
left lower extremity
In splint, toes slightly swollen
Fires ___, FHL
SILT sp/p/s/s
WWP
Pertinent Results:
___ 01:30PM BLOOD WBC-9.3 RBC-3.71* Hgb-11.8* Hct-35.4*
MCV-96 MCH-31.8 MCHC-33.3 RDW-12.5 Plt ___
___ 04:25AM BLOOD WBC-10.5 RBC-3.93* Hgb-12.7 Hct-37.1
MCV-95 MCH-32.3* MCHC-34.2 RDW-12.5 Plt ___
___ 01:30PM BLOOD Neuts-66.7 ___ Monos-5.3 Eos-2.2
Baso-0.2
___ 04:25AM BLOOD Neuts-70.0 ___ Monos-3.4 Eos-2.6
Baso-0.6
___ 01:30PM BLOOD Plt ___
___ 04:25AM BLOOD ___ PTT-26.5 ___
___ 01:30PM BLOOD Glucose-111* UreaN-10 Creat-0.7 Na-136
K-4.0 Cl-97 HCO___-29 AnGap-14
___ 04:25AM BLOOD GreenHd-HOLD
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have left ankle fracture dislocation and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for ORIF left ankle, which the patient
tolerated well (for full details please see the separately
dictated operative report). The patient was taken from the OR to
the PACU in stable condition and after recovery from anesthesia
was transferred to the floor. The patient was initially given
IV fluids and IV pain medications, and progressed to a regular
diet and oral medications by POD#1. The patient was given
perioperative antibiotics and anticoagulation per routine. The
patients home medications were continued throughout this
hospitalization. The patient worked with ___ who determined that
discharge to home was appropriate. The ___ hospital course
was otherwise unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is TDWB in the left lower extremity
extremity, and will be discharged on lovenox for DVT
prophylaxis. The patient will follow up in two weeks per
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course, and
all questions were answered prior to discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. fesoterodine *NF* 4 mg Oral QHS
2. Zolpidem Tartrate 10 mg PO HS Insomnia
3. Pristiq *NF* (desvenlafaxine succinate) 100 mg Oral QD
4. ALPRAZolam 1 mg PO TID:PRN anxiety
5. Caltrate 600 + D *NF* (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit Oral QD
6. Soma *NF* (carisoprodol) 350 mg Oral QHS
7. OxycoDONE (Immediate Release) 10 mg PO Q6H:PRN Pain
8. QUEtiapine Fumarate 600 mg PO QHS
Discharge Medications:
1. ALPRAZolam 1 mg PO TID
2. fesoterodine *NF* 4 mg Oral QHS Reason for Ordering: Wish to
maintain preadmission medication while hospitalized, as there is
no acceptable substitute drug product available on formulary.
3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
4. Pristiq *NF* (desvenlafaxine succinate) 100 mg Oral QHS
Reason for Ordering: Wish to maintain preadmission medication
while hospitalized, as there is no acceptable substitute drug
product available on formulary.
5. Soma *NF* (carisoprodol) 350 mg Oral QHS Reason for Ordering:
Wish to maintain preadmission medication while hospitalized, as
there is no acceptable substitute drug product available on
formulary.
6. Zolpidem Tartrate 10 mg PO HS:PRN Insomnia
7. Enoxaparin Sodium 40 mg SC Q24H Duration: 2 Weeks
RX *enoxaparin 40 mg/0.4 mL 40 mg sc daily Disp #*14 Syringe
Refills:*0
8. Caltrate 600 + D *NF* (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit Oral QD
9. QUEtiapine Fumarate 600 mg PO QHS
10. Tolterodine 2 mg PO BID
11. Venlafaxine XR 112.5 mg PO DAILY
12. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth q4hrs
Disp #*61 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Left bimalleolar ankle fracture.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
ANTICOAGULATION:
- Please take lovenox 40mg daily for 2 weeks
WOUND CARE:
- Keep splint on, it must stay dry until removed at your follow
up appointment
- No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
ACTIVITY AND WEIGHT BEARING:
- Touch down weight bearing left lower extremity
-Elevate left leg to reduce swelling and pain.
-Do not remove splint. Keep splint dry.
Other Instructions
- Resume your regular diet.
- Avoid nicotine products to optimize healing.
- Resume your home medications. Take all medications as
instructed.
- Continue taking the Lovenox to prevent blood clots.
-You have also been given Additional Medications to control your
pain. Please allow 72 hours for refill of narcotic
prescriptions, so plan ahead. You can either have them mailed
to your home or pick them up at the clinic located on ___ 2.
We are not allowed to call in narcotic (oxycontin, oxycodone,
percocet) prescriptions to the pharmacy. In addition, we are
only allowed to write for pain medications for 90 days from the
date of surgery.
- Narcotic pain medication may cause drowsiness. Do not drink
alcohol while taking narcotic medications. Do not operate any
motor vehicle or machinery while taking narcotic pain
medications. Taking more than recommended may cause serious
breathing problems.
If you have questions, concerns or experience any of the below
danger signs then please call your doctor at ___ or go
to your local emergency room.
Followup Instructions:
___
|
19580789-DS-11
| 19,580,789 | 22,268,123 |
DS
| 11 |
2136-03-23 00:00:00
|
2136-03-23 21:47:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lisinopril
Attending: ___
Chief Complaint:
fall
Major Surgical or Invasive Procedure:
echocardiogram
History of Present Illness:
The patient is an ___ ___ speaking female physician
with ___ of hypertension, fatigue, iron deficiency, and
transaminitis, presenting s/p loss of consciousness with
unwitnessed fall onto face on ___.
Per patient, she woke up ___ feeling her usual self, though
somewhat weak (tired legs, hard to move them). She went to her
usual daycare program on ___ and the day was going normally
until she noticed an unsettled stomach while sitting outside.
She headed towards the bathroom but fell outside the door. As
she was falling she had a "pretty vision" of a forest/lake
despite being inside; this was instantaneous. She woke up
moments later (though unobserved, so cannot know how long )on
the floor. She was not confused. She went to the bathroom and
then presented to the nurse. The nurse noted she was hypotensive
and sent her to the ED. She was admitted to ___ but was
transferred to medicine once it was determined that there was no
surgical intervention.
The patient feels otherwise well, though now she has significant
right-sided chest pain where her ribs are broken, and it hurts
to raise her arm.
She has a normal-to-increased appetite but may have lost a small
amount of weight because she's concerned that it would be
unhealthy to eat too much.
She denies tripping (though she has had mechanical falls in the
past), dizziness, or palpitations. She had no confusion or sense
of brain fog. She denies chest pain, back pain, headache,
fevers/chills, new blurry vision, weight loss, dyspnea on
exertion, or muscle aches. She has had no other episodes of
diarrhea. No history of seizures.
She does endorse some abdominal pain which she associates with
her esophageal hernia for which she is on pantoprazole. She has
some pain associated with eating and some heaviness in her
abdomen.
Per the patient, she has trouble with her blood pressure being
too high or too low and she is on many medications. She is
fatigued in the morning for several years, and feels better in
the afternoon, so she does not think about it. Per her daughter,
she does sometimes modify her own antihypertensives, including
taking more.
Past Medical History:
hypertension
hyperlipidemia
depression with past suicide attempt
hydronephrosis (L kidney)
anxiety
LBP with sciatica
TAH-BSO
osteopenia
h/o atypical chest pain with 2 normal EST previously
knee pain
monoclonal gammopathy
PUD
Social History:
___
Family History:
Father, HTN, MI
Brother, CAD, renal cancer
Physical Exam:
ADMISSION PHYSICAL EXAM
========================
VS: 97.2 70 108/55 16 100% RA
General: Well appearing female, in NAD, A&Ox3
HEENT: no bruising, step offs or deformities. mucous membranes
dry.
Abdomen: S, NT, ND
P/ chest: CTAP. Pain on palpation right chest lower rib cage.
no
bruising. no step offs.
CV: RRR
Extremities: pulses palp b/l. no edema, no bruising, no step
offs.
Neuro: cranial nerves intact. no focal deficits.
TRANSFER PHYSICAL EXAM
======================
Vital Signs: 98.4 | 132/58 | 59 | 18 | 97%RA
GENERAL: ___ woman laying in bed, alert, oriented,
no acute distress, telling cogent history through translator.
HEENT: Pupils equal and reactive, moist mucous membranes. Left
front tooth with small chip.
LUNGS: Clear to auscultation of anterior fields. No increased
work of breathing.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs
appreciated despite AR history, rubs, gallops
MUSCULOSKELETAL: Tenderness to palpation of right ribs.
ABDOMEN: patient in abdominal binder. Abdomen soft, non-tender,
non-distended, no rebound tenderness
EXTREMITIES: Warm, well perfused, 2+ pulses, no clubbing,
cyanosis or edema
SKIN: Large 8cm mostly-round purple-yellow ecchymosis of right
arm.
NEURO: Alert, face grossly symmetric, no dysarthria, hand grip
strength intact, moving all limbs against gravity, though right
shoulder is only extended/abducted with pain.
DISHCARGE PHYSICAL EXAM
======================
Vital Signs: 97.9 | 154/78 | 65 | 17 | 98%ra
GENERAL: ___ woman laying in bed, alert, oriented,
no acute distress, telling cogent history through MS3 fluent in
___.
HEENT: Pupils equal and reactive, moist mucous membranes. Left
front tooth with small chip.
LUNGS: Clear to auscultation of anterior fields though patient
w/ splinting on deep inspiration. No increased work of shallow
breathing.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs
appreciated despite AR history, no rubs, gallops
MUSCULOSKELETAL: Tenderness to palpation of right ribs. No
hematoma.
ABDOMEN: patient in abdominal binder. Abdomen soft, non-tender,
non-distended, no rebound tenderness. No rashes.
EXTREMITIES: Warm, well-perfused, 2+ pulses, no clubbing,
cyanosis or edema
SKIN: Large 8cm mostly-round purple-yellow ecchymosis of right
lateral upper arm.
NEURO: Alert, face grossly symmetric, no dysarthria
Pertinent Results:
ADMISSION LABS
==============
___ 01:11PM BLOOD WBC-5.7 RBC-4.15 Hgb-8.9* Hct-31.4*
MCV-76* MCH-21.4*# MCHC-28.3* RDW-17.2* RDWSD-46.5* Plt ___
___ 01:11PM BLOOD Neuts-73.0* Lymphs-16.3* Monos-9.6
Eos-0.5* Baso-0.2 Im ___ AbsNeut-4.17 AbsLymp-0.93*
AbsMono-0.55 AbsEos-0.03* AbsBaso-0.01
___ 01:11PM BLOOD Glucose-122* UreaN-28* Creat-1.1 Na-134
K-6.0* Cl-99 HCO3-24 AnGap-17
___ 01:11PM BLOOD cTropnT-<0.01
___ 02:32PM BLOOD K-5.0
___ 04:11PM BLOOD Lactate-1.3
INTERVAL LABS
=============
URINALYSIS
___ 05:00PM URINE Color-Yellow Appear-Clear Sp ___
___ 05:00PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 05:00PM URINE RBC-2 WBC-1 Bacteri-FEW Yeast-NONE Epi-<1
___ 05:00PM URINE AmorphX-RARE
___ 05:00PM URINE Mucous-RARE
DISCHARGE LABS
==============
___ 08:47AM BLOOD WBC-5.9 RBC-4.41 Hgb-9.6* Hct-32.5*
MCV-74* MCH-21.8* MCHC-29.5* RDW-17.1* RDWSD-44.8 Plt ___
___ 08:47AM BLOOD Glucose-90 UreaN-22* Creat-0.9 Na-139
K-3.8 Cl-102 HCO3-22 AnGap-19
___ 08:47AM BLOOD Calcium-9.3 Phos-3.6 Mg-1.9
STUDIES
=======
___ CT C-SPINE W/O CONTRAST IMPRESSION: No fracture or
traumatic malalignment.
___ CT HEAD W/O CONTRAST IMPRESSION: No fracture or acute
intracranial process.
___ CT CHEST W/O CONTRAST IMPRESSION:
1. Nondisplaced fractures of the lateral fifth and ninth right
ribs, and minimally displaced fractures of the lateral sixth,
seventh, and eighth right ribs. No pneumothorax or pulmonary
contusion.
2. Cholelithiasis, with no evidence of acute cholecystitis.
___ ECHOCARDIOGRAM Conclusions: The left atrium is
elongated. No atrial septal defect is seen by 2D or color
Doppler. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%). There
is no left ventricular outflow obstruction at rest or with
Valsalva. There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic root is mildly dilated at the sinus level. The ascending
aorta is mildly dilated. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. Mild (1+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Trivial mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. There is mild
pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion. There are no
echocardiographic signs of tamponade. Compared with the prior
study (images reviewed) of ___, no change.
MICRO
=====
___ Blood Cx pending, no growth to date ___ Urine Cx pending MIXED BACTERIAL FLORA ( >= 3 COLONY
TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION.
Brief Hospital Course:
# FALL: This seems to be an episode of orthostatic hypotension,
especially given the reported blood pressure of 80/40 and known
history of hypertension on numerous medications. Per daughter,
patient often modifies her medication, not taking them
day-to-day unless she "feels" hypertensive, and then taking ___
of one or both of the labetalol/losartan. She was bradycardic on
EKG on admission, likely due to labetalol. She had one 10-second
run of SVT on admission, but was otherwise stable. No infectious
trigger, with normal CXR, normal UA. Urine/Blood cx pending.
History is not consistent with mechanical fall or seizure. Small
concern for bleed given Hgb around 8.6 from baseline ___, but
improve to 9.6 on discharge w/o intervention. Discharged on
losartan but holding other blood pressure medications.
# RIB FRACTURES/PAIN CONTROL: Found to have nondisplaced
fractures of the lateral fifth and ninth right ribs, and
minimally displaced fractures of the lateral sixth, seventh, and
eighth right
ribs. Receiving 1g acetaminophen standing, lidocaine patch qAM,
and 2.5mg oxycodone q6h PRN for breakthrough pain.
# HYPERTENSION: Initially held antihypertensives given unclear
etiology of fall/presumed orthostasis. Discharged on losartan,
holding labetalol (to prevent bradycardia) and spironolactone.
# ESOPHAGEAL HERNIA WITH GERD: Continued home pantoprazole 40mg
daily. ___ merit stool hemoccult as outpatient; likely not a
colonoscopy candidate given age. ___ benefit from improved
medical management.
# TRANSAMINITIS of UNCLEAR ORIGIN: Followed in outpatient. Liver
enzymes in ___ were notable for mildly elevated alkaline
phosphatase. Continued home ursadiol BID
# DEPRESSION WITH HX SUICIDE ATTEMPT IN ___: Home sertraline.
# VENTRAL HERNIA: Continue abdominal binder.
- Code Status: DNAR/DNI
HCP: ___
Relationship: Daughter
Phone number: ___ home
Cell phone: ___ cell
TRANSITIONAL ISSUES:
====================
#MEDICATION CHANGES: Holding labetalol given bradycardia and
presumed hypotension, and holding spironolactone for presumed
hypotension. Patient seems to judge her hypertension based on
symptoms and adjust medications accordingly, so a simple regimen
is likely better. If patient is hypertensive as outpatient,
would consider restarting at lower doses.
#RIB FRACTURES: Continue 1000mg acetaminophen. Continue
lidocaine patch. Can take 2.5mg oxycodone as needed for
breakthrough pain every ___ hours. sent home with docusate
sodium and senna to avoid constipation from the opiates.
#GERD: She endorsed symptoms of worsening discomfort from her
esophageal hernia. Can consider additional workup of this as
outpatient.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Labetalol 100 mg PO DAILY
2. Pantoprazole 40 mg PO Q24H
3. Losartan Potassium 100 mg PO QHS
4. Sertraline 100 mg PO DAILY
5. Spironolactone 25 mg PO DAILY
6. Ursodiol 300 mg PO BID
7. Aspirin 81 mg PO DAILY
8. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 500
mg(1,250mg) -125 unit oral BID
Discharge Medications:
1. Acetaminophen 1000 mg PO TID
2. Docusate Sodium 100 mg PO BID
3. Lidocaine 5% Patch 1 PTCH TD QAM
4. OxyCODONE (Immediate Release) 2.5 mg PO Q6H:PRN Pain -
Moderate
5. Senna 8.6 mg PO BID:PRN constipation
6. Aspirin 81 mg PO DAILY
7. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 500
mg(1,250mg) -125 unit oral BID
8. Losartan Potassium 100 mg PO QHS
9. Pantoprazole 40 mg PO Q24H
10. Sertraline 100 mg PO DAILY
11. Ursodiol 300 mg PO BID
12. HELD- Spironolactone 25 mg PO DAILY This medication was
held. Do not restart Spironolactone until instructed to do so by
PCP.
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES
=================
#FALL WITH LOSS OF CONSCIOUSNESS, secondary to
ORTHOSTATIC HYPOTENSION
#RIGHT RIB FRACTURES ___
SECONDARY DIAGNOSES
===================
#HYPERTENSION
#GERD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
WHY WAS I IN THE HOSPITAL?
*You were admitted ___ on
___ after a fall from standing.
*You had right sided rib fractures.
*You had intermittent slow heart rate (bradycardia)
WHAT WAS DONE IN THE HOSPITAL?
*We suspect that your fall may have been due to a slow heart
rate or a low blood pressure. We made some changes to your
medications.
*We monitored your heart with EKG and telemetry to make sure you
had no abnormal rhythms to cause your fall
*We did an echocardiogram to see if you had abnormal heart
structure that could have caused your fall. Your heart was
normal.
*We ruled out infection as cause for your low blood pressure
*You were given pain medication and encouraged to use your
incentive spirometer to take deep breaths
*We held your blood pressure medications
WHAT SHOULD I DO AT HOME:
* Continue your losartan. DO NOT take your labetalol or
spironolactone.
* Your injury caused right 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
* Continue Tylenol for pain control. You can use 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).
It was a pleasure taking care of you!
- Your Care Team at ___
Followup Instructions:
___
|
19580789-DS-9
| 19,580,789 | 27,035,901 |
DS
| 9 |
2133-07-02 00:00:00
|
2133-07-02 21:17:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Aspirin
Attending: ___.
Chief Complaint:
anxiety, dyspnea, altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old ___ Female with PMH of hypertension,
hydronephrosis, who presented to the ED with anxiety and acute
onset dyspnea. Pt reports that she was having problems with her
breathing and felt chills/rigors. Of note, patient had somewhat
similar presentation in ___ during which time labs
were normal, ambulatory sats were 94-100% on RA. She was found
to have low potassium.Per her daughter pt called her on ___
AM during which time she reported falling on her way to getting
the phone and that she had taken more of her sleeping
medications. She reports ___ speech was slower than usual.
When her daughter talked with her later in the day and saw her
at 7pm she was acting normally and conversing normally but
reported feeling "funny in her head" when she took her
antibiotics for her Hpylori. Pts daughter reports that her mom
takes her own medications and they are not sure what she is
actually taking at home. At the end of the conversation, pts
daughter reported concerns that ___ was talking about no
longer wanting to be alive and that her first thought when she
did not answer in the morning was that she had overdosed on her
medications.
In the ED, her initial VS were 98.0 94 152/100 32 98% 4L Nasal
Cannula. She was anxious and tremulous, Labs were notable for
new onset hyponatremia to 114 (from 130s baseline 1 mo prio),
Troponin 0.13, BNP 1128. EKG showed no changes. CT head was
limited by motion but prelim read was unremarkable. Cardiology
was consulted that felt may be type II NSTEMI. CTPA was
attempted x 3 however pt unable to lie still secondary to
agitation. Received zofran for nausea, 1mg IV lorazepam x 2,
Haldol 5mg and 2.5mg. And started on a heparin drip and given
aspirin PR.
Of note, pt had recent fall and has visible ecchymosis over the
right eye. On arrival to the ICU patient's VS were afebrile, HR
82, BP 121/104. Pt reported feeling "in the middle". She was
aware she was in the hospital.
Past Medical History:
hydronephrosis (L kidney)
hypertension
hyperlipidemia
depression
anxiety
LBP with sciatica
TAH-BSO
osteopenia
h/o atypical chest pain with 2 normal EST previously
knee pain
monoclonal gammopathy
Social History:
___
Family History:
Father, HTN, MI
Brother, CAD, renal cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals- afebrile, HR 82, BP 121/104.
General- Elderly female lying in bed, arousable to voice in NAD,
following commands and appropriate answers with normal speech
without
HEENT- PEERLA, MMM
Neck- no elevated JVP present
CV- RRR, no MRG appreciated
Lungs- CTAB
Abdomen- soft, nontender, nondistended, normoactive bowel sounds
GU- foley in place draining pale yellow urine 700cc present in
the bag
Ext- no peripheral edema, warm and well perfused
Neuro- altered, falls asleep easily
DISCHARGE PHYSICAL EXAM:
Vitals: T:97.9 BP:131/60 P:71 R:18 O2:98RA
General: Well-appearing, alert, oriented, NAD
HEENT: Echymosis around the R eye, small underlying hematoma, no
step-offs or deformities, normocephalic, sclera anicteric,
conjunctiva noninjected, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: CTAB, no wheezes, rales, rhonchi
CV: RRR, normal S1 + S2, no m/r/g
Abdomen: soft, NTND, +BS, no rebound tenderness or guarding, no
HSM
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: no rashes or lesions
Neuro: AAOx3, EOMI, tongue protrudes to midline, moving all
extremities
Psych: alert and oriented, interactive, appropriate, normal
affect, denies depressed mood, denies SI
Pertinent Results:
ADMISSION LABS:
___ 04:00AM BLOOD WBC-12.4*# RBC-4.54 Hgb-14.2 Hct-39.7
MCV-87 MCH-31.4 MCHC-35.9* RDW-12.3 Plt ___
___ 08:39AM BLOOD ___ PTT-32.4 ___
___ 04:00AM BLOOD Glucose-125* UreaN-12 Creat-1.0 Na-114*
K-3.8 Cl-80* HCO3-20* AnGap-18
___ 08:00PM BLOOD CK(CPK)-679*
___ 04:00AM BLOOD cTropnT-0.13*
___ 04:00AM BLOOD proBNP-1128*
___ 11:45AM BLOOD Calcium-7.9* Phos-3.2# Mg-1.6
___ 08:39AM BLOOD D-Dimer-417
___ 11:45AM BLOOD TSH-1.9
___ 11:45AM BLOOD Cortsol-9.3
___ 04:00AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 03:22PM BLOOD Lactate-1.0
PERTINENT LABS:
___ 08:00PM BLOOD Glucose-84 UreaN-8 Creat-1.0 Na-127*
K-3.3 Cl-97 HCO3-22 AnGap-11
___ 09:25AM BLOOD Glucose-76 UreaN-6 Creat-1.0 Na-131*
K-4.0 Cl-102 HCO3-23 AnGap-10
___ 08:00PM BLOOD CK-MB-9 cTropnT-0.06*
DISCHARGE LABS:
___ 05:15AM BLOOD WBC-4.5 RBC-3.76* Hgb-11.5* Hct-34.0*
MCV-91 MCH-30.5 MCHC-33.7 RDW-12.7 Plt ___
___ 05:15AM BLOOD Glucose-75 UreaN-12 Creat-1.0 Na-135
K-3.7 Cl-104 HCO3-24 AnGap-11
___ 05:15AM BLOOD Calcium-8.1* Phos-2.6* Mg-2.0
Micro:
Blood culture, ___: PENDING
Stool c diff, ___: negative
Urine:
Urine Culture, ___: negative
Urine legionella antigen, ___: negative
EKG:
___
Normal sinus rhythm. Left anterior hemiblock. Delayed R wave
progression in the precordial leads. Diffuse non-specific ST-T
wave abnormalities with Q-T interval prolongation. A prior
anterolateral myocardial infarction may be present. Compared to
the previous tracing of ___ the Q-T interval prolongation and
ST-T wave abnormalities are new. Clinical correlation is
suggested to rule out acute myocardial ischemia.
Imaging:
CXR, ___:
No acute cardiopulmonary process.
CT Spine, ___:
Multilevel moderate degenerative changes. No evidence of
fracture or
dislocation.
CT Head, ___:
Extremely limited evaluation due to motion artifact. No
definite acute
intracranial abnormality.
Echo, ___:
Mild-moderate aortic regurgitation. Normal biventricular cavity
sizes with preserved regional and global biventricular systolic
function. The other findings are similar to prior study ___.
CT Head, ___:
No evidence of acute intracranial process.
Brief Hospital Course:
Ms. ___ is an ___ woman with a past medical
history significant for hypertension, hydronephrosis, anxiety
and depression who initially presented with acute onset
shortness of breath, dyspnea and altered mental status, and was
found to be severely hyponatremic to 114 ___s elevated
troponin (0.15) concerning for NSTEMI. She was admitted to the
MICU for management of her symptomatic hyponatremia.
ACUTE ISSUES:
#Acute onset hyponatremia: The patient provided the history that
in the setting of her treatment for her H. pylori she was not
eating a significant amount, and was drinking a lot of tea.
Given her tea and toast like diet, it is likely that she has
euvolemic hyponatremia secondary to poor solute intake. This may
have been further exacerbated by chlorthalidone therapy for
hypertension. Her altered mental status was likely due to
cerebral edema from severe symptomatic hyponatremia. Urine lytes
were not suggestive of another etiology of hyponatremia such as
SIADH. She was initially found to be hyponatremic to 114 and was
given 1L NS, with trend toward correction of hyponatremia. In
ICU, was started on ___ NS for correction of hyponatremia with a
goal of correcting no more than 12meq/L per day. The patient's
sodium was trended while in the unit, and upon transfer from
MICU her sodium was 131. At the time of discharge, her sodium
level had normalized at 135.
#Altered mental status / Depression with ?suicidal ideation
The patient was altered in the ED; was thought that this could
be due to underlying hyponatremia. The patient also reports
that she took an extra ambien (15 mg total), so also possible
that this could be due to medication effect. She received
haldol, lorazepam and ativan for agitation. Her altered mental
status resolved in the ICU with correction of her hyponatremia.
Notably, patient has history of anxiety and depression and there
was initially concern for possible intentional medication OD.
Her daughter reports that patient has been depressed and also
notes that she stated desire to "sleep and not wake up". She may
have overdosed in the setting of confusion ___ symptomatic
hyponatremia. Once her altered mental status resolved, she had a
mml mood and affect, was alert and oriented and had a normal
neurological exam. She denied any suicidal ideation or suicide
attempt. Given this history, psychiatry was consulted and per
their evaluation, she was felt to have overdosed in the setting
of acute confusion secondary to hyponatremia. She was judged to
be safe for discharge. Zolpidem and fluvoxamine were held until
follow-up with her outpatient psychiatrist and she was given
mirtazapine 7.5mg for sleep and anxiety until that time.
#Fall with headstrike and R periorbital hematoma
Patient fell in the setting of altered mental status secondary
to symptomatic hyponatremia and zolpidem overdose. She struck
right side of face and on evaluation had significant ecchymosis
and small hematoma around right orbit. Physical exam revealed no
step-offs or deformity and she had a normal neurological exam.
Initial CT was of poor quality due to agitation, but a repeat
head CT was normal, without any evidence of intracranial
bleeding. She received standing tylenol for pain.
#Acute onset shortness of breath:
Likely due to underlying anxiety, and improved over the course
of her MICU stay. Of note, she did have elevated troponin noted
in the ED (see below), but this trended down. Chest x-ray was
negative for acute cardiopulmonary process. Of note, d-dimer was
checked in the ED and was normal. CT pulmonary angiography was
not done due to agitation and inability to lay flat. However,
there was low suspicion for pulmonary embolism given clinical
history and exam. Troponins trended down in the ICU and she
experienced no further symptoms of dyspnea or low oxygen
saturation.
#Elevated troponins / Demand ischemia:
The patient initially had troponin of 0.13 with CK-MB of 13. Her
EKGs were unchanged from prior. Cardiology was consulted in the
ED and felt could be an NSTEMI, and the patient was started on
heparin drip, which was discontinued in the unit as her
troponins started trending downwards. Her elevated troponins
likely reflect demand ischemia in the setting of severe
agitation. She has a history of hypertension, hyperlipidemia and
atypical chest pain but did not experience chest pain during
this hospitalization and her dyspnea resolved. Repeat EKG on the
floor was also normal. Outpatient stress test should be pursued.
#Hypertension: The patient's home chlorthalidone and lisinopril
were held while in house. Discharged with a mml BP.
CHRONIC ISSUES:
#Anxiety
The patient has anxiety at her baseline and follows with
outpatient psych. Per patient's daughter, the patient had been
making remarks about her being better off dead. This was in the
setting of acute confusion and likely overdose of zolpidem.
Psych was consulted on the floor to assess for suicidal ideation
and ongoing risk to self or others. As above, psych felt she was
safe to discharge home. Psych and sedating medications were held
at discharge pending follow-up with her outpatient psychiatrist.
#H pylori gastritis
Patient has a history of gastroesophageal reflux with diagnosis
of H pylori gastritis. She had started treatment and completed 5
days total but was experiencing significant side effects. She
was taking poor PO for several weeks secondary to GERD and this
worsened in the setting of medication side effects. This likely
contributed to the development of her symtompatic hyponatremia.
Patient self-discontined medication and denied any symptoms of
reflux during hospitalization. Triple cocktail therapy was held
pending revaluation by her PCP and she was discharged on
omeprazole for symptomatic relief of GERD.
#Hypertension
Patient has a history of hypertension. However, she was
hypotensive in MICU requiring boluses. She was normotensive on
transfer to the floor and remained stable through discharge.
Chlorthalidone and lisinopril were held during hospitalization
and at discharge pending revaluation by PCP. Normotensive at
d/c.
#Hyperlipidemia
Patient has a history of hyperlipidemia and was continued on
simvastatin.
#Pain control
During this hospitalization, patient received tylenol for her
history of sciatica and knee pain. Given her history of
confusion on admission, sedating medications were avoided during
this hospitalization and should be minimized going forward.
-tylenol PRN for pain
-avoid sedating medications
#Deconditioning
Physical therapy was consulted for likely deconditioning and it
was recommended patient be discharged with home physical therapy
and a rolling walker.
TRANSITION ISSUES:
# Chlorithalidone was held due to concern for it contributing to
hyponatremia. Patient should follow-up with PCP to discuss
whether to restart this medication.
# Lisinopril was held in the setting of hypotension. Her blood
pressure on discharge was 120s systolic. Outpatient PCP ___
decide when to restart this medication.
# Recommended patient discontinue taking zolpidem and
fluvoxamine due to this possibly contributing to her confusion
and fall. Patient should follow-up with her psychiatrist before
restarting these medications.
# Patient discharged on mirtazapine 7.5mg for insomnia (2 week
supply). Patient should follow-up with PCP to discuss whether to
continue this medication.
# Patient discontinued h pylori triple cocktail secondary to
side effects. Patient should follow-up with PCP before resuming
these medications (amoxacillin and clarithromycin). She should
continue taking omeprazole for reflux/gastritis.
# Follow-up final read of head CT
# Follow-up final blood cultures
# Outpt psych f/u (arrangement of this was pending at d/c, appt
should be scheduled by outpt providers if still not made at the
time of f/u)
# Consideration should be given to stress test in the future,
defer to PCP
___ on ___:
The Preadmission Medication list is accurate and complete.
1. Simvastatin 10 mg PO QPM
2. risedronate 35 mg oral 1 tablet/weekly
3. Lisinopril 40 mg PO DAILY
4. Chlorthalidone 25 mg PO DAILY
5. Amoxicillin 500 mg PO BID
6. Clarithromycin 500 mg PO Q12H
7. Fluvoxamine Maleate 100 mg PO HS
8. Ondansetron 4 mg PO ___ TABLETS Q6H:PRN nausea
9. Omeprazole 20 mg PO DAILY reflux
10. Ferrous GLUCONATE 240 mg PO DAILY
Discharge Medications:
1. Omeprazole 20 mg PO DAILY reflux
2. Simvastatin 10 mg PO QPM
3. Acetaminophen 500 mg PO Q6H:PRN pain
4. Ondansetron 4 mg PO Q6H:PRN nausea
5. risedronate 35 mg oral 1 tablet/weekly
6. Mirtazapine 7.5 mg PO HS
RX *mirtazapine 7.5 mg 1 tablet(s) by mouth at bedtime Disp #*14
Tablet Refills:*0
7. Ferrous GLUCONATE 240 mg PO DAILY
8. rolling walker
Diagnosis - fall
prognosis - good
length of need - lifetime
___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnoses:
Symptomatic hyponatremia
Altered mental status
Demand ischemia
Secondary diagnoses:
Depression
Anxiety
Hypertension
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___. You were admitted
with symptoms of shortness of breath, anxiety and confusion. You
were found to have low sodium levels in your blood that likely
caused your confusion. Your low sodium level was mostly likely
caused by not eating enough and made worse by one of your blood
pressure medications. You also took too much of your home
sleeping medicine, which contributed to your confusion. Because
you have underlying depression we had the psychiatrists see you
to recommend the best medication regimen for your sleep and
depression. We have stopped the ambien and fluvoxamine and
started you on mirtazipine. While you were in the hospital you
were treated with IV fluids, your low sodium levels improved and
your confusion resolved.
You should follow-up as scheduled in our ___ clinic
on ___ at 2:40PM on the ___ floor of the ___
building. You should also schedule an appointment with your
psychiatrist, Dr. ___, to discuss your current medications
for anxiety and depression.
Best Regards,
Your ___ Team
Followup Instructions:
___
|
19580974-DS-20
| 19,580,974 | 20,867,349 |
DS
| 20 |
2169-08-21 00:00:00
|
2169-08-22 07:27:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
aripiprazole
Attending: ___.
Chief Complaint:
Back Pain / Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with h/o CVA ___ with left hemiparesis, hypothyroidism,
HTN, who developed worsening back pain overnight and fever to
100.1. Seen by NP at ___ where he is a resident. KUB
done there was c/f possibly ileus. Xray of lumbar spine was
negative for fracture. Patient was given morphine and Tylenol.
Patient's pain continued to worsen and temp rose to 100.6 so
sent in to ED for w/u. Patient was given full dose ASA prior to
arrival to ED.
In the ED, initial vitals were: 100.7 91 160/67 50 97%
Non-Rebreather
- Labs were significant for WBC 24.0, Hgb/Hct 14.2 / 41.7, Phos
2.1, LFTs wnl, Trop <0.01, INR 1.4, U/A trace leuks, negative
nitrites/negative bacteria, lactate 2.0
- Imaging revealed multiple segmental and subsegmental
pulmonary emboli involving the right lower lobe and right upper
lobe. CT head showed evidence of prior infarcts, no acute
intracranial abnormality
- The patient was given 4.5g zosyn, 1g IV vanc, 2L NS for
presumed sepsis. Started on heparin gtt for PEs.
Upon arrival to the floor, VS: 98.3, 93/57 P68 RR 18 93% 4L NC.
patient appeared comfortable. ROS limited by non-verbal status,
but acknowledged feeling short of breath, denied chest pain,
abdominal pain.
Past Medical History:
-Disc degeneration NOS
-Aortic valve disorder
-CVA
-Hypothyroidism
-HLD
-seborrheic dermatitis
-Urinary incontinence
-Anxiety
-Bipolar disorder
-Hypertension
-BPH
-Depression
-Prurigo
Social History:
___
Family History:
patient uncertain
Physical Exam:
ADMISSION EXAM:
Vitals: 98.3, 93/57 P68 RR 18 93% 4L NC
General: Laying in bed, in NAD, non-verbal
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated
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
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Follows commands, nods yes/no to questions, ___ strength
at LUE and LLE c/w known hemiparesis from prior stroke, right
facial droop
DISCHARGE EXAM:
Vitals: T 98.3 P 57 BP 153/73 RR 20 SpO2 95% RA
GENERAL: Alert, no acute distress. Appears comfortable, not
diaphoretic. Oriented to self, not to place, answered ___
for month
HEENT: Sclerae anicteric, MMM
NECK: Supple, JVP not elevated
RESP: Breathing comfortably. Lungs clear to auscultation
bilaterally.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops.
ABD: +BS, soft, nondistended, nontender to palpation.
GU: No Foley
EXT: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. No pressure ulcers. No calf tenderness, cords, erythema
bilaterally.
NEURO: Follows commands, answers questions appropriately with
occasional long speech latency, right facial droop, ___ strength
in left upper extremity, able to grip hand, ___ strength left
foot
Pertinent Results:
LABS ON ADMISSION:
___ 07:05PM GLUCOSE-120* UREA N-13 CREAT-0.7 SODIUM-136
POTASSIUM-3.8 CHLORIDE-101 TOTAL CO2-23 ANION GAP-16
___ 07:05PM ALBUMIN-3.6 CALCIUM-9.1 PHOSPHATE-2.1*
MAGNESIUM-2.0
___ 07:05PM ALT(SGPT)-21 AST(SGOT)-26 ALK PHOS-78 TOT
BILI-0.7
___ 07:05PM WBC-24.0*# RBC-4.66 HGB-14.2 HCT-41.7 MCV-90
MCH-30.5 MCHC-34.1 RDW-14.0 RDWSD-45.5
___ 07:05PM ___ PTT-30.1 ___
___ 07:05PM ALT(SGPT)-21 AST(SGOT)-26 ALK PHOS-78 TOT
BILI-0.7
___ 07:05PM LIPASE-15
___ 07:05PM cTropnT-<0.01
PERTINENT RESULTS:
___ 11:00AM BLOOD cTropnT-<0.01
LABS ON DISCHARGE:
___ 06:29AM BLOOD WBC-14.0* RBC-4.07* Hgb-12.1* Hct-36.6*
MCV-90 MCH-29.7 MCHC-33.1 RDW-15.1 RDWSD-48.6* Plt ___
___ 06:29AM BLOOD Glucose-96 UreaN-10 Creat-0.5 Na-137
K-4.0 Cl-107 HCO3-21* AnGap-13
___ 06:29AM BLOOD Calcium-8.3* Phos-2.4* Mg-2.1
MICRO:
Blood cultures from ___ and ___ without growth
Urine culture from ___ and ___ without growth
IMAGING:
Non-contrast head CT ___:
IMPRESSION: No acute intracranial process. Stigmata of chronic
small vessel ischemic disease, basal ganglia lacunar infarctions
and chronic right frontal infarct.
CT torso ___:
IMPRESSION:
1. Segmental and subsegmental pulmonary emboli within the right
lower lobe and to a lesser extent right upper lobe.
Consolidation in the right lower lobe concerning for acute
pulmonary infarct.
2. Mild cardiomegaly.
3. Severe atherosclerosis.
4. Diverticulosis.
Chest x-ray ___:
IMPRESSION: The patient is status post median sternotomy with
stable postoperative cardiac and mediastinal contours. There
has been interval appearance of a layering right effusion and
increasing consolidation at the right base which may reflect
atelectasis, although pneumonia or aspiration should also be
considered. Lung volumes remain low with crowding of the
vasculature. However, there now is mild perihilar edema. No
large pneumothorax.
EKG ___
Baseline artifact. Sinus rhythm with atrial premature beats.
Leftward axis. Prominent voltage in leads I, aVL and precordial
leads. Consider left ventricular hypertrophy. There are Q waves
in leads V1-V2. Possible septal myocardial infarction. There is
borderline intraventricular conduction delay. Compared to the
previous tracing of ___ the rate is now faster. ST-T wave
abnormalities are more prominent. The QRS width is similar.
Atrial and possible ventricular premature beats are new. Repeat
tracing and clinical correlation are suggested.
Brief Hospital Course:
___ with CVA c/b left hemiparesis here with back pain, fever,
found to have multiple PEs, also fever and leukocytosis with
chest x-ray consistent with pneumonia.
#Pulmonary embolism: Found on admission to have multiple
segmental and subsegmental emboli, likely from to limited
mobility due to prior CVA. He had no hemodynamic compromise. He
was initially treated with heparin and subsequently lovenox
bridge to Coumadin, with goal INR of 2.0-3.0 for ___ months for
PE with a persistent underlying risk factor.
#Health care associated pneumonia: The patient was febrile with
leukocytosis that resolved in the setting of antibiotics, with
CXR consistent with pneumonia. He was treated with vancomycin
and cefepime and narrowed to levoquin for a 5 day course to end
on ___.
#Afib with RVR: The patient developed afib with RVR with heart
rate in 150s in the setting of underlying pneumonia and PEs.
This responded to metoprolol and he was discharged on metoprolol
succinate 100mg daily.
CHRONIC ISSUES:
#Pancreatic insuffiency: Creon 6 held during hospitalization,
resume as outpatient
# HTN: antihypertensives initially held. Metoprolol uptitrated
as above and amlodipine restarted on discharge
# Psych: patient w/ h/o depression / bipolar, continued home
venlafaxine and risperidone
# HLD: continued home pravastatin
# Hypothyroidism: continued home levothyroxine
TRANSITIONAL ISSUES:
-Coumadin titrated to goal INR 2.0-3.0 for ___ months for PE in
the setting of persistent underlying risk factors (immobility).
If INR is subtherapeutic, bridge with lovenox
-Metoprolol uptitrated for Afib with RVR
-Continue Levofloxacin 750mg po daily with last dose to be given
___
-Leukocytosis on admission that was resolving with antibiotics,
but slight increase on day of discharge. Recommend checking ___
on ___ to ensure resolution
#CODE: full
#COMMUNICATION: ___ (___) son ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Sodium Chloride Nasal 1 SPRY NU BID
2. Acetaminophen 650 mg PO Q6H:PRN pain
3. Coal Tar 3% Shampoo 1 Appl TP 2X/WEEK (___)
4. Amlodipine 2.5 mg PO DAILY
5. Pravastatin 20 mg PO QPM
6. melatonin 1 mg oral QHS
7. Aspirin 81 mg PO DAILY
8. Levothyroxine Sodium 50 mcg PO DAILY
9. Venlafaxine 75 mg PO BID
10. Creon (lipase-protease-amylase) 6,000-19,000 -30,000 unit
oral TID W/MEALS
11. RISperidone 0.25 mg PO QHS
12. Metoprolol Tartrate 12.5 mg PO BID
13. Zolpidem Tartrate 10 mg PO QHS
14. Morphine Sulfate (Concentrated Oral Soln) 4 mg PO Q6H:PRN
pain
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Levothyroxine Sodium 50 mcg PO DAILY
4. Pravastatin 20 mg PO QPM
5. RISperidone 0.25 mg PO QHS
6. Sodium Chloride Nasal 1 SPRY NU BID
7. Venlafaxine 75 mg PO BID
8. Enoxaparin Sodium 90 mg SC Q12H
Start: Today - ___, First Dose: Next Routine Administration
Time
9. Levofloxacin 750 mg PO DAILY Duration: 3 Days
Last dose on ___.
10. Warfarin 2.5 mg PO DAILY16
11. Amlodipine 2.5 mg PO DAILY
12. Coal Tar 3% Shampoo 1 Appl TP 2X/WEEK (___)
13. Creon (lipase-protease-amylase) 6,000-19,000 -30,000 unit
oral TID W/MEALS
14. melatonin 1 mg oral QHS
15. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN shortness of
breath
16. Metoprolol Succinate XL 100 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Pulmonary ___ pneumonia
SECONDARY DIAGNOSES:
Atrial fibrillation with rapid ventricular response
Hypertension
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at ___
___. You came to the hospital because of back pain
and fever. You were found to have multiple clots in your lungs.
We treated you for this with blood thinning medications, which
you will take daily after leaving the hospital.
You also were found to have a pneumonia while you were here. We
treated you for this with antibiotics, and you improved.
Please go to the follow-up appointments listed below, and be
sure to take your new medications as directed.
We wish you the best!
-Your ___ Team
Followup Instructions:
___
|
19581102-DS-9
| 19,581,102 | 25,286,550 |
DS
| 9 |
2141-09-15 00:00:00
|
2141-09-15 13:35:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ female with a PMH of RA presents with the above fracture s/p
mechanical fall. Patient sustained her injury last night during
a fall in her room. Positive head strike and loss of
consciousness. When she awoke, patient attempted to get up and
fell again onto her left side. She remained on the floor until
EMS arrival. Patient was taken to OSH, where outside imaging
revealed pelvic fractures with associated pelvic wall hematoma.
Additional injury burden includes possible rib fractures and
left periorbital hematoma. On examination, patient endorsing
pain in her bilateral hips. She denies any numbness or tingling
distally.
Past Medical History:
PMH
- RA
- Diverticulosis
- CKD Stage III
PSH:
- Appendectomy ___ ago)
- Hysterectomy ___ ago)
- Colon resection (couldn't find it in medical records) with
ileostomy (___) reversal 6 months later
Social History:
___
Family History:
Non-contributory
Physical Exam:
Admission Physical Exam:
=========================
Vitals: HR 96, BP 178/77, RR 16
General: A&O complaining of pain in Leg
Ecchymosis in left periorbital region
RRR
Tender to palpation left anterior chest wall, nonlabored
respirations
Abdomen soft, tender
Bilateral lower extremities:
- Skin intact
- Pelvis is tender but stable compression
- Fires ___
- SILT S/S/SP/DP/T distributions
- 1+ ___ pulses, WWP
Discharge Physical Exam:
=========================
Vitals: 98.4, 110 / 69, 74, 16, 96% Ra
Gen: NAD, AOX3
Head: hematoma on L temporal area, echymoses over left face
CV: RRR, normal s1,s2, no MGR
Chest: mildly tender over ribs b/l
Resp: breaths unlabored, CTAB, no adventitious sounds
appreciated
Abdomen: soft, non distended, tender over pelvic bones, no
rebound/guarding
Ext: WWP, LLE mildly tender diffusely, no edema
Neuro: CN2-12 grossly intact, sensation intact in ___ to soft
touch, strength ___ in ___
Pertinent Results:
Admission Labs:
===================
___ 04:30PM BLOOD WBC-6.7 RBC-2.59* Hgb-9.7* Hct-28.6*
MCV-110* MCH-37.5* MCHC-33.9 RDW-14.0 RDWSD-56.3* Plt ___
___ 04:30PM BLOOD Plt ___
___ 04:50PM BLOOD ___ PTT-19.0* ___
___ 04:30PM BLOOD UreaN-11 Creat-1.3*
___ 04:30PM BLOOD Lipase-31
___ 04:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 04:34PM BLOOD Type-MIX pO2-46* pCO2-36 pH-7.42
calTCO2-24 Base XS-0
___ 04:34PM BLOOD Glucose-110* Lactate-0.9 Na-137 K-4.5
Cl-106
___ 04:34PM BLOOD Hgb-10.2* calcHCT-31 O2 Sat-79 COHgb-3
MetHgb-1
___ 04:34PM BLOOD freeCa-1.00*
IMAGING:
==========
___: CXR:
Left-sided rib deformities involving the left fourth through
seventh ribs
along the posterolateral arch, please correlate for acuity. No
pneumothorax or large effusion on this supine radiograph.
___: CT Cystogram:
No evidence of bladder rupture. Extraperitoneal hematoma
related to known
pubic bone fractures.
___: CT Chest:
1. Chronic appearing fourth through seventh rib fractures on the
left. No
acute rib fracture. No pneumothorax. No focal consolidation.
2. Pleural base nodules measure up to 4 mm in the right upper
lobe. No
specific follow-up is recommended in low risk population. See
full set of
recommendations below.
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 recommend in a high-risk patient.
___: Pelvis x-ray:
Re-demonstrated comminuted, minimally displaced fracture of the
right
parasymphyseal superior and inferior pubic rami, more completely
assessed on same-day CT.Left parasymphyseal pubic rami fractures
are not radiographically apparent, and are seen on the prior CT.
___: Left tib/fib xray:
No acute osseous abnormality of the left tibia or fibula.
___: Left foot x-ray:
No acute osseous injury of the left foot.
___: Left femur x-ray:
No acute osseous injury of the left femur.
Discharge Labs:
================
___ 06:24AM BLOOD WBC-4.4 RBC-2.02* Hgb-7.6* Hct-22.8*
MCV-113* MCH-37.6* MCHC-33.3 RDW-14.0 RDWSD-57.0* Plt ___
___ 06:24AM BLOOD Plt ___
___ 06:24AM BLOOD Glucose-90 UreaN-11 Creat-1.2* Na-138
K-4.2 Cl-105 HCO3-22 AnGap-11
___ 06:24AM BLOOD Calcium-8.1* Phos-3.0 Mg-2.0
Brief Hospital Course:
Ms. ___ is a ___ year old female with a history of
Rhumatoid Arthritis, Stage III CKD, Diverticulosis who presented
after ___t home. She was found to have two
pelvic fractures and chronic appearing fourth through seventh
rib fractures on the left. Additionally an incidental findings
of pleural base nodules measure up to 4 mm in the right upper
lobe and a single solid pulmonary nodule smaller than 6 mm.
Additionally she was found to have a associated large retropubic
and right pelvic sidewall hematoma, which was monitored, her
hemoglobin was stable at time of discharge. She was evaluated by
orthopedics who determined her injuries to be nonoperative in
nature. Orthopedic Surgery recommended WBAT BLE using rolling
walker for support, ___ control, and repeat AP Pelvis XR in
one month. She was evaluated by physical therapy and
occupational therapy and was recommended to be discharged to
rehab. A tertiary trauma exam was performed which was negative.
At the time of discharge her pain was under control, with
oxycodone and acetaminophen, she was ambulating and was
requesting discharge to rehab.
Active Issues:
===============
# Pubic symphysis fracture & Left Sacral Alar fracture:
Patient was found to have two pelvic fractures after ___t home. She was found to have a small bleed in
her pelvis, which was monitored, her hemoglobin was stable at
time of discharge. She was evaluated by orthopedics who
determined her injuries to be nonoperative in nature. She was
evaluated by physical therapy and occupational therapy and was
recommended to be discharged to rehab.
# Mechanical Falls:
Patient was evaluated by physical therapy and occupational
therapy and was recommended to be discharged to rehab.
Secondary Issues:
==================
# Rhumatoid Arthritis: Stable
# CKD: Stable
# Diverticulosis: Stable
Transitional Issues:
=====================
# Follow up with your primary care physician
1. 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 recommend in a
high-risk patient.
2. pleural base nodules measure up to 4 mm in the right upper
lobe
# Follow up with the Orthopedics department
# Take your medications as directed
# Medication Changes:
NEW Medications:
Acetaminophen 1000 mg PO Q8H
Calcium Carbonate 500 mg PO QID:PRN Indigestion, heartburn
Docusate Sodium 100 mg PO BID
Heparin 5000 UNIT SC BID
OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain
Senna 8.6 mg PO BID:PRN Constipation - First Line
Prior To Arrival Medications:
Gabapentin 100 mg PO TID
Mirtazapine 15 mg PO QHS
abatacept 1 unknown subcutaneous monthly RA
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 100 mg PO TID
2. Mirtazapine 15 mg PO QHS
3. abatacept 1 unknown subcutaneous monthly RA
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Calcium Carbonate 500 mg PO QID:PRN Indigestion, heartburn
3. Docusate Sodium 100 mg PO BID
Hold for loose stool
4. Heparin 5000 UNIT SC BID
5. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain
Wean as tolerated. Patient may request partial fill.
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*10 Tablet Refills:*0
6. Senna 8.6 mg PO BID:PRN Constipation - First Line
7. abatacept 1 unknown subcutaneous monthly RA
8. Gabapentin 100 mg PO TID
9. Mirtazapine 15 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Pubic symphysis fracture
Left Sacral Alar fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital after two falls and were found
to have left and right-sided pelvic fractures with associated
bleeding. Your bleeding was monitored and was stable prior to
your discharge. The Orthopedic Surgery service evaluated your
fractures and determined that no surgery was needed. You may
bear weight on both your legs as tolerated. You were evaluated
by physical therapy and it is recommended that you be discharged
to rehab to regain your strength and mobility.
You are now ready to be discharged from the hospital. Please
note the following discharges instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Best,
Your Surgical Team
___
Followup Instructions:
___
|
19581614-DS-3
| 19,581,614 | 23,914,819 |
DS
| 3 |
2171-12-31 00:00:00
|
2172-01-04 10:30:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Back pain, fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ history of untreated HCV and active IVDU. Pain began in R.
ankle after injecting heroin and cocaine on ___,
which he does frequently. The following morning, the ankle pain
subsided but severe lower back pain began, associated with
new-onset fever. Patient describes the pain as being ___,
throbbing, limiting movement and improving moderately after
getting home methadone. He also states that the pain prevents
him from sleeping. Patient has been experiencing vomiting
starting 4 days ago, which makes his current back pain worse. He
denies any blood or bile in vomit. He also complains of
palpitations and a "racing heart", which has been occurring
on-and-off throughout today (___). He originally presented to
___ ___ morning (___) with atraumatic back
pain. Reports fevers at home. 99.4 at ___. No pain at injection
site. Currently c/o severe back pain limiting movement but
improved . Complains of chills. No urinary/bowel incontinence.
Chest pain, which radiates from his back. Pan MRI was negative
for spinal abscess. Blood cultures returned positive within
hours growing GPCs ___ bottles. He denies any concerning neuro
symptoms.
In the ED, initial vitals were: ___ 126 132/71 18 95%
RA
In the ED labs notable for WBC to 21 (85N), H&H 12&36, lactate
2.1, Clean UA, normal Chem 10. Code Cord was called and
neurology evaluated. No cord compression found. Pt was started
on Vanc/Zosyn, given 3L fluid, 5 mg Morphine, and 110 mg of
Methadone after confirmation of dose.
On the floor, initial vitals were:
T 98.3, BP 141/74, P ___, R 18, O2Sat 98% RA, Pain ___
Past Medical History:
- Active Polysubstance/IVDA- currently involved in a ___
clinic
- Anxiety
Social History:
___
Family History:
Noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
S: T 98.3, BP 141/74, P ___, R 18, O2Sat 98% RA, Pain ___
GENERAL: Alert, oriented, ill-appearing
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Tachycardic, normal rhythm, normal S1 S2, no murmurs, rubs,
gallops. Cardiac sounds appreciable on auscultation of right
carotid.
ABD: Epigastric and LLQ pain with deep palpation. Liver edge
palpable. Otherwise abdomen is soft, bowel sounds present.
EXT:
- R. Lower Extremity: Mild R. ankle pain with passive external
rotation. No pain with resisted R. ankle motion in all
directions. No tenderness, erythema, or warmth of R. ankle.
Needle tracks for IVDU appreciated at R. ankle. No pain of R.
knee with movement. Otherwise warm, well perfused, 2+ pulses, no
clubbing, cyanosis or edema
- L. Lower Extremity: no pain of knee or ankle with movement.
Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema
- R. and L Upper Extremities: Warm, well perfused, 2+ pulses, no
clubbing, cyanosis or edema
SKIN: Normal
NEURO: A&Ox3
MSK: Point tenderness at coccyx. No paraspinal tenderness on
palpation. Pain is ___ and throbbing. Improves with flexion and
worsens with extension of hips and knees.
DISCHARGE PHYSICAL EXAM:
VS
GENERAL: alert,oriented NAD
HEENT: NC/AT, PERRL, pupils enlarged, sclerae anicteric, MMM
LUNGS: Clear to auscultation, no w/r/r
HEART: No MRG, normal S1&S2.
ABDOMEN: NABS, soft/NT/ND.
EXTREMITIES: WWP. No swelling, erythema, or pain of lower or
upper extremities.
NEURO: A&Ox3
MSK: No point tenderness over coccyx
Pertinent Results:
ADMISSION LABS:
___ 10:10PM BLOOD WBC-17.9* RBC-4.83 Hgb-13.9 Hct-43.6
MCV-90 MCH-28.8 MCHC-31.9* RDW-13.7 RDWSD-44.7 Plt ___
___ 10:10PM BLOOD Neuts-85.6* Lymphs-9.2* Monos-4.3*
Eos-0.0* Baso-0.3 Im ___ AbsNeut-15.28* AbsLymp-1.64
AbsMono-0.77 AbsEos-0.00* AbsBaso-0.06
___ 10:10PM BLOOD Glucose-110* UreaN-8 Creat-0.9 Na-136
K-4.1 Cl-102 HCO3-19* AnGap-19
___ 12:00AM BLOOD ALT-33 AST-89* LD(LDH)-902* AlkPhos-64
TotBili-0.7
___ 07:30AM BLOOD Albumin-4.1 Calcium-9.4 Phos-1.9* Mg-1.6
PERTINENT LABS:
___ 07:30AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HAV
Ab-POSITIVE
___ 06:30AM BLOOD HBcAb-NEGATIVE
___ 07:30AM BLOOD HIV Ab-NEGATIVE
___ 12:00AM BLOOD CRP-92.1*
DISCHARGE LABS:
IMAGING:
MR head ___: IMPRESSION:
Normal brain MRI.
CT pelvis ___: IMPRESSION:
The soft tissues in the presacral area and adjacent to the
coccyx are
unremarkable, without drainable fluid collection, fat stranding,
or evidence
of abscess.
TEE ___: IMPRESSION: No echocardiographic evidence of
endocarditis or pathologic flow. Normal biventricular systolic
function.
MR spine ___:
IMPRESSION:
No evidence for diskitis, osteomyelitis, epidural collection or
paravertebral
collection. Please refer to the separately reported precontrast
MRI for
further detail.
MICRO:
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
BACILLUS SPECIES; NOT ANTHRACIS.
Isolated from only one set in the previous five days.
SENSITIVITY REQUESTED BY ___.
FINAL SENSITIVITIES. Sensitivity testing performed by
Sensititre.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
BACILLUS SPECIES; NOT ANTHRACIS
|
CLINDAMYCIN----------- 0.5 S
GENTAMICIN------------ <=2 S
LEVOFLOXACIN----------<=0.25 S
VANCOMYCIN------------ <=1 S
Anaerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___ ___ AT 2324.
GRAM POSITIVE ROD(S).
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STAPH AUREUS COAG +.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus, yeast or other
fungi.
SENSITIVITIES PERFORMED ON CULTURE # ___ ___.
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN CLUSTERS.
Brief Hospital Course:
___ is a ___ man with a past medical history of
active IVDA (heroin and cocaine) and anxiety, who presented with
back pain, fevers, leukocytosis, and was found to be bacteremic.
#Sepsis
Mr. ___ was initially tachycardic with WBC count of 20.
Blood cultures quickly grew out GPC. He was started on
vancomycin, then narrowed to nafcillin when sensitivities showed
MSSA. He then had cultures growing gram positive rods, so
vancomycin was restarted. Given gram positive bacteremia, there
was high concern for endocarditis, but TTE and TEE were both
normal. MRI of the head to eval for septic emboli (due to HA)
was also normal. He has responded well to vancomycin and his
blood cultures subsequently cleared. With ID recs, he was put on
a 2 week course of IV vancomycin from ___, his first day of
clear blood cultures requiring continued hospitalization. A PICC
line was placed. Unfortunately, Mr. ___ mother suddenly
passed away this week. Therefore, we are discharging him today
with a planned readmission for later this evening so that Mr.
___ can attend his mother's wake and mass. He is to present
to the ED tonight to continue recieving his abx.
#Back Pain
His severe back pain in the setting of bacteremia raised concern
for osteomyelitis or a paraspinal or epidural abscess, however
MRI of the spine came back benign. There was concern that the
imaging did not extend low enough to include the area of his
pain. Therefore, he had a CT pelvis done which was normal.
However, pain improved markedly when vancomycin was initiated.
Given no clear source of bacteremia, we are still very
suspicious of a musculoskeletal source in the back that resolved
with abx.
# Untreated HCV. LFTs initially normal, but uptrended, likely
due to nafcillin. A RUQ ultrasound showed steatosis. Hep A
antibody was positive. Hep B surface antibody was positive, core
aby and Ag negative. HCV negative.
TRANSITIONAL ISSUES
******TO ED PHYSICIANS AT ___
Mr. ___ is on IV vancomycin to treat bacteremia. He was
discharged this morning so that he can attend his mother's
funeral with a planned representation to the ED between ___
for an expedited admission to continue IV antibiotics. Please
give him 1500mg of IV vancomycin BID in time for his 8:30 dose
and admit him to medicine (CC7 if a bed is available). Resource
nurses at ___ and in the ED are aware of the situation.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Methadone 110 mg PO DAILY Heroin addiction
2. ALPRAZolam 1 mg PO 5X/DAY
3. CloniDINE 0.3 mg PO BID
4. Promethazine 25 mg PO Q6H
5. BuPROPion 150 mg PO BID
6. Amphetamine-Dextroamphetamine 30 mg PO TID
7. Gabapentin 600 mg PO QID
8. TraZODone 100 mg PO BID
9. TraZODone 100 mg PO QHS:PRN sleep
Discharge Disposition:
Home
Discharge Diagnosis:
bacteremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ for a blood infection. It is unclear
where the original source of your infection was, but it improved
once we started you on the appropriate antibiotics. You should
continue getting IV vancomycin until ___. You are being
discharged today so that you can attend your mother's wake and
subsequent mass and so that you can spend time with loved ones
during this very difficult situation. Please return to the ___
ED tonight between ___ so that you can continue your course of
IV antibiotics. Bring all of your paperwork with you.
Sincerely,
Your ___ team
Followup Instructions:
___
|
19581826-DS-22
| 19,581,826 | 27,603,823 |
DS
| 22 |
2133-05-13 00:00:00
|
2133-06-01 13:58:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ yo female with extensive surgical history
most recently including SBO requiring ex lap LOA in ___
followed by ventral hernia repair with component separation and
paraesophageal hernia repair in ___. Patient was last seen
in ___ and noted to be doing well without recurrent
obstructions or hernia.
However, 2 days ago she started to have vague abdominal pain.
Yesterday, she had multiple episodes of bilious emesis and felt
as though she had another obstruction. She has not passed flatus
for at least 1 day. She had a BM 2 days ago. She denies recent
illness, diarrhea, fevers, chills, malaise, and sick contacts.
Past Medical History:
PMH: bipolar disorder, SBO, arthritis and HTN
PSH: right oopherectomy, ventral hernia repair x3 (two at
___, last in ___ at ___, exlap/SBR in 1990s at ___
(reason unknown per pt), ORIF R tibia and humerus (___), R knee
arthroscopy (___), R finger surgeries (___), removal R tibial
hardware (___)
Social History:
___
Family History:
Non-contributory
Physical Exam:
Admission Physical Exam:
Vitals: 98.2 73 129/92 20 96% RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR
PULM: Clear to auscultation b/l
ABD: Soft, distended, nontender, no rebound or guarding, well
healed midline laparotomy incision
Ext: No ___ edema, ___ warm and well perfused
Discharge Physical Exam:
VS:98.1 PO 128 / 69 L Lying 63 18 95 Ra
GEN: Awake, alert, pleasant and interactive.
HEENT: PERRL, EOMI. mucus membranes pink moist.
CV: RRR
PULM: clear to auscultation bilaterally.
ABD: Soft, non-tender, non-distended. Active bowel sounds.
EXT: Warm and dry. No edema. ___ pulses.
Pertinent Results:
___ 04:55AM BLOOD WBC-7.0 RBC-4.83 Hgb-14.3 Hct-44.0 MCV-91
MCH-29.6 MCHC-32.5 RDW-13.2 RDWSD-44.0 Plt ___
___ 04:09AM BLOOD WBC-9.0 RBC-5.20 Hgb-15.4 Hct-46.6*
MCV-90 MCH-29.6 MCHC-33.0 RDW-13.4 RDWSD-44.2 Plt ___
___ 06:00PM BLOOD WBC-9.3 RBC-5.38* Hgb-15.7 Hct-48.3*
MCV-90 MCH-29.2 MCHC-32.5 RDW-13.6 RDWSD-45.1 Plt ___
___ 04:38AM BLOOD ___ PTT-30.7 ___
___ 04:55AM BLOOD Glucose-74 UreaN-26* Creat-0.7 Na-142
K-3.9 Cl-103 HCO3-23 AnGap-16
___ 04:09AM BLOOD Glucose-99 UreaN-26* Creat-0.7 Na-144
K-4.0 Cl-103 HCO3-26 AnGap-15
___ 06:00PM BLOOD Glucose-97 UreaN-33* Creat-0.8 Na-144
K-4.3 Cl-103 HCO3-28 AnGap-13
___ 04:38AM BLOOD Glucose-137* UreaN-39* Creat-0.9 Na-145
K-4.1 Cl-101 HCO3-27 AnGap-17
___ 04:55AM BLOOD Calcium-8.5 Phos-2.8 Mg-2.0
___ 04:09AM BLOOD Calcium-8.7 Phos-2.7 Mg-2.1
___ 04:38AM BLOOD Calcium-9.7 Phos-4.5 Mg-2.0
___ 06:09PM BLOOD Lactate-1.5
___ 04:55AM BLOOD Lactate-2.0
___ Abdominal Xray:
Interval passage of contrast material through the level of the
rectum. No
evidence of a small bowel obstruction.
___ Chest Xray:
Enteric tube tip terminates near the gastroesophageal junction
and should be advanced 10 cm to move all the side ports into the
stomach. No acute
cardiopulmonary process.
___ CT Abdomen/Pelvis:
CT abdomen/pelvis:
Small bowel obstruction with transition point at the mid ileum
distal to prior anterior enteric anastomosis. Obstructed loops
measure up to 6.2 cm in diameter. Distal ileal loops are
decompressed. However, there is moderate stool in the proximal
colon. Enteritis of the stool-filled distal obstructed small
bowel loops with some mucosal enhancement and mesenteric
engorgement. Negative for pneumatosis, free fluid, or free air.
Brief Hospital Course:
Ms. ___ is a ___ yo F with history significant for bipolar,
multiple abdominal surgiers and small bowel obstructions
requiring lysis of adhesions and removal of mesh in ___, who
presented to the emergency department on ___ with abdominal
pain and emesis. CT scan concerning for small bowel obstruction
with transition point at the mid ileum distal to prior anterior
enteric anastomosis. White blood cell count normal at 9.0 and
lactate 2.0. She was given bowel rest, IV fluids, and
nasogastric tube placed. She was admitted to the surgical floor
for further management.
On HD2 she was given gastroview via nasogastric tube and serial
abdominal xrays were done that eventually showed resolution of
bowel obstruction on HD3. She had return of bowel function. The
nasogastric tube was therefore removed and she was advanced to a
regular diet with good tolerability. Serial abdominal exams
showed resolution of abdominal pain. The patient's fever curves
were closely watched for signs of infection, of which there were
none. The patient's blood counts were closely watched for signs
of bleeding, of which there were none. The patient received
subcutaneous heparin and ___ dyne boots were used during this
stay and was encouraged to get up and ambulate as early as
possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. The patient's primary care
provider was contacted and the patient was strongly encouraged
to follow up at outpatient appointment.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze/SOB
2. Docusate Sodium 100 mg PO BID
3. GuaiFENesin ER 600 mg PO Q12:PRN congestion
4. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate
5. Polyethylene Glycol 17 g PO DAILY:PRN constipation
6. Senna 8.6 mg PO BID:PRN Constipation - First Line
7. Cephalexin 2 grams PO PRN prior to dental procedures
8. Chlorthalidone 25 mg PO DAILY
9. Losartan Potassium 50 mg PO DAILY
10. OLANZapine 7.5 mg PO QHS
11. TraZODone 150 mg PO QHS:PRN insomnia
12. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
13. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit oral BID
14. Psyllium Powder 1 PKT PO TID:PRN constipation
15. Ferrous Sulfate 325 mg PO DAILY
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild
Reason for PRN duplicate override:
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze/SOB
3. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit oral BID
4. Cephalexin 2 grams PO PRN prior to dental procedures
5. Chlorthalidone 25 mg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. Ferrous Sulfate 325 mg PO DAILY
8. GuaiFENesin ER 600 mg PO Q12:PRN congestion
9. Losartan Potassium 50 mg PO DAILY
10. OLANZapine 7.5 mg PO QHS
11. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
12. Polyethylene Glycol 17 g PO DAILY:PRN constipation
13. Psyllium Powder 1 PKT PO TID:PRN constipation
14. Senna 8.6 mg PO BID:PRN Constipation - First Line
15. TraZODone 150 mg PO QHS:PRN insomnia
Discharge Disposition:
Home
Discharge Diagnosis:
small bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ on ___ with abdominal pain and
concern for a small bowel obstruction. You were given bowel
rest, IV fluids, and had nasogastric tube placed. You then were
given oral contrast and an xray showed the contrast was able to
flow through your intestinal tract all the way to the colon.
Once you had return of bowel function, you were given a regular
diet which you tolerated well. You are now ready to be
discharged home to continue your recovery.
Please note the following discharge instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids.
Avoid driving or operating heavy machinery while taking pain
medications.
Followup Instructions:
___
|
19582136-DS-17
| 19,582,136 | 20,374,164 |
DS
| 17 |
2179-11-28 00:00:00
|
2179-11-28 16:06:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
Mycobacterium Tuberculosis (Tuberculin PPD)
Attending: ___.
Chief Complaint:
Transient left sided weakness, slurred speech and left facial
droop
Major Surgical or Invasive Procedure:
___ Coil embolization Rt MCA aneurysm
___ Placement of right frontal EVD, removed ___
History of Present Illness:
___ is a ___ year old female with no significant pmhx
who presented to an OSH with sudden onset of slurred speech,
left facial droop, and left upper extremity weakness at aporox
0130. Her husband called her PCP who then instructed him to call
___. On arrival of EMS she was noted to be hypertensive, and was
brought to ___. On arrival to the OSH her
exam was improving, Nicardipine gtt was started and a head CT
was obtained which showed a right SAH. She subsequently
transferred here to ___ for further work up and treatment. Per
the patient and her husband they were on vacation in ___, on
___ in the evening she developed a posterior head and neck pain
associated with nausea, she took Ibuprofen and went to bed, she
states she
felt better the next day but had no appetite. On ___
___ she went hiking for 3 hours with her husband when she
developed bilateral lower leg pain, she continue to take her
Ibuprofen for the leg pain with intermittent effect. On ___
night, the ___ she returned home and felt worse, however she
related it to her long flight back home. Yesterday she presented
to her PCP with the bilateral leg pain and received a toradol
injection with good effect. She went aprox at 9pm, at 0130 her
husband went to bed and noticed her slurred speech.
Past Medical History:
Borderline HTN
Social History:
___
Family History:
No family history of aneurysms
Physical Exam:
============
ON ADMISSION:
============
___ and ___:
[x]Grade I: Asymptomatic, mild headache, slight nuchal rigidity
[ ]Grade II: Moderate to severe headache, nuchal rigidity, no
neurological deficit other than cranial nerve palsy.
[ ]Grade III: Drowsiness/Confusion, mild focal neurological
deficit.
[ ]Grade IV: Stupor, moderate-severe hemiparesis.
[ ]Grade V: Coma, decerebrate posturing.
Fisher Grade:
[ ]1 No hemorrhage evident
[ ]2 Subarachnoid hemorrhage less than 1mm thick
[x]3 Subarachnoid hemorrhage more than 1mm thick
[ ]4 Subarachnoid hemorrhage of any thickness with IVH or
parenchymal extension
WFNS SAH Grading Scale:
[x]Grade I: GCS 15, no motor deficit
[ ]Grade II: GCS ___, no motor deficit
[ ]Grade III: GCS ___, with motor deficit
[ ]Grade IV: GCS ___, with or without motor deficit
[ ]Grade V: GCS ___, with or without motor deficit
___ Coma Scale:
[ ]Intubated [x]Not intubated
Eye Opening:
[ ]1 Does not open eyes
[ ]2 Opens eyes to painful stimuli
[ ]3 Opens eyes to voice
[x]4 Opens eyes spontaneously
Verbal:
[ ]1 Makes no sounds
[ ]2 Incomprehensible sounds
[ ]3 Inappropriate words
[ ]4 Confused, disoriented
[x]5 Oriented
Motor:
[ ]1 No movement
[ ]2 Extension to painful stimuli (decerebrate response)
[ ]3 Abnormal flexion to painful stimuli (decorticate response)
[ ___ Flexion/ withdrawal to painful stimuli
[ ]5 Localizes to painful stimuli
[x]6 Obeys commands
15 Total
T: 98.3 BP: 186/117 HR: 70 R:16 O2Sats: 97% RA
Gen: WD/WN, comfortable, NAD.
Extrem: Warm and well-perfused. No C/C/E.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: ___ objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2
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 finger rub bilaterally.
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 DISCHARGE:
============
She is awake, alert, and cooperative with the exam. She is
oriented to self, location, and date. PERRL, EOMI. Slight left
facial droop, tongue midline. No pronator drift. She moves all
extremities with ___ strength. Sensation is intact to light
touch throughout all extremities. Incision is clean, dry, and
intact with staples.
Pertinent Results:
Please refer to ___ for pertinent lab and imaging results.
Brief Hospital Course:
___ is a ___ year old female who was transferred from
an OSH to the ED with transient left sided weakness, slurred
speech and left facial droop. CT head concerning for
subarachnoid hemorrhage. CTA head and neck revealed a R MCA
aneurysm with moderate to severe vasospasm. The patient was
admitted to the neurosurgery service in the ICU for close
monitoring.
#R MCA aneurysm/SAH
The patient underwent a coiling embolization of her R MCA
aneurysm on ___. She had an intraoperative controlled
re-rupture of the R MCA aneurysm which was successfully coiled
with 5 coils. Post-operatively she was plegic on the left side.
A STAT NCHCT on the angio table showed no IPH, so plegia was
likely due to vasospasm. She was extubated and transferred back
to the neuro ICU for further monitoring. In the ICU her strength
returned on her left side. She remained lethargic but oriented
then began dry heaving with improvement after Zofran. Her BP
dropped to 130's and her nimodipine was changed to 30mg q2h, she
was maxed out on Neo/Levo and given IV fluid boluses. Repeat
NCHCT repeated and concerning for hydrocephalus. Patient
returned to the OR for EVD placement. She underwent a CTA ___
which revealed spasm in the R MCA but patient was clinically
stable. The Milrinone was decreased and the standing IVF
decreased. TCD done ___ negative for spasm. ___ patient had an
exam change, stat CTA redemonstrated moderate to severe
vasospasm in the right ACA and MCA. She was started on pressors
with SBP goal of 160-180. On ___, the EVD was raised to 15cm
above the tragus and the pressors were discontinued in the
setting of close neurologic exam monitoring. On ___ the EVD was
increased to 20 cm with no changes to her neurologic exam. She
did well and was transferred to the floor. On ___, the EVD was
clamped. On ___, the patient remained neurologically intact. A
head CT was performed in the morning which showed stable size
of the ventricles. The EVD was removed and a post-pull head CT
was obtained which was negative for hemorrhage. Physical therapy
and occupational therapy were consulted for disposition planning
and recommended home with outpatient ___. On ___, her pain was
well controlled on oral medications. She was tolerating a diet
and ambulating independently. Her vital signs were stable and
she was afebrile. She was discharged to home in a stable
condition.
#Nutrition
NGT was placed on ___ for nutrition and she was started on tube
feeds. A few days later she was trialed for puree and did well.
Her po intake continued to improve and was later transitioned to
regular solid and thin liquids.
#DVT Prophylaxis
The patient was started on prophylactic subcutaneous heparin.
SQH was held secondary to an elevated PTT. Hematology was
consulted. The workup was essentially normal. She was later
restarted on lower dose SQH.
Medications on Admission:
Ibuprofen PRN
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
2. Senna 8.6 mg PO DAILY:PRN constipation
3.Outpatient Physical Therapy
Please evaluate and treat
Discharge Disposition:
Home
Discharge Diagnosis:
Subarachnoid hemorrhage
Cerebral vasospasm
Hydrocephalus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Discharge Instructions
Dr. ___
Activity
You may gradually return to your normal activities, but we
recommend you take it easy for the next ___ hours to avoid
bleeding from your groin.
Heavy lifting, running, climbing, or other strenuous exercise
should be avoided for ten (10) days. This is to prevent bleeding
from your groin.
You make take leisurely walks and slowly increase your
activity at your own pace. ___ try to do too much all at once.
Do not go swimming or submerge yourself in water for five (5)
days after your procedure.
You make take a shower.
Medications
Resume your normal medications and begin new medications as
directed.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
If you take Metformin (Glucophage) you may start it again
three (3) days after your procedure.
Care of the Puncture Site
You will have a small bandage over the site.
Remove the bandage in 24 hours by soaking it with water and
gently peeling it off.
Keep the site clean with soap and water and dry it carefully.
You may use a band-aid if you wish.
What You ___ Experience:
Mild tenderness and bruising at the puncture site (groin).
Soreness in your arms from the intravenous lines.
Mild to moderate headaches that last several days to a few
weeks.
Fatigue is very normal
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the puncture
site.
Fever greater than 101.5 degrees Fahrenheit
Constipation
Blood in your stool or urine
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Followup Instructions:
___
|
19582545-DS-20
| 19,582,545 | 27,921,823 |
DS
| 20 |
2133-08-29 00:00:00
|
2133-09-01 16:38:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Lasix / hydralazine / HCTZ / macrolides / simvastatin /
Penicillins / spironolactone
Attending: ___
Chief Complaint:
Nausea, Vomiting, Diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ woman with past medical history of diarrhea with
recent C. difficile history, dementia, hypertension,
hyperlipidemia, chronic kidney disease, presents with diarrhea.
Patient developed loose stools in ___, was diagnosed with C.
difficile and was treated outpatient with 14 days of oral
antibiotics. Patient had some improvement initially, but now has
had continued loose stools with up to ___ episodes of diarrhea
per day. Associated with nausea and nonbilious nonbloody emesis
roughly once every 3 days. Patient and family also note
decreased
p.o. intake, not eating or drinking, and feeling fatigued. Last
night, patient developed chills. Denies any fevers, chest pain,
shortness of breath, abdominal pain, dysuria.
In the ED:
- Initial vital signs were notable for:
T 97.3, HR 74, BP 116/51, RR 15, Sat 98% RA
- Exam notable for:
General: Patient lying in bed, pleasant, no apparent distress,
awake aware and oriented Ã-3
HEENT: Atraumatic, Moist mucous membranes, pupils equal and
reactive bilaterally, no JVD
Cardiovascular: Regular rate and rhythm no murmurs rubs or
gallops
Lungs: Clear to auscultation bilaterally
Abdomen: Soft nontender nondistended, no rebound or guarding
Extremities: 2+ pulses bilaterally
Neuro: ___ strength bilaterally in UE and ___. SLTIT.
- Labs were notable for:
Hgb 10.9
Cr 1.3
UA - trace leuk esterase, positive nitrites, 6 WBC, few bacteria
C. diff PCR positive, toxin pending
- Studies performed include:
CXR
IMPRESSION:
No evidence of focal consolidation or other acute process in the
chest.
CT ABd/Pelvis w/ Contrast:
IMPRESSION:
-Diffuse colonic wall thickening with mucosal enhancement
compatible with
colitis, most notably involving the ascending colon and
rectosigmoid.
-No evidence of bowel obstruction or organized fluid
collections.
- Patient was given:
IVF LR 125 mL/hr
IV MetroNIDAZOLE 500 mg
Vitals on transfer:
T 97.7, HR 79, BP 110/69, RR 15, Sat 97% RA
Upon arrival to the floor, patient states that she is feeling
well without complaints. She suffers from severe dementia is
unable to appropriately answer any questions appropriately
regarding her history.
REVIEW OF SYSTEMS: Unable to obtain due to patient's dementia
Past Medical History:
Dementia
Glaucoma
Depression
Insomnia
Hearing Loss
CKD 3
HTN
HLD
C. diff infection
Breast Cancer - s/p lumpectomy ___
Social History:
___
Family History:
Unable to obtain ___ patient's dementia
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: ___ ___ Temp: 98.6 PO BP: 118/54 HR: 76 RR: 18 O2
sat: 94% O2 delivery: Ra
GENERAL: Alert and interactive. In no acute distress.
HEENT: NCAT. Surgical pupil on left, EOMI. Sclera anicteric and
without injection. MMM, OP Clear.
NECK: No cervical lymphadenopathy. No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
BACK: No spinous process tenderness. No CVA tenderness.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
SKIN: Warm. Cap refill <2s. No rash.
NEUROLOGIC: CN2-12 intact, moving all extremities with purpose
against gravity. Oriented only to self
DISCHARGE PHYSICAL EXAM:
========================
VITALS:24 HR Data (last updated ___ @ 719)
Temp: 98.5 (Tm 98.7), BP: 128/77 (102-128/57-77), HR: 74
(74-98), RR: 18 (___), O2 sat: 93% (93-94), O2 delivery: RA
GENERAL: Alert and interactive. In no acute distress.
HEENT: NCAT. Surgical pupil on left, EOMI. Sclera anicteric and
without injection. MMM, OP Clear.
NECK: No cervical lymphadenopathy. No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
SKIN: Warm. Cap refill <2s. No rash.
NEUROLOGIC: CN2-12 intact, moving all extremities with purpose
against gravity. Oriented only to self
Pertinent Results:
ADMISSION LABS:
===============
___ 12:05AM BLOOD WBC-9.8 RBC-3.42* Hgb-10.9* Hct-34.1
MCV-100* MCH-31.9 MCHC-32.0 RDW-13.6 RDWSD-49.0* Plt ___
___ 12:05AM BLOOD Neuts-77.7* Lymphs-10.3* Monos-10.8
Eos-0.5* Baso-0.2 Im ___ AbsNeut-7.61* AbsLymp-1.01*
AbsMono-1.06* AbsEos-0.05 AbsBaso-0.02
___ 12:05AM BLOOD ___ PTT-27.7 ___
___ 12:05AM BLOOD Glucose-112* UreaN-25* Creat-1.3* Na-136
K-4.8 Cl-104 HCO3-22 AnGap-10
___ 12:05AM BLOOD ALT-13 AST-25 AlkPhos-93 TotBili-0.5
___ 12:05AM BLOOD Albumin-2.9* Calcium-8.5 Phos-3.3 Mg-1.9
___ 12:19AM BLOOD Lactate-1.4
___ 01:45AM URINE Color-Yellow Appear-Clear Sp ___
___ 01:45AM URINE Blood-NEG Nitrite-POS* Protein-TR*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-TR*
___ 01:45AM URINE RBC-1 WBC-6* Bacteri-FEW* Yeast-NONE
Epi-0
DISCHARGE LABS:
===============
___ 06:47AM BLOOD WBC-6.2 RBC-3.34* Hgb-10.7* Hct-33.5*
MCV-100* MCH-32.0 MCHC-31.9* RDW-14.1 RDWSD-51.2* Plt ___
___ 06:47AM BLOOD Glucose-94 UreaN-21* Creat-1.1 Na-147
K-4.3 Cl-110* HCO3-27 AnGap-10
___ 06:47AM BLOOD Calcium-8.6 Phos-2.8 Mg-1.8
MICROBIOLOGY:
=============
___ 12:05 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile PCR (Final ___:
Reported to and read back by ___ @ ___ ON ___
- ___.
POSITIVE. (Reference Range-Negative).
The C. difficile PCR is highly sensitive for toxigenic
strains of
C. difficile and detects both C. difficile infection
(CDI) and
asymptomatic carriage. Therefore, positive C. diff PCR
tests
trigger reflex C. difficile toxin testing, which is
highly
specific for CDI.
C. difficile Toxin antigen assay (Final ___:
POSITIVE. (Reference Range-Negative).
PERFORMED BY EIA.
This result indicates a high likelihood of C. difficile
infection
(CDI).
___ 12:05 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO
FOUND.
FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___:
No E. coli O157:H7 found.
___ 1:45 am URINE
IMAGING:
========
CXR ___:
IMPRESSION:
No evidence of focal consolidation or other acute process in the
chest.
CT Abd/Pelvis ___:
IMPRESSION:
1. Diffuse colonic wall thickening with mucosal enhancement
compatible with
colitis, most notably involving the ascending colon and
rectosigmoid.
2. No evidence of bowel obstruction or organized fluid
collections.
Brief Hospital Course:
SUMMARY:
========
___ woman with past medical history of diarrhea with
recent C. difficile infection, dementia, hypertension,
hyperlipidemia, chronic kidney disease, who presented with
diarrhea nausea, vomiting. Found to be C. diff PCR and toxin
positive
concerning for recurrent C. diff infection. Started on oral
vancomyin to complete slow taper for ___ recurrence,
mild-moderate severity. Her Creatinine was also noted to be
slightly above baseline which was felt to be a pre-renal ___ in
the setting of GI losses and poor po intake as an outpatient.
Her Creatinine downtrended with IVF and encouraged oral intake.
TRANSITIONAL ISSUES:
====================
-Follow up appointments: PCP
-___ up labs: Chem 7 within ___ weeks to ensure stable renal
function and electrolytes given ongoing GI losses
-Discharge Creatinine 1.1
[]Please continue oral vancomycin taper as outlined: 125mg QID
for 14 days (End ___, 125mg BID ___ - ___, 125mg Daily ___
- ___, 125mg every other day ___ - TBD ___ weeks at this
dose)
[]Liquid vancomycin expires 2 weeks after reconstituted. Will
need to write new prescriptions/have new liquid vancomycin
delivered for each step of the above taper. PLEASE NOTE THAT
PATIENT WAS DISCHARGED WITH ONLY THE QUANTITY OF THE FIRST 2
WEEKS AND WILL NEED A PRESCRIPTION RE-WRITTEN FOR THE TAPER
ITSELF.
[]Liquid vancomycin preferred over pill form as per staff at
___ facility there was concern she was pocketing or
otherwise not tolerating pills and not actually taking all of
her doses
ACUTE ISSUES:
=============
#Diarrhea
#Recurrent C. diff infection
Patient recently treated for C. diff infection finishing her
course of oral vancomycin near the end of ___. Symptoms
had resolved at that time. Now presenting with recurrence of
diarrhea in addition to nausea and vomiting. CT findings on
admission concerning for acute colitis. Found to be C. diff PCR
and toxin positive consistent with recurrent infection. Based on
critera recurrence fits mild-moderate severity category. Patient
started on oral Vancomycin taper. Continued to have diarrhea
while inpatient but was felt to be safe for discharge home.
Additional infectious stool studies were pending at discharge.
Vancomycin taper as follows: 125mg QID for 14 days (End ___,
125mg BID ___ - ___, 125mg Daily (___), 125mg every
other day ___ - TBD ___ weeks at this dose)
___ on CKD
Cr 1.3 on admission, increased from recent values near 1.0.
Improved after IV hydration and increased po intake. Likely
pre-renal azotemia iso poor po at home and GI losses.
CHRONIC ISSUES:
===============
#Glaucoma
Continued home eye drops
#Depression
Continued home sertraline
#Insomnia
Changed melatonin to ramelteon while admitted
HTN
Continue amlodipine, chlorthalidone, metoprolol
#HLD
Continued home pravastatin
#Dementia
Held home galantamine while admitted as nonformulary
#Allergic Rhinitis
Continued home loratidine. Held home intranasal ipratropium as
nonformulary
#Reactive Airway Disease
Continued home Spiriva, Albuterol inhalers
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 500 mg PO TID
2. Lactobacillus acidophilus 1 billion cell oral TID
3. Tiotropium Bromide 1 CAP IH DAILY
4. Metoprolol Succinate XL 25 mg PO DAILY
5. Timolol Maleate 0.5% 1 DROP LEFT EYE BID
6. Docusate Sodium 100 mg PO BID
7. Senna 8.6 mg PO BID:PRN Constipation - First Line
8. amLODIPine 7.5 mg PO DAILY
9. ipratropium bromide 42 mcg (0.06 %) nasal QID
10. Melatin (melatonin) 3 mg oral 1600
11. vit A-vit C-vit E-zinc-copper ___ unit-mg-unit
oral BID
12. galantamine 8 mg oral BID
13. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
14. Omeprazole 20 mg PO DAILY
15. Potassium Chloride 30 mEq PO DAILY
16. Loratadine 10 mg PO DAILY
17. Chlorthalidone 25 mg PO DAILY
18. Cyanocobalamin 1000 mcg PO DAILY
19. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4H:PRN Wheezing, SOB
20. zinc oxide 20 % topical BID
21. Aspercreme (lidocaine) (lidocaine;<br>lidocaine HCl) 4 %
topical DAILY
22. Pravastatin 40 mg PO QPM
23. Sertraline 25 mg PO DAILY
Discharge Medications:
1. Vancomycin Oral Liquid ___ mg PO QID
RX *vancomycin [Firvanq] 50 mg/mL 2.5 ml by mouth four times a
day Refills:*0
2. Acetaminophen 500 mg PO TID
3. amLODIPine 7.5 mg PO DAILY
4. Aspercreme (lidocaine) (lidocaine;<br>lidocaine HCl) 4 %
topical DAILY
5. Chlorthalidone 25 mg PO DAILY
6. Cyanocobalamin 1000 mcg PO DAILY
7. Docusate Sodium 100 mg PO BID
8. galantamine 8 mg oral BID
9. ipratropium bromide 42 mcg (0.06 %) nasal QID
10. Lactobacillus acidophilus 1 billion cell oral TID
11. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
12. Loratadine 10 mg PO DAILY
13. Melatin (melatonin) 3 mg oral 1600
14. Metoprolol Succinate XL 25 mg PO DAILY
15. Omeprazole 20 mg PO DAILY
16. Potassium Chloride 30 mEq PO DAILY
17. Pravastatin 40 mg PO QPM
18. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4H:PRN Wheezing, SOB
19. Senna 8.6 mg PO BID:PRN Constipation - First Line
20. Sertraline 25 mg PO DAILY
21. Timolol Maleate 0.5% 1 DROP LEFT EYE BID
22. Tiotropium Bromide 1 CAP IH DAILY
23. vit A-vit C-vit E-zinc-copper ___ unit-mg-unit
oral BID
24. zinc oxide 20 % topical BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
==================
Recurrent C. diff infection mild-moderate
Alzheimer's Dementia
___
SECONDARY DIAGNOSIS:
====================
CKD
Glaucoma
Depression
Insomnia
HTN
HLD
Allergic Rhinitis
Reactive Airway Disease
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 privilege taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
===================================
- You were admitted to the hospital because you were having
diarrhea, nausea, and vomiting at home and there was concern
that you were not eating as much as normal
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
==========================================
- Lab tests showed that you were dehydrated and we gave you
fluid through you IV to fix this
- A test on your stool showed that your infection with a
bacteria called C. difficile had recurred. We treated this with
an oral antibiotic called vancomycin
- We monitored you closely to make sure you were eating and
drinking enough and had our physical therapists evaluate you to
make sure you were strong enough to return home.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
============================================
- Please continue to take all your medications and follow up
with your doctors at your ___ appointments.
We wish you all the best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19583131-DS-13
| 19,583,131 | 27,201,238 |
DS
| 13 |
2142-08-04 00:00:00
|
2142-08-07 22:35:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left wrist swelling
Major Surgical or Invasive Procedure:
Joint aspiration x 2 ___, Joint aspiration ___
History of Present Illness:
Ms. ___ is a ___ year old woman with a history of
pseudogout, positive lupus anticoagulant with h/o multiple PE,
on coumadin, who presented to the ED with left wrist swelling.
She first noticed the swelling as she began to feel a throbbing
in her wrist while watching TV. She took two tylenol and waited
4 hours, she took two more tylenol but the throbbing worsened.
She called her PCPs office and was told to report to the ED for
further management given her history of VTE with positive lupus
anticoagulant. She has had no sick contacts or outdoors
exposures. She denies any fevers, chills, nausea, vomiting, ___
pain, shortness of breath, or swelling in her legs. She had URI
symptoms last week that have now resolved. Her last INR was
checked on ___ and was 2.9. Pain feels different than when she
had pseudogout of her right big toe.
In the ED, initial vitals were 97.6 65 134/74 18 99%RA. Labs
were notable for WBC 9.6 Hgb 13.2 INR 3.6 CRP 5.4, Chem 7 WNL.
She had a CXR with no acute cardiopulmonary process. US of her
LUE without DVT and left elbow and wrist XR negative for
fracture or dislocation. She was given acetominophen, oxycodone
5 mg, Vancomycin 1000 mg, dilaudid 0.5 mg x2, and colchicine 1.2
mg.
Her left wrist was initially drained by the ED with return of
prurulent appearing fluid. Hand surgeryw as consulted and she
was retapped and found to have non prurulent material in the
joint. The joint fluid returned with a WBC count of 31.5, with
93% polys, and no crystals were seen. She was admitted to
medicine for further management.
On the floor she continues to endorse some throbbing in her left
wrist. She denies any numbness or tingling in her fingers. She
states her hand pain feels better when it is being held upwards.
Otherwise she had no other concerns.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. Denies nausea, vomiting. Denies
arthralgias or myalgias.
Past Medical History:
Psuedogout
Iron deficiency anemia
Colonic adenomas
Lupus anticoagulant with multiple PE after surgery
Diet controlled DM
HTN
Pseudoaneurysm of the aorta
GERD
Status post tubal ligation ___
Status post CCY, oophorectomy for ovarian torsion, TAH
Social History:
___
Family History:
Positive for MELAS
Family history of DM
Colon CA in mother and father
Cardiac disease in mother
Physical ___:
PHYSICAL EXAM ON ADMISSION
===========================
Vital Sigsn: T 99.6 BP 140/96 HR 86 RR 18 99 RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple
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 rebound or guarding
GU: No foley
Ext: Warm, well perfused, no clubbing, cyanosis or edema.
L upper extremity: left elbow not tender to palpation, no
warmth. Range of motion limited somewhat by wrist pain, splint
with bandage overlying forearm to mid hand. Patient with pain to
palpation of wrist but no warmth appreciated through the splint.
Able to flex hand though appears limited ___ pain. 2 second
capillary refill of tips of all digits
Neuro: CN II-XII intact, ___ strength in upper/lower on R and ___
on L, UE on L limited ___ pain, grossly normal sensation, gait
deferred
PHYSICAL EXAM ON DISCHARGE
============================
Vital Signs: T 98.5 Tmax 98.8 BP 94-54/54-70 HR 60-63 RR 16 98
RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple
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 rebound or guarding
GU: No foley
Ext: Warm, well perfused, no clubbing, cyanosis or edema.
L upper extremity: left elbow not tender to palpation, no
warmth, Full ROM, splint with bandage overlying forearm to mid
hand. Patient with mild pain to palpation of wrist but no warmth
appreciated through the splint. 4+/5 grip strength, limited
somewhat by pain. No involvement of MCP joints. 2 second
capillary refill of tips of all digits. Hand warm and well
perfused.
Neuro: CNII-XII intact, grossly normal sensation, gait deferred.
Pertinent Results:
LABS ON ADMISSION
===================
___ 11:37PM BLOOD WBC-9.6# RBC-4.66 Hgb-13.2 Hct-41.8
MCV-90 MCH-28.3 MCHC-31.6* RDW-14.6 RDWSD-48.2* Plt ___
___ 11:37PM BLOOD Neuts-62.5 ___ Monos-8.8 Eos-0.2*
Baso-0.3 Im ___ AbsNeut-6.02 AbsLymp-2.68 AbsMono-0.85*
AbsEos-0.02* AbsBaso-0.03
___ 11:37PM BLOOD ___ PTT-52.7* ___
___ 11:37PM BLOOD Glucose-117* UreaN-19 Creat-0.9 Na-141
K-4.7 Cl-103 HCO3-23 AnGap-20
___ 11:37PM BLOOD CRP-5.4*
PERTINENT LABS
==================
___ 06:15AM JOINT FLUID ___ HCT,Fl-3.0* Polys-93*
___ ___ 05:42AM BLOOD Calcium-9.6 Phos-2.8 Mg-1.8 UricAcd-5.0
___ 05:42AM BLOOD ___ PTT-44.9* ___
___ 05:56AM BLOOD ___ PTT-41.7* ___
___ 05:56AM BLOOD CRP-133.2*
MICROBIOLOGY
==================
___ 1:02 am JOINT FLUID Source: wrist.
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___:
Reported to and read back by ___ ___
12:45PM.
STAPH AUREUS COAG +. SPARSE 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 in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN-------------<=0.25 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
___ 1:30 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 1:40 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
IMAGING/STUDIES
======================
ECG ___
Baseline artifact. Sinus rhythm with an atrial premature beat.
Left axis
deviation. Low precordial lead voltage. Inferior and anterior T
wave
abnormalities. Compared to the previous tracing of ___ the
rate is now
faster. Atrial premature beat is new. T wave abnormality is
similar.
Clinical correlation is suggested.
CXR ___
No acute cardiopulmonary process. The aortic knob appears
mildly dilated
which could be further assessed for on non emergent chest CT.
UNILAT UP EXT VEINS US LEFT ___
No evidence of deep vein thrombosis in the left upper extremity.
WRIST(3 + VIEWS) LEFT, ELBOW (AP, LAT & OBLIQUE) LEFT ___
Left elbow: No fracture, dislocation, bone destruction or
degenerative changeis detected. No joint effusion. No soft
tissue calcification or radiopaque
foreign body is detected. Enthesopathy is present along the
triceps insertion
on the proximal posterior ulna and along the distal medial
humeral condyle.
Left wrist: No evidence of fracture or dislocation. No
radiopaque foreign
body. Degenerative changes, including subchondral cysts, at the
first CMC,
triscaphe, and equivocal at the distal radioulnar joint.
IMPRESSION:
No fracture or bone destruction. Minor degenerative changes
triscaphe and
first CMC joints
TTE ___
The left atrium is elongated. The estimated right atrial
pressure is ___ mmHg. Left ventricular wall thickness, cavity
size and regional/global systolic function are normal (LVEF
>55%). Doppler parameters are indeterminate for left ventricular
diastolic function. Right ventricular chamber size and free wall
motion are normal. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present. No
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. Physiologic mitral
regurgitation is seen (within normal limits). There is mild
pulmonary artery systolic hypertension. No masses or vegetations
are seen on the pulmonic valve, but cannot be fully excluded due
to suboptimal image quality. There is no pericardial effusion.
IMPRESSION: Normal biventricular cavity sizes with preserved
global and regional biventricular systolic function. No valvular
vegetations or pathologic flow identified. Mild pulmonary
hypertension.
CHEST PORT. LINE PLACEMENT ___
Right-sided PICC terminates the upper SVC.
LABS ON DISCHARGE
======================
___ 06:07AM BLOOD WBC-5.3 RBC-4.05 Hgb-11.5 Hct-36.0 MCV-89
MCH-28.4 MCHC-31.9* RDW-14.4 RDWSD-47.2* Plt ___
___ 06:07AM BLOOD ___ PTT-47.1* ___
___ 06:07AM BLOOD Glucose-120* UreaN-20 Creat-0.9 Na-138
K-3.8 Cl-99 HCO3-29 AnGap-14
___ 06:07AM BLOOD ALT-16 AST-19 AlkPhos-119* TotBili-0.5
___ 06:07AM BLOOD Mg-2.0
Brief Hospital Course:
Ms. ___ is a ___ year old woman with a history of
pseudogout, positive lupus anticoagulant with h/o of multiple PE
on Coumadin, MELAS syndrome, who presented to the ED with left
wrist swelling.
# Septic arthritis due to MSSA
Patient presented with left wrist swelling concerning for
arthritis vs. thrombus. UE US was negative. Her left wrist was
tapped in the ED which showed pus, however joint fluid could not
be sent to the lab. Her wrist was retapped by hand surgery
without frank pus but the joint aspirate had 31.5K WBC with 93%
PMNS, with a HCT of 3.0. Cultures from the initial aspirate in
the ED grew MSSA bacteremia. She was initially started on IV
Vancomycin/Ceftriaxone, narrowed to IV Vancomycin with culture
growing staph aureus, narrowed to IV nafcillin when
sensitivities returned MSSA. Blood cultures were negative to
date and TTE was negative for vegetation. She was seen by ID and
will continue a 4 week course of IV nafcillin (___) and she will be followed by OPAT. A PICC was
placed on ___ with tip terminating in upper SVC. XR wrist and
elbow were negative for fracture or bone destruction. There were
no crystals appreciated on aspirate and uric acid WNL. She was
retapped for a third time on the morning of discharge without
resultant fluid able to be collected. Given the continued
improvement in her hand exam she did not need to go to the OR
for washout. She was seen by OT for ROM exercises. Her pain and
range of motion improved significantly post aspiration and with
antibiotics. She will follow up with hand surgery and ID in
clinic as an outpatient.
# Antiphospholipid syndrome with history of PEs on warfarin
The patient was ruled out for a LUE DVT with a negative US. She
was initially supratherapeutic with an INR of 3.6. Her warfarin
was held given concern for the need for a possible washout in
the ED. She was started on Lovenox 90 mg SC BID given her
history of APA. Her warfarin was restarted on ___ given no need
for OR, and she will be bridge with lovenox with 48 hours of
continued lovenox coverage. Her INR on discharge was 1.4.
# Hypertension
The patient had softer pressures during the admission so her
home hydrochlorothiazide was held. She continued losartan and
metoprolol which were continued on discharge.
Transitional Issues
======================
[ ] Nafcillin 2 gm IV q 4 h
Start Date: ___
Projected End Date: ___
[ ] WEEKLY LABS: For NAFCILLIN: WEEKLY: CBC with differential,
BUN, Cr, AST, ALT, TB, ALK PHOS. WEEKLY: ESR/CRP
[ ] STOPPED hydrochlorothiazide due to low blood pressures
[ ] ID f/u
[ ] Hand surgery f/u
[ ] Lovenox 90 mg SC BID bridge to coumadin given goal INR
2.5-3.5 (overlap for 48 hours once INR therapeutic)
[ ] Check INR ___ at ___, please
continue lovenox for 48 hours after patient is therapeutic on
Coumadin due to lupus anticoagulant - INR on discharge 1.4
[ ] OT ROM hand exercises
# CODE: FULL
# CONTACT: ___ (daughter) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Losartan Potassium 25 mg PO DAILY
2. Metoprolol Succinate XL 50 mg PO DAILY
3. Hydrochlorothiazide 12.5 mg PO DAILY
4. Warfarin 5 mg PO 2X/WEEK (MO,FR)
5. Warfarin 7.5 mg PO 5X/WEEK (___)
6. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Enoxaparin Sodium 90 mg SC Q12H
Start: ___, First Dose: Next Routine Administration Time
For Coumadin Bridge
RX *enoxaparin 100 mg/mL 0.9 ml SC twice a day Disp #*10 Syringe
Refills:*0
2. Nafcillin 2 g IV Q4H
RX *nafcillin in dextrose iso-osm 2 gram/100 mL 100 ml Q4H every
four (4) hours Disp #*150 Intravenous Bag Refills:*0
3. Aspirin 81 mg PO DAILY
4. Losartan Potassium 25 mg PO DAILY
5. Metoprolol Succinate XL 50 mg PO DAILY
6. Warfarin 7.5 mg PO 5X/WEEK (___)
7. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN pain
RX *oxycodone 5 mg 1 capsule(s) by mouth Every 6 Hours Disp #*10
Capsule Refills:*0
8. Senna 8.6 mg PO BID:PRN constipation
9. Docusate Sodium 100 mg PO BID:PRN constipation
10. Warfarin 5 mg PO 2X/WEEK (MO,FR)
11. Ibuprofen 400 mg PO Q8H:PRN Pain
Do not take this medication for more than one more week
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnoses
==================
Septic Arthritis
Antiphospholipid syndrome
Secondary Diagnoses
====================
Hypertension
Diet Controlled Diabetes Mellitus
Pseudogout
Tested positive for MELAS syndrome (mitochondrial myopathy,
encephalopathy, lactic acidosis, and stroke)
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 during your stay at ___. You
were admitted to the hospital because of left wrist pain and
swelling. Fluid was removed from the joint which showed signs
that the joint was infected. You were started on IV antibiotics
and your pain improved. You were seen by the hand surgeons who
recommended conservative treatment, and you did not need to have
surgery. You will need to have IV antibiotics for 4 weeks to
clear the infection. You had a PICC placed for you to receive
these antibioics. There were no signs of an infection in your
blood or heart.
You should continue the range of motion exercises that you were
given by the occupational therapists. You will need to follow
up with the Hand Surgeons to ensure that things are still going
well.
Your Coumadin was stopped because we were concerned you might
need surgery. Your coumadin was restarted but you were started
on lovenox shots until your INR is again in the right range
(2.5-3.5) due to your history of blood clots. You will need to
follow up with the ___ clinic on ___ to have your
INR checked.
We also stopped one of your anti hypetensive medications
hydrochlorothiazide because your blood pressures were on the
lower side. Your complete medication list is included in your
discharge paperwork.
We wish you the best!
-Your ___ Care Team
Followup Instructions:
___
|
19583275-DS-8
| 19,583,275 | 27,489,218 |
DS
| 8 |
2136-07-27 00:00:00
|
2136-07-28 02:46:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Penicillins / Colcrys / clarithromycin / amoxicillin
Attending: ___
Chief Complaint:
Worsening Dizziness
Major Surgical or Invasive Procedure:
NA
History of Present Illness:
___ yo woman with a h/o HTN and chronic dizziness, presented with
worsening of her dizziness and HTN to the 200s. CT/CTA head/neck
was obtained in the ED which revealed a left vertebral artery
dissection, prompting neurology consultation.
Yesterday morning, the patient had worsening of her chronic
dizziness so called her daughter at 11am to say she didn't feel
well. Her BP was mildly elevated at that time. Later that
afternoon ~4pm, her daughter checked on her. Her BP was elevated
to 207/98. The patient has labile BP at baseline, but this is
higher than usual, so they presented to the ED where CTA
revealed a possible dissection. Upon further questioning, the
patient had an episode of slurred speech ___, witnessed by
her other daughter (not present); BP was reportedly normal at
that time and the episode resolved relatively quickly. Speech is
now at baseline. In the ED, her HTN was treated and improved to
the 150s. The patient continues to feel dizzy.
Past Medical History:
- DM
- HTN with labile BPs
- HLD
- osteoporosis
- memory problems
- colon polyps
- goiter
- arthritis
- dizziness
- ascending aortic aneurysm
Social History:
___
Family History:
- sister with breast cancer and CAD, MI
Physical Exam:
EXAMINATION
General: Awake, cooperative, NAD.
HEENT: NC/AT
Neck: Supple.
Pulmonary: clear to auscultation bilaterally
Cardiac: RRR, no murmurs
Abdomen: soft, nondistended
Extremities: no edema, warm
Skin: no rashes or lesions noted.
NEUROLOGIC EXAMINATION
-Mental Status: Alert, cooperative with the exam. Has difficulty
relating her history and says she has memory problems. Language
is fluent, without dysarthria, and at patient's baseline per the
daughter, who is translating. Pt. was able to name both high and
low frequency objects. Able to follow both midline and
appendicular commands.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 2.5 to 2mm bilaterally.
III, IV, VI: EOMI without nystagmus.
V: Facial sensation intact to light touch in all distributions
VII: No facial droop with symmetric upper and lower facial
musculature bilaterally
VIII: Hearing intact to voice.
IX, X: Palate elevates symmetrically.
XI: Full strength in trapezii bilaterally.
XII: Tongue protrudes in midline
-Motor: No pronator drift bilaterally. Mild action tremor.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L ___ ___ ___ 5 5 5 5 5
R ___ ___ ___ 5 5 5 5 5
-DTRs:
Bi Tri ___ Pat Ach
L 3 3 3 3 3
R 3 3 3 3 3
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense throughout.
-Coordination: No dysmetria on FNF bilaterally. Rapid
alternating
movements were symmetric.
-Gait: Appears antalgic upon standing. Narrow-based, short
stride. Walks with a cane.
Pertinent Results:
___ 09:24PM BLOOD WBC-5.4 RBC-3.95 Hgb-12.1 Hct-36.7 MCV-93
MCH-30.6 MCHC-33.0 RDW-12.4 RDWSD-42.5 Plt ___
___ 09:24PM BLOOD ___ PTT-34.1 ___
___ 09:24PM BLOOD Glucose-165* UreaN-24* Creat-0.9 Na-139
K-4.3 Cl-102 HCO3-24 AnGap-17
___ 12:44PM BLOOD ALT-15 AST-24 LD(LDH)-222 AlkPhos-48
TotBili-0.6
___ 12:44PM BLOOD Albumin-4.6 Calcium-10.2 Phos-4.6* Mg-2.0
Cholest-179
___ 12:44PM BLOOD %HbA1c-6.9* eAG-151*
___ 12:44PM BLOOD Triglyc-225* HDL-57 CHOL/HD-3.1
LDLcalc-77
___ 09:24PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-MOD
___ 09:24PM URINE RBC-1 WBC-19* Bacteri-FEW Yeast-NONE
Epi-0
Imaging
MRI & MRA Brain (___)
Preliminary Impression:
1. No acute intracranial abnormality.
2. Intracranial atherosclerosis with focal luminal narrowing and
irregularity involving bilateral vertebral and internal carotid
arteries.
CTA Head & Neck (___)
IMPRESSION:
1. Volume loss and chronic microvascular ischemic changes.
Otherwise, no acute intracranial abnormality on CT. MRI can be
considered if not contraindicated.
2. Contour irregularity, with tortuosity, multifocal narrowing
with associated focal dilation seen at multiple levels
throughout the intracranial vasculature, as described above.
This can relate to atherosclerotic disease or other
vasculopathy, etc.
3. Small focal irregularity/ defect in the proximal right
vertebral artery, which is favored to represent a fenestration,
though focal dissection/filling defect can appear similar. No
distal flow limitation.
4. Focal 2 mm outpouching from the anterior left V4 vertebral
artery and right A2 anterior cerebral artery, likely
representing irregularity of the vasculature secondary to
atherosclerotic calcification rather than an
aneurysm.
5. Heterogeneous multi nodular thyroid gland. Ultrasound of the
thyroid gland is to be considered
6. C spine degenerative changes
Brief Hospital Course:
The patient was admitted for acute on chronic dizziness and for
CTA which showed a luminal irregularity of the right
extracranial vertebral artery that was initially read as a
possible dissection. However this was re-read as more likely
fenestration. MRI was negative for stroke. She was found to have
positive UA and treated with Bactrim for UTI, which was thought
to be the likely trigger for exacerbation of her presenting
symptoms. In addition she was intermittently hypertensive and
hypotensive thought likely due to discrepancy between her
medication reconciliation and her actual regimen (she does not
take hydrochlorothiazide unless her blood pressure is very high,
per daughter this is an instruction from her PCP's office). She
was discharged with instructions to follow up with her PCP to
clarify her regimen and to order an MRI cervical spine to assess
for suspected degenerative disease as an explanation for her
chronic symptoms. She was advised to start aspirin 81mg for
primary prevention.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 20 mg PO BID
2. Labetalol 50/75/50 mg
3. Pravastatin 20 mg and 40 mg every other day
4. Losartan Potassium 6.25 mg PO DAILY
5. Calcium Carbonate 500 mg PO DAILY
6. Vitamin D 400 UNIT PO DAILY
7. Hydrochlorothiazide 6.25 mg PO DAILY
Discharge Medications:
1. Calcium Carbonate 500 mg PO DAILY
2. Labetalol 50/75/50 mg.
3. Omeprazole 20 mg PO BID
4. Pravastatin 20 mg and 40 mg every other day
5. Vitamin D 400 UNIT PO DAILY
6. Aspirin 81 mg PO DAILY
7. Hydrochlorothiazide 6.25 mg PO DAILY
8. Losartan Potassium 6.25 mg PO DAILY
9. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 2 Days
Discharge Disposition:
Home
Discharge Diagnosis:
Acute on Chronic Dizziness
Hypertension
Hyperlipidemia
Diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital for worsening of chronic
dizziness and because CT imaging of your neck vessels showed an
irregularity. Upon further review, we do not believe this
represents anything worrisome, and an MRI of the brain did not
show a stroke. We think your acute dizziness is probably
multifactorial, due to arthritis in your spine, fluctuating
blood pressure, and a UTI. We started you on antibiotics and
recommended following up with your PCP to obtain MRI of your
cervical spine as an outpatient. We also recommend taking
aspirin 81mg daily to prevent stroke in the future. Please take
your blood pressure medications as prescribed as changes in the
dosing can cause uncontrollable fluctuations.
It was a pleasure taking care of you. We wish you the best.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19583275-DS-9
| 19,583,275 | 27,932,490 |
DS
| 9 |
2137-12-18 00:00:00
|
2137-12-19 06:39:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Colcrys / clarithromycin / amoxicillin / Ativan
Attending: ___
Chief Complaint:
Blurry Vision
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o ___ woman c DM, HTN, HLD, ascending aortic
aneurysm and admission to Neurology service ___ for acute on
chronic dizziness in setting of right vertebral luminal
irregularity thought to be fenestration presenting with
dizziness and blurry vision found to be hypertensive.
Per documentation, patient experienced new onset dizziness at
6am after waking from sleeping and rising to stand. It was
associated with blurry vision but without numbness, tingling or
focal weakness. Her daughter ___ called her cardiologist's
office who advised her to take her mother to the ___.
In the ___, initial vitals: 97.6 74 ___ RA
- Labs notable for:
WBC 5.4, H+H 12./37.5, Plt 152
Trop neg x1
- Imaging notable for: CXR: No acute cardiopulmonary process
___ CTA Head/Neck CTA head and neck:
1. Similar appearance of the V1 segment of the right vertebral
artery
compared to ___, consistent with known dissection
versus
fenestration. The right vertebral artery distal to this site is
patent.
2. No flow limiting occlusion, stenosis, dissection, or aneurysm
greater than 3 mm.
3. Severe atherosclerotic ossification involving the bilateral
carotid bulbs, bilateral cavernous carotid arteries, right ACA,
V4 segment of the left vertebral artery are similar to prior.
4. Similar appearance a heterogeneously enhancing large left
thyroid.
- Pt was given:
___ 13:03 IV Labetalol 10 mg
Neurology was consulted. They noted that "exam most notable for
inattention (nonspecific) and in this setting, difficult to
perform a reliable neurologic exam though there is no clear
visual field defect." They suspected hypertensive urgency as the
etiology of her symptoms and recommended admission to medicine
for BP control with stroke consult service to follow. They also
recommended non-contrast brain MRI to rule out PRES or small
infarct in the setting of her hypertension.
On arrival to the floor, pt reports blurry vision, started at
noon ___, which she hasn't had before and is different from her
chronic dizziness. She can see people and objects but they do
not appear sharp. Other than that, she denies headaches, chest
pain, shoulder or back pain, she has some right knee pain from
surgery (knee replacement in ___. She also has been having
frequent urination, no pain, says she urinates about ___ times a
night. No bowel incontinence.
ROS: As above
Past Medical History:
- HTN with labile BPs
- HLD
- osteoporosis
- memory problems
- colon polyps
- goiter
- arthritis
-DM not on medications, previously on medications ___ years ago
- Dizziness
- ascending aortic aneurysm
- S/p right TKR on ___
Social History:
___
Family History:
Sister with breast cancer and CAD, MI. No hx of renal disease,
idiopathic HTN, polycystic kidney.
Physical Exam:
ADMISSION PHYSICAL EXAM:
==========================
Vitals: 97.8 BP ___ on arrival, HR ___ RR 12 99RA
General: Alert, oriented, sitting up
HEENT: Sclerae anicteric, no nystagmus, PERRL, MMM, oropharynx
clear. On my fundoscopic exam, no signs of papilledema
Neck: supple, JVP not elevated, no LAD, palpable thyroid
Lungs: CTAB no wheezes, rales, rhonchi
CV: RRR, S1 and S2, diastolic murmur in RUSB
Abdomen: soft, NT/ND bowel sounds present, no rebound tenderness
or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CN2-12 intact, no focal deficits
DISCHARGE PHYSICAL EXAM:
=========================
Vitals: Tm/Tc 99.4 BP 123-178/69-77 HR 16 99RA
General: Alert, oriented, sitting up
HEENT: Sclerae anicteric, no conjunctival injection,no
nystagmus, PERRL, MMM, oropharynx clear.
Lungs: CTAB no wheezes, rales, rhonchi
CV: RRR, S1 and S2, diastolic murmur in RUSB unchanged
Abdomen: soft, NT/ND bowel sounds present
Ext: warm, well perfused, no edema
Neuro: CN2-12 intact, no focal deficits, intact finger to nose
testing
Pertinent Results:
ADMISSION LABS:
===================
___ 11:45AM BLOOD WBC-5.4 RBC-3.95 Hgb-12.1 Hct-37.5 MCV-95
MCH-30.6 MCHC-32.3 RDW-12.4 RDWSD-43.6 Plt ___
___ 11:45AM BLOOD Glucose-127* UreaN-22* Creat-0.8 Na-135
K-4.1 Cl-100 HCO3-23 AnGap-16
___ 11:45AM BLOOD ALT-12 AST-18 AlkPhos-54 TotBili-0.6
___ 11:45AM BLOOD Albumin-4.4 Calcium-9.3 Phos-3.4 Mg-2.1
___ 11:45AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
DISCHARGE LABS:
===================
___ 06:55AM BLOOD WBC-4.4 RBC-4.09 Hgb-12.5 Hct-38.7 MCV-95
MCH-30.6 MCHC-32.3 RDW-12.5 RDWSD-43.4 Plt ___
___ 06:55AM BLOOD Glucose-154* UreaN-25* Creat-0.9 Na-140
K-3.9 Cl-103 HCO3-21* AnGap-20
___ 06:55AM BLOOD Calcium-9.3 Phos-4.1 Mg-2.1
MICRO:
=========
___ 1:10 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
IMAGING:
==========
___ MRI head:
Small focus (<1mm) of diffusion signal in the ventral pons is
likely artifact given adjacent pre pontine abnormality, late
subacute infarct is unlikely unless clinically suspected. No MRI
evidence of PRES. There are multifocal areas of arterial
intracranial narrowing, similar to ___.
___ CTA Head/Neck CTA head and neck:
1. Similar appearance of the V1 segment of the right vertebral
artery
compared to ___, consistent with known dissection
versus
fenestration. The right vertebral artery distal to this site is
patent.
2. No flow limiting occlusion, stenosis, dissection, or aneurysm
greater than 3 mm.
3. Severe atherosclerotic ossification involving the bilateral
carotid bulbs, bilateral cavernous carotid arteries, right ACA,
V4 segment of the left vertebral artery are similar to prior.
4. Similar appearance a heterogeneously enhancing large left
thyroid.
___ CXR:
The lungs are clear without consolidation, effusion, or edema.
Moderate
cardiac enlargement and tortuosity of the thoracic aorta is
again noted.
There is rightward deviation of the trachea at the thoracic
inlet compatible with left-sided thyroid enlargement as seen on
same-day neck CTA. No acute osseous abnormalities.
Brief Hospital Course:
___ y/o F DM, HTN, HLD, acute on chronic dizziness in setting of
right vertebral luminal irregularity thought to be fenestration
presenting with dizziness and blurry vision found to be
hypertensive.
#Hypertensive emergency: Patient has a history of labile BP
control, presented with blurry vision setting of elevated blood
pressure, reaching max SBP 225, with normal renal and liver
function. Etiology was most concerning for uncontrolled HTN
although she reports medication compliance. Per PCP note, BPs
are predominately 130's-140's/60's-70's. We continued her home
medication without further change given how labile her BPs tend
to be. She was initially given IV labetalol 10 and then 2.5,
with rapid lowering of her blood pressure past goal reduction of
about 25%. Thus she was allowed to equilibrate without addition
of additional medications. She would likely benefit from a low
dose B-blocker for both AAA and BP control so she will follow
up Dr. ___ Dr. ___ plans as an outpatient. Her blurry
vision improved throughout the course of her hospitalization
without other new symptoms.
#Dizziness: She has known chronic dizziness and had a CTA which
showed a luminal irregularity of the right extracranial
vertebral artery showing a fenestration. MRI was negative for
stroke at prior admission. Repeat MRI without signs of PRES. The
pontine anomaly noted was clarified with radiology, as likely
artifact and her cerebellar exam was normal.
CHRONIC ISSUES:
================
#AAA: ascending aortic dilation, stable at 4.8 cm, with moderate
AR
#GERD: continued omeprazole 20 mg BID
#Multinodular goiter: continued methimazole 2.5 mg daily
#HLD: continued atorvastatin 40 qpm
#OA, s/p RTKR: pain control with acetaminophen
TRANSITIONAL ISSUES:
=====================
-No new medications
-Discharge BPs: ___
-Note: MRI head repeated to assess for PRES which was negative.
There was a Small focus (<1mm) of diffusion signal in the
ventral pons is likely artifact given adjacent pre pontine
abnormality, late subacute infarct is unlikely unless clinically
suspected. Her cerebellar exam was normal and this area of
imaging per radiology is susceptible to artifact. Please keep
for your records and reassess if clinically indicated.
-MRI cervical spine to assess for suspected degenerative disease
as an explanation for her chronic symptoms
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 20 mg PO BID
2. Losartan Potassium 25 mg PO BID
3. Calcium Carbonate 600 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Methimazole 2.5 mg PO DAILY
6. Atorvastatin 40 mg PO QPM
7. Acetaminophen 650 mg PO QAM
8. Fluticasone Propionate 110mcg 2 PUFF IH BID
Discharge Medications:
1. Acetaminophen 650 mg PO QAM
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Calcium Carbonate 600 mg PO DAILY
5. Fluticasone Propionate 110mcg 2 PUFF IH BID
6. Losartan Potassium 25 mg PO BID
7. Methimazole 2.5 mg PO DAILY
8. Omeprazole 20 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
-Hypertensive Urgency
Secondary:
-Acute on Chronic Dizziness/Known Vertebral Fenestration
-Aortic Dilation 4.8 CM
-GERD
-Multinodular Goiter
-Osteoarthritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___
___ were admitted to ___ on ___ for worsening blurry
vision and found to have very high blood pressures. ___
initially required IV medication for this and your vision
improved, and ___ were continued on your Losartan 25 mg twice a
day.
We did not increase your blood pressure medications further
given that ___ also get low blood pressures.
___ have a primary care appointment (Dr. ___ scheduled as
below. Please call the office to reschedule to an earlier
appointment (within 1 week) if possible.
Best wishes and Happy Birthday
Your ___ care team
Followup Instructions:
___
|
19583452-DS-8
| 19,583,452 | 20,708,159 |
DS
| 8 |
2185-01-21 00:00:00
|
2185-01-21 21:46:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
left flank and back pain
Major Surgical or Invasive Procedure:
Bone marrow biopsy on ___
History of Present Illness:
Mr. ___ is a ___ male with no significant
past medical history who presented to ___
with 2 days of left flank pain and found to have leukocytosis
and
splenomegaly and transferred to ___ for further evaluation.
Patient woke up with sharp intermittent non-radiating pain in
left flank for the past 2 days. Pain is worse with movement and
deep inspiration. Episodes of pain last seconds. No history of
trauma to the area or prior similar pain. He has been feeling
more fatigued. He notes a bruise on his abdomen appeared about 1
week ago. He presented to ___ and was
found
to have WBC count 381k.
On arrival to the ED, initial vitals were 97.6 118 138/52 18 97%
RA. Exam was notable for abdominal LUQ tenderness to palpation
with some guarding. Labs were notable for WBC 383.2, H/H
11.5/34.2, Plt 131, INR 1.4, fibrinogen 324, Na 142, K 3.4,
BUN/Cr ___, phos 3.9, LFTs wnl, LDH 778, trop < 0.01, D-dimer
402, uric acid 8.9, serum tox negative, lactate 1.0, VBG
7.40/37/40, and UA negative. CT torso was negative for PE but
noted massive splenomegaly with possible infarction. Patient was
given hydrea 1500mg PO, allopurinol ___ PO, and 1L NS. BMT was
consulted who preformed bone marrow biopsy. Prior to transfer
vitals were
On arrival to the floor, patient reports no pain. He denies
fevers/chills, night sweats, headache, vision changes,
dizziness/lightheadedness, weakness/numbnesss, shortness of
breath, cough, hemoptysis, chest pain, palpitations,
nausea/vomiting, diarrhea, hematemesis, hematochezia/melena,
dysuria, and hematuria.
Past Medical History:
None
Social History:
___
Family History:
Heart disease present on mother and father's sides of
the family. Grandfather's cousin had unknown type of cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
=======================
VS: Temp 98.2, BP 122/68, HR 124, RR 18, O2 sat 96% RA.
___: Pleasant man, in no distress, lying in bed comfortably.
HEENT: Anicteric, PERLL, OP clear.
CARDIAC: Tachycardic, normal s1/s2, no m/r/g.
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi.
ABD: Soft, LUQ tenderness, non-distended, positive bowel sounds,
palpable spleen.
EXT: Warm, well perfused, no lower extremity edema, erythema or
tenderness.
NEURO: A&Ox3, good attention and linear thought, CN II-XII
intact. Strength full throughout. Sensation to light touch
intact.
SKIN: No significant rashes.
DISCHARGE PHYSICAL EXAM:
=======================
VS: 98.4 BP 104 / 60 R Sitting HR: 103 RR: 18 ___: 97 Ra
___: young obese male resting in bed with NAD.
HEENT: AT/AC. EOM intact. Moist mucus membranes without ulcers
or lesions.
Neck: supple with no lymphadenopathy
CV: RRR with no MRG
Lungs: no increased WOB and CTAB
Abdomen: +BS, soft, distended from body habitus. Spleen
severely
enlarged. No TTP at all quadrants
Ext: WWP. No ___ edema
Neuro: Alert and oriented.
Skin: No rashes visualized. bruising at site of bone marrow
biopsy
Pertinent Results:
ADMISSION LABS:
===============
___ 06:05PM BLOOD WBC-383.2* RBC-3.99* Hgb-11.5* Hct-34.2*
MCV-86 MCH-28.8 MCHC-33.6 RDW-17.9* RDWSD-55.6* Plt ___
___ 06:05PM BLOOD Neuts-51 Bands-10* Lymphs-2* Monos-0
Eos-4 Baso-2* ___ Metas-14* Myelos-12* Promyel-5* Other-0
AbsNeut-233.75* AbsLymp-7.66* AbsMono-0.00* AbsEos-15.33*
AbsBaso-7.66*
___ 06:05PM BLOOD ___ PTT-33.1 ___
___ 06:05PM BLOOD Ret Aut-3.3* Abs Ret-0.13*
___ 06:10AM BLOOD ALT-16 AST-23 LD(LDH)-737* AlkPhos-95
TotBili-0.8
___ 06:05PM BLOOD Albumin-4.1 Calcium-8.7 Phos-3.9 Mg-2.1
UricAcd-8.9* Iron-23*
___ 06:05PM BLOOD Glucose-85 UreaN-9 Creat-0.9 Na-142
K-3.4* Cl-107 HCO3-20* AnGap-15
RELEVANT LABS:
=============
___ 06:05PM BLOOD TSH-3.4
___ 09:54PM BLOOD HBsAg-NEG HBsAb-Borderline HBcAb-NEG
___ 09:54PM BLOOD HIV Ab-NEG
___ 03:25AM URINE Blood-MOD* Nitrite-NEG Protein-TR*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-TR*
___ 03:25AM URINE RBC-2 WBC-42* Bacteri-NONE Yeast-NONE
Epi-0 RenalEp-10
MICRO:
=====
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
DISCHARGE LABS:
==============
___ 06:35AM BLOOD WBC-75.7* RBC-4.21* Hgb-11.0* Hct-35.1*
MCV-83 MCH-26.1 MCHC-31.3* RDW-18.4* RDWSD-50.4* Plt ___
___ 06:35AM BLOOD Neuts-54 Bands-9* Lymphs-16* Monos-4*
Eos-0 Baso-0 ___ Metas-4* Myelos-13* AbsNeut-47.69*
AbsLymp-12.11* AbsMono-3.03* AbsEos-0.00* AbsBaso-0.00*
___ 06:35AM BLOOD ___
___ 06:35AM BLOOD Glucose-84 UreaN-14 Creat-0.8 Na-138
K-4.7 Cl-104 HCO3-23 AnGap-11
___ 06:35AM BLOOD ALT-71* AST-55* LD(LDH)-476* AlkPhos-172*
TotBili-1.0
___ 06:35AM BLOOD Albumin-3.5 Calcium-8.5 Phos-3.8 Mg-2.5
PATHOLOGY:
=========
Bone Marrow (___):
CHRONIC MYELOID LEUKEMIA, BCR/ABL1 POSITIVE, IN STABLE PHASE.
SEE NOTE.
Note: No significant blast population is present.
Cytogenetics -
INTERPRETATION/COMMENT: Every metaphase bone marrow cell
examined had an abnormal
karyotype with the translocation involving chromosomes 9 and 22
that generates the ___
chromosome characteristic of chronic myelogenous leukemia. ___
has confirmed that this
translocation has resulted in the BCR/ABL gene rearrangement
(see below).
IMAGING:
=======
CTA Chest ___:
1. Suboptimal CTA due to technical factors. No central PE and
no obvious
aortic abnormality. Distal segmental/subsegmental PE cannot be
excluded.
2. Increased left basal opacity and new small left pleural
effusion. This
could be atelectasis secondary to an inflammatory process
involving the
massively enlarged spleen (showing suspected infarct on recent
abdominal
imaging), or could reflect pneumonia/aspiration.
3. Slight evolution of partially visualized splenic
hypodensity. New
associated subcapsular fluid collection, not fully imaged and
whose
attenuation is difficult to assess, although there may be a
hemorrhagic
component.
Echo ___:
IMPRESSION: Mild symmetric left ventricular hypertrophy with
normal cavity size and regional/global
biventricular systolic function. No valvular pathology or
pathologic flow identified. Normal estimated
pulmonary artery systolic pressure.
CXR ___:
Lungs are low volume with bibasilar atelectasis. Heart size is
normal. There
is no pleural effusion. No pneumothorax is seen. There is no
evidence of
pneumonia
CTA chest and abdomen/pelvis ___:
1. Massive splenomegaly measuring up to 31.2 cm, with a focal
hypodense region
located posteriorly, possibly concerning for infarction.
2. Suboptimal bolus timing limits the visualization of the
pulmonary
vasculature, however within these limitations there is no
evidence of filling
defect to indicate a pulmonary embolus.
Brief Hospital Course:
___ is a ___ year old previously healthy man diagnosed with
CML after presenting to ___ with left flank pain.
He was transferred from ___ for further work up and
management.
ACUTE ISSUES:
============
#Chronic myeloid leukemia:
Presented with 2 days of left flank pain. Labs notable for
markedly elevated white count of 385,000. CT notable for massive
splenomegaly and splenic infarct. He was initiated on hydroxurea
and transferred to ___. BMBx c/w CML, cytogenetics w/ FISH
show 96.5% cells w/ BCR-ABBL mutation.
EUTOS score suggest that patient is at high risk for incomplete
cytogenetic response. He was thus started on dasatinib rather
than imatinib. Hydroxyurea was also discontinued after
improvement of his WBC on dasatinib. Acyclovir was continued for
prophylaxis.
#Massive splenomegaly:
#Splenic Infarct:
#Left flank pain:
This was observed on CT abdomen as a hypodense region located in
the posterior spleen. This corresponds to his left flank
abdominal pain. Pain was well controlled initially with minimal
oxycodone. On discharge, he denied pain from the left flank and
was given instructions to use Tylenol for pain control.
#Fevers:
#UTI:
Pt spiked a sustained fever to 100.4. U/A was obtained showing
trace ___, moderate blood, 42 WBC, and no bacteria. He was
asymptomatic. The patient's fever defervesced but given his
immunosuppressed state with CML and persistent tachycardia, we
treated him for UTI with IV CTX. Urine culture showed mixed
flora consistent with contaminate but we continued him for a
course of treatment for 6 days. He remained afebrile for the
rest of the admission.
#Sinus tachycardia: On presentation to the ED and during this
admission, the patient had HRs ranging from 100-115 at rest,
with an increase to the 130s upon minimal activity. He was
asymptomatic. EKG in the ED/floor showed sinus tachycardia
without ST segment changes. Our differential included inadequate
pain control, volume depletion, sepsis, and pulmonary embolism.
CTA chest on admission did not show PE in the proximal pulmonary
veins but was inadequate for assessing the distal pulmonary
vasculature. A repeat CTA chest showed more of the pulmonary
vasculature without PE, but showed a new small left pleural
effusion and left base opacity. Sinus tachycardia not responsive
to fluid bolus and pain has been well controlled. Cardiology
evaluated and believed this was physiologic from inactivity and
obesity.
#Transaminitis:
His LFTs increased slightly after starting dasatinib but was
stable with an AST 55and ALT 71. His WBC count continued to
downtrend and decreased to 83 on discharge.
# Nausea:
# Vomiting:
Intermittent, resolved by discharge. Thought to be secondary to
dasatinib.
#Hyperuricemia: The patient presented with a uric acid of 8.9,
phos of 3.9, Ca of 8.7, and K of 3.4. There was concern for TLS
and the patient was started on IVF and allopurinol ___. His
uric acid downtrended and on discharge was 5.0. He was continued
on allopurinol on discharge.
#CTA Chest findings:
Repeat CTA chest on ___ showed a new left small pleural
effusion and left base opacity consistent with atelectasis from
inflammation from a large spleen versus pneumonia. He has
remained afebrile after starting CTX for UTI and denied cough or
shortness of breath concerning for a pneumonia. A subcapsular
splenic fluid accumulation was also seen but this is unlikely a
developing hematoma given his stable hemoglobin and resolution
of pain when this imaging was done.
#Flat affect/social anxiety?:
During his in-patient admission, the patient has maintained a
flat affect but denies having problems with his mood. Social
work has evaluated and reports the patient has been evaluated
for anxiety in the past but was not started on pharmacotherapy.
His mother been consistently at bedside and the patient
frequently defers to his mother when answering questions. His
father has been to visit once but has not been involved in his
life for the last ___ years. He denies going to school or work
and spends his day on the computer.
TRANSITIONAL ISSUES:
===================
CODE: Full Code (presumed)
EMERGENCY CONTACT HCP: ___ (mother) ___
Admission Wt: 108.09kg (238.3lb) Discharge Wt: 113.63 kg (250.51
lb)
Discharge CBC: WBC:75.7 Hgb:11.0 Platelets:121 Hct:35.1
Discharge Cr: 0.8
[] NEW MEDICATIONS:
- Started dasatinib 100mg daily for high risk CML treatment
- Started acyclovir 400mg BID for prophylaxis
- Started allopurinol ___ daily for hyperuricemia
[] Follow up with oncologist Dr. ___ on ___,
___ at 2:30PM.
[] BCL-ABL PCR pending at discharge
[] F/u LFTs/ALk Phos (desatinib?)
[] F/u nausea/vomiting and left flank pain
[] Pt is hepatitis B non-immune. Would likely benefit from
immunization.
[] Will need EKG ___ and ___ while on dasatinib to
monitor for QTc.
[] Pt would likely benefit from outpatient social
work/psychology
[] Will need to find a PCP that accepts their insurance.
[] F/u sinus tachycardia. Consider cardiology appointment for
sinus tachycardia.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acyclovir 400 mg PO Q12H
RX *acyclovir 400 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*3
2. Allopurinol ___ mg PO DAILY
RX *allopurinol ___ mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*3
3. DASatinib 100 mg PO DAILY )
( )
4. Ondansetron 8 mg PO Q8H:PRN nausea
RX *ondansetron 8 mg 1 tablet(s) by mouth every 8 hours Disp
#*10 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Chronic myeloid leukemia
Leukocytosis
Anemia
Thrombocytopenia
SECONDARY DIAGNOSIS:
Massive splenomegaly
Splenic Infarct
Left flank pain
Fevers
Urinary tract infection
Sinus tachycardia
Transaminitis
Nausea and vomiting
Hyperuricemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring of you at ___.
WHY WAS I IN THE HOSPITAL?
- You came to the hospital with pain along your left flank and
back.
WHAT HAPPENED TO ME IN THE HOSPITAL?
You had a bone marrow biopsy done which showed that you had
Chronic Myeloid Leukemia (CML) and were started on a
chemotherapy called Dasatinib. The pain on your side was found
to be caused by your spleen being too large from the CML. You
were also treated for a urinary tract infection with antibiotics
and evaluated by cardiology, the heart doctors, for your fast
heart rate. The cardiologists recommend exercise and losing
weight.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Please continue taking the Dasatinib daily, making sure not to
miss ___ dose as well as your other medications.
- Please follow up with your oncologist Dr. ___
at ___ on ___ at 2:30PM.
- Please set up an appointment with a primary care doctor that
accepts your insurance.
- For pain, please do not take medications with ibuprofen
(advil, motrin, naproxen, aleve). You can take Acetaminophen
(Tylenol).
If you develop symptoms of chest pain, shortness of breath,
palpitations, light headedness or dizziness, severe pain,
worsening nausea or vomiting, fevers to 100.4F, chills or severe
night sweats, please call your doctor or go to the emergency
room.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19584538-DS-6
| 19,584,538 | 28,041,463 |
DS
| 6 |
2178-06-27 00:00:00
|
2178-06-28 17:07:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
lightheadness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year-old ___ speaking man with no past
medical history who presents following an episode of
unresponsiveness post coitus.
Patient states having sexual intercourse with his fiancee (which
he calls his wife). ___, and felt very tired and sleepy.
He remember everything. However, he said that his fiancee
apparently has never seem him this fatigued before and called
911. He denies LOC. He denies having any chest pain/tightness,
palpitation, shortness of breath, nausea, vomiting,
lightheadness/dizziness, abnormal rhythmic movements, loss of
urine or bowel movement. He denies any prodrome. He has never
had seizure or syncope. He denies family history of sudden
cardiac death, arrythmia, or seizure.
He smokes 1 ppd x ___ years. He does not exercise. He does not
walk much and does not climb stairs. He has never had chest
pain, palpitation, shortness of breath.
In the ED, initial VS were 97.9 68 116/78 17 94%RA. Labs were
notable to TropT <0.01, Chem7 WNL and reassuring WBC. EKG showed
sinus rhythm at 57bmp with no ischemic changes. Head CT and CXR
were reassuring. The patient was then admitted to medicine for
futher evaluation. Vitals on transfer were 97.8 65 118/73 26
97%.
On arrival to the floor, patient appears comfortable and denies
additional complaints.
Past Medical History:
PAST MEDICAL & SURGICAL HISTORY:
reports having a suture placed on the left forehead after a
laceration from a fall as a child
denies HTN, diabetes, high cholesterol
Social History:
___
Family History:
Denies family history of seizure disorder or arrhythmia.
Mother passed away from kidney disease
Father is healthy and alive
Physical Exam:
PHYSICAL EXAM:
VS - 108/76, 67, 18, 98% RA
GENERAL - well-appearing man in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
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:
Labs at admission:
___ 07:35PM BLOOD WBC-11.4* RBC-5.32 Hgb-15.3 Hct-46.7
MCV-88 MCH-28.8 MCHC-32.8 RDW-13.5 Plt ___
___ 07:35PM BLOOD Neuts-48.8* Lymphs-43.1* Monos-5.6
Eos-1.9 Baso-0.5
___ 07:35PM BLOOD ___ PTT-31.8 ___
___ 07:35PM BLOOD Glucose-113* UreaN-17 Creat-0.8 Na-140
K-3.8 Cl-106 HCO3-23 AnGap-15
___ 07:35PM BLOOD Calcium-9.1 Phos-2.8 Mg-2.2
Pertinent labs:
___ 07:35PM BLOOD cTropnT-<0.01
___ 01:54AM BLOOD cTropnT-<0.01
___ 10:10AM BLOOD cTropnT-<0.01
Labs at discharge:
___ 10:10AM BLOOD WBC-8.6 RBC-5.20 Hgb-15.8 Hct-45.9 MCV-88
MCH-30.4 MCHC-34.5 RDW-13.8 Plt ___
___ 10:10AM BLOOD Plt ___
Exercise stress test ___:
IMPRESSION: No anginal or presyncopal type symptoms in the
absence of
ischemic EKG changes at a high cardiac demand and average
functional
capacity. Occasional low-grade AEA during recovery.
Brief Hospital Course:
___ year-old ___ speaking man admitted for evaluation of
lightheadness after exertion. His cardiac work up including
exercise stress test was unremarkable, so he was discharged
home.
# Lightheadness after exertion: At admission the patient
reported having sexual intercourse, and then following
ejaculation felt very tired and sleepy.Patient denies losing
conscioussness and recalled all of the events. The description
of the event was not typical for seziure. Similarly, timing of
the episode was not classic for a vasovagal syncopal event, but
could have a pronounced parasympathetic drive post coitally.
Although the patient has no known history of heart disease or
family history of early MI or suddent death, and he did not
report any chest symptoms we pursued a cardiac work up given
that he has some cardiac risk factors, such as tobacco abuse and
cholestrol >200. He had serial EKGs which showed left axis
deviation. Serial troponins were negative. His exercise stress
test demonstrated no anginal or presyncopal type symptoms in the
absence of ischemic EKG changes at a high cardiac demand and
average functional capacity, but did note occasional low-grade
AEA during recovery phase. He was not orthostatic. He was
monitored on telemetry without any notable events. Head CT and
CXR were also unconcerning. At discharge it was suggested that
his symptoms were likely due to over-exertion.
# Tobacco abuse: At admission the patient reported smoking 1 ppd
x ___ years. He reported trying to quit several times by
stopping abruptly but none of these attempts were successful.
During this hospitalization the team discussed the importance of
smoking cessation. He was given a nicotine patch during his stay
in the hospital.
# Elevated cholestrol: Per patient he was told he had elevated
cholestrol at a previous PCP appointment in ___ -- however
he was told his cholestrol was not high enough to need to start
medications. At discharge he was advised to discuss rechecking
his cholestrol in 6 months and assess the utility of starting
cholestrol lowering agents at that time.
TRANSITIONAL ISSUES:
- Patient advised to f/u with PCP for smoking cessation
.
# CODE: Full, confirmed
# CONTACT: ___ ___, sister ___ ___
___ on Admission:
None.
Discharge Medications:
None.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Lightheadedness/tiredness after exertion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure to participate in your care at ___. You
came to the hospital after feeling tired after sexual
intercourse. We did imaging and lab tests including a
electrical heart tracings, a stress test, cardiac enzymes, head
cat scan, and chest x-ray -- all of which were normal.
Please keep all of your follow up appointment (see below).
We would recommend you stop smoking to protect the long-term
health of your heart.
Followup Instructions:
___
|
19584570-DS-12
| 19,584,570 | 21,697,419 |
DS
| 12 |
2168-09-24 00:00:00
|
2168-09-29 16:06:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Citrus Derived
Attending: ___.
Chief Complaint:
left arm/face numbness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old right handed woman with HTN, HLD,
obesity, colon cancer, tobacco use who presents with fluctuating
left hand/arm/face numbness over several hours which has now
resolved. Patient woke up this am and noted the entire L hand
and small part of the wrist was numb and heavy in a glove like
distribution. She is not sure about weakness because she did
not
try to use the hand. The symptoms improved after a few minutes,
but did not fully resolve. Patient went to work. At 9:30, the
numbness progressed to involve the entire LUE over ~1 minute and
was a novacaine like feeling. She states the sensation was
50-60% of that in the RUE. This lasted for 5 minutes and then
again somewhat improved. Then, she noted left sided numbness
around the mouth and ~2 inches of her cheek. At that time, she
also had a mild L occipital pain which she thought was a
migraine
was starting, but it resolved on its own. At that time, she
became nervous and went down to the clinic in her building. She
did not have any facial droop per her friend there. Her
strength
was "5 and 5" per RN there. The nurse gave her a baby aspirin
and referred her to the ED. The numbness in the face
transiently
improved and then returned. The left arm/face numbness
fluctuated and then fully resolved at ~10:30am. Now, has just
mild tingling in the finger tips. Otherwise, symptoms are
resolved. She has never had anything like this before. Ms.
___ denies any other neurologic symptoms, only endorses
numbness. She has never had a similar episode in the past. She
maybe felt lightheaded with these symptoms.
In regards to stroke risk factors, HbA1c 5.8 in was ___, LDL
165 in ___. Patient was on aspirin transiently, but stopped
it "a lot time ago." She is also an active smoker with a 15pack
year history.
In regards to migraines-She has had them since childhood.
Usually, they are localized to the left occpital/parietal
region.
They are throbbing and pulling. There is no associated
photophobia, nausea/vomiting, vision changes. She takes Imitrex
for them. On average, she has migraines every other month, but
never with neurological symptoms.
On neuro ROS, the pt denies loss of vision, blurred vision,
diplopia, dysarthria, dysphagia, vertigo, tinnitus or hearing
difficulty. Denies difficulties producing or comprehending
speech. Denies focal weakness. 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:
Hypertension (compliant with meds; runs ~130 at home)
Obesity
Hyperlipidemia
Colon ca stage I ___ s/p partial colectomy ___ last
colonoscopy ___ years ago (now ___ yrs)
Degenerative joint disease
Migraines
Osteoarthritis
Partial colectomy
TAH/BSO for fibroids
Carpal tunnel release b/l
Tarsal tunnel release on R
Gangion cysts
Knee repair on left ___
Social History:
___
Family History:
Mother-stroke at age ___, vaginal cancer
Father-lung cancer (was smoker)
No history of seizures, heart disease
Physical Exam:
Admission Exam:
Vitals: T 96.5 HR 83 BP 178/120 RR 18 O2 100%
General: Awake, cooperative, NAD.
HEENT: NC/AT
Neck: Supple, no carotid bruits appreciated.
Pulmonary: CTABL
Cardiac: RRR, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: no edema, pulses palpated
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward
without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic
errors.
Pt. was able to name both high and low frequency objects. Able
to read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. There was no
evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
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 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation
throughout. No extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was mute 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 Exam:
T 97.9, HR 68, BP 150/79, RR 20, O2 100% on RA
Gen: NAD, up in bed
Neuro:
Awake, alert, oriented x3. Speech fluent. Good comprehension.
EOMI, VFF, face symmetric with activation, sensation intact to
light touch and pinprick. SCM, trapezius strong.
Strength ___. Babinski downgoing bilaterally.
Sensation in extremities intact to light touch, pinprick
throughout.
Normal FNF, HKS, no apraxia.
Pertinent Results:
___ CT Head
1. No evidence of acute intracranial process.
2. Incidentally noted empty or partially empty sella. Recommend
clinical
correlation.
___ CXR
No acute intrathoracic process.
___ CTA Head/Neck
1. No steno-occlusive disease, aneurysm, or vascular
malformation of the
intracranial arterial system. Incidentally noted azygous
anterior cerebral artery, a developmental variant.
2. No steno-occlusive disease (by NASCET criteria) of the major
arterial
system of the neck.
3. Left thyroid nodule, increased in size to 2.5 cm from 2.1 cm
on ___. Ultrasound can be considered for further
evaluation as indicated.
4. Left upper lobe peripheral irregular nodule with dilated
airspaces versus cavitation. This lesion is suspicious for
malignancy. Please refer to the subsequently performed CT chest
for further evaluation.
___ TTE
The left atrium is elongated. No atrial septal defect or patent
foramen ovale is seen by 2D, color Doppler or saline contrast
with maneuvers. Left ventricular wall thicknesses are normal.
The left ventricular cavity size is normal. Overall left
ventricular systolic function is normal (LVEF = 65%). Tissue
Doppler imaging suggests a normal left ventricular filling
pressure (PCWP<12mmHg). Right ventricular chamber size and free
wall motion are normal. The aortic valve leaflets are mildly
thickened (?#). There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. The pulmonary artery
systolic pressure could not be determined. There is no
pericardial effusion.
___ MR ___
1. No acute infarct, intracranial hemorrhage, or evidence of a
mass lesion.
2. Multiple foci of increased T2/FLAIR signal scattered in the
supratentorial white matter, nonspecific but consistent with
mild chronic small vessel ischemic disease. Additional
diagnostic considerations in the appropriate clinical setting
are demyelinating disease or prior infectious/inflammatory
disease.
___ CT Chest
1. NEW 1.9 CM PERIPHERAL LEFT UPPER LOBE LUNG NODULE WITH
INTERNAL CYSTIC
LUCENCIES AND ADJACENT FOCAL PLEURAL THICKENING. APPEARANCE IS
MOST
CONSISTENT WITH A PRIMARY LUNG CANCER. FURTHER EVALUATION COULD
BE PERFORMED BY PET CT OR A LUNG BIOPSY.
2. LONG-TERM STABILITY OF 2 SUBCENTIMETER NODULES IN THE RIGHT
LUNG,
CONSISTENT WITH A BENIGN ETIOLOGY.
___ 07:16AM BLOOD WBC-6.6 RBC-5.18 Hgb-13.2 Hct-43.2 MCV-84
MCH-25.6* MCHC-30.6* RDW-16.3* Plt ___
___ 07:16AM BLOOD Glucose-81 UreaN-22* Creat-0.7 Na-140
K-4.6 Cl-106 HCO3-23 AnGap-16
___ 12:00PM BLOOD ALT-18 AST-59* AlkPhos-103 TotBili-0.5
___ 12:00PM BLOOD Lipase-31
___ 07:16AM BLOOD CK-MB-2 cTropnT-<0.01
___ 07:16AM BLOOD %HbA1c-5.8 eAG-120
___ 07:16AM BLOOD Triglyc-118 HDL-57 CHOL/HD-3.9
LDLcalc-141*
Brief Hospital Course:
Ms. ___ is a ___ year old right handed woman with HTN, HLD,
obesity, colon cancer, tobacco use who presented with
fluctuating left hand/arm/face numbness over several hours which
resolved. Upon discharge, she just has mild tingling in the
finger tips. Her neurological exam normalized, with no deficits
evident. NCHCT and CTA head/neck are unremarkable except for a
new lung nodule, which was evaluated on CT Chest and is
concerning for malignancy. Given multiple small vessel risk
factors and now a potential new malignancy, she is at high risk
for infarct. However, MRI does not show an infarct. Current
diagnosis is sensory TIA. She was discharged on aspirin and
statin to modify stroke risk factors.
# Neuro:
- MRI head w/o contrast - no acute infarct
- LDL 141 and HbA1c 5.8
- aspirin 81mg daily
- atorvastatin 40 mg daily
# ___:
- CEs negative
- restart home antihypertensives (lisinopril and amlodipine)
# RS:
- CXR - no acute process
- dedicated chest CT w/ and w/o contrast concerning for lung
malignancy - PCP to follow up and arrange for CT guided lung
biopsy. Based on the results, the patient can be seen in
Thoracic ___ (___). Her PCP ___ coordinate
this plan, and ___ in Thoracic ___ is
aware of this patient and the concern for malignancy.
# ENDO:
- HbA1c 5.8
# Toxic/Metabolic
- LFTs: wnl
- urine and serum tox screens: wnl
# ID:
- UA: wnl
- CXR - no acute process
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes [performed
and documented by admitting resident] () No
2. DVT Prophylaxis administered by the end of hospital day 2?
(x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No
4. LDL documented (required for all patients)? (x) Yes (LDL =
141) - () No
5. Intensive statin therapy administered? (x) Yes - () No [if
LDL >= 100, reason not given: ____ ]
(intensive statin therapy = simvastatin 80mg, simvastatin
80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, rosuvastatin
20mg or 40mg, for LDL >= 100)
6. Smoking cessation counseling given? (x) Yes - () No [if no,
reason: () non-smoker - () unable to participate]
7. Stroke education given (written form in the discharge
worksheet)? (x) Yes - () No
(stroke education = personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup)
8. Assessment for rehabilitation or rehab services considered?
() Yes - (x) No [if no, reason not assessed: deficits had fully
resolved ]
9. Discharged on statin therapy? (x) Yes - () No [if LDL >= 100
or on a statin prior to hospitalization, reason not discharged
on statin: ____ ]
10. Discharged on antithrombotic therapy? (x) Yes [Type: (x)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No [if no, reason not
discharge on anticoagulation: ____ ] - (x) N/A
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 5 mg PO DAILY
2. Lisinopril 40 mg PO DAILY
3. Fluocinonide 0.05% Cream 1 Appl TP BID:PRN rash
4. Sumatriptan Succinate 50 mg PO X1 PRN migraine pain
5. Naproxen 500 mg PO Q8H:PRN pain
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. Lisinopril 40 mg PO DAILY
3. Naproxen 500 mg PO Q8H:PRN pain
4. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*90 Tablet
Refills:*3
5. Atorvastatin 40 mg PO DAILY
RX *atorvastatin 40 mg 1 tablet(s) by mouth daily Disp #*90
Tablet Refills:*30
6. Nicotine Patch 14 mg TD DAILY
RX *nicotine 14 mg/24 hour Use one patch as needed for smoking
cessation, up to one patch daily daily as needed Disp #*90 Patch
Refills:*0
7. Fluocinonide 0.05% Cream 1 Appl TP BID:PRN rash
8. Sumatriptan Succinate 50 mg PO X1 PRN migraine pain
Discharge Disposition:
Home
Discharge Diagnosis:
Sensory transient ischemic attack
Lung nodule
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were hospitalized due to symptoms of left hand, arm, and
face numbness resulting from an TRANSIENT ISCHEMIC ATTACK, a
condition in which a blood vessel providing oxygen and nutrients
to the ___ is blocked by a clot. The ___ is the part of your
body that controls and directs all the other parts of your body,
so damage to the ___ from being deprived of its blood supply
can result in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
Hypertension
High cholesterol
Smoking
History of cancer
We are changing your medications as follows:
Start aspirin, atorvastatin, nicotine patch
Please take your other medications as prescribed.
You have a lung nodule that was found incidentally on imaging
and further evaluated with a chest CT. Your primary doctor has
been notified and you will need a biopsy of this nodule as an
outpatient, based on the results of the biopsy, your treatment
plan will be determined.
Please followup with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- sudden partial or complete loss of vision
- sudden loss of the ability to speak words from your mouth
- sudden loss of the ability to understand others speaking to
you
- sudden weakness of one side of the body
- sudden drooping of one side of the face
- sudden loss of sensation of one side of the body
- sudden difficulty pronouncing words (slurring of speech)
- sudden blurring or doubling of vision
- sudden onset of vertigo (sensation of your environment
spinning around you)
- sudden clumsiness of the arm and leg on one side or sudden
tendency to fall to one side (left or right)
- sudden severe headache accompanied by the inability to stay
awake
It was a pleasure providing you with care during this
hospitalization.
Followup Instructions:
___
|
19584791-DS-10
| 19,584,791 | 25,011,236 |
DS
| 10 |
2159-09-01 00:00:00
|
2159-09-01 16:59:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Percocet
Attending: ___.
Chief Complaint:
hematemesis
Major Surgical or Invasive Procedure:
Esophagogastroduodenoscopy ___
History of Present Illness:
Mr. ___ is a ___ yo M with h/o uncontrolled type 2 DM and
HTN, who presented to his PCP today with hematemesis. About
9-days prior to admission, patient awoke around 3am w/ intense
dizziness and N/V that was nonbloody and nonbilious. He also
noted pain in his RUQ and RLQ at this time. He presented to his
PCP ___ ___ for this and was started on omeprazole for
presumed ulcer w/ plan for EGD. He doesn't think the omeprazole
provided any relief and doesn't report any alleviating or
aggravating factors. The N/V had gotten progressively worse over
the week, where he was vomiting ___ times a day w/ constant
nausea. One day prior to admission, the patient vomit a small
tablespoon of dark red blood w/out clots. The next morning the
same thing happened so he presented to his PCP, who recommended
he go to the ER. He denies any bloody or black stools, or
diarrhea. He is not on any blood thinners, except baby ASA. He
currently drinks a few drinks in a month, but supports a
significant alcohol history in the past. He denies any recent
travel, sick contacts. He has been unable to keep any food down
the past week. He notes increased stress and sadness recently
due to the loss of his sister (___) to melanoma this past
___.
Most recent H/H 11.1/32.4 on ___ per Atrius. His last EGD
was in ___ which showed gastropathy and gastritis. Last
colonscopy was in ___ which showed a colonic polyp,
diverticula, and internal hemorrhoids.
Review of Systems:
(+) chest pressure that seems to be related to vomiting, GERD,
urinary hesitancy
(-) fever, chills, night sweats, headache, rhinorrhea,
congestion, sore throat, odynophagia, cough, shortness of
breath, dysuria, hematuria
In the ED, initial vital signs were: 98.1 62 171/81 18 99% RA
- Exam notable for: guiac neg brown stool, TTP in the RLQ
- Labs were notable for Coags WNL, UA with few bacteria, 0 epi.
Lactate 1.9, chem 7 WNL, LFTs notable for Alb 3.3, otherwise
WNL. CBC with 7.6 / 11.8 / 32.0 / 235.
- Studies performed include CT abd/pelvis showing findings c/w
possible UTI, diverticulosis, and previously noted splenic cyst.
- Patient was given zofran 4mg, metaclopramide 10mg,
ceftriaxone 1g, ativan 1mg, 1L NS, protonix 40mg IV.
- Vitals on transfer: 98.2 62 148/58 16 99% RA
Upon arrival to the floor, pt was experiencing nausea, and
ondansetron was administered. Pt was also hypertensive w/ BP at
200/87, but systolic BP decreased to 175 w/ lorazapam and better
control of nausea.
Past Medical History:
ARTHROPATHY - CHARCOT'S
Anemia
DIVERTICULITIS
ALCOHOL ABUSE - IN REMISSION
NEUROPATHY - DIABETIC
IMPOTENCE DUE TO ERECTILE DYSFUNCTION
HYPERTENSION - ESSENTIAL, BENIGN
PERIPHERAL VASC DISEASE
VARICOSE VEINS
HYPERLIPIDEMIA
Obesity
METHICILLIN RESISTANT STAPH AUREUS CULTURE POSITIVE
DM type II w/ renal manif, uncontrolled
LOWER LIMB ULCER, left foot - plantar surface
Serrated adenoma of colon due ___
Osteomyelitis of toe of left and right foot
Splenic cyst
Social History:
___
Family History:
Father: diverticulosis, passed away at ___ from accident
Mother: ___, currently living
2 brothers who passed away from substance abuse issues
Sister, ___ passed away from melanoma
Physical Exam:
Exam On Admission:
==================
Vitals-T 98 BP 200/87 HR 55 RR 18 99% on RA
General: well-nourished, middle aged man, who appears his stated
age, sitting up in bed and able to speak in full sentences in
NAD
HEENT: conjunctiva clear, sclera anicteric, pupils equally round
and reactive to light, MMM
Neck: supple, no LAD, JVP 8 cm at 45 degrees
CV: RRR, nl S1 and S2, no murmurs rubs or gallops
Lungs: clear to asculation bilaterally, no wheezes, rhonchi, or
rales
Abdomen: bowel sounds present, RUQ and RLQ tender to palpation
w/ gaurding, no rebound tenderness. LUQ and LLQ non-tender to
palpation. No organomeglay.
GU: no folly
Ext: WWP, charcot on sole of right foot
Skin: errythmatous papular rash across face
Neuro: moving all four limb symmetrically
Exam on Discharge:
============================
Vitals: T 97.3, Laying 162/70 HR 69, standing 158/78 HR 87 18
97% on RA
Glucose 93-133-254
General: well-nourished, middle aged man, who appears his stated
age, sitting up in bed and able to speak in full sentences in
NAD
HEENT: sclera anicteric, MMM
CV: RRR, nl S1 and S2, no murmurs rubs or gallops
Lungs: clear to asculation bilaterally, no wheezes, rhonchi, or
rales
Abdomen: bowel sounds present, non-tender, non-distend w/ no
gaurding or rebound tenderness.
GU: no folly
Ext: WWP, charcot on sole of right foot, 2+ and 1+ pedal pulses
on left and right foot, respectively
Skin: errythmatous papular rash across face
Neuro: moving all four limb symmetrically
Pertinent Results:
Labs on Admission:
===================
___ 01:06PM BLOOD WBC-7.6 RBC-3.80* Hgb-11.8* Hct-32.0*
MCV-84 MCH-31.0 MCHC-36.8* RDW-14.4 Plt ___
___ 01:06PM BLOOD Neuts-74.8* Lymphs-17.5* Monos-5.2
Eos-1.9 Baso-0.6
___ 02:18PM BLOOD ___ PTT-30.4 ___
___ 01:06PM BLOOD Glucose-221* UreaN-19 Creat-0.8 Na-139
K-4.5 Cl-106 HCO3-23 AnGap-15
___ 01:06PM BLOOD ALT-15 AST-15 AlkPhos-68 TotBili-0.7
___ 01:06PM BLOOD Albumin-3.3*
___ 01:27PM BLOOD Lactate-1.9
___ 06:20AM BLOOD calTIBC-280 Ferritn-283 TRF-215
Labs on Discharge:
===================
___ 06:50AM BLOOD WBC-6.4 RBC-3.63* Hgb-11.1* Hct-30.6*
MCV-84 MCH-30.6 MCHC-36.3* RDW-14.5 Plt ___
___ 06:50AM BLOOD Glucose-307* UreaN-17 Creat-0.9 Na-138
K-4.0 Cl-102 HCO3-32 AnGap-8
Microbiology
=================
___ 02:04PM URINE Color-Yellow Appear-Clear Sp ___
___ 02:04PM URINE Blood-SM Nitrite-NEG Protein-600
Glucose-1000 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 02:04PM URINE RBC-2 WBC-4 Bacteri-FEW Yeast-NONE Epi-0
TransE-<1
___ 02:04PM URINE CastGr-11* CastHy-19*
Time Taken Not Noted Log-In Date/Time: ___ 2:05 pm
URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
Imaging:
================
CT ___:
1. Stranding involving the left mid and distal ureter suggestive
of ascending urinary tract infection. Correlation with
urinalysis is recommended.
2. Diverticulosis without evidence of acute diverticulitis.
3. Large multi lobulated splenic cyst with peripheral rim
calcification.
EGD, ___
Normal mucosa in the esophagus
Polyp in the cardia (biopsy)
Mild erythema in the cardia
Erythema in the duodenal bulb compatible with duodenitis
Otherwise normal EGD to third part of the duodenum
Brief Hospital Course:
___ gentleman w/ a history notable for poorly controlled DM2
(HbA1c in 11%s) on insulin, and HTN, who present w/ a 9-day
history of N/V and 2 episodes of hematemesis of tablespoon of
dark blood each time as well as dizziness.
# Hematemesis: pt was hemodynamically stable w/ stable H/H
throughout hospitalization. Pt had no emesis or hematemesis in
hospital. Pt underwent EGD to look for sources of GI bleed. EGD
did not show anything concerning for active bleeds or ulcers,
but scope did identify a polyp in the cardia of the stomach that
was biopsied, and duodenitis was seen. Hematemesis may be
related to bleed in polyp ___ tears in the setting
of 9-days of vomiting. GI recommends that pt be followed-up in
outpatient and continue omeprezole.
# Dizziness: pts main complaint during admission was dizziness.
The dizziness was mainly lightheadedness that was brought on by
standing up and walking to the bathroom. Pt denied any vertigo.
He was made npo for EGD and blood glucose was in ___, where
his baseline A1c is ~11, with BGs around 250s. He was also
positive for orthostatics initially which resolved by time of
discharge. Dizziness was most likely related to volume
depeletion and low blood glucose. Pts dizziness improved w/
fluids and normal diet.
# Nausea: unclear etiology, most likely viral gastroenteritis.
Nausea improved w/ IV fluids and Zofran. Pt was able to resume
normal diet w/out issue.
# RUQ and RLQ pain: pt presented w/ soreness on right side that
was worse w/ palpation. Most likely MSK related to vomiting.
Pain had resolved by discharge.
# HTN: pt systloic BPs ranged from 130s-200s. He seems to
chronically run high, but BP during hospitalizations was above
his normal range, most likley related to anxiety and pain.
Recommended f/u with PCP regarding chronic BP control.
# Chronic normocytic anemia: on discharge H/H 11.___ w/ MVC 84.
Iron studies showed Fe 64, ferritin 283, TIBC 280, transferrin
215, all WNL. Based on these iron studies, it suggests pt does
not have iron deficency anemia or anemia of chornic disease.
Recommended f/u w/ PCP
# ?UTI: pelvic CT showed stranding of ureter concerning for
possible UTI. UA showed some bacteria and blood, but negative
nitrites or leukoesterase. Pt denied any pain w/ urination or
frank blood in the urine. He was empircally started w/
ceftiaxone in the ED, but abx was discontinued on floor due to
lack of sypmptoms. Urine culture was negative.
# DM2: on home insulin and metformin. pt reports he is not
compliant w/ medications or diet. Blood glucose runs in the
___ typically.
TRANSITIONAL ISSUES:
# Patient hypertensive on presentation but improving at time of
discharge. Consider adjusting home regimen if still elevated at
appointment on ___
# EGD showing polyp in cardia of stomach - please follow up
biopsies with GI appointment in ___
# Patient with asymptomatic bacteriuria during admission -
consider repeat UA
# Please repeat hemoglobin/hematocrit to assess for resolution
of anemia - consider further work up with colonoscopy/other
studies if ongoing
# Please recheck abd pain symptoms, which were mild at time of
discharge.
# Encourage compliance with home anti-hyperglycemic regimen
# Code status during hospitalization: Full code
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 20 mg PO DAILY
2. Gabapentin 600 mg PO TID
3. Ferrous Sulfate 325 mg PO BID
4. Pravastatin 80 mg PO QPM
5. Metoprolol Tartrate 25 mg PO BID
6. Lisinopril 60 mg PO DAILY
7. MetFORMIN (Glucophage) 1000 mg PO BID
8. Detemir 82 Units BreakfastMax Dose Override Reason:
maintaining patient's home dose
9. Aspirin 81 mg PO DAILY
10. Cyanocobalamin 1000 mcg PO DAILY
11. HumuLIN R (insulin regular human) ___ ml SC unknown
12. Cialis (tadalafil) 20 mg oral PRN
13. Sildenafil 100 mg PO PRN activity
14. AmLactin (ammonium lactate;<br>ammonium,pot.and sodium
lactat) 12% topical cream topical BID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Cyanocobalamin 1000 mcg PO DAILY
3. Ferrous Sulfate 325 mg PO BID
4. Gabapentin 600 mg PO TID
5. Detemir 82 Units BreakfastMax Dose Override Reason:
maintaining patient's home dose
6. Lisinopril 60 mg PO DAILY
7. Metoprolol Tartrate 25 mg PO BID
8. Omeprazole 20 mg PO DAILY
9. Pravastatin 80 mg PO QPM
10. AmLactin (ammonium lactate;<br>ammonium,pot.and sodium
lactat) 12% topical cream topical BID
11. Cialis (tadalafil) 20 mg oral PRN
12. HumuLIN R (insulin regular human) 0 ml SC Frequency is
Unknown
13. MetFORMIN (Glucophage) 1000 mg PO BID
14. Sildenafil 100 mg PO PRN activity
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
nausea/vomiting
hematemesis
Secondary:
type II diabetes mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It has been a pleasure taking part in your care during your
hospitalization at ___
nausea, vomiting with some blood, and lightheadedness. Your
nausea improved, and you did not have further episodes of
vomiting or of vomiting blood. You underwent an upper endoscopy
to look for a cause of your nausea and vomiting, and this showed
no ulcers, but did show a polyp in your stomach that was
biopsied. You continued to feel better, and were able to eat and
drink.
Please continue to take all home medications as prescribed.
Please be especially careful to monitor your diabetes, and to
follow up with your primary care physician and GI doctor as
noted below. Good control of your diabetes can help prevent many
health complications, including nausea and vomiting.
Again, it was a pleasure taking part in your care, and we wish
you the best!
- Your ___ care team
Followup Instructions:
___
|
19584791-DS-11
| 19,584,791 | 28,503,233 |
DS
| 11 |
2159-11-09 00:00:00
|
2159-11-10 07:55:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Percocet
Attending: ___.
Chief Complaint:
Abdominal pain, nausea, vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old man with poorly controlled DM2 (HbA1c in 11%s) on
insulin and HTN, with recent admission for abdominal pain and
hematemesis, presenting with 1.5 weeks of abdominal pain, nausea
and vomiting. He said that he first had dry heaving, chills and
abdominal pain. A few days later he developed vomiting and then
specks of bright red blood spots appeared in vomit. He has not
been eating much. He said he "just like" abdominal pain in ___
admission (at that time he had negative EGD and abdominal pain
was attributed to musculoskeletal pain from vomiting). He denied
recent travel or new foods, and has no known history of ulcer.
Still has nausea and epigastric pain, ___, but no vomiting
since last night. Reported no bowel movements in 2 days, no
passing gas to his knowledge. A little dizzy upon standing.
Denied headache and chest pain. Has not been taking metoprolol
or lisinopril because he was concerned about bleeding.
In the ED, initial vitals were: 98.2 74 188/92 16 100% RA
- Labs were significant for normal CBC (chronic anemia), chem-7,
trop
- Imaging revealed negative CXR
- The patient was given 1 mg ativan X2, magic mouthwash, vicous
lidocaine, pantoprazole 40 mg, famotidine 20 mg, zofran 4 mg,
apap 1000 mg, morphine 5 mg, metoprolol 25 mg, and 2L IV normal
saline.
Past Medical History:
ARTHROPATHY - CHARCOT'S
Anemia
DIVERTICULITIS
ALCOHOL ABUSE - IN REMISSION
NEUROPATHY - DIABETIC
IMPOTENCE DUE TO ERECTILE DYSFUNCTION
HYPERTENSION - ESSENTIAL, BENIGN
PERIPHERAL VASC DISEASE
VARICOSE VEINS
HYPERLIPIDEMIA
Obesity
METHICILLIN RESISTANT STAPH AUREUS CULTURE POSITIVE
DM type II w/ renal manif, uncontrolled
LOWER LIMB ULCER, left foot - plantar surface
Serrated adenoma of colon due ___
Osteomyelitis of toe of left and right foot
Splenic cyst
Social History:
___
Family History:
Father: diverticulosis, passed away at ___ from accident
Mother: ___, currently living
2 brothers who passed away from substance abuse issues
Sister, ___ passed away from melanoma
Physical Exam:
ON ADMISSION
Vitals: BP 186/79 HR 57 RR 20 99 % RA
General: Alert, oriented, mild distress, obese
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi, slight bibaslilar crackles on posterior
Abdomen: Soft, diffusely tender, no rebound or guarding, no
fluid wave shift
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
ON DISCHARGE
Vitals- Tc 97.4 Tm 98.6 BP 140-185/59-88 HR ___ RR 18 97-99%RA
BS ___
General- Alert, oriented, no acute distress
HEENT- Sclerae anicteric, MMM, oropharynx clear, reddened face
with comedones
Neck- supple
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- obese, soft, diffuse mild tenderness, normoactive bowel
sounds present, no rebound tenderness or guarding, negative
___
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- EOMI, tongue midline, face symmetric, motor function
grossly normal. Right foot has ballotable cystic prominence on
sole (patient said this is not new).
Pertinent Results:
ON ADMISSION
___ 12:00PM BLOOD WBC-7.8 RBC-3.72* Hgb-11.1* Hct-33.2*
MCV-89 MCH-29.8 MCHC-33.4 RDW-13.9 RDWSD-45.7 Plt ___
___ 12:00PM BLOOD Neuts-76.3* Lymphs-15.6* Monos-5.6
Eos-1.4 Baso-0.6 Im ___ AbsNeut-5.98 AbsLymp-1.22
AbsMono-0.44 AbsEos-0.11 AbsBaso-0.05
___ 12:02PM BLOOD ___ PTT-30.5 ___
___ 12:00PM BLOOD Plt ___
___ 12:00PM BLOOD Glucose-206* UreaN-17 Creat-0.9 Na-139
K-4.1 Cl-102 HCO3-29 AnGap-12
___ 12:00PM BLOOD ALT-13 AST-14 AlkPhos-82 TotBili-0.7
___ 12:00PM BLOOD Lipase-18
___ 12:00PM BLOOD cTropnT-<0.01
___ 12:00PM BLOOD Albumin-3.2* Calcium-8.9 Phos-3.9 Mg-1.4*
ON DISCHARGE
___ 06:00AM BLOOD WBC-6.7 RBC-3.18* Hgb-9.6* Hct-29.2*
MCV-92 MCH-30.2 MCHC-32.9 RDW-14.2 RDWSD-47.8* Plt ___
___ 06:00AM BLOOD Plt ___
___ 06:00AM BLOOD ___ PTT-28.4 ___
___:00AM BLOOD Glucose-247* UreaN-17 Creat-1.1 Na-137
K-4.0 Cl-103 HCO3-31 AnGap-7*
___ 06:00AM BLOOD Calcium-8.3* Phos-4.5 Mg-2.0
IMAGING
___ CXR
The lungs are clear without focal consolidation. No pleural
effusion or
pneumothorax is seen. The cardiac and mediastinal silhouettes
are
unremarkable. No evidence of pneumomediastinum is seen.
___ Abdominal XRay
There are no abnormally dilated loops of large or small bowel.
There is no free intraperitoneal air. Osseous structures are
unremarkable. Curvilinear density in the left upper quadrant
likely reflects known splenic cyst with a calcific rim.
Brief Hospital Course:
___ is a ___ year old man with PMH of poorly
controlled DM2 (HbA1c in 11%s) on insulin, complicated by
charcot arthropathy, peripheral neuropathy and lower extremity
ulcers, with recent admission for abdominal pain/hematemesis in
___ (nl EGD), who presented with 1.5 weeks of abdominal
pain and vomiting.
ACTIVE ISSUES:
# Abdominal pain, nausea, vomiting
Differential was broad, including PUD, gastritis, gastroparesis,
gastroenteritis, cholecystitis, constipation. CBC and
electrolytes were within normal limits. He had no infectious
symptoms. Recent normal EGD along with no recent history of
NSAID or EtOH use also made PUD/gastritis less likely.
Gastroparesis was felt to be the most likely cause of his
symptoms, even though he has not had a formal diagnosis, given
poorly controlled T2DM and past history of similar abdominal
pain. Patient does not He received anti-emetics along with
Maalox/Diphenhydramine/Lidocaine as needed. His symptoms
improved, with no vomiting after admission, and resolving
abdominal pain and nausea. He was able to eat several meals on
the day of discharge.
# Hematemesis
Per history sounds likely small ___ tear vs (less
likely) peptic ulcer disease. Hematemesis appeared after several
days of dry heaving, and only as small flecks of blood. He had
no vomiting while hospitalized, and given likelihood ___
___ tear, EGD was deferred. He remained on a PPI.
# DM II, insulin dependent, uncontrolled
Last A1C 11%. He was continued on long-acting insulin, but did
required humalog with meals.
# Hypertension
Patient has elevated systolic BP to 180's, after he decided to
hold home regimen (lisnopril, metoprolol) due to worries that he
"might be bleeding" from hematemesis episode. He was restarted
on his antihypertensives on the day of discharge.
CHRONIC ISSUES:
# Chronic anemia
He was continued on home iron, b12.
# Microscopic hematuria
Has been noted previously, arranging for a cystoscopy as an
outpatient.
TRANSITIONAL ISSUES:
- Close follow up for glucose control on insulin. Has elevated
fasting blood sugars, may need uptitration of long-acting
insulin and considerating of mealtime short-acting insulin.
- Close follow up for blood pressure control (on metoprolol and
lisinopril)
- Patient should have continued outpatient GI follow-up. Would
consider gastric emptying study for evaluation of suspected
gastroparesis.
- KUB showed a curvilinear density in the left upper quadrant
likely reflects known splenic cyst with a calcific rim. (CT A/P
done ___ noted "Large multi lobulated splenic cyst with
peripheral rim calcification, possibly representing a pseudocyst
in the setting of prior trauma).
- Full Code
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Cyanocobalamin 1000 mcg PO DAILY
3. Ferrous Sulfate 325 mg PO BID
4. Gabapentin 600 mg PO TID
5. Lisinopril 60 mg PO DAILY -> patient not taking recently
6. Metoprolol Tartrate 25 mg PO BID -> patient not taking
recently
7. Omeprazole 20 mg PO DAILY -> patient ran out
8. Pravastatin 80 mg PO QPM
9. AmLactin (ammonium lactate;<br>ammonium,pot.and sodium
lactat) 12% topical cream topical BID
10. Cialis (tadalafil) 20 mg oral PRN
11. MetFORMIN (Glucophage) 1000 mg PO BID
12. Sildenafil 100 mg PO PRN activity
13. levemir 82 Units BreakfastMax Dose Override Reason: home
dose
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Cyanocobalamin 1000 mcg PO DAILY
3. Ferrous Sulfate 325 mg PO BID
4. Gabapentin 600 mg PO TID
5. levemir 82 Units BreakfastMax Dose Override Reason: home dose
6. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
7. Pravastatin 80 mg PO QPM
8. AmLactin (ammonium lactate;<br>ammonium,pot.and sodium
lactat) 12% topical cream topical BID
9. Cialis (tadalafil) 20 mg oral PRN
10. Lisinopril 60 mg PO DAILY
11. MetFORMIN (Glucophage) 1000 mg PO BID
12. Metoprolol Tartrate 25 mg PO BID
13. Sildenafil 100 mg PO PRN activity
14. Metoclopramide 10 mg PO QID
RX *metoclopramide HCl 10 mg 1 tablet by mouth four times per
day (before meals and before bedtime) Disp #*120 Tablet
Refills:*0
15. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
abdominal pain
RX *alum-mag hydroxide-simeth 200 mg-200 mg-20 mg/5 mL ___ mL
by mouth four times per day Refills:*0
16. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth every 8 hours Disp
#*10 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Abdominal pain
Secondary:
Insulin-dependent type II diabetes
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking part in your care at ___
___. You were admitted because of > 1 week
of nausea, vomiting, and abdominal pain. You had a small amount
of blood in your vomit, and this is likely a result of some
injury that can happen to your esophagus when you have frequent
vomiting. Your blood counts were stable and you had no further
bleeing while in the hospital. Your lab tests showed no
abnormality to explain your symptoms. We treated your pain and
nasuea, and you were able to eat and drink on the day of
discharge.
Your symptoms may be secondary to something called
gastroparesis. This occurs in people who have poorly controlled
diabetes, and leads to very slow emptying of the stomach causing
nausea, early fullness, bloating, and can lead to abdominal
pain. You are being discharged on a medication called
metoclopramide which can help these symptoms. Please talk to
your primary care physician and GI physician about the
possibility of gastroparesis and futher testing that can be done
to diagnose this.
You should eat small and frequent meals, avoiding high-fat
meals. In addition, it is very important to talk to your doctor
about managing diabetes and keeping your blood sugars in a
healthy range. Improved control of your diabetes may help your
symptoms.
We wish you the best,
Your ___ Team
Followup Instructions:
___
|
19584791-DS-13
| 19,584,791 | 28,642,080 |
DS
| 13 |
2161-02-09 00:00:00
|
2161-02-13 23:40:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Percocet
Attending: ___.
Chief Complaint:
Dizziness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ here for recurrent exertional lightheadedness. History of
uncontrolled DM on insulin c/b CKD last Cr 2.05 in ___,
gastroparesis, and neuropathy; HLD, HTN, PVD, anemia. Patient
got up and became dizzy after walking earlier today after
eating. Patient again began walking at the T stop, felt dizzy
and fell down 2 steps, bumping L elbow. No headstrike. He then
tried to ambulate with EMTs on scene and again felt dizzy and
weak. Has had good PO intake lately. Denies bleeding, black or
bloody stools. Denies fevers or rigors, chest pain, dyspnea,
palpitations, cough. He does endorse headache over the past
week, intermittent, not worse in morning. Patient describes it
as pins and needles. Denies sensation of motion. Denies shaking,
urinary incontinence, tongue biting. Denies prior episodes, no
hx of CAD in him. Of note he was recently admitted to ___
from ___ for gastroparesis. Only med change was stopping
metoprolol and starting labetalol but patient states he may have
taken both.
In the ED, initial vitals were:
T 98.0, HR 66, BP 136/55, RR 16, O2 sat 96% RA
Exam notable for 2+ pedal edema, guaiac negative
Labs notable for Hgb 8.3, Cr 2.1, BNP ___
EKG showed NSR
Imaging:
CXR showed central vascular engorgement without overt pulmonary
edema. Stable cardiomegaly.
POC US showed symmetric squeeze, no effusion, no tamponade
Patient was given 1L normal saline
Decision was made to admit for symptomatic anemia and ___
On the floor,
Pt is resting comfortably in bed. Denies current dizziness,
chest pain, shortness of breath
Past Medical History:
ARTHROPATHY - CHARCOT'S
CHRONIC ANEMIA
DIVERTICULITIS
ALCOHOL ABUSE - IN REMISSION
NEUROPATHY - DIABETIC
IMPOTENCE DUE TO ERECTILE DYSFUNCTION
HYPERTENSION - ESSENTIAL, BENIGN
PERIPHERAL VASC DISEASE
VARICOSE VEINS
HYPERLIPIDEMIA
OBESITY
METHICILLIN RESISTANT STAPH AUREUS CULTURE POSITIVE
DM type II w/ renal manif, uncontrolled
LOWER LIMB ULCER, left foot - plantar surface
H/O SERRATED COLONIC ADENOMA
H/O OSTEOMYELITIS
GASTROPARESIS
Social History:
___
Family History:
Father: diverticulosis, passed away at ___ from accident
Mother: ___, currently living
2 brothers who passed away from substance abuse issues
Sister, ___ passed away from melanoma
Physical Exam:
======================
ADMISSION PHYSICAL EXAM:
VS: 97.6, 172 / 77, 63, 20, 97% Ra
Gen: Pleasant, very conversive, NAD. AAOx3
HEENT: conjunctival pallor
CV: RRR, no m/r/g
Pulm: CTAB. No w/r/r
Abd: Protuberant, soft, NTND.
Ext: WWP. No c/c. Peripheral edema 3+. Venous stasis changes on
___ b/l
Neuro: CNII-XII intact. Moving all extremities spontaneously
========================
DISCHARGE PHYSICAL EXAM
:
Gen: Pleasant, very conversive, NAD. AAOx3
HEENT: conjunctival pallor
CV: RRR, no m/r/g
Pulm: CTAB. No w/r/r
Abd: Protuberant, soft, NTND.
Ext: WWP. No c/c. Peripheral edema 3+. Venous stasis changes on
___ b/l
Neuro: CNII-XII intact. Moving all extremities spontaneously
Pertinent Results:
=======================
ADMISSION LABS:
___ 04:00PM BLOOD WBC-8.7 RBC-2.89* Hgb-8.3* Hct-26.5*
MCV-92 MCH-28.7 MCHC-31.3* RDW-14.9 RDWSD-50.1* Plt ___
___ 04:00PM BLOOD Neuts-75.5* Lymphs-14.6* Monos-5.3
Eos-3.3 Baso-0.6 Im ___ AbsNeut-6.58* AbsLymp-1.27
AbsMono-0.46 AbsEos-0.29 AbsBaso-0.05
___ 04:00PM BLOOD Glucose-121* UreaN-26* Creat-2.1* Na-141
K-3.8 Cl-107 HCO3-25 AnGap-13
___ 04:00PM BLOOD ___ 04:00PM BLOOD cTropnT-<0.01
___ 04:00PM BLOOD Iron-44*
___ 04:00PM BLOOD calTIBC-203* Ferritn-188 TRF-156*
=======================
OTHER PERTINENT LABS:
___ 06:46AM BLOOD calTIBC-187* ___ Ferritn-161
TRF-144*
___ 06:46AM BLOOD Ret Aut-2.2* Abs Ret-0.06
=======================
DISCHARGE LABS:
___ 07:35AM BLOOD WBC-6.9 RBC-2.96* Hgb-8.6* Hct-27.4*
MCV-93 MCH-29.1 MCHC-31.4* RDW-14.5 RDWSD-48.9* Plt ___
___ 07:35AM BLOOD Glucose-146* UreaN-29* Creat-2.4* Na-141
K-4.5 Cl-104 HCO3-28 AnGap-14
___ 07:35AM BLOOD Calcium-8.1* Phos-3.9 Mg-2.1
=========================
IMAGING:
ECHO ___:
The left atrial volume index is normal. The right atrium is
moderately dilated. The estimated right atrial pressure is ___
mmHg. There is moderate symmetric left ventricular hypertrophy.
The left ventricular cavity size is normal. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%). Quantitative (biplane)
LVEF = 67 %. Doppler parameters are most consistent with Grade
II (moderate) left ventricular diastolic dysfunction. There is
no left ventricular outflow obstruction at rest or with
Valsalva. Right ventricular chamber size and free wall motion
are normal. The right ventricular free wall is hypertrophied.
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:
1) Moderate left ventricular hypertrophy with normal
biventricular regional/global systolic function.
2) Grade II diastolic dysfunction with elevated LVEDP.
MRI BRAIN ___:
There is no hemorrhage or infarction. There is no mass lesion,
mass effect,
midline shift on this unenhanced study. There is a small focus
of reduced
signal (magnetic susceptibility), on gradient echo images within
the right
frontal lobe (11:19), suggestive of hemosiderin. There is mild
diffuse
parenchymal volume loss with commensurate prominence of the
ventricles, sulci,
and cisterns. There is mild mucosal opacification of the
bilateral ethmoid
sinuses, with small mucosal retention cysts are partial
opacification of
bilateral maxillary sinuses. The visualized portions of the
major
intracranial flow voids are preserved.
IMPRESSION:
1. No hemorrhage, infarction, or midline shift.
2. Nonspecific small focus of microhemorrhage within the right
frontal lobe,
which can be seen with hypertension or amyloid angiopathy.
3. Paranasal sinus disease as above.
Brief Hospital Course:
___ here for recurrent exertional lightheadedness. History of
uncontrolled DM on insulin c/b CKD last Cr 2.05 in ___,
gastroparesis, and neuropathy; HLD, HTN, PVD, anemia presents
with several episodes of new-onset syncope for one day. He had
recently been discharged from ___ where he was started
on labetalol and metoprolol was stopped. It seems as though he
took both on the morning of his presentation. This was likely
causing chronotropic insufficency while he was walking, and
could have contributed to his syncope. The other contributing
factor may have been autonomic dysfunction as the patient was
found to have persistent orthostatic vital signs during
admission despite being significantly volume overloaded.
MRI showed small microhemorrhage in the left frontal lobe. No
active signs of acute hemorrhage. Likely secondary to
uncontrolled blood pressure and diabetes. Discussed findings
with neurology, who felt this was not an acute bleed, and
management is reducing risk factors (blood pressure, diabetes)
longitudinally. Recommendation by team for patient to stay for
improved blood pressure control and monitoring. However, the
patient had a funeral to go to and wanted to leave and be
followed up as an outpatient. He was explained the risks of
possible seizures and further syncopal events, and explained
warning symptoms of stroke and when to return to the hospital.
The patient will obtain a referral from his PCP, ___ a
neurologist with ___. If unable to obtain, ___
neurology should be contacted at ___.
During admission patient was also found to be significantly
volume overloaded. He had an elevated BNP of ___ and an ECHO on
___ which showed grade II diastolic dysfunction. The patient
was diuresed with 40 mg lasix IV with significant improvement in
his volume status. However his Cr ___ from his baseline of 2.1
to 2.4. The patient had a funeral that he insisted on leaving
for on ___. He will have a Chem 10 drawn on ___ and make an
appointment with his PCP on ___. He will likely a follow up
with cardiology for further management of his heart failure.
Also during admission he was found to be anemic with Hgb in the
8's down from 10's previously. He had a positive stool guiac and
thus EGD was done on ___, which showed antral polyps but no
stigmata of bleeding. Patient's Hgb remained stable and
therefore colonscopy was deferred. He will probably need this or
a capsule study as an outpatient.
==================
TRANSITIONAL ISSUES
- PATIENT FOUND TO HAVE LEFT FRONTAL LOBE MICROHEMORRHAGE. Ok to
continue aspirin. Discussed findings with neurology, who felt
this was not an acute bleed, and management is reducing risk
factors (blood pressure, diabetes) longitudinally.
Recommendation by team for patient to stay for improved blood
pressure control and monitoring. However, the patient had a
funeral to go to and wanted to leave and be followed up as an
outpatient. He was explained the risks of possible seizures and
further syncopal events, and explained warning symptoms of
stroke and when to return to the hospital. The patient will
obtain a referral from his PCP, ___ a neurologist with
___. If unable to obtain, ___ neurology should be
contacted at ___.
-Changed Medications: Omeprazole 40 mg BID
-Stopped Medications: Labetalol
- continue amlodipine at 10mg despite lower extremity edema
- consider switching to atorvastatin as outpatient
-Patient written for Chem 10 to be drawn on ___ to
check electrolytes and kidney function given the Cr rise with
diuresis on ___.
-Patient was instructed to throw his pills out and start over
with this updated medication list.
-Diastolic HF: Diuresed on ___ with improvement in fluid
overload but Cr increased to 2.4 from 2.1. Chem 10 should be
checked on ___ and will need to be followed up next
week. Further diuresis was held given ___. He will most likely
need maintenance diuresis in the future, but will need to be
monitored closely. Recommend cardiology consultation to help
manage this in the future
-Orthostasis: Pt continued to have orthostatic vital signs
despite adequate volume status. This is likely due to autonomic
dysfunction in the setting of his long-standing diabetes. Could
consider a neurology consult as an outpatient to further
evaluate and manage this.
-Anemia: Chronic anemia c/w ACD. Hgb 8 on admission down from
baseline of 10. EGD showed no signs of bleeding. He would most
likely benefit from outpatient follow up with GI for possible
colonscopy or capsule study to further evaluate
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Cyanocobalamin 1000 mcg PO DAILY
4. Ferrous GLUCONATE 324 mg PO DAILY
5. Metoclopramide 10 mg PO TID gastroparesis
6. Metoprolol Succinate XL 50 mg PO DAILY
7. Pravastatin 80 mg PO QPM
8. ammonium lactate 12 % topical BID:PRN legs
9. Omeprazole 20 mg PO BID
10. tadalafil 20 mg oral DAILY:PRN activity
11. Gabapentin 800 mg PO TID
12. Gabapentin 300 mg PO QHS
13. Ranitidine 150 mg PO BID:PRN indigestion
14. LORazepam 0.5 mg PO BID:PRN Anxiety
15. HumaLOG Mix ___ KwikPen (insulin lispro protamin-lispro)
100 unit/mL (75-25) subcutaneous BREAKFAST
16. HumaLOG Mix ___ KwikPen (insulin lispro protamin-lispro)
100 unit/mL (75-25) subcutaneous DINNER
Discharge Medications:
1. Omeprazole 40 mg PO BID
RX *omeprazole 40 mg 1 capsule(s) by mouth twice a day Disp #*60
Capsule Refills:*0
2. Amlodipine 10 mg PO DAILY
3. ammonium lactate 12 % topical BID:PRN legs
4. Aspirin 81 mg PO DAILY
5. Cyanocobalamin 1000 mcg PO DAILY
6. Ferrous GLUCONATE 324 mg PO DAILY
7. Gabapentin 800 mg PO TID
8. Gabapentin 300 mg PO QHS
9. HumaLOG Mix ___ KwikPen (insulin lispro protamin-lispro)
100 unit/mL (75-25) subcutaneous BREAKFAST
10. HumaLOG Mix ___ KwikPen (insulin lispro protamin-lispro)
100 unit/mL (75-25) subcutaneous DINNER
11. LORazepam 0.5 mg PO BID:PRN Anxiety
12. Metoclopramide 10 mg PO TID gastroparesis
13. Metoprolol Succinate XL 50 mg PO DAILY
14. Pravastatin 80 mg PO QPM
15. Ranitidine 150 mg PO BID:PRN indigestion
16. tadalafil 20 mg oral DAILY:PRN activity
17.Outpatient Lab Work
Please obtain CBC and CHEM 10 on ___
ICD 9: ___
Name: ___.
Phone: ___
Fax: ___
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Syncope
Secondary diagnosis
Autonomic dysfunction
Acute on chronic diastolic heart failure
Gastroparesis
Hypertension
Anemia
Insulin dependent diabetes mellitus
Chronic kidney disease
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 you had been dizzy
while walking. You had several tests to get to the cause of this
dizziness, but it appears that the likely cause is the
combination of a few things. It seems that you may have been
taking two medications that can slow your heart rate (metoprolol
and labetalol). Also it seems as though some of the nerves that
control your blood vessels do not work properly (autonomic
neuropathy), which is probably a result of your diabetes. This
is something that you should see a nerve doctor (___)
about for further testing and management.
During your hospitalization, an ultrasound of your heart shows
that it doesn't relax properly (diastolic heart failure).
Although this is a scary sounding word, it is something that you
can manage by controlling how much salt you eat (<2g of sodium
per day) and taking a diuretic. You should also be sure to weigh
yourself every day and seek medical attention if your weight
increases by more than 3 lbs or if you start to feel more short
of breath. You were given a diuretic to get some of the fluid
off your legs and lungs, but this worsened your kidney function.
You need to have labs drawn on ___ and you should make
an appointment with your primary care doctor as soon as possible
to follow up on this. You should also follow up with a heart
doctor (___) to help further manage this.
You had an MRI of your brain while you were here. It showed some
old blood in the front of your brain. This is due to your high
blood pressure and diabetes, which puts you at risk for strokes.
It is very important that you follow up with a neurologist and
take your blood pressure medication.
Please get labs done at ___ on ___.
Please throw out the medications in your pill box and re-fill it
with the attached medication list.
It was a pleasure participating in your care. We wish you the
best!
-Your ___ Care Team
Followup Instructions:
___
|
19584791-DS-20
| 19,584,791 | 21,793,846 |
DS
| 20 |
2163-07-04 00:00:00
|
2163-07-04 14:41:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
Percocet / ceftriaxone / omeprazole
Attending: ___.
Chief Complaint:
dizziness and chest pain
Major Surgical or Invasive Procedure:
LV Mass resection ___
History of Present Illness:
Mr. ___ is a ___ with history of recently diagnosed LV
thrombus (diagnosed during ___ hospitalization, on
apixaban), CAD s/p 2v CABG (___), cardiac arrest (___) c/b
ESRD
on HD (MWF), T2DM, and HTN who presents with dizziness and chest
pain.
Notably, he was hospitalized in ___ where he was
diagnosed
with an LV outflow tract mass, felt most consistent with
thrombus
and was started on low-dose apixaban for anticoagulation.
Past Medical History:
- Coronary Artery Disease s/p revascularization ___
- Diabetes mellitus type II c/b gastroparesis, retinopathy,
neuropathy, and nephropathy
- ESRD on HD with RUE AV fistula. (___)
- Charcot feet
- CHF
- Hypertension
- Hyperlipidemia
- Peripheral neuropathy
- ETOH abuse- last drink ___
- Obesity
- Diverticulitis
- Osteomyelitis left foot
- GERD
Social History:
___
Family History:
Uncle: Died of an MI at age ___.
Father: ___ abuse, ?cirrhosis
Brother: ___ at age ___ Alcohol abuse, ?cirrhosis
Brother: ___ at age ___ Heroin overdose
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
PHYSICAL EXAM:
VITALS: 24 HR Data (last updated ___ @ 507)
Temp: 97.5 (Tm 97.5), BP: 181/81, HR: 71, RR: 17, O2 sat:
100%, O2 delivery: Ra, Wt: 290.78 lb/131.9 kg
GENERAL: NAD
HEENT: AT/NC, anicteric sclera, MMM
NECK: supple, no LAD
CV: RRR, S1/S2, no murmurs, gallops, or rubs
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
GI: abdomen soft, nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: 1+ lower extremity edema
PULSES: 2+ radial pulses bilaterally
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric
DISCHARGE PHYSICAL EXAM:
T: 98.1 HR: ___ SR BP: 110-130's/70 RR: 18 Sats: 95% RA
Wt: 130 kg
General: NAD
Cardiac: RRR
Resp: clear breath sounds
GI: obese,benign
Extr: warm no edema
Wound: sternal clean dry intact. stable
Neuro: awake, alert oriented
Pertinent Results:
ADMISSION LABS:
===============
___ 04:06PM WBC-8.0 RBC-3.10* HGB-9.3* HCT-29.5* MCV-95
MCH-30.0 MCHC-31.5* RDW-18.5* RDWSD-63.1*
___ 04:06PM NEUTS-74.9* LYMPHS-13.0* MONOS-6.7 EOS-2.9
BASOS-0.5 IM ___ AbsNeut-6.00 AbsLymp-1.04* AbsMono-0.54
AbsEos-0.23 AbsBaso-0.04
___ 04:06PM ___ PTT-34.8 ___
___ 04:06PM cTropnT-0.06*
___ 04:06PM GLUCOSE-354* UREA N-56* CREAT-6.6*#
SODIUM-135 POTASSIUM-4.6 CHLORIDE-91* TOTAL CO2-25 ANION GAP-19*
___ 06:55PM CK-MB-3 ___
___ 06:55PM CK(CPK)-65
___ 07:03PM LACTATE-0.9
___ 12:01AM cTropnT-0.05*
___ 11:35AM PLT COUNT-250
___ 11:35AM WBC-10.0 RBC-2.87* HGB-8.6* HCT-27.2* MCV-95
MCH-30.0 MCHC-31.6* RDW-18.4* RDWSD-63.3*
___ 11:35AM CALCIUM-8.7 PHOSPHATE-6.9* MAGNESIUM-2.1
___ 11:35AM GLUCOSE-294* UREA N-60* CREAT-7.2*
SODIUM-133* POTASSIUM-4.9 CHLORIDE-93* TOTAL CO2-24 ANION GAP-16
REPORTS:
========
___ CTA HEAD AND NECK
IMPRESSION:
1. No evidence of acute intracranial process or hemorrhage.
2. Mild-to-moderate atherosclerotic disease involving the origin
of the left
internal carotid artery and right V4 segment without evidence of
flow-limiting
stenosis. Otherwise, patent head and neck vasculature.
___ MR HEAD
1. No evidence of acute intracranial process or hemorrhage.
___ TTE
IMPRESSION: 1) Moderate to large mobile echodensity (likely
thrombus) prolapsing into the LVOT.
This maybe related to the patients prominent MAC (ulceration and
thrombus generation) however
a cardiac MRI if not already obtained could bring clarity on
etiology. 2) Echocardiographic evidence
for diastolic dysfunction with elevated PCWP with mild pHTN/RV
and RA dilation. 3) Severe
systolic arterial hypertension.
Compared with the prior TTE (images reviewed) of ___, the
findings are similar.
CLINICAL IMPLICATIONS: The patient has a mildly dilated
ascending aorta. Based on ___ ACCF/AHA
Thoracic Aortic Guidelines, if not previously known or a change,
a follow-up echocardiogram is suggested in ___
year; if previously known and stable, a follow-up echocardiogram
is suggested in ___ years.
DISCHARGE LABS:
___ WBC-13.1* RBC-2.77* Hgb-8.2* Hct-27.3* MCV-99* MCH-29.6
MCHC-30.0* RDW-18.7* RDWSD-67.8* Plt ___
___ Glucose-146* UreaN-67* Creat-7.4*# Na-134* K-5.6*
Cl-93* HCO3-23 AnGap-18
___ K-5.1
___ ALT-10 AST-17 LD(LDH)-230 AlkPhos-128 Amylase-11
TotBili-0.4
___ Calcium-8.4 Phos-9.3* Mg-2.8*
___ %HbA1c-7.4* eAG-166*
Micro:
___ TISSUE LEFT VENTRICULAR MASS.
GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES
SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final ___:
NO FUNGAL ELEMENTS SEEN.
Brief Hospital Course:
SUMMARY
=======================
Mr. ___ is a ___ with history of recently diagnosed LV
thrombus (diagnosed during ___ hospitalization, on
apixaban), CAD s/p 2v CABG (___), cardiac arrest (___) c/b
ESRD on HD (MWF), T2DM, and HTN who was admitted with dizziness
and chest pain. Chest pain was felt to be unlikely cardiac given
unremarkable workup; stress test was deferred due to LV mass. He
underwent CT head/neck and MRI which did not show any etiology
of his dizziness, and his symptoms were felt ultimately to be
consistent with orthostatic hypotension. He additionally
underwent repeat TTE for workup of his LV mass which was found
to be unchanged after anticoagulation, and he had surgical
resection of this mass.
PUMP: LVEF 63% (TTE ___
CORONARIES: Cath ___ with 50% stenosis of LAD, 90% stenosis
of pPDA, s/p CABG ___ LIMA to LAD, reverse SVG to PDA
VALVES: trivial MR
RHYTHM: sinus
ACUTE ISSUES:
=============
# LV mass, likely calcified thrombus:
Unclear etiology, per last discharge summary felt to be likely
calcified thrombus but possibly malignancy, infection. TTE on
___ demonstrated unchanged appearance from prior. Has persisted
despite anticoagulation since last hospitalization, though true
efficacy of anticoagulation on reduced dose apixiban in this
situation is unclear. Utility of cardiac MRI discussed
extensively with Dr. ___ was ultimately felt that it
was unlikely to be helpful in clarifying etiology (and is not
without risk given need for contrast iso his ESRD). Repeat TEE
was also felt unlikely to add further information (last TEE in
___, repeat TTE during this admission unchanged from prior).
Cardiac surgery consulted and recommended resection of this
mass, which was performed on ___.
#Type II NSTEMI
# Chest pain:
# Hx CAD s/p revascularization (___)
He initially presented with L sided chest pain which was
constant and non-exertional. There was lower suspicion ACS given
lack of ischemic changes on ECG and relatively flat troponins.
It was thought that this may have represented Type II NSTEMI in
setting of hypertension (SBP 190-200's in ED). Lower suspicion
for HFpEF driving NSTEMI despite elevated BNP (difficult to
interpret iso ESRD) given he appeared euvolemic on presentation.
Initially there was plan for nuclear stress test, however
decision was made to hold off given low clinical suspicion for
ACS and persistent LV thrombus which was a contraindication to
the study.
# Dizziness:
There was initially concern for embolic neurological event given
his known LVOT mass. He underwent CTA head and neck and MRI
which were without clear cause of his symptoms. He was found to
have positive orthostatics despite mild hypervolemia on exacm,
and upon further chart review it was noted that the patient has
had previous episodes of dizziness with positive orthostatics in
the past despite volume overloaded state. Orthostasis was
previously attributed to autonomic dysfunction iso DM, and it
was felt that this was the most likely contributor to his
symptoms during this admission as well. AM cortisol was checked
and normal. His dizziness resolved on its own during his
hospitalization.
# HTN:
He presented with poorly controlled hypertension likely in the
setting of self-discontinuing his home amlodipine due to
dizziness. His carvedilol was uptitrated to 25mg BID. He was
restarted on a reduced dose of amlodipine 5mg.
# ESRD on HD via RUE AV fistula
Undergoing renal transplant workup as outpatient. There was
concern that plans for renal transplant will be on hold pending
definitive mgmt of LV mass. He continued his home ___ HD
sessions while inpatient. Continued home sevelamer, nephrocaps,
calcitriol. Continued home torsemide 20mg PO on non-HD days for
volume.
CHRONIC ISSUES:
===============
# T2DM
Complicated by gastroparesis, retinopathy, neuropathy, and
nephropathy. Follows with ___. Continued home glargine 44u
qam with HISS while inpatient. Continued home gabapentin 300mg
BID.
# Anemia
Multifactorial secondary to AOI and iron deficiency. Previously
on ferrous sulfate but this was stopped on last admission due to
minimal benefit with AOI.
# Depression
Continued home sertraline 100mg daily.
# GERD
Continued home ranitidine 150mg BID.
Cardiac Surgery Course:
The patient was brought to the Operating Room on ___ where
the patient underwent Redo sternotomy and removal of
leftventricular mass. Cardiopulmonary bypass time was 55
minutes with a Cross-clamp time of 22 minutes.
Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable, weaned from inotropic and
vasopressor support. Beta blocker was initiated. The patient
was transferred to the telemetry floor for further recovery.
Chest tubes and pacing wires were discontinued without
complication.
Cardiac: metoprolol was titrated. His home Carvedilol 12.5 mg
bid was held his blood pressure would not tolerate while
hospitalized. It can be resumed prior discharge from rehab.
Renal: He was followed by Nephrology for continuation of HD.
Last HF ___ for 3.7 Liters. Epogen 20,000 units was given.
Next HD ___. Torsemide 20 mg was restarted
GI/nutrition: tolerated a diabetic diet. PPI/H2 blockers
continue. Aggressive bowel regimen in place.
Endocrine: Diabetes T2: his blood sugars were well controlled on
his home regimen.
Anticoagulation: Apixaban is no longer needed. LV mass removed
Disposition: He was seen by physical therapy who recommended
rehab. He was discharged to Encompass ___.,
___
He will follow-up with Dr. ___ as an outpatient.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Apixaban 2.5 mg PO BID
2. Gabapentin 300 mg PO DAILY
3. Glargine 40 Units Breakfast
4. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever
5. Aspirin 81 mg PO DAILY
6. Calcitriol 0.25 mcg PO DAILY
7. CARVedilol 12.5 mg PO BID
8. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
9. LORazepam 0.5 mg PO BID:PRN anxiety
10. Nephrocaps 1 CAP PO DAILY
11. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Second
Line
12. Pravastatin 80 mg PO QPM
13. Ranitidine 150 mg PO BID
14. Sertraline 50 mg PO DAILY
15. sevelamer CARBONATE 800 mg PO TID W/MEALS
16. Torsemide 20 mg PO 4X/WEEK (___)
Discharge Medications:
1. Bisacodyl ___AILY:PRN constipation
2. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
3. Glucose Gel 15 g PO PRN hypoglycemia protocol
4. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN Pain - Moderate
RX *hydromorphone 2 mg 1 tablet(s) by mouth every four (4) hours
Disp #*20 Tablet Refills:*0
5. Lactulose 30 mL PO DAILY:PRN constipation
6. Metoprolol Tartrate 25 mg PO BID
hold HR < 55 SBP < 100
7. Ramelteon 8 mg PO QHS:PRN insomnia
8. Senna 17.2 mg PO DAILY
9. Acetaminophen 650 mg PO Q6H
10. Docusate Sodium 100 mg PO BID
11. Glargine 40 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
12. Polyethylene Glycol 17 g PO DAILY
13. Sertraline 100 mg PO DAILY
14. sevelamer CARBONATE 1600 mg PO TID W/MEALS
15. Aspirin EC 81 mg PO DAILY
16. Calcitriol 0.25 mcg PO DAILY
17. Gabapentin 300 mg PO DAILY
18. Nephrocaps 1 CAP PO DAILY
19. Pravastatin 80 mg PO QPM
20. Ranitidine 150 mg PO BID
21. Torsemide 20 mg PO 4X/WEEK (___)
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis: LV thrombus, orthostatic hypotension
Secondary Diagnosis:
Coronary Artery Disease LVEF 63% (TTE ___
Congestive heart failure
Diabetes mellitus type II c/b gastroparesis, retinopathy,
neuropathy ESRD on HD with RUE AV fistula. (___)
Hypertension, Hyperlipidemia
Peripheral neuropathy: Charcot foot
ETOH abuse- last drink ___, Obesity
Diverticulitis
Osteomyelitis left foot
GERD
Discharge Condition:
Alert and oriented x3, non-focal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Edema: none
Discharge Instructions:
Prevena instructions
· The Prevena Wound dressing should be left on for a total
of 7 days post-operatively to receive the full benefit of the
therapy. The date of Day # 7 should be written on a piece of
tape on the canister to ensure that the nurse from the ___ or
___ facility knows when to remove the dressing and inspect the
incision. If the date is not written, please alert your nurse
prior to discharge.
· You may shower, however, please avoid getting the dressing and
suction canister soiled or saturated.
· You will be sent home with a shower bag to hold the suction
canister while bathing.
· If the dressing does become soiled or saturated, turn the
power off and remove the dressing. The entire unit may then be
discarded. Should this happen, please notify your ___ nurse, so
they may make plans to see you the following day to assess your
incision.
· Once the Prevena dressing is removed, you may wash your
incision daily with a plain white bar soap, such as Dove or
___. Do not apply any creams, lotions or powders to your
incision and monitor it daily.
· If you notice any redness, swelling or drainage, please
contact your surgeon's office at ___.
.
1. Shower daily -wash incisions gently with mild soap,
2. No baths or swimming, look at your incisions daily
3. NO lotion, cream, powder or ointment to incisions
4. Monitor your incisions for signs of infection: fever > 101.5,
redness, drainage or increased pain. Should you have any of
these symptoms please call the office immediately. ___
5. Daily weights: keep a log. Call for additional diuretic
instructions should you have a weight gain of ___ pounds
6. No driving for approximately one month and while taking
narcotics
Clearance to drive will be discussed at follow up appointment
with surgeon
7. No lifting more than 10 pounds for 10 weeks
8. Encourage full shoulder range of motion, unless otherwise
specified
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
Followup Instructions:
___
|
19584791-DS-21
| 19,584,791 | 23,376,246 |
DS
| 21 |
2163-09-09 00:00:00
|
2163-09-11 18:13:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Percocet / ceftriaxone / omeprazole
Attending: ___.
Chief Complaint:
nausea, vomiting
Major Surgical or Invasive Procedure:
N/A
History of Present Illness:
___ w hx LV thrombus (dx ___ hospitalization, on apixaban),
CAD s/p 2v CABG (___), cardiac arrest (___) c/b ESRD on HD
(MWF), T2DM, and HTN who presents with 1 week of abdominal pain
and dry heaving, which has caused him to miss HD, now with
volume
overload.
Reports his current symptoms feel like prior gastroparesis
flares. Started dry heaving 1 week ago, has had ___ loose stools
per day since. No fevers/chills. His last completed dialysis
session was 1 week prior to admission, as he had to cut his
session yesterday short due to feeling unwell. He is also over
the past few days had some mild shortness of breath worse with
lying flat and with exertion.
- In the ED, initial vitals were: HR 103, BP 180/87, RR 16 97%
on
2L NC
- Exam was notable for: course lung sounds, epigastric ttp
- Labs were notable for: WBC 13.6, Hgb 9.1 ___ 9.5)
----- Na 134, K 7.8, BUN 70; whole blood K 3.7 following HD
----- Trop 0.06 ---> 0.06; MB 3 --> 2
- Studies were notable for: CXR showing Small bilateral, right
greater than left, pleural effusions and mild pulmonary vascular
congestion. No frank pulmonary edema.
- The patient was given: Dialysis
--- pain/n/v: hydromorphone 1mg x 2, metoclopramide 10mg x 2,
diphenhydramine 25mg x 2
--- Hyperkalemia: insulin reg 10 units, calcium gluconate
- Renal was consulted
On arrival to the floor, he reports his nausea/non-bloody dry
heaving started 1 week ago, without any clear trigger (no change
in diet, no new medications, his fBGs have been in 140-150s). He
has a gastroparesis flare once ever ___ months, and these are
similar to prior symptoms. He has had episodes of dry heaving
___
x per day, and is currently nauseous. He also had diarrhea ___
times per day but this has resolved in the past couple of days;
no blood or black tarry stools. He has been taking his Ativan
and
ondansetron for n/v but these have not been helpful. He has not
been able to keep down much food (only small bites), but has
been
able to keep down liquids.
Past Medical History:
- Coronary Artery Disease s/p revascularization ___
- Diabetes mellitus type II c/b gastroparesis, retinopathy,
neuropathy, and nephropathy
- ESRD on HD with RUE AV fistula. (___) (since ___
- Charcot feet
- CHF
- Hypertension
- Hyperlipidemia
- ETOH use disorder - last drink ___
- Obesity
- Diverticulitis
- Osteomyelitis left foot
- GERD
Social History:
___
Family History:
Uncle: Died of an MI at age ___.
Father: ___ abuse, ?cirrhosis
Brother: ___ at age ___ Alcohol abuse, ?cirrhosis
Brother: ___ at age ___ Heroin overdose
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
___ 2050 Temp: 97.5 PO BP: 169/75 HR: 103 RR: 18 O2
sat: 96% O2 delivery: Ra FSBG: 103
GENERAL: Laying flat in bed in NAD, alert and interactive.
HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.
NECK: JVD to the mid-neck at 90 degrees.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: normal BS, non distended, tender to palpation in
epigastrum; tender to deep palpation throughout; No
organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
SKIN: Warm. Cap refill <2s. No rashes. Midline incision over
sternum.
NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs
spontaneously. ___ strength throughout. Normal sensation.
DISCHARGE PHYSICAL EXAM:
========================
VITALS:24 HR Data (last updated ___ @ 020)
Temp: 97.9 (Tm 97.9), BP: 166/84 (166-169/75-84), HR: 84
(84-103), RR: 18, O2 sat: 96%, O2 delivery: Ra, Wt: 267.2
lb/121.2 kg
GENERAL: Laying flat in bed in NAD, alert and interactive.
HEENT: Sclera anicteric and without injection. MMM.
NECK: JVD difficult to appreciate given neck caliber.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: decreased BS at bases. No wheezes, rhonchi or rales. No
increased work of breathing.
ABDOMEN: normal BS, non distended, no longer tender to
palpation,
no r/r/g
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
trace bilaterally.
SKIN: Warm. Cap refill <2s. No rashes. Midline incision over
sternum.
NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs
spontaneously. ___ strength throughout. Normal sensation.
Pertinent Results:
ADMISSION LABS
===============
___ 08:35AM BLOOD WBC-13.6* RBC-3.18* Hgb-9.1* Hct-30.2*
MCV-95 MCH-28.6 MCHC-30.1* RDW-18.7* RDWSD-63.6* Plt ___
___ 08:35AM BLOOD Neuts-84.7* Lymphs-6.3* Monos-4.1*
Eos-3.2 Baso-0.4 Im ___ AbsNeut-11.48* AbsLymp-0.85*
AbsMono-0.55 AbsEos-0.44 AbsBaso-0.06
___ 08:40AM BLOOD ___ PTT-38.9* ___
___ 08:35AM BLOOD Glucose-168* UreaN-70* Creat-9.4*#
Na-134* K-7.8* Cl-98 HCO3-18* AnGap-18
___ 08:35AM BLOOD Glucose-168* UreaN-70* Creat-9.4*#
Na-134* K-7.8* Cl-98 HCO3-18* AnGap-18
___ 08:40AM BLOOD ALT-12 AST-14 CK(CPK)-30* AlkPhos-144*
TotBili-0.4
___ 08:40AM BLOOD Lipase-73*
___ 08:40AM BLOOD CK-MB-3 cTropnT-0.06*
___ 08:40AM BLOOD Albumin-3.4*
___ 08:51AM BLOOD K-7.1*
DISCHARGE LABS
===============
___ 06:09AM BLOOD WBC-9.5 RBC-3.13* Hgb-9.0* Hct-29.3*
MCV-94 MCH-28.8 MCHC-30.7* RDW-18.4* RDWSD-62.0* Plt ___
___ 06:09AM BLOOD Glucose-121* UreaN-48* Creat-7.6* Na-139
K-4.8 Cl-96 HCO3-23 AnGap-20*
___ 06:09AM BLOOD Calcium-8.6 Phos-7.3* Mg-2.3
OTHER PERTINENT LABS
=====================
___ 05:52PM BLOOD cTropnT-0.06*
___ 07:36AM BLOOD %HbA1c-5.8 eAG-120
IMAGING/STUDIES
===============
___ Imaging CHEST (PORTABLE AP)
IMPRESSION:
Small bilateral, right greater than left, pleural effusions and
mild pulmonary vascular congestion. No frank pulmonary edema.
Brief Hospital Course:
___ with history of recently diagnosed LV thrombus (s/p
resection ___ hospitalization, on
apixaban), CAD s/p 2v CABG (___), cardiac arrest (___) c/b
ESRD on HD (MWF), T2DM, and HTN who presented on ___ with
nausea/vomiting consistent with prior episodes of gastroparesis
as well as hyperkalemia and c/f volume overload in the setting
of missed HD appointments x2.
ACUTE/ACTIVE ISSUES:
====================
#Nausea/Vomiting
#Concern for Gastroparesis
Most consistent with gastroparesis given symptoms similar to
prior flares and negative preliminary work up. EKG did not show
evidence of active ischemia, trops were near baseline. Lipase
was not elevated, LFTs were unremarkable. Blood and urine
cultures no growth to date. Deferred imaging given symptoms
similar to prior presentaions with negative work up. He was
treated with metoclopramide 5mg TID PO and symptoms resolved.
Encouraged low fat, low fiber diet. Will not continue
metoclopramide at discharge given prolonged QTc (490).
#Leukocytosis
Unclear etiology as patient had no focal signs/symptoms of
infection other than abdominal symptoms (no cough, dysuria, no
fever, CXR without focal consolidation). Likely reactive given
ongoing nausea/dry heaving. Leukocytosis resolved prior to
discharge. Blood and urine cultures no growth to date and C diff
was negative.
#ESRD on ___ Dialysis
#Volume Overload
On the kidney transplant waitlist at ___, and patient reports
his brother will be donating a kidney to him. Per chart review,
estimated dry weight 122kg; was 2kg over dry weight on admission
likely ___ missed HD from GI upset as above. Received HD with
volume removal on admission and continued home schedule of HD on
MWF through right arm AVF. Now euvolemic on exam. He was
continued on home torsemide 20mg on non-dialysis daysm as well
as home sevelamer, calcitriol, nephrocaps daily with low
phos/low K renal diet.
#Hyperkalemia
K+ on admission 7.1 likely in the setting of missed HD
appointment. No ECG changes. Was treated with Ca gluconate,
insulin/dextrose on admission, then HD as above and K+
normalized.
#Type II DM complicated by neuropathy, nephropathy, retinopathy
Follows with ___, taking Lantus 44 units every morning at
home, does not use any short acting. Patient reported that he
does not check fingerticks and has poor PO intake at home. Was
found to have a low A1c of 5.8% here concerning for hypoglycemic
episodes. Would target goal a1c for him likely 7-8% given high
cardiovascular disease burden, but will defer to ___
providers as an outpatient. Home lantus was reduced to 30U qam
to avoid hypoglycemia. Please ensure ___ follow up on
discharge.
#Troponinemia/NSTEMI II
On admission, troponins were elevated and stable at 0.06 x 2
with CK-MB index 4. Possibly due to demand ischemia from volume
overload and reduced clearance from renal disease. No ST segment
changes on EKG. No anginal symptoms/chest pain on admission.
CHRONIC/STABLE ISSUES:
======================
#HTN
Patient reported not taking amlodipine 10mg QDaily at home since
it makes him dizzy and has known hx of orthostasis/dysautonomia.
He was continued on home metoprolol 37.5mg BID though would
favor carvedilol if hypertension continues to be above goal
(>140/90).
#Normocytic Anemia
Hgb this admission 9.5, approximately his baseline. Prior
workups revealing multifactorial ___ anemia of chronic disease
and iron deficiency.
#GERD - continued ranitidine QDaily
#Depression -continued Sertraline 100 Qdaily
#Insomnia
Given ramelteon prn as concern for QTC prolongation with
trazodone.
#Hx of Left Ventricular thrombus s/p resection ___
Diagnosed in ___ and ultimately removed by cardiac
surgery in ___ after he presented with dizziness and
chest pain. Previously on Eliquis 2.5 BID but now no longer
indicated after thrombus resection.
#CAD s/p CABG - continued home ASA 81, pravastatin QHS
#Hx of Constipation
Pt previously on lactulose, miralax, and docusate for
constipation. Held given diarrhea.
TRANSITIONAL ISSUES
===================
#DM2
[] A1c 5.8, below goal. Lantus was reduced from 44 to 30U but
should follow up with ___ for further titration
#HTN
[] Consider switching metoprolol to carvedilol for better
antihypertensive effect
[] Please continue to monitor QTc in the outpatient setting and
avoid QTc prolonging medications if possible (elevated here to
508ms)
# CODE: Full Code confirmed
# CONTACT: Brother ___ ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H
2. Aspirin EC 81 mg PO DAILY
3. Calcitriol 0.25 mcg PO DAILY
4. Polyethylene Glycol 17 g PO DAILY
5. Sertraline 100 mg PO DAILY
6. sevelamer CARBONATE 1600 mg PO TID W/MEALS
7. Bisacodyl ___AILY:PRN constipation
8. Lactulose 30 mL PO DAILY:PRN constipation
9. Metoprolol Tartrate 37.5 mg PO BID
10. Ramelteon 8 mg PO QHS:PRN insomnia
11. Senna 17.2 mg PO DAILY
12. Torsemide 20 mg PO 4X/WEEK (___)
13. Gabapentin 300 mg PO DAILY
14. Pravastatin 80 mg PO QPM
15. Nephrocaps 1 CAP PO DAILY
16. Docusate Sodium 100 mg PO BID
17. Ranitidine 150 mg PO BID
18. Glargine 44 Units Breakfast
Discharge Medications:
1. Gabapentin 200 mg PO QHS
2. Glargine 30 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
3. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
4. Senna 8.6 mg PO BID:PRN Constipation - First Line
5. Acetaminophen 650 mg PO Q6H
6. Aspirin EC 81 mg PO DAILY
7. Bisacodyl ___AILY:PRN constipation
8. Calcitriol 0.25 mcg PO DAILY
9. Docusate Sodium 100 mg PO BID
10. Lactulose 30 mL PO DAILY:PRN constipation
11. Metoprolol Tartrate 37.5 mg PO BID
12. Nephrocaps 1 CAP PO DAILY
13. Pravastatin 80 mg PO QPM
14. Ramelteon 8 mg PO QHS:PRN insomnia
15. Ranitidine 150 mg PO BID
16. Sertraline 100 mg PO DAILY
17. sevelamer CARBONATE 1600 mg PO TID W/MEALS
18. Torsemide 20 mg PO 4X/WEEK (___)
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
=================
Concern for Gastroparesis
ESRD on ___ Dialysis
Hyperkalemia
Volume Overload
SECONDARY DIAGNOSES:
=====================
Type II Diabetes
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
WHY WERE YOU ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital because you were having
abdominal pain and vomiting.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- You were given medication to help treat your gastroparesis by
stimulating your intestines to move
- You were given dialysis to remove the extra fluid and
electrolytes in your body
- You improved and were ready to leave the hospital.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Please take all of your medications as prescribed and go to
your follow up appointments with your doctors ___ below)
- Seek medical attention if you have new or concerning symptoms
It was a pleasure participating in your care. We wish you the
best!
- Your ___ Care Team
Followup Instructions:
___
|
19584791-DS-24
| 19,584,791 | 24,189,273 |
DS
| 24 |
2163-11-19 00:00:00
|
2163-11-20 15:59:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Percocet / ceftriaxone / omeprazole
Attending: ___.
Chief Complaint:
nausea, lack of appetite, vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with history of recently diagnosed LV thrombus (s/p
resection ___ hospitalization, on apixaban), CAD s/p 2v CABG
(___), cardiac arrest (___) c/b ESRD on HD (MWF) with plan for
renal transplant in ___, T2DM c/b gastroparesis, HTN, and
3 recent admissions for gastroparesis flare presenting with
epigastric pain, vomiting, inability to tolerate PO and having
missed multiple HD sessions.
The patient states he has substernal chest pressure, mild
intensity without radiation, but associated with dyspnea with
exertion.
Denies cough, fevers, back pain.
Endorses lower abdominal pain, described as a throbbing
sensation. Sates the pain is similar to gastroparesis.
Patient has taken reaglan without relief.
Patient still makes urine. Patient states has been unable to
take
his home medications due to persistent nausea.
Patient is endorsing constipation for the past several days, but
denies obstipation. Additionally, patient has PSH of colectomy
___
years ago.
Patient has multiple near identical admissions in last few
months.
- In the ED, initial vitals were:
97.7, 85, 196/89, 18, 100% RA
- Exam was notable for:
TTP hypogastrium
- Labs were notable for:
Mild leukocytosis with neutrophilia, anemia 10.9, BUN/Cr
elevated
(missed HD), AG 20, Phos 9.3, ALP 152 but otherwise normal LFTs
- Studies were notable for:
CT A/P
1. No bowel obstruction or acute abdominopelvic findings.
2. New right pleural effusion with overlying relaxation
atelectasis of the right lung base. An overlying pneumonia is
not
excluded. Persistent small left pleural effusion.
3. Redemonstration of sequela from chronic pancreatitis without
evidence of active inflammation.
4. Stable appearance of a lobulated splenic cyst with peripheral
calcification, which could reflect prior trauma.
- The patient was given:
Dilaudid, Ativan, prochlorperazine
- Renal was consulted without urgent indication for HD found,
agree with admission.
On arrival to the floor, he gives the above history.
REVIEW OF SYSTEMS:
==================
Per HPI, otherwise, 10-point review of systems was within normal
limits.
Past Medical History:
- Coronary Artery Disease s/p revascularization ___
- Diabetes mellitus type II c/b gastroparesis, retinopathy,
neuropathy, and nephropathy
- ESRD on HD with RUE AV fistula. (___) (since ___
- Charcot feet
- CHF
- Hypertension
- Hyperlipidemia
- ETOH use disorder - last drink ___
- Obesity
- Diverticulitis
- Osteomyelitis left foot
- GERD
Social History:
___
Family History:
Uncle: Died of an MI at age ___.
Father: ___ abuse, ?cirrhosis
Brother: ___ at age ___ Alcohol abuse, ?cirrhosis
Brother: ___ at age ___ Heroin overdose
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS:
hypertensive 205/96 on arrival to floor
96%+ on RA
HR ___
GEN: antalgic discomfort but otherwise not in distress
HEENT: MM dry
CV: RRR s1s2 no mrg
PULM: CTA anteriorly
GI: Obese, Soft, Mild-mod distension, diffuse TTP mild
concentrated most periumbilical and epigastrium
EXT: WWP non-edematous
DISCHARGE PHYSICAL EXAM
===========================
VITALS:24 HR Data (last updated ___ @ 537)
Temp: 97.5 (Tm 98.6), BP: 135/71 (134-159/70-80), HR: 58
(58-77), RR: 18, O2 sat: 97% (94-99), O2 delivery: RA, Wt:
264.11
lb/119.8 kg
GEN: awake and alert, in no acute distress
HEENT: NC/AT, sclera anicteric and without injection
CV: RRR, normal S1 and S2, no murmurs, rubs or gallops
PULM: CTAB anteriorly
GI: Obese, Soft, Mild-mod distension, not TTP
EXT: WWP non-edematous
Psych: appropriate mood and affect
Neuro: A and O x 3
Pertinent Results:
ADMISSION LABS
========================
___ 07:13PM ___ PTT-34.9 ___
___ 06:41PM K+-4.9
___ 05:37PM GLUCOSE-132* UREA N-83* CREAT-9.4* SODIUM-140
POTASSIUM-5.1 CHLORIDE-98 TOTAL CO2-22 ANION GAP-20*
___ 05:37PM ALT(SGPT)-14 AST(SGOT)-14 ALK PHOS-152* TOT
BILI-0.4
___ 05:37PM LIPASE-54
___ 05:37PM cTropnT-0.05*
___ 05:37PM ALBUMIN-3.8 CALCIUM-8.4 PHOSPHATE-9.3*
MAGNESIUM-2.3
___ 05:37PM WBC-10.3* RBC-3.71* HGB-10.9* HCT-35.4*
MCV-95 MCH-29.4 MCHC-30.8* RDW-16.5* RDWSD-57.9*
___ 05:37PM NEUTS-82.7* LYMPHS-8.6* MONOS-5.7 EOS-2.1
BASOS-0.5 IM ___ AbsNeut-8.50* AbsLymp-0.89* AbsMono-0.59
AbsEos-0.22 AbsBaso-0.05
___ 05:37PM PLT COUNT-228
___ 09:20AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 09:20AM URINE BLOOD-NEG NITRITE-NEG PROTEIN->600*
GLUCOSE-300* KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-NEG
___ 09:20AM URINE RBC-2 WBC-<1 BACTERIA-FEW* YEAST-NONE
EPI-0
___ 08:55AM GLUCOSE-259*
___ 08:55AM UREA N-64* CREAT-8.6* SODIUM-137
POTASSIUM-4.7 CHLORIDE-92* TOTAL CO2-24 ANION GAP-21*
___ 08:55AM estGFR-Using this
___ 08:55AM ALT(SGPT)-16 AST(SGOT)-16 LD(LDH)-189 ALK
PHOS-155* TOT BILI-0.4
___ 08:55AM MAGNESIUM-2.2
___ 08:55AM %HbA1c-7.5* eAG-169*
___ 08:55AM OTHER BODY FLUID SAURPCR-POS* MRSA PCR-NEG
___ 08:55AM WBC-10.5* RBC-3.43* HGB-10.2* HCT-32.9*
MCV-96 MCH-29.7 MCHC-31.0* RDW-17.2* RDWSD-60.9*
___ 08:55AM PLT COUNT-243
___ 08:55AM ___ PTT-35.0 ___
========================
DISCHARGE LABS
=======================
___ 08:04AM BLOOD WBC-9.7 RBC-3.64* Hgb-10.5* Hct-35.2*
MCV-97 MCH-28.8 MCHC-29.8* RDW-17.2* RDWSD-58.7* Plt ___
___ 08:04AM BLOOD Plt ___
___ 08:04AM BLOOD Glucose-140* UreaN-34* Creat-6.3* Na-137
K-4.8 Cl-95* HCO3-27 AnGap-15
___ 08:04AM BLOOD Calcium-9.3 Phos-4.9* Mg-2.3
================
IMAGING
=====================
CT A/P ___
IMPRESSION:
1. No bowel obstruction or acute abdominopelvic findings.
2. New right pleural effusion with overlying relaxation
atelectasis of the
right lung base. An overlying pneumonia is not excluded.
Persistent small
left pleural effusion.
3. Redemonstration of sequela from chronic pancreatitis without
evidence of
active inflammation.
4. Stable appearance of a lobulated splenic cyst with peripheral
calcification, which could reflect prior trauma.
Brief Hospital Course:
====================
PATIENT SUMMARY:
====================
___ with history of recently diagnosed LV thrombus (s/p
resection ___ hospitalization, on apixaban), CAD s/p 2v CABG
(___), cardiac arrest (___) c/b ESRD on HD (MWF) with plan for
renal transplant in ___, T2DM c/b gastroparesis, HTN, and
3 recent admissions for gastroparesis flare who presented with
epigastric pain, vomiting, inability to tolerate PO consistent
with gastroparesis and having missed multiple HD sessions. On
admission his QTc was checked and was 484. He was started on
home reglan QAC, Ativan and was encouraged to eat small meals.
He was dialized as needed. During his admission he reported
ongoing nausea and anxiety related to both his gastroparesis and
his upcoming kidney transplant. He was able to tolerate small
amounts of food without emesis. On day of discharge he reported
his nausea had resolved and he was able to eat breakfast. Will
be discharged with plan for f/u with his transplant team,
___, and his PCP.
====================
TRANSITIONAL ISSUES:
====================
#stopped meds: none
#changed meds: gabapentin decreased from ___ mg to 200
mg qHS, insulin glargine decreased from 36u daily to 30u daily
#new meds: simethicone 40-80 mg QID PRN gas
[ ] Gabapentin dose decreased as it was felt that it may be
contributing to his gastroparesis flare
[ ] Insulin dose decreased in setting of poor PO intake and
sugars well controlled on decreased dose. Please check ___ at
next outpatient appointment and adjust insulin regimen
accordingly.
[ ] Continue to manage his anxiety. He endorses anxiety around
upcoming kidney transplant.
[ ] Continue to monitor BPs. He was intermittently hypertensive
on his home carvedilol this admission. Would discuss with renal
team and consider adding second agent.
#code status: full
#contact:
Name of health care proxy: ___
Relationship: Brother
Phone number: ___
====================
ACUTE ISSUES:
====================
# Abdominal pain
# Nausea/vomiting
# inability to tolerate PO
Presentation consistent with prior Gastroparesis episodes
requiring admission given inability to tolerate PO. No
concerning findings on abdominal exam this admission. His EKG
QTc was 484. Was initially eating small amounts for first ___
days, but then on ___ after
dialysis reporting worsening nausea, inability to tolerate solid
foods. His nausea was likely multifactorial as he endorsed lots
of anxiety regarding upcoming kidney transplant and concern that
it would be postponed. He was continued on reglan QAC, Ativan
PRN, tylenol for pain. He did not receive any opiates. On day of
discharge he was able to tolerate small amounts of food and
reported his nausea was resolved.
# Elevated troponin
# Chest discomfort
Pt reported chest pressure in setting of gastroparesis flare -
typical for his flares per report. Trop elevated to 0.05 in ED,
after having missed multiple dialysis sessions. No concerning
EKG
changes. Chest discomfort resolved on arrival to floor. On last
admission chest discomfort noted to resolve with ranitidine. On
the floor he explained the chest pressure did not feel like his
prior
cardiac pain. He was continued on ranitidine and did not have
any further chest pain or discomfort.
# HTN
Again hypertensive in ED in the setting of N/V, abdominal pain,
and missing multiple doses of his home Carvedilol. He was
continued on home carvedilol 25mg BID.
# Microcytic anemia
Old iron, ferritin and transferrin labs ___ total iron
binding capacity (244) and low serum iron (44) with a TSAT of
18%, consistent with anemia of chronic disease/ESRD.
# ESRD:
He gets HD MWF at ___ in ___. Currently making
urine. Planned for
living donor transplant from brother on ___. Was
dialized per his schedule while an inpatient. His home
sevelamer, calcitriol, nephrocaps were continued. He continued
home torsemide 20mg 4x/week (___)
# T2DM c/b neuropathy, retinopathy, dysautonomia
Long history of diabetes. He told the team this admission that
he has not checked his home blood sugars in months and does not
think he has a glucometer at home. During his admission he was
continued on lantus 30u qAM (dose reduced from home 36u) + ISS
but did not require much ISS, likely given he did not have much
PO intake. He was also continued on gabapentin. He will be sent
home with a glucometer and other supplies he was missing.
====================
CHRONIC ISSUES:
====================
# Depression
-continued home sertraline
# CAD s/p PCI ___
-continued home ASA 81, pravastatin 80mg qPM
-continued home carvedilol 25mg BID with holding parameters
# hx LV thrombus s/p resection ___
Diagnosed in ___ and ultimately removed by cardiac
surgery in ___ after he presented with dizziness and
chest
pain. Previously on Eliquis 2.5 BID but now no longer indicated
after thrombus resection
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Aspirin 81 mg PO DAILY
3. Calcitriol 0.25 mcg PO DAILY
4. CARVedilol 25 mg PO BID
5. Docusate Sodium 100 mg PO BID
6. Gabapentin 200 mg PO QHS
7. LORazepam 0.5 mg PO QHS:PRN anxiety
8. Metoclopramide 5 mg PO BID
9. Nephrocaps 1 CAP PO DAILY
10. Pravastatin 80 mg PO QPM
11. Ramelteon 8 mg PO QPM:PRN insomnia
12. Ranitidine 150 mg PO BID
13. Sertraline 100 mg PO DAILY
14. sevelamer CARBONATE 2400 mg PO TID W/MEALS
15. Torsemide 20 mg PO 4X/WEEK (___)
16. Capsaicin 0.025% 1 Appl TP TID:PRN foot pain
17. Lantus U-100 Insulin (insulin glargine) 36 u subcutaneous
DAILY
18. Gabapentin 300 mg PO BID
Discharge Medications:
1. Glargine 30 Units Breakfast
RX *blood sugar diagnostic ___ Guide] use strips to
check your blood sugar 3 times per day Disp #*100 Strip
Refills:*0
RX *blood-glucose meter ___ Nano] use to check your
blood sugar 3 times per day Disp #*1 Each Refills:*0
RX *lancets ___ Multiclix Lancet] use to check your
blood sugar 3 times per day Disp #*100 Each Refills:*0
2. Simethicone 40-80 mg PO QID:PRN gas pain
RX *simethicone [Gas-X] 62.5 mg 1 strip by mouth once a day as
needed Disp #*30 Strip Refills:*0
3. Ranitidine 150 mg PO DAILY
4. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
5. Aspirin 81 mg PO DAILY
6. Calcitriol 0.25 mcg PO DAILY
7. Capsaicin 0.025% 1 Appl TP TID:PRN foot pain
8. CARVedilol 25 mg PO BID
9. Docusate Sodium 100 mg PO BID
10. Gabapentin 200 mg PO QHS
11. LORazepam 0.5 mg PO QHS:PRN anxiety
12. Metoclopramide 5 mg PO BID
13. Nephrocaps 1 CAP PO DAILY
14. Pravastatin 80 mg PO QPM
15. Ramelteon 8 mg PO QPM:PRN insomnia
16. Sertraline 100 mg PO DAILY
17. sevelamer CARBONATE 2400 mg PO TID W/MEALS
18. Torsemide 20 mg PO 4X/WEEK (___)
Discharge Disposition:
Home
Discharge Diagnosis:
Gastroparesis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at the ___
___!
WHY WAS I IN THE HOSPITAL?
==========================
- You were admitted because you were having nausea and abdominal
pain from your gastroparesis
WHAT HAPPENED IN THE HOSPITAL?
==============================
- You had dialysis for your kidneys
- You were given medicine to help with your stomach discomfort.
WHAT SHOULD I DO WHEN I GO HOME?
================================
- Be sure to take all your medications and attend all of your
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:
___
|
19584791-DS-30
| 19,584,791 | 24,535,135 |
DS
| 30 |
2164-02-19 00:00:00
|
2164-02-20 19:46:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Percocet / ceftriaxone / omeprazole
Attending: ___
Chief Complaint:
nausea, abdominal pain, dry heaves
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ y/o M with PMHx of CAD s/p CABG ___, DM II
complicated by gastroparesis, HTN, ESRD, s/p LRRT ___ with
recent discharge ___ with dyspnea with negative workup who
presented to the hospital after 1.5 week of nausea, abdominal
pain
and dry heaving in addition to shortness of breath and chest
heaviness for the last ___ days.
The patient stated his abdominal pain is ___, epigastric and
consistent with previous episodes of gastroparesis. He had
noticed that at home his diabetes has not been as well
controlled
recently and despite him reportedly taking his metoclopramide he
had ongoing issues with this. He had decreased his PO intake
recently given this discomfort. He stated dilaudid was the only
thing that helped.
He stated his pain and dyspnea are both worse on exertion and
when lying flat.
In the ED:
- Initial vital signs were notable for:
Pain 8, temp 96.6, HR 85, BP 128/73, RR 16, Pox 98% RA
- Exam notable for:
Resp: Nl WOB, bibasilar rales
CV: Regular rhythm, nl ___ and ___ heart sounds, normal rate
Abd: ND, soft, pain to left of the epigastrium with palpation,
no
rebound or guarding, well-healing right lower quadrant surgical
incision
- Labs were notable for:
Lactate:1.3
Trop-T: <0.01
proBNP: 1131
INR 1.1, Hgb 11.8 (macrocytic), WBC 9.5
CK 29 MB 2
Na 132
without AG
UA
Glu >1000
Ket Tr
pH 7.33
- Studies performed include:
EKG: Sinus rhythm, left axis, QTC 480, no hypertrophy, no
obvious
ischemic changes but poor baseline
Renal transplant US
Resistive indices within the transplanted kidney are slightly
elevated when compared with most recent prior in the mid and
upper pole. Otherwise unremarkable exam.
CXR
Chronic bibasilar atelectasis with tiny pleural effusions - not
significantly changed from prior exam.
- Patient was given:
PO Lorazepam 1 mg
IV Ondansetron 4 mg
IV Morphine Sulfate 4 mg
IM Haloperidol 2.5 mg
PO OxyCODONE (Immediate Release) 5 mg
Past Medical History:
- Coronary Artery Disease s/p revascularization ___
- Diabetes mellitus type II c/b gastroparesis, retinopathy,
neuropathy, and nephropathy
- ESRD on HD with RUE AV fistula. (___) (since ___,
with LRRT in ___
- Charcot feet
- CHF
- Hypertension
- Hyperlipidemia
- ETOH use disorder - last drink ___
- Obesity
- Diverticulitis
- Osteomyelitis left foot
- GERD
- LV thrombus s/p resection in ___
Social History:
___
Family History:
Uncle: Died of an MI at age ___.
Father: ___ abuse, ?cirrhosis
Brother: ___ at age ___ Alcohol abuse, ?cirrhosis
Brother: ___ at age ___ Heroin overdose
Physical Exam:
ADMISSION PHYSICAL EXAM:
===========================
VITALS:24 HR Data (last updated ___ @ 1800)
Temp: 97.2 (Tm 97.2), BP: 138/78, HR: 77, RR: 18, O2 sat:
97%, O2 delivery: RA, Wt: 235.2 lb/106.69 kg
GENERAL: Alert and interactive overweight male, appears stated
age. In no acute distress.
EYES: NCAT. PERRL, conjugate gaze. Sclera anicteric and without
injection.
ENT: MMM. No JVP appreciated when sitting upright at 90 degrees.
CARDIAC: Distant. Regular rhythm, normal rate. Audible S1 and
S2.
No murmurs/rubs/gallops.
RESP: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: soft, LLQ pain to palpation ("it's my gastroparesis
pain") otherwise non-tender, non-distended. Surgical scar
covered
with dressing without discharge (in RLQ), no pain to palpation
around site, no erythema or induration
MSK: No spinous process tenderness. No clubbing, cyanosis, or
edema. Warm. No rash.
NEUROLOGIC: Alert, appropriately conversational with recent and
remote memory intact. CN2-12 intact. ___ strength throughout.
Normal sensation.
PSYCH: appropriate,fine mood and c/w affect
DISCHARGE PHYSICAL EXAM:
=========================
___ 1530 Temp: 98.2 PO BP: 146/70 L Lying HR: 62 RR: 20 O2
sat: 98% O2 delivery: RA
GENERAL: Alert and interactive overweight male, appears stated
age. In no acute distress.
EYES: NCAT. PERRL, conjugate gaze. Sclera anicteric and without
injection.
ENT: MMM. No JVP appreciated when sitting upright at 90 degrees.
CARDIAC: Regular rate, rhythm. Audible S1 and S2. No
murmurs/rubs/gallops.
RESP: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: soft, midline/ RUQ pain to palpation, otherwise
non-tender, non-distended. Surgical scar covered with dressing
without discharge (in RLQ), no pain to palpation around site, no
erythema or induration
MSK: No spinous process tenderness. No clubbing, cyanosis, or
edema. Warm. No rash.
NEUROLOGIC: Alert, appropriately conversational with recent and
remote memory intact. CN2-12 intact. ___ strength throughout.
Normal sensation.
PSYCH: appropriate, fine mood and c/w affect
Pertinent Results:
ADMISSION LABS:
===================
___ 12:13PM BLOOD WBC-9.5 RBC-3.59* Hgb-11.8* Hct-35.8*
MCV-100* MCH-32.9* MCHC-33.0 RDW-15.9* RDWSD-58.2* Plt ___
___ 12:13PM BLOOD Neuts-81.4* Lymphs-10.4* Monos-5.9
Eos-1.3 Baso-0.4 Im ___ AbsNeut-7.77* AbsLymp-0.99*
AbsMono-0.56 AbsEos-0.12 AbsBaso-0.04
___ 12:13PM BLOOD ___ PTT-32.8 ___
___ 12:13PM BLOOD Plt ___
___ 12:13PM BLOOD Glucose-295* UreaN-23* Creat-1.0 Na-132*
K-5.0 Cl-100 HCO3-20* AnGap-12
___ 12:13PM BLOOD ALT-10 AST-16 CK(CPK)-29* AlkPhos-175*
TotBili-0.5
___ 12:13PM BLOOD Lipase-14
___ 12:13PM BLOOD CK-MB-2 proBNP-1131*
___ 12:13PM BLOOD cTropnT-<0.01
___ 04:43PM BLOOD cTropnT-<0.01
___ 12:13PM BLOOD Albumin-4.0 Calcium-9.6 Phos-2.8 Mg-1.7
___ 04:37PM BLOOD ___ pO2-28* pCO2-52* pH-7.33*
calTCO2-29 Base XS--1
___ 12:22PM BLOOD Lactate-1.3 K-4.6
___ 04:37PM BLOOD O2 Sat-44
DISCHARGE LABS:
===================
___ 06:20AM BLOOD WBC-7.7 RBC-3.50* Hgb-11.4* Hct-35.1*
MCV-100* MCH-32.6* MCHC-32.5 RDW-15.4 RDWSD-56.4* Plt ___
___ 06:20AM BLOOD Plt ___
___ 06:20AM BLOOD Glucose-249* UreaN-22* Creat-1.1 Na-138
K-5.1 Cl-99 HCO3-24 AnGap-15
___ 06:20AM BLOOD Calcium-9.2 Phos-3.0 Mg-1.8
___ 06:20AM BLOOD tacroFK-9.6
IMAGING:
PHARMACOLOGIC STRESS TEST ___
FINDINGS:
The image quality is adequate but limited due to soft tissue
attenuation.
Left ventricular cavity size is normal.
Rest and stress perfusion images reveal uniform tracer uptake
throughout the
left ventricular myocardium.
Gated images reveal septal akinesis with normal thickening,
consistent with
cardiac surgery.
The calculated left ventricular ejection fraction is 49% with an
EDV of 82 ml.
IMPRESSION:
1. Normal myocardial perfusion.
2. Normal left ventricular cavity size and systolic function.
EXERCISE RESULTS:
INTERPRETATION: This ___ year old man with h/o ESRD s/p LRRT in
___, PVD, IDDM, HTN, HLD and CAD s/p CABG in ___ was
referred to the
lab for evaluation of chest discomfort. He was injected with 0.4
mg of
regadenoson over 20 seconds. No anginal symptoms reported. No ST
segment
changes noticed from baseline. Rhythm was sinus with rare
isolated VPBs.
Appropriate HR and BP response to the Lexiscan infusion.
Caffeine 30 mg
IV given to the patient at minute 2 of recovery.
IMPRESSION : No anginal symptoms or ST segment changes. Nuclear
report
sent separately.
EKG: ___
Severe Baseline artifact present Sinus rhythm with PACs and
sinus arrhythmia Probable left atrial enlargement Repol abnrm
suggests ischemia, lateral leads QTc prolongation Compared with
the previous tracing of ___ 1122, rate slightly slower and
frontal plane QRS axis more vertical.
RENAL TRANSPLANT ULTRASOUND: ___
IMPRESSION:
Resistive indices within the transplanted kidney are slightly
elevated when
compared with most recent prior in the mid and upper pole.
Otherwise
unremarkable exam.
CHEST XRAY ___:
IMPRESSION:
Chronic bibasilar atelectasis with tiny pleural effusions not
significantly
changed from prior exam.
Brief Hospital Course:
TRANSITIONAL ISSUES
====================
[] Tacrolimus level was monitored this admission. Discharged on
2mg BID. Will need follow up tacro level and appropriate
adjustment of dose.
[] Presented with hyperglycemia contributing to worsening
gastroparesis symptoms. Will need ongoing titration of insulin
for optimal glucose control. Discharged on Levemir 44 units with
Humalog 16 units at meal time + ISS.
[] Pravastatin 80mg was switched to atorvastatin 40mg for
high-intensity statin due to history of CAD s/p CABG
[] Fludrocortisone increased from 0.2mg daily to 0.2mg BID for
symptomatic orthostatic hypotension.
BRIEF SUMMARY
==============
___ y/o M with PMHx of CAD s/p CABG, DM II complicated by
gastroparesis, HTN, ESRD, s/p LRRT ___ who presented with
dyspnea and chest heaviness for several weeks, worse in past ___
days, and chronic nausea and abdominal pain. He had a stress
MIBI to further evaluate which was normal. Tacrolimus dose was
adjusted.
ACUTE ISSUES:
=============
#Dyspnea
#Chest pressure
#Fatigue
#CAD s/p 2v CABG ___
Concern for angina with history of CAD s/p CABG. EKG and
troponin negative. Recent admission noted to have elevated
methemoglobin level, dapsone stopped that admission. No signs of
significant volume overload. Cardiology was consulted and
recommended stress MIBI. This showed normal myocardial perfusion
and normal left ventricular cavity size and systolic function.
Per cardiology, low concern for ischemia contributing to chest
pressure. Continued home aspirin and metoprolol. Pravastatin
80mg was switched to atorvastatin 40mg for high-intensity
statin.
#Nausea
#Gastroparesis
#T2DM c/b neuropathy, nephropathy, gastroparesis
Hx gastroparesis due to poorly controlled T2DM. Continued home
metoclopramide. Insulin regimen was increased with addition of
mealtime insulin. Continued gabapentin for diabetic neuropathy.
#Hyponatremia (resolved)
In setting of ESRD s/p LRRT ___, though with stable renal
function per nephrology assessment. Likely due to elevated ADH
in setting of pain and nausea. Resolved prior to discharge.
#Orthostatic Hypotension
Per chart review, known orthostasis thought to be ___
dysautonomia from DM. Recent admission with symptomatic
orthostasis, transitioned from carvedilol to metoprolol and
started on fludricortisone 0.2 mg, increased from 0.2mg daily to
0.2mg BID this admission due to persistent orthostatic
hypotension with dizziness on standing.
CHRONIC ISSUES:
===============
# ESRD ___ type 2 DM s/p LRRT ___
# Immunosuppression
# chronic abdominal pain h/o wound dehiscence
S/p transplant for HLA identical brother on ___. Stable
renal function and transplant US this admission. Continued on
tacrolimus, dose adjusted based on level with goal ___.
Continued on azathioprine 150mg daily (previously unable to
tolerate mycophenolate due to diarrhea). Continued on
valganciclovir and atovaquone for prophyaxis.
# Depression
Continued on home Sertraline 100 mg PO daily.
# Anxiety
Continued on home LORazepam 0.5 mg PO QHS, increased to BID
while inpatient given significant anxiety regarding
hospitalization.
# GERD
Continued on home Ranitidine 150 mg PO BID.
# Vit D deficiency
Continued home Vitamin D ___ UNIT PO 1X/WEEK (WED)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
2. Aspirin 81 mg PO DAILY
3. AzaTHIOprine 150 mg PO DAILY
4. Docusate Sodium 100 mg PO BID:PRN Constipation - Second Line
5. Fludrocortisone Acetate 0.2 mg PO DAILY
6. Gabapentin 200 mg PO BID
7. LORazepam 0.5 mg PO QHS
8. Metoclopramide 5 mg PO TID W/MEALS
9. Metoprolol Succinate XL 25 mg PO BID
10. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain -
Moderate
11. Pravastatin 80 mg PO QPM
12. Ranitidine 150 mg PO BID
13. Senna 8.6 mg PO BID:PRN Constipation - First Line
14. Sertraline 100 mg PO DAILY
15. Tacrolimus 3 mg PO Q12H
16. ValACYclovir 500 mg PO BID
17. Vitamin D ___ UNIT PO 1X/WEEK (WE)
18. Atovaquone Suspension 1500 mg PO DAILY
19. Levemir 28 Units Breakfast
Discharge Medications:
1. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. Famotidine 20 mg PO Q12H
RX *famotidine 20 mg 1 tablet(s) by mouth twice a day Disp #*30
Tablet Refills:*0
3. Fludrocortisone Acetate 0.2 mg PO BID
4. Humalog 16 Units Breakfast
Humalog 16 Units Lunch
Humalog 16 Units Dinner
levemir 44 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
RX *insulin lispro [Humalog U-100 Insulin] 100 unit/mL AS DIR 16
units with meals + ISS correction Disp #*10 Cartridge Refills:*0
RX *lancets [Prodigy Lancets] 28 gauge Disp #*120 Each
Refills:*0
RX *insulin detemir U-100 [Levemir FlexTouch U-100 Insuln] 100
unit/mL (3 mL) AS DIR 44 Units before BKFT; Disp #*7 Syringe
Refills:*0
5. Tacrolimus 2 mg PO Q12H renal transplant
6. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
7. Aspirin 81 mg PO DAILY
8. Atovaquone Suspension 1500 mg PO DAILY
9. AzaTHIOprine 150 mg PO DAILY
10. Docusate Sodium 100 mg PO BID:PRN Constipation - Second
Line
11. Gabapentin 200 mg PO BID
RX *gabapentin 100 mg 200 mg by mouth twice a day Disp #*120
Capsule Refills:*0
12. LORazepam 0.5 mg PO QHS
RX *lorazepam [Ativan] 0.5 mg 1 tablet by mouth Before bed Disp
#*7 Tablet Refills:*0
13. Metoclopramide 5 mg PO TID W/MEALS
RX *metoclopramide HCl 5 mg 5 mg by mouth three times a day Disp
#*90 Tablet Refills:*0
14. Metoprolol Succinate XL 25 mg PO BID
15. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain -
Moderate
16. Senna 8.6 mg PO BID:PRN Constipation - First Line
17. Sertraline 100 mg PO DAILY
18. ValACYclovir 500 mg PO BID
19. Vitamin D ___ UNIT PO 1X/WEEK (WE)
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Dyspnea
T2DM
Gastroparesis
Secondary diagnosis:
CAD s/p CABG
ESRD s/p kidney transplant
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You were having chest heaviness and shortness of breath.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were seen by cardiology who felt your chest heaviness
could be related to your heart.
- You had a stress test which was normal. This is good news.
- Your blood sugar was elevated so we readjusted your insulin
regimen
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Please follow up with your primary care doctor in the next ___
weeks. Please also follow up with your cardiologist.
- Please continue to take all of your medications and follow-up
with your appointments as listed below.
- Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19584906-DS-21
| 19,584,906 | 23,763,587 |
DS
| 21 |
2182-09-30 00:00:00
|
2182-10-09 10:37:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Headache, SAH
Major Surgical or Invasive Procedure:
Diagnostic carotid/cerebral angiogram
History of Present Illness:
___ yr old female transfer from OSH with headache, imaging
positive for SAH and transferred for Neurosurgical evaluation.
Per the patient, patient states this past ___ she had onset
of headache ___ during a colonoscopy and the procedure was
aborted and transferred to local ED - per the patient CT Head
was
negative was treated with nausea medications and her headache
subsided within a few hours. This morning woke up with no issues
then at 1000 had similar symptoms, onset of headache following
with nausea and vomiting, presented to OSH and CT Head positive
as described above. Patient denies family history of aneurysms.
Denies weakness/numbness/tingling. Denies anticoagulation
medications. Patient on nicardipine gtt in the ED.
Past Medical History:
- ulerative colitis
- endometrosis
Social History:
___
Family History:
N/A
Physical Exam:
Exam on admission:
O: T: BP: 144 / 68 HR: 82 R 14 O2Sats 99% RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 2 brisk bilat EOMs intact
Neck: Supple.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: ___ objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to finger rub bilaterally.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger
Exam on discharge:
Neuro intact as above.
Pertinent Results:
CTA Head ___
1. No aneurysms. Patent circle of ___.
2. No evidence of dural venous sinus thrombosis.
3. Unchanged right frontal subarachnoid hemorrhage. No new
hemorrhages.
Diagnositic Angio ___
Unremarkable 3 vessel cerebral angiogram.
___ 05:30AM BLOOD WBC-5.8# RBC-4.64 Hgb-13.6 Hct-40.9
MCV-88 MCH-29.3 MCHC-33.3 RDW-12.7 RDWSD-41.0 Plt ___
___ 02:44PM BLOOD WBC-11.8* RBC-5.10 Hgb-15.1 Hct-45.2*
MCV-89 MCH-29.6 MCHC-33.4 RDW-12.5 RDWSD-40.3 Plt ___
___ 02:44PM BLOOD Neuts-85.8* Lymphs-7.9* Monos-5.3
Eos-0.3* Baso-0.3 Im ___ AbsNeut-10.13* AbsLymp-0.93*
AbsMono-0.63 AbsEos-0.03* AbsBaso-0.04
___ 02:44PM BLOOD ___ PTT-27.1 ___
___ 05:30AM BLOOD Glucose-89 UreaN-19 Creat-0.6 Na-138
K-3.8 Cl-103 HCO3-25 AnGap-14
___ 02:44PM BLOOD Glucose-112* UreaN-18 Creat-0.7 Na-141
K-3.8 Cl-104 HCO3-20* AnGap-21*
___ 05:30AM BLOOD Calcium-9.6 Phos-3.6 Mg-2.1
Brief Hospital Course:
On ___, the patient was transferred from OSh with findins of
frontal cortical SAH on CT after evaluation for headaches
without any history of trauma. The patients exam was stable and
CTA showed no obvious aneurysm. The patient was also evalutaed
by Neurology who diagnosed the patient with possible RCVS and
started her on Nimodipine.
On ___, the patient remained stable and continued to complain
of headaches. She underwent a diagnostic cerebral angiogram
which was normal.
On ___, the patients headaches were improving. She was changed
to Verapamil for ease of administration. Neurology recommends
staying until tomorrow and discharge home if headaches remain
improved.
Mrs. ___ was discharged home on ___. Her headaches were
better controlled on the current regimen as recommended by
Neurology. Per her discharge instructions, she will follow up
with Neurosurgery and Neurology.
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain/Fever
2. Acetaminophen-Caff-Butalbital ___ TAB PO Q8H:PRN headache
RX *butalbital-acetaminophen-caff 50 mg-325 mg-40 mg ___
tablet(s) by mouth every eight (8) hours Disp #*30 Tablet
Refills:*0
3. Calcium Carbonate 500 mg PO QID:PRN heartburn
4. Docusate Sodium 100 mg PO BID
5. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every eight (8) hours
Disp #*30 Tablet Refills:*0
6. Verapamil SR 240 mg PO Q24H
RX *verapamil 240 mg 1 capsule(s) by mouth once a day Disp #*30
Capsule Refills:*1
7. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron HCl 4 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*10 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Subarachnoid hemorrhage
Reversible Cerebrovascular Spasm
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
Do not partake in contact sports until follow-up with
your neurosurgeon.
Medications
You are being discharged on Fioricet which should be
utilized sparingly for headaches. If used too often, the
medication can cause or exacerbate headaches.
Do not exceed more than 4000mg of acetaminophen
(Tylenol) in one day. Each tablet of fioricet has 325mg of
acetaminophen in them.
Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
Headaches:
Headache is one of the most common symptom after a brain
bleed.
Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
Mild pain medications may be helpful with these headaches but
avoid taking pain medications on a daily basis unless prescribed
by your doctor.
There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs.
Followup Instructions:
___
|
19585137-DS-5
| 19,585,137 | 21,108,459 |
DS
| 5 |
2139-02-27 00:00:00
|
2139-02-27 14:52:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
left sided weakness, left visual changes
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Time/Date the patient was last known well: ___ at 22:00
Pre-stroke mRS ___ social history for description): 1
t-PA Administration
[] Yes - Time given:
[x] No - Reason t-PA was not administered: outside window at OSH
Endovascular intervention:
[]Yes - Time:
[x]No - Reason EVT was not performed: M2 occlusion on OSH
imaging, low NIHSS at time of transfer
___ Stroke Scale - Total [1]
1a. Level of Consciousness - 0
1b. LOC Questions - 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 - 1
6b. Motor leg, right - 0
7. Limb Ataxia - 0
8. Sensory - 0
9. Language - 0
10. Dysarthria - 0
11. Extinction and Neglect - 0
NIHSS was performed within 6 hours of patient presentation or
neurology consult at 13:02 on ___.
HPI:
Ms. ___ is a ___ left-handed woman with history
notable for hypertension and ___ transferred from ___ after presenting with left-sided weakness.
Ms. ___ reports initially noticing vision change yesterday
evening at around 22:00, finding that while looking at a face on
television, she was able to make out the face's right eye but
saw
"bright lights, like Christmas lights" along the left half of
the
figure's face. She closed each eye individually, noting normal
vision out of the left eye but the appearance of small "lights"
or "fires" out of the right eye. Her symptoms prompted her to
retire to bed, where she tried deep breathing to calm down, but
incidentally noticed a "sharp," pleuritic pain unlike her usual
reflux symptoms. She ultimately fell asleep, but on waking at
approximately 04:00, she noted that she was unable to move her
left arm to remove her blankets, and after attempting to rise to
use the restroom, found that she was similarly unable to move
her
legs. She used her right hand to activate EMS, and was taken to
the ___ for further evaluation.
Per ___ records, Ms. ___ underwent CT/CTA H&N that was
initially read as unrevealing, prompting MRI brain that
demonstrated multifocal diffusion restriction in the right MCA
territory; on review of the CTA, note was made of an M2 right
MCA
filling defect with distal opacification, prompting transfer to
___ for further evaluation.
On review of systems, aside from the above, Ms. ___ denies
recent headache, dizziness, speech disturbance, diplopia,
dysarthria, dysphagia, paresthesiae, bowel or bladder
incontinence, gait disturbance, fevers, chills, nausea,
vomiting,
cough, dyspnea, chest discomfort, abdominal pain, or changes in
bowel or bladder habits.
Past Medical History:
Hypertension
GERD
Social History:
___
Family History:
Negative for neurologic disorders.
Physical Exam:
PHYSICAL EXAMINATION
Vitals: T: 99.1 HR: 70 BP: 140/100 RR: 18 SpO2: 98% RA
General: NAD
___: NCAT, no oropharyngeal lesions, neck supple
___: warm, well-perfused
Pulmonary: no tachypnea or increased WOB
Abdomen: soft, NT, ND
Extremities: warm, no edema
Neurologic Examination:
- Mental status: Awake, alert, oriented x 3. Attentive, able to
name ___ backward without difficulty. Speech is fluent with
intact comprehension and naming. Mild lingual dysarthria due to
missing dentures. No apparent hemineglect. Able to follow both
midline and appendicular commands.
- Cranial Nerves: Subtle anisocoria (3 to 2 mm OD, 2 to 1 mm
OS).
VF full to number counting. EOMI, no nystagmus. V1-V3 without
deficits to light touch bilaterally. No facial movement
asymmetry. Hearing intact to conversation. Palate elevation
symmetric. Trapezius strength ___ bilaterally. Tongue midline.
- Motor: Mild pronation on left without drift. Fast finger taps
bilaterally.
[Delt][Bic][Tri][ECR][FEx][IP][Quad][Ham][TA]
L 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5
- Reflexes:
[Bic] [Tri] [___] [Quad] [Gastroc]
L 1+ 1+ 1+ 1+ 0
R 1+ 1+ 1+ 1+ 0
- Sensory: No deficits to light touch or pinprick bilaterally.
No extinction to DSS.
- Coordination: No dysmetria with FNF and HKS testing
bilaterally.
- Gait: Grossly unsteady with symptomatic orthostasis.
ON DISCHARGE:
==============
24 HR Data (last updated ___ @ 858)
Temp: 98.1 (Tm 99.1), BP: 139/71 (115-139/65-77), HR: 51
(51-62),
RR: 20 (___), O2 sat: 95% (94-95), O2 delivery: RA
General: NAD, awake and lying in bed, daughter at bedside
___: NCAT, no oropharyngeal lesions
___: warm, well-perfused
Pulmonary: no tachypnea or increased WOB
Abdomen: soft, NT, ND
Extremities: warm, no edema
Psych: reports good mood, no thoughts of hurting self or others
Neurologic Examination:
- Mental status: Awake, alert, oriented x 3. Hypophonic
- Cranial Nerves: Subtle anisocoria (3 to 2 mm OD, 2 to 1 mm
OS).
EOMI, no gaze preference, no nystagmus. Visual fields appear
full. V1-V2 without deficits to light touch bilaterally, V3 on
left with decreased
sensation to touch. L facial droop, slow to
activate with smile. L eyelid weak closing. Hearing intact to
conversation. Palate elevation symmetric. Trapezius strength ___
Left side, ___ right side. Tongue midline.
- SensoriMotor:
LUE plegic, no sensation to noxious.
RUE ___
LLE plegic, triple flexion to noxious
RLE ___, sensation to light pinch intact.
- Left to extensor, right toe flexor
- Coordination: FNF on right intact
- Gait: deferred
Pertinent Results:
___ 06:45AM BLOOD WBC-7.7 RBC-4.04 Hgb-12.0 Hct-37.1
MCV-92 MCH-29.7 MCHC-32.3 RDW-11.8 RDWSD-39.2 Plt ___
___ 06:45AM BLOOD ___ PTT-26.2 ___
___ 06:45AM BLOOD Glucose-116* UreaN-18 Creat-0.7 Na-142
K-4.3 Cl-104 HCO3-28 AnGap-10
___ 10:30PM BLOOD CK-MB-2 cTropnT-<0.01
___ 06:45AM BLOOD Phos-3.6 Mg-2.4
___ 07:25AM BLOOD %HbA1c-5.9 eAG-123
___ 07:25AM BLOOD Triglyc-181* HDL-28* CHOL/HD-5.4
LDLcalc-86
___ 07:25AM BLOOD TSH-1.2
___ 01:02PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
IMAGING:
========
TTE: The visually estimated left ventricular ejection fraction
is
>=55%. IMPRESSION: Mild symmetric left ventricular hypertrophy
with normal cavity size and regional/global biventricular
systolic function. Mildly dilated thoracic aorta with mild
functional aortic regurgitation. No 2D echocardiographic
evidence for endocarditis. If clinically suggested, the
absence of a discrete vegetation on echocardiography does not
exclude the diagnosis of endocarditis.
___ CTH:
Large right frontal lobe hematoma is unchanged in size currently
measuring 5.4 x 3.2 cm, previously 5.1 x 3.0 cm (02:24). This
is associated with mild to moderate surrounding edema and
effacement of adjacent sulci, which appears slightly worsened.
There may be slight increase in shift of midline structures now
measuring up to 5 mm (02:19), previously 3-4 mm.
There continues to be layering hemorrhagic blood products in the
right lateral ventricle (02:19), occipital horn of the right
lateral ventricle, and cavum vergae. No evidence of
ventriculomegaly. The basilar cisterns remain patent.
There is no evidence of fracture. The visualized portion of the
paranasal
sinuses, mastoid air cells, and middle ear cavities are clear.
The visualized portion of the orbits are unremarkable.
IMPRESSION:
1. Unchanged size of a right large right frontal lobe hematoma
with
intraventricular extension, similar to prior exam. The degree
of surrounding edema pattern has slightly increased as well as
local sulcal effacement.
2. Slight interval increase in midline shift, now measuring 5
mm. Basilar
cisterns remain patent.
Brief Hospital Course:
Ms. ___ is a ___ left-handed woman with history of
hypertension and ___ transferred from ___
after presenting with left vision changes and left-sided
weakness and imaging demonstrating a right MCA ischemic infarct.
Patient was not a thrombectomy candidate due to M2 occlusion and
low NIHSS and was out of the tPA window. In the evening the day
of admission she had a bowel movement with subsequent left
hemiplegia and left facial droop. Repeat imaging showed right
MCA territory hemorrhagic conversion. She was transferred to the
neuroICU for frequent neuro
checks but able to transfer to floor after stable exams.
Etiology of initial infarct concerning for embolic phenomenon.
Since admission, EKG reviewed by ourselves and cardiology
concerning for atrial flutter. She will need long term
anticoagulation but this will be held currently due to ___.
Possible choices for novel anti-coagulant include Pradaxa and
Eliquis. TTE without cardioembolic source of stroke. A1c of 5.9
and LDL of 86. Statin therapy not yet started due to hemorrhagic
conversion. Further workup did not reveal additional
toxic/metabolic sources of symptoms. Hospital course complicated
by urinary tract infection for which she received a full course
of antibiotics. Also with adjustment disorder with active
suicidal ideation for which psychiatry was involved in her care.
She was started on fluoxetine for motor recovery and mood, and
has reported stable mood and denies SI/HI for the past week.
Neurologic:
1) Right MCA M2 occlusion, Right MCA stroke with hemorrhagic
conversion measuring 53 x 34 mm.
- Continue fluoxetine 20 daily for motor recovery optimization,
concomitant depression
- Will need CTH on ___ appointment scheduled as above
- Long term will need anticoagulation for newly diagnosed atrial
flutter
- Will need to be started on atorvastatin when appropriate
2) Right occipital headache/neck pain, improved
- Continue gabapentin 200 mg PO TID
- Continue tylenol ___ mg PO q6h PRN
- Continue Lidocaine patch to neck
3) Sleep
- Continue trazodone 50 mg QHS
Cardiovascular:
1)Essential (primary) hypertension
- Keep SBP < 150
- Decreased metoprolol tartrate to 12.5 5 BID (home dose
succinate 50 daily) due to heart rate in ___
- amlodipine 5 mg daily
2)Intermittent atrial flutter
- Metoprolol Tartrate 12.5 mg PO/NG BID
- Will need long term anticoagulation, currently not started in
setting of hemorrhagic conversion
Infectious Disease:
1) Proteus Mirabilis UTI
- Ceftriaxone ___
2) fluconazole PO x1 for vaginal yeast infection
Psych:
1) Adjustment Disorder with intermittent SI, resolved
- fluoxetine 20 daily as above
TRANSITIONAL ISSUES:
============================
[] Follow up with Dr. ___ Neurology, on ___ week CT scan for stability of bleed (scheduled for ___
- Atrial flutter new diagnosis during hospitalization. Will need
anticoagulation started if 2 week scan stable
- Continue fluoxetine for motor recovery
- Start statin when appropriate
[] Follow up with PCP for management of blood pressure and
monitoring of mood
[] Follow up with already established cardiologist
============================
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?
() Yes - (x) No. If not, why not? (hemorrhagic transformation)
4. LDL documented? (x) Yes (LDL = 86) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 70) () Yes - (x) No [if LDL
>70, reason not given: hemorrhagic transformation
[ ] Statin medication allergy
[ x] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharm___
[ ] LDL-c less than 70 mg/dL
6. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No. If no, why not? (I.e. patient at baseline
functional status)
9. Discharged on statin therapy? () Yes - (x) No [if LDL >70,
reason not given:
[ ] Statin medication allergy
[ x] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist;
hemorrhagic transformation
[ ] LDL-c less than 70 mg/dL
10. Discharged on antithrombotic therapy? () Yes [Type: ()
Antiplatelet - () Anticoagulation] - (x) No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - (x) No - If no, why not (bleeding
risk) () N/A
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 40 mg PO DAILY
2. Vitamin D 1000 UNIT PO DAILY
3. Metoprolol Tartrate Dose is Unknown PO BID
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. amLODIPine 5 mg PO DAILY
3. FLUoxetine 20 mg PO DAILY
4. Gabapentin 200 mg PO Q8H
5. Lidocaine 5% Patch 2 PTCH TD QAM
6. TraZODone 50 mg PO QHS insomnia
7. Metoprolol Tartrate 25 mg PO BID
8. Omeprazole 40 mg PO DAILY
9. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Acute infarct with hemorrhagic transformation
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 hospitalized due to symptoms of left sided weakness
resulting from an ACUTE ISCHEMIC STROKE, a condition where a
blood vessel providing oxygen and nutrients to the brain is
blocked by a clot. The brain is the part of your body that
controls and directs all the other parts of your body, so damage
to the brain from being deprived of its blood supply can result
in a variety of symptoms. Additionally, the area around the
stroke bled causing further swelling of the brain.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
- Atrial flutter, new diagnosis
- High blood pressure
We are changing your medications as follows:
- Lowered metoprolol tartrate 25 mg daily due to low heart rate
- Continue amlodipine 5 mg PO daily for blood pressure
- Continue fluoxetine 20 mg daily for motor recovery
- Continue gabapentin 200 mg PO TID for headache
- Continue tylenol ___ mg PO q6h as needed for headache
- Continue Lidocaine patch to neck as needed to pain
- Continue trazodone 50 mg QHS as needed for sleep
Please take your other medications as prescribed.
Please follow up with Neurology, Cardiology, and your primary
care physician as listed below. You will also need a repeat CT
scan of your head ___ to assess if your bleed is
stable.
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:
___
|
19585869-DS-23
| 19,585,869 | 27,899,272 |
DS
| 23 |
2151-04-13 00:00:00
|
2151-04-13 21:29:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Ampicillin / Benadryl / Codeine / Bactrim / Zantac
Attending: ___
Chief Complaint:
Urinary retention
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mrs. ___ is a ___ yo F with history of CAD, ESRD s/p
transplant x2 not on HD, HTN, constipation, and osteoarthritis,
who presented with urinary retention and constipation.
She reported 1 day of urinary retention and constipation. Prior
to arrival at the ___ ED ___, 20:00), her last urination was
12 noon ___ however patient states now able to go and has
urinated ___ times since arrival to ED.
She noted that her urination has slowed down from how used to
go. No itching/burning with urination, no dysuria, no hematuria,
no vaginal discharge. She denied back/abdominal pain,
nausea/vomiting.
She was recently hospitalized ___ for dyspnea, found to
have symptomatic bradycardia & 2nd degree AV block (Mobitz I).
She notes that she hasn't had much of appetite since being
discharged from the hospital (per daughter, all she has had is
soup).
She also complained of alternating constipation & diarrhea for a
few years, for which she has taken multiple medications. Her
last BM was the day prior to admission.
In the ED initial vitals: pain ___, T 97.4 HR 96 BP 113/84 R 18
SpO2 99%/RA
- Exam notable for: dry membranes, L pupil large & distorted
with inappropriate pupillary response to light, mild L ptosis
(baseline, after cataract surgery), irregular HR
- Renal ultrasound was notable for: [1.] Persistent elevation
of the resistive indices, now measuring 0.55-0.79 (previously
0.83 -0.87) with new parvus tardus waveforms within the
interlobar arteries worris
Past Medical History:
- ESRD secondary to HTN, s/p DDRT x2, most recent ___
- CAD
- Thrombocytopenia
- Second-degree AV block, type I - Wenckebach
- Depression
- Esophageal dysmotility
- GERD
- Osteoarthritis
- Constipation
- Osteopenia
- Vitamin D deficiency
- History of C. difficile colitis, ___
Social History:
___
Family History:
Multiple family members with DM2, Mom with HTN
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VITAL SIGNS - 70.6 kg | 97.9 | 134/70 | 81 | 18 | 96%/RA
GENERAL - chronically ill appearing elderly woman, curled up at
side of bed though generally able to be engaged
HEENT - sclerae anicteric, R pupil normal, pupil large &
distorted with inappropriate pupillary response to light, mild L
ptosis (baseline, after cataract surgery), mucous membranes dry
NECK - supple
CARDIAC - irregular, normal S1/S2, faint murmur without
radiation to carotids
PULMONARY - clear to auscultation bilaterally, though soft
breath sounds, no adventitial sounds
ABDOMEN - soft, non-tender, non-distended, normal bowel sounds,
no organomegaly, transplant kidney non-tender
EXTREMITIES - warm, no edema, no clubbing
SKIN - warm, dry
NEUROLOGIC - face symmetric apart from mild left eye ptosis,
tongue midline, oriented x3, able to sit in bed unassisted, gait
not assessed
PSYCHIATRIC - pleasant, though flat affect
DISCHARGE PHYSICAL EXAMINATION:
VITAL SIGNS - 97.9 | 144/78 | 88 | 18 | 99%RA
GENERAL - elderly, chronically ill appearing woman, asleep in
bed, rouses easily to voice
HEENT - sclerae anicteric, R pupil reactive to light, L pupil
large & distorted with inappropriate pupillary response to
light, mild L ptosis (baseline, after cataract surgery), mucous
membranes moist
CARDIAC - irregular, normal S1/S2, faint murmur without
radiation to carotids
PULMONARY - soft breath sounds, clear to auscultation though
with faint expiratory wheeze intermittently/scattered, no
adventitial sounds
ABDOMEN - soft, non-tender, non-distended, normal-to-hypoactive
bowel sounds, no hepatomegaly aprpeciated, transplant kidney
non-tender
EXTREMITIES - warm, no edema, no clubbing
SKIN - warm, dry
NEUROLOGIC - face symmetric apart from mild left eye ptosis,
tongue midline, oriented x3. Visual fields grossly normal to
confrontation.
PSYCHIATRIC - pleasant, though flat affect
Pertinent Results:
ADMISSION LABS:
===============
___ 04:20AM BLOOD WBC-6.7 RBC-4.48 Hgb-12.5 Hct-37.9 MCV-85
MCH-27.9 MCHC-33.0 RDW-14.1 RDWSD-43.2 Plt ___
___ 04:20AM BLOOD Glucose-120* UreaN-4* Creat-0.9 Na-122*
K-3.0* Cl-77* HCO3-24 AnGap-24*
___ 04:20AM BLOOD Calcium-9.6 Phos-1.8* Mg-1.3*
___ 04:20AM BLOOD Osmolal-252*
IMAGING:
========
___ RENAL ULTRASOUND
1. Persistent elevation of the resistive indices, now measuring
0.55-0.79 (previously 0.83 -0.87) with new parvus tardus
waveforms within the interlobar arteries worrisome for renal
parenchymal process.
2. Large postvoid residual of 195 cc.
___ AXR
Minimal fecal loading.
___ CXR
Mild pulmonary edema.
___ AXR
Minimal stool right colon
STUDIES:
========
Discharge post void residual (___) - ___
DISCHARGE LABS
==============
___ 05:04AM BLOOD WBC-5.2 RBC-3.72* Hgb-10.9* Hct-34.8
MCV-94 MCH-29.3 MCHC-31.3* RDW-16.1* RDWSD-54.8* Plt Ct-83*
___ 05:04AM BLOOD Glucose-110* UreaN-5* Creat-0.8 Na-134
K-3.4 Cl-98 HCO3-24 AnGap-15
___ 05:04AM BLOOD Calcium-9.2 Phos-2.4* Mg-1.8
Brief Hospital Course:
Outpatient ___ is a ___ yo F with history of
CAD, ESRD s/p transplant x2 not on HD, HTN, constipation, and
osteoarthritis, who presented with urinary retention secondary
to constipation, found to be hyponatremic.
ACTIVE ISSUES
# URINARY RETENTION, evolving to URINARY FREQEUNCY: Patient
presented without urination x >12 hours, however resolved
shortly after presentation in ED. Suspect related to
constipation. UA indicative of possible bacteriuria. Renal
ultrasound normal. Discharge bladder scan with post-void
residual of 68cc. No obvious inciting factor for retention.
Other possible diagnosis includes low urine output, interpreted
as retention by patient, in setting of poor PO intake.
Nursing noted increased urinary frequency on ___, but repeat UA
with only 1 WBC and few bacteria. Bladder scan (above) ruled out
overflow incontinence. Likely overactive bladder. She may
benefit from oxybutynin or in the outpatient setting. This was
not started due to potential side effects and due to patient's
preference to be discharged.
# CONSTIPATION: Endorsed as a problem during most recent
hospitalization. Reports BM every ___ days, though soft (denies
pellet-like stools). KUB without significant fecal loading,
though patient endorsed bloating sensation throughout
hospitalization. Differential also includes obstruction, ileus,
volvulus, malignancy, though abdominal exam benign. Most recent
cross-sectional imaging in ___ without concerning findings.
Further review of records and discussion with patient indicates
alternating diarrhea with constipation. Her senna was increased
to 17.2 BID and her home bowel regimen including lubiprostone
were continued. She would benefit from an outpatient colonoscopy
to rule out underlying process.
# MILD MALNUTRITION, leading to
# HYPONATREMIA,
# HYPOPHOSPHATEMIA, and
# HYPOMAGNESEMIA: Admitted with low serum Osm and dry on exam.
Most consistent with hypovolemic hyponatremia secondary to
decreased PO intake. Suspected secondary to depression. Low
urinary Na further supports this (though low urinary Osm is
curious and would raise consideration for psychogenic
polydipsia, however patient clearly dry on exam). No significant
neurologic findings on examination. She was given IV fluids and
had regular chemistry checks. Her labs normalized with fluids
and with repletion of phosphate and magnesium. She also had a
nutrition consult, which recommended supplemental nutrition
three times per day (ensure) and a daily multivitamin.
# DEPRESSED MOOD: patient with depression, likely exacerbated by
recent loss of family members. On sertraline 25 mg daily at
home, which was increased to 50 mg in house.
CHRONIC ISSUES
# THROMBOCYTOPENIA: noted to be chronic issue. During most
recent hospitalization, evaluated for liver disease (normal). On
___, evaluated by Hematology, thought to be related to
medications vs. indolent marrow process (such as MDS) vs. ITP.
Recommended to continue monitoring.
# END-STAGE RENAL DISEASE S/P DDRT TRANSPLANT, x2: baseline Cr
0.9-1.2. Adequate UOP, though did have initial retention.
Previous immunosuppression regimen with tacrolimus, prednisone
and azathioprine, though azathioprine was stopped in the setting
of leukopenia and thrombocytopenia in ___ (leukopenia has
improved, but she remains stably thrombocytopenic). She was
continued on home tacrolimus and prednisone.
# HYPERTENSION: continued on amlodipine 5 mg daily
# 2ND DEGREE AV BLOCK, TYPE I (___): metoprolol stopped
during previous hospitalization for AV block, as well as
symptomatic bradycardia. Metoprolol was held and she was kept on
telemetry for much of her hospitalization. She will follow up
with Dr. ___ in clinic to review ___ of Hearts monitoring
TRANSITIONAL ISSUES
===================
MEDICATION CHANGES
- Senna - increased to 17.2mg BID
- Sertraline - increased to 50mg due to concern for low mood
- Supplements - patient should continue to take Ensure Enlive or
other nutritional supplement to boost her calorie intake
OUTPATIENT CARE
- Patient would benefit from screening colonoscopy in outpatient
setting due to symptoms of intermittent constipation/diarrhea
without clear underlying cause
- Consider oxybutynin for possible overactive bladder if patient
continues to have frequency
- She should have labs checked at her outpatient visit,
including a Chem-10.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 10 mg PO QPM
2. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
3. Lubiprostone 24 mcg PO BID with meals
4. Mirtazapine 15 mg PO HS
5. PredniSONE 5 mg PO DAILY
6. Prograf (tacrolimus) 2.5 mg ORAL BID Brand name medically
___
7. ___ 25 mg PO DAILY
8. Sucralfate 1 gm PO DAILY:PRN heartburn,upset stomach
9. Potassium Chloride 20 mEq PO BID
10. Dorzolamide 2% Ophth. Soln. 1 DROP RIGHT EYE TID
11. Pilocarpine 4% 1 DROP RIGHT EYE Q8H
12. amLODIPine 5 mg PO DAILY
13. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
14. Docusate Sodium 100 mg PO BID
15. Senna 8.6 mg PO BID:PRN constipation
16. Psyllium Wafer 1 WAF PO BID constipation
17. Sodium Bicarbonate 1300 mg PO TID
18. Vitamin D 3000 UNIT PO DAILY
Discharge Medications:
1. Multivitamins 1 TAB PO DAILY
2. Polyethylene Glycol 17 g PO DAILY
3. Senna 17.2 mg PO BID
4. Sertraline 50 mg PO DAILY
RX *sertraline 50 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
5. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
6. amLODIPine 5 mg PO DAILY
7. Atorvastatin 10 mg PO QPM
8. Docusate Sodium 100 mg PO BID
9. Dorzolamide 2% Ophth. Soln. 1 DROP RIGHT EYE TID
10. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
11. Lubiprostone 24 mcg PO BID with meals
12. Mirtazapine 15 mg PO HS
13. Pilocarpine 4% 1 DROP RIGHT EYE Q8H
14. Potassium Chloride 20 mEq PO BID
15. PredniSONE 5 mg PO DAILY
16. Prograf (tacrolimus) 2.5 mg ORAL BID Brand name medically
___
17. ___ Wafer 1 WAF PO BID constipation
18. Sodium Bicarbonate 1300 mg PO TID
19. Sucralfate 1 gm PO DAILY:PRN heartburn,upset stomach
20. Vitamin D 3000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES
=================
# CONSTIPATION, causing
# URINARY RETENTION
# MILD MALNUTRITION, leading to
# HYPONATREMIA
# HYPOPHOSPHATEMIA
# HYPOMAGNESEMIA
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 ___,
WHY WERE YOU ADMITTED TO THE HOSPITAL?
*You came to the ___ because of constipation and trouble
peeing
*We found that the special salt levels in your blood were low
WHAT DID WE DO FOR YOU HERE?
*We gave you medicine to help you go to the bathroom
*We gave you fluids through an IV to help your salts
*We did a test to make sure you did not have an infection in
your bladder
WHAT SHOULD YOU DO WHEN YOU GO HOME?
*Continue to take your medicine
*Continue to eat and drink normally, make sure to eat full meals
*Take Ensure Enlive, Carnation Instant Breakfast, or another
supplement 3 times per day to make sure you get enough calories
*Follow up with your doctors
___ yourself ___ morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
19585869-DS-25
| 19,585,869 | 22,816,145 |
DS
| 25 |
2151-05-04 00:00:00
|
2151-05-04 12:29:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
Penicillins / Ampicillin / Benadryl / Codeine / Bactrim / Zantac
Attending: ___
Chief Complaint:
Mrs. ___ is a ___ year old female on Coumadin for Afib S/P
left kidney transplant on ___ who is currently at ___ for
fluid overload, SOB and AFIB. The patient was transferred to
___ from ___ after she had an unwitnessed
fall while at rehab when reaching for her walker. She patient
denies any syncope, or lightheadedness prior to her fall. A
NCHCT
was performed at the OSH and demonstrated a right SDH. She was
given Keppra, K-centra and Vitamin K prior to transfer to ___.
Her INR upon arrival to ___ was 1.6. Neurosurgery was
consulted
for further evaluation and recommendations. On exam the patient
denied chest pain, SOB, fevers, chills, dizziness or vision
changes.
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mrs. ___ is a ___ year old female on Coumadin for Afib S/P
left kidney transplant on ___ who is currently at ___ for
fluid overload, SOB and AFIB. The patient was transferred to
___ from ___ after she had an unwitnessed
fall while at rehab when reaching for her walker. She patient
denies any syncope, or lightheadedness prior to her fall. A
NCHCT
was performed at the OSH and demonstrated a right SDH. She was
given Keppra, K-centra and Vitamin K prior to transfer to ___.
Her INR upon arrival to ___ was 1.6. Neurosurgery was
consulted
for further evaluation and recommendations. On exam the patient
denied chest pain, SOB, fevers, chills, dizziness or vision
changes.
Past Medical History:
- ESRD secondary to HTN, s/p DDRT x2, most recent ___
- CAD
- Thrombocytopenia
- Second-degree AV block, type I - Wenckebach
- Depression
- Esophageal dysmotility
- GERD
- Osteoarthritis
- Constipation
- Osteopenia
- Vitamin D deficiency
- History of C. difficile colitis, ___
Social History:
___
Family History:
Multiple family members with DM2, Mom with HTN
Physical Exam:
ON ADMISSION:
O: T: 98.5 BP: 131/76 HR: 60 R:18 O2Sats: 97% RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: Right pupil 1MM- Surgical NR, Left pupil
Irregular shape, NR. EOMs intact. Subgaleal swelling to right
eyebrow, Laceration repaired at ___ 4 sutures in place.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils -Right pupil 1MM- Surgical, Left pupil Irregular
shape, NR.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Left NL flatteing, tongue midline
VIII: Hearing intact to voice.
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 except left IP ___.
No pronator drift
Sensation: Intact to light touch.
ON DISCHARGE:
patient is awake, oriented x3. right pupil 1mm NR, left pupil
4-5mm NR irregular shape. Speech is clear and appropriate.
Follows commands, grossly ___ strengths with slight weakness in
bilateral IP. face symmetric, tongue midline, no pronator drift.
right face: + swelling/bruising, laceration repaired with
sutures.
Pertinent Results:
___ CT HEAD W/O CONTRAST
1. Minimal increase in the thickness of the evolving right
subdural hematoma, now measuring up to 10 mm compared with 9 mm
previously. Minimal 1 mm, if any, leftward shift of normally
midline structures. Basal cisterns remain patent.
2. 2.2 cm subgaleal hematoma in the right frontal region.
3. Re demonstration of sclerotic, thickened calvarium, as can
be seen in
renal osteodystrophy or Paget's disease.
___ CT HEAD W/O CONTRAST
1. No significant change since ___. Minimal
midline shift if
any. Stable appearance of the right cerebral convexity subdural
hematoma.
Brief Hospital Course:
Mrs. ___ is a ___ year old female on Coumadin for Afib S/P
left kidney transplant on ___ who is currently at ___ for
fluid overload, SOB and AFIB. The patient was transferred to
___ from ___ after she had an unwitnessed
fall while at rehab when reaching for her walker. A NCHCT was
performed at the OSH and demonstrated a right SDH. She was given
Keppra, K-centra and Vitamin K prior to transfer to ___.
Patient was admitted to the Neuro Step Down Unit for continued
care and observation.
On ___, patient remains neurologically stable. A 24hr CT Head
was completed to evaluate for interval change and right SDH is
stable.
On ___, patient remains neurologically stable. Physical therapy
consulted on patient for disposition planning.
On ___, patient remains neurologically stable. Patient
discharged to skilled nursing facility. Patient is in agreement
with this plan and acknowledges follow up plan.
Medications on Admission:
Amitiza, dorzolamide, Metamucil,
ventolin HA, Acetaminophen, amlodipine, atorvastatin,
cholecalciferol, Colace, latanoprost, metformin, metoprolol,
mirtazapine, MVI, pilocarpine, miralax, potassium Chloride,
Prednisone, Senna, Sertraline, sodium bicarbonate, sucralfate,
tacrolimus, warfarin
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Moderate
2. Docusate Sodium 100 mg PO BID
3. LevETIRAcetam 500 mg PO BID
4. Polyethylene Glycol 17 g PO DAILY
5. amLODIPine 5 mg PO DAILY
6. Atorvastatin 10 mg PO QPM
7. Dorzolamide 2% Ophth. Soln. 1 DROP RIGHT EYE TID
8. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
9. Lubiprostone 24 mcg PO BID
10. MetFORMIN (Glucophage) 1000 mg PO BID
11. Metoprolol Succinate XL 25 mg PO DAILY
12. Mirtazapine 15 mg PO QHS
13. Multivitamins 1 TAB PO DAILY
14. Pilocarpine 4% 1 DROP RIGHT EYE Q8H
15. Potassium Chloride 20 mEq PO BID
16. PredniSONE 5 mg PO DAILY
17. Psyllium Powder 1 PKT PO DAILY:PRN constipation
18. Senna 17.2 mg PO BID
19. Sertraline 50 mg PO DAILY
20. Sodium Bicarbonate 1300 mg PO TID
21. Sucralfate 1 gm PO DAILY:PRN heartburn
22. Tacrolimus 2.5 mg PO Q12H
23. Vitamin D 3000 UNIT PO DAILY
24. ___ MD to order daily dose PO DAILY16
TO BE RESTARTED ON ___
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Right Subdural Hematoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid
Discharge Instructions:
Activity
· We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
· You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
· No driving while taking any narcotic or sedating medication.
· If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
· No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
· Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
Coumadin can be restarted on ___.
· You have been discharged on Keppra (Levetiracetam). This
medication helps to prevent seizures. Please continue this
medication as indicated on your discharge instruction. It is
important that you take this medication consistently and on
time. TO BE STOPPED ON ___.
·You may use Acetaminophen (Tylenol) for minor discomfort if you
are not otherwise restricted from taking this medication.
What You ___ Experience:
· You may have difficulty paying attention, concentrating, and
remembering new information.
· Emotional and/or behavioral difficulties are common.
· Feeling more tired, restlessness, irritability, and mood
swings are also common.
· Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
Headaches:
· Headache is one of the most common symptom after a brain
bleed.
· Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
· Mild pain medications may be helpful with these headaches but
avoid taking pain medications on a daily basis unless prescribed
by your doctor.
· There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs.
When to Call Your Doctor at ___ for:
· Severe pain, swelling, redness or drainage from the incision
site.
· Fever greater than 101.5 degrees Fahrenheit
· Nausea and/or vomiting
· Extreme sleepiness and not being able to stay awake
· Severe headaches not relieved by pain relievers
· Seizures
· Any new problems with your vision or ability to speak
· Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
· Sudden numbness or weakness in the face, arm, or leg
· Sudden confusion or trouble speaking or understanding
· Sudden trouble walking, dizziness, or loss of balance or
coordination
· Sudden severe headaches with no known reason
Followup Instructions:
___
|
19585869-DS-26
| 19,585,869 | 23,463,508 |
DS
| 26 |
2151-06-08 00:00:00
|
2151-06-08 15:32:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
Penicillins / Ampicillin / Benadryl / Codeine / Bactrim / Zantac
Attending: ___
Chief Complaint:
subdural hematoma
Major Surgical or Invasive Procedure:
___ right craniotomy for subdural evacuation
History of Present Illness:
Ms. ___ is a ___ year old female with history of afib on
Coumadin who was recently admitted to the neurosurgery service
with R SDH on ___. Her Coumadin was held and she did not
require
neurosurgical intervention. She was discharged to rehab on ___
after stable serial head CTs and restarted her Coumadin on ___.
While at rehab she was found to be increasingly confused over
the
last ___ days, having possible visual hallucinations, and had an
episode of bowel incontinence when she is normally continent of
both bowel and bladder. She was transferred to ___ for
evaluation and a CT head was concerning for interval increase of
the SDH with mixed density components causing mass effect and
compressing the right lateral ventricle causing 13mm of left
midline shift. On exam she was alert and confused. Moving all
extremities. She denies recent trauma, headaches, falls,
seizures.
Past Medical History:
- ESRD secondary to HTN, s/p DDRT x2, most recent ___
- CAD
- Thrombocytopenia
- Second-degree AV block, type I - Wenckebach
- Depression
- Esophageal dysmotility
- GERD
- Osteoarthritis
- Constipation
- Osteopenia
- Vitamin D deficiency
- History of C. difficile colitis, ___
Social History:
___
Family History:
Multiple family members with DM2, Mom with HTN
Physical Exam:
ON ADMISSION:
O: Mild restlessness. Cooperative with exam.
T: 98.3 BP: 119/70 HR: 73 R: 18 O2Sats: 100%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: L irregular, NR. Right 2mm sluggish. EOMs:
intact without nystagmus
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, mild
restlessness, normal affect.
Orientation: Oriented to person, ___, ___. Confused during conversation regarding reason for
hospitalization and history.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: L pupil irregular, NR. R pupil 2mm sluggish. Visual fields
are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Mild L facial. Corrects with activation.
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. R tricep ___. L quad and L gastroc ___. StrengthGen:
WD/WN, comfortable, NAD.
HEENT: Pupils: L irregular, NR. Right 2mm sluggish. EOMs:
intact without nystagmus
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, mild
restlessness, normal affect.
Orientation: Oriented to person, ___, ___. Confused during conversation regarding reason for
hospitalization and history.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
On DISCHARGE:
110/57 HR 80 and regular, 97.8, RR 22, 100% trach collar
General: trach in place, EO spont
HEENT: Sclera white, crani incision intact
Neck: supple, trachea midline, trach in place
CV: RRR, S1>S2
Lungs: CTAB
Abdomen: Soft, NT/ND, no drainage from PEG site. flexiseal
GU: deferred, foley
Neuro:
-MS: EO to spont, no commands(at times follows on right, but
rare), does not regard examiner or track examiner
-Cranial Nerves: L pupil surgical, 4, irregular and
nonreactive; R pupil pinpoint and NR. Left facial droop, not
cooperating w/ EOM,
-Motor: moves RUE/RLE spontaneously in plane of bed after
noxious. LUE extensor postures to noxious. LLE slight purposeful
movement in plane of bed, at times requires noxious for
purposeful movement. spastic BLE
-Coordination, Gait: unable to assess
Skin: warm/dry, old rectal ulcer on lateral aspect of anus,
increased skin turgor
Pertinent Results:
___ CT HEAD W/O CONRTAST 1100
Interval significant increase in size of a 1.8 cm mixed density
right subdural collection, with new significant mass effect
causing effacement of the right lateral ventricle, 13 mm of
leftward midline shift, and subfalcine herniation. Basal
cisterns are patent.
___ CT HEAD W/O CONTRAST ___
Interval right frontal craniotomy with evacuation of the large
right subdural hematoma with postoperative changes as described
above. Interval decrease in the extent of the leftward midline
shift.
___ MRI BRAIN W/O CONTRAST
1. No evidence of infarction.
2. No significant interval change in 10 mm right hemispheric
subdural
hematoma, with 6-7 mm leftward shift of midline structures.
3. Numerous scattered areas of intraparenchymal hemorrhage,
which may reflect diffuse axonal injury in the setting of
trauma, or amyloid angiopathy.
___ CT CHEST
1. Small bilateral pleural effusions with overlying atelectasis.
Evaluation
for superimposed infection is limited given the lack of
intravenous contrast.
2. Vascular calcification.
3. Anemia
4. Anasarca
___ CT HEAD W/O CONTRAST 2300
Mild interval increase in size of the right extra-axial fluid
collection with increasing hyperdense material within it,
consistent with acute/ongoing hemorrhage. The degree of 6 mm
leftward midline shift is unchanged.
Unchanged subdural hemorrhage along the falx and tentorial
leaflets.
HEAD CT: ___
IMPRESSION:
1. Right frontal subdural hematoma measuring 1.1 cm is increased
in size from
head CT ___.
2. 10 mm of leftward midline shift with almost complete
effacement of the
right lateral ventricle is new and concerning for subfalcine
herniation.
3. Right uncal herniation.
Left Upper ext venous US: ___
IMPRESSION:
No evidence of deep vein thrombosis in the right upper extremity
HEAD CT: ___
IMPRESSION:
1. Status post right craniotomy with persistent but interval
decrease in size of a now 8-mm right subdural hemorrhage with
persistent but interval decrease in associated partial
effacement of the right lateral ventricle and 8-mm left shift of
normally midline structures.
2. Interval decrease in bilateral hyperdense material layering
along the
tentorium and falx.
3. No new hemorrhage.
4. Bony changes of secondary hyperparathyroidism, likely
related to history of renal insufficiency.
CT NECK: ___
IMPRESSION:
1. Moderate hematoma overlying the trachea in the region of
tracheostomy tube.
2. Airspace opacities in bilateral upper lobes concerning for
multifocal
pneumonia or aspiration.
3. Findings concerning for anemia as described.
4. Bilateral temporomandibular joint degenerative changes.
CT ABD/PELVIS: ___
IMPRESSION:
1. A PEG tube appears appropriately positioned in the stomach,
with trace
expected pneumoperitoneum. No evidence of intra-abdominal or
pelvic hematoma.
2. A new faint hyperdensity in the left iliac fossa transplanted
kidney may represent a 5 mm nonobstructing renal stone.
3. Interval decrease in size of small nonhemorrhagic bilateral
pleural
effusions and adjacent atelectasis.
4. Diffuse anasarca.
CT ADB/PELVIS: ___
IMPRESSION:
1. No intra-abdominal abnormality to explain the patient's
vomiting and high residuals. No evidence of obstruction.
2. Appropriate PEG tube placement, stable from ___.
3. Morphologically normal-appearing left iliac fossa transplant
kidney.
Previously described possible renal calculus not well seen.
4. Anasarca, unchanged from ___.
5. Central hypoattenuation in the right common femoral vein
which may reflect mixing of contrast, however an underlying
thrombus cannot be entirely excluded. Further evaluation with
ultrasound is recommended.
CT CHEST: ___
IMPRESSION:
Patchy parenchymal opacities, most confluent in the right upper
lobe.
Findings may be secondary to pulmonary edema. Infection is not
excluded.
BILATERAL LOWER EXT VENOUS US: ___
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower
extremity
veins to at least the bilateral popliteal veins. Evaluation of
the left
posterior tibial and peroneal veins are limited due to patient
non
cooperation.
MRI HEAD: ___
IMPRESSION:
1. No evidence of acute infarct or new hemorrhage.
2. A right hemispheric convexity subdural mixed age hematoma
measuring up to 1.0 cm greatest thickness is slightly improved
in size from prior examination.
3. There is improved leftward midline shift now measuring
approximately 3 mm compared to previously measured 8mm, with
decreased effacement of the right lateral ventricle. There
remains left lateral ventricle ventriculomegaly comm similar to
prior exam.
4. Additional findings described above.
CXR: ___
IMPRESSION:
In comparison to ___ chest radiograph, bilateral
heterogeneous
pulmonary opacities have worsened in the interval, particularly
at the lung bases. No other relevant change.
Brief Hospital Course:
Ms. ___ is a ___ year old female with history of afib on
coumadin who was recently admitted to the neurosurgery service
with R SDH on ___. This was managed medically and patient was
discharged back to rehab, and resumed Coumadin ___. Patient
then re-presented to ___ on ___ with complaints increased
confusion over the ___ days, having possible visual
hallucinations, and had an episode of bowel incontinence when
she is normally continent of both bowel and bladder; CT Head
revealed interval increase of right subdural hematoma, and she
was taken to OR ___ for emergent R craniotomy for evacuation of
SDH. She was admitted to Neuro ICU post-operatively for close
neurologic monitoring. Her 23-day ICU stay has been complicated
by a fluctuation neuro exam due to seizures and encephalopathy,
respiratory failure requiring subsequent trach with redo trach,
PEG placement, pulmonary edema and aspiration pneumonia.
1) 1.8 cm mixed density right subdural collection, with new
significant mass effect 13 mm of leftward midline shift, and
subfalcine herniation s/p craniotomy for ___ evacuation: Patient
went to the OR emergently for right craniotomy for subdural
evacuation on ___. Post-operatively patient was transferred to
the Neuro ICU for continued care. Serial post op head CT scans
were obtained in setting of increased left sided weakness,
confusion, and difficulty following commands. Repeat NCHCT on
___ showed stable decreased SDH with decrease in MLS to 6mm.
On ___ NCHCT showed increase in SDH to 1cm with 10mm of MLS,
however, neurosurgery did not feel the reaccumulation of SDH was
large enough to surgically intervene. 3% Hypertonic saline was
started for Na goal of 145-155 and vent settings were modified
for goal PCo2 ___. HTS was eventually weaned off on ___.
NCHCT on ___ showed decrease in SDH collection to 8mm with
decrease in MLS to 8mm. No further NSurg intervention necessary.
2) Seizures: On ___, when patient off sedation, she was noted
patient having LUE twitching and left gaze deviation, not
following commands. Patient was placed on cvEEG for monitoring,
and epileptiform discharges were captured. Keppra was increased
to Keppra 1500mg BID and Vimpat 200mg po BID was added. She
remained on EEG from ___. On ___, patient was
consistently not following commands. MRI brain showed no
interval change, EEG was placed ___ which showed no
epileptiform discharges and therefore no adjustments were made
to AEDs. She will continue on Keppra 1500mg BID and vimpat
200mg po BID, checking weekly to twice a week PR and QTc to eval
for prolongation in setting of vimpat. On discharge, QTc is 491
ad PR is 257.
3) Encephalopathy, ICU-related: Patient has had a fluctuating
mental status throughout her stay. In the beginning of her stay
she would intermittently follow commands, however in the past 7
days of her stay she has consistently not followed commands.
She will however, spontaneously move her right side in plane of
bed. At times she will also move her left leg in plane of bed
but this is inconsistent, other times she will only withdraw.
Her LUE hyperexteneds. She has had serial NCHCT, ___ MRI brain,
and cvEEG, as well as infectious work up as part of
encephalopathy eval. MRI brain shows chronic microhemorrhages,
no acute infact. Serial NCHCT and cvEEG as above. At this
point, we expect that patient is experiencing a degree of
ICU-related encephalopathy. She will need neurology follow up,
(___) please schedule appointment for ___ weeks.
4) Ventilator dependent respiratory failure, aspiration PNA
(MRSA), pulmonary edema: Patient was extubated post-operatively
on ___. She was reintubated on ___ in setting of acute
respiratory failure with lethargy and decreased movement of left
side. She was unable to wean off vent in setting of pulmonary
edema, seizures, and encephalopathy, and required tracheostomy.
Trach was placed on ___ and that evening a spontaneous
ventilator mode was attempted, but she became agitated with
respiration rate in the 35-40. Aspirin 81mg was restarted on
___. Bleeding and hematoma was noted at trach site on ___,
ASA and subcu heparin were stopped, and her H and H ultimately
dropped to 6:18. She was transfused 2u prbc and taken to OR for
exploratory surgery on ___ where entire trach track was
cauterized. Since ___ there has been no further bleeding.
Unfortunately she did develop an aspiration PNA in setting of
bleeding trach site, which grew out MRSA. She has completed an
8 day course of vancomycin from ___. She has been getting
intermittent Lasix for pulmonary edema, last dose ___ lasix
20mg IV, and has not required Lasix on ___. She has failed
multiple attempts at trach collar due to tachypnea, increased
work of labor; however, on day of transfer to ___ she has
tolerated trach collar for 7 hours, previously on PSV 10, PEEP 5
at 30% FiO2. Please continue to diuresis as needed.
5) Anemia: While the patient's Coumadin continued to be held
after surgery, she was started on aspirin 81mg on ___. On
___, an abdominal hematoma was noted with a hematocrit of 23.
One unit of packed red blood cells was administered. Later in
the evening, there was notable oozing from trach and PEG site.
The ACS service requested a TEG after bleeding at multiple
sites. The TEG was within normal limits. Hematology was
consulted after the continued bleeding, and after a ___
hematocrit was found to have again dropped to 23.9. Hematology
recommended another transfusion of PRBCs as well as checks on
fibrinogen which resulted as 520. On ___, the patient was
given vitamin K as well as another 2 units of PRBCS after the
hematocrit dropped to 18.7 and then another unit on ___ prior
to a trach exploration in the OR with ACS. She was since had no
further bleeding but has required one additional unit of PRBC on
___ for H and H of ___. Her H and H on discharge to rehab is
stable at 8:26.5.
6) PEG/Diarrhea: A PEG tube was placed on ___ with initiation
of tube feeds the following day. ON ___ in OR for redo trach,
she had a superficial bleeder cauterized at PEG site. She has
had persistent diarrhea which has been negative x2 for cdiff. CT
abdomen/pelvis negative for obstruction ___. Her Tube feeds
have been changed and she is currently on Osmolite 1.5 Cal Full
strength with Flush w/ 30 ml water q6h. Banana flakes have been
added to formula without improvement. She is getting prn
Imodium, and has a flexiseal in place.
7) Chronic afib: Patient has a history of afib, and has been in
and out of afib during her stay, rate well controlled. Her
Coumadin has been held during her entire hospitalization in
setting of SDH. She did have ___ MRIs during her stay because of
her fluctuating mental status. MRI did show chronic
microhemorrhages in the peripheral cortex, basal ganglia,
brainstem and cerebellar hemispheres, likely secondary to
amyloid or hypertensive etiology. Patient should follow up with
Dr ___ Neurology stroke clinic (___)
prior reinitiating anticoagulation. She should continue on ASA
81mg po daily. Her rate has been controlled on labetalol 200mg
po q8.
8) ESRD s/p renal transplant, DDRT x2, ___ and most recent
___: Patient was followed by transplant nephrology during
her stay. She remained on prednisone 5mg po daily. Her tacro
level was drawn daily, and on discharge her tacro level has been
stable at 6.9 on 2mg SL BID. She should continue on tacro 2mg
SL BID, checking tacro levels every 48 hours, with tacro goal
___. Her creatinine has been stable at 0.6-0.7. She should
avoid nephrotoxins including NSAIDs.
9)DMII: patient's metformin has been changed to RISS during ICU
stay
Transitions of care issues:
1. Neurology: concern for micro hemorrhage on MRI
Please follow up with neurology in ___ weeks. Please call
neurology clinic per d/c summary ___
2. Neurosurgery Follow-Up:
Please follow-up with Dr. ___ in 4 weeks. You will
need a CT head without contrast. Please call ___ to make
this appointment.
Please call ___ with any questions or concerns.
3. Renal Transplant:
Please follow up with nephrology in ___ months per routine
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 25 mg PO QHS
2. Multivitamins 1 TAB PO DAILY
3. Polyethylene Glycol 17 g PO DAILY constipation
4. Sertraline 50 mg PO DAILY
5. Senna 17.2 mg PO BID
6. amLODIPine 5 mg PO DAILY
7. Docusate Sodium 100 mg PO BID
8. Atorvastatin 10 mg PO QPM
9. Dorzolamide 2% Ophth. Soln. 1 DROP RIGHT EYE TID
10. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
11. Lubiprostone 24 mcg PO BID
12. Mirtazapine 15 mg PO QHS
13. MetFORMIN (Glucophage) 1000 mg PO DAILY
14. Pilocarpine 4% 1 DROP RIGHT EYE TID
15. Potassium Chloride 20 mEq PO BID
16. PredniSONE 5 mg PO DAILY
17. Sucralfate 1 gm PO BID:PRN heartburn
18. Tacrolimus 2.5 mg PO Q12H
19. Sodium Bicarbonate 1300 mg PO TID
20. Vitamin D 3000 UNIT PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild/Fever
2. Albuterol Inhaler ___ PUFF IH Q6H wheezes
3. Aspirin 81 mg PO DAILY
4. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL BID
5. Famotidine 20 mg PO BID
6. Heparin 5000 UNIT SC BID
7. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using REG Insulin
8. Ipratropium Bromide MDI 2 PUFF IH Q6H
9. Labetalol 200 mg PO Q8H
10. LACOSamide 200 mg PO BID
11. LevETIRAcetam 1500 mg PO BID
12. Lisinopril 5 mg PO DAILY
13. LOPERamide 2 mg PO Q12H:PRN diarrhea
14. amLODIPine 10 mg PO DAILY
15. Docusate Sodium 100 mg PO BID:PRN Constipation
16. Senna 17.2 mg PO QHS:PRN Constipation
17. Tacrolimus 2 mg SL Q12H
18. Atorvastatin 10 mg PO QPM
19. Dorzolamide 2% Ophth. Soln. 1 DROP RIGHT EYE TID
20. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
21. Mirtazapine 15 mg PO QHS
22. Multivitamins 1 TAB PO DAILY
23. Pilocarpine 4% 1 DROP RIGHT EYE TID
24. PredniSONE 5 mg PO DAILY
25. Sertraline 50 mg PO DAILY
26. Sodium Bicarbonate 1300 mg PO TID
27. Vitamin D 3000 UNIT PO DAILY
28. Vitamin D 3000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right Subdural
Seizures
Respiratory Failure
Anemia
MRSA/PNA
Diarrhea
Renal transplant
CAfib
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic and not arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Brain Hemorrhage with Surgery
Surgery
· You underwent a surgery called a craniotomy to have blood
removed from your brain.
· It is best to keep your incision open to air but it is ok
to cover it when outside.
· Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
· We recommend that you avoid heavy lifting, running,
climbing, or other strenuous exercise until your follow-up
appointment.
· You may take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
· No driving while taking any narcotic or sedating
medication.
· If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
· No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
· Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
· You have been discharged on Keppra (Levetiracetam). This
medication helps to prevent seizures. Please continue this
medication as indicated on your discharge instruction. It is
important that you take this medication consistently and on
time.
· You may use Acetaminophen (Tylenol) for minor discomfort
if you are not otherwise restricted from taking this medication.
What You ___ Experience:
· You may have difficulty paying attention, concentrating,
and remembering new information.
· Emotional and/or behavioral difficulties are common.
· Feeling more tired, restlessness, irritability, and mood
swings are also common.
· You may experience soreness with chewing. This is normal
from the surgery and will improve with time. Softer foods may be
easier during this time.
· Constipation is common. Be sure to drink plenty of fluids
and eat a high-fiber diet. If you are taking narcotics
(prescription pain medications), try an over-the-counter stool
softener.
Headaches:
· Headache is one of the most common symptoms after a brain
bleed.
· Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
· Mild pain medications may be helpful with these headaches
but avoid taking pain medications on a daily basis unless
prescribed by your doctor.
· There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs.
When to Call Your Doctor at ___ for:
· Severe pain, swelling, redness or drainage from the
incision site.
· Fever greater than 101.5 degrees Fahrenheit
· Nausea and/or vomiting
· Extreme sleepiness and not being able to stay awake
· Severe headaches not relieved by pain relievers
· Seizures
· Any new problems with your vision or ability to speak
· Weakness or changes in sensation in your face, arms, or
leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
· Sudden numbness or weakness in the face, arm, or leg
· Sudden confusion or trouble speaking or understanding
· Sudden trouble walking, dizziness, or loss of balance or
coordination
· Sudden severe headaches with no known reason
Followup Instructions:
___
|
19585869-DS-29
| 19,585,869 | 27,711,038 |
DS
| 29 |
2152-01-27 00:00:00
|
2152-01-27 17:27:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Penicillins / Ampicillin / Benadryl / Codeine / Bactrim / Zantac
/ pineapple
Attending: ___.
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
EVD
History of Present Illness:
Ms. ___ is a ___ y/o patient with history subdural
hematoma s/p fall on ___ followed by subsequent acute on
chronic ___ s/p evacuation on ___, seizures on lacosamide
and levitiracetam, atrial fibrillation on apixiban, and ESRD s/p
DDRT who presents with AMS and fever from LTAC found to have
right
thalamic IPH with IVH and 4mm midline shift.
Briefly, per report, patient was in her usual state of health
until circa 4 ___ on day of admission when she was noted to be
febrile to 100.4 and more confused from baseline. EMS was called
and was concerned for left-sided weakness. Patient was brought
to ___ where CT head showed
right thalamic intraparenchymal hemorrhage with intraventricular
extension as well as 4 mm midline shift. Blood pressure was
153/70, HR she was noted to be febrile to 102.8, found to have a
UTI and CXR with b/l opacities, started on cefepime and vanc.
CT abdomen/pelvis showed no acute intra-abdominal abnormality,
but did show a subacute right superior and inferior pubic rami
fractures (patient states she fell last week). INR was 1.4.
Of note pt was recently admitted to ___ in from ___ to
___ for transplant pyelonephritis. Neurology was consulted
twice during that admission initially for confusion which was
thought to be due toxic metabolic etiology vs seizure and then
subsequently for right hemiparesis found to have subacute left
occipital infarct on MRI/MRA brain. She was subsequently started
on apixaban 5 mg BID for anticoagulation.
Regarding her seizures hx, per OMR:
"She was initially started on keppra 500mg BID after her initial
SDH. Then on ___, the patient was noted to have LUE
twitching and left gaze deviation, not following commands.
Patient was placed on cvEEG for monitoring, and epileptiform
discharges were captured. Keppra was increased to
Keppra 1500mg BID and Vimpat 200mg BID was added. She was
discharged to rehab on this regimen.
She was subsequently re-admitted from ___ to ___ for
increased clinical seizure frequency at her rehab. During that
admission continuous EEG monitoring did not reveal further
seizures and she was continued on her antiepileptic regimen. The
patient had intermittent shaking movements throughout the
admission and was evaluated by Neurology, who thought that these
movements did not represent seizures given lack of EEG
correlate.
The patient was seen in Neurology clinic on ___. At that
time, the patient's sitter reported a decline in the patient's
mental status since her discharge on ___. On discharge she was
noted to be oriented to place and year and following commands
intermittently; however by the time of her appointment she was
no
longer consistently following commands. A NCHCT was obtained
that
was unchanged from prior. No EEG was obtained at that time. The
patient was continued on her antiepileptic regimen of lacosamide
200 mg BID and levitarecetam 1500 mg BID.
The patient was seen in ___ clinic on ___, at which
time there was "no evidence of seizures, and she can wean off
her
Keppra." The patient has been completely off the Keppra since
___. "
Then during her most recent admission in ___ she was noted to
have an episode of unresponsiveness and associated slight right
facial/eye and right leg twitching which self resolved and was
c/f seizure in the setting of infection and seizure threshold
lowering abx. No changes to her AED's were made.
On neuro ROS, the pt endorses mild headache, denies loss of
vision, blurred vision, diplopia.
On general review of systems, the pt denies cough, shortness of
breath. Denies chest pain or tightness, palpitations. Denies
nausea, vomiting, diarrhea, constipation or abdominal pain.
Past Medical History:
THROMBOCYTOPENIA
CONSTIPATION
CORONARY ARTERY DISEASE
DEPRESSION
END-STAGE RENAL DISEASE s/p RENAL TRANSPLANT
ESOPHAGEALDYSMOTILITY
GASTROPARESIS (R/O)
GERD/DYSPHAGIA
HYPERTENSION
INC ALK PHOS
OSTEOARTHRITIS
OSTEOPENIA
VITAMIN D DEFICIENCY
GLAUCOMA
COLON POLPYS
INSOMNIA
URINARY INCONTINANCE
PRE-DIABETES
SUBDURAL HEMATOMA s/p craniotomy
with Dr. ___ on ___
H/O SHINGLES
Social History:
___
Family History:
Multiple family members with DM2, Mom with HTN
Physical Exam:
ADMISSION Physical Exam:
Vitals: T:102.8 P:77 R: 16 BP:153/70 SaO2:94%RA
- General: Awake, cooperative
- HEENT: NC/AT
- Neck: Supple
- Pulmonary: no increased WOB
- Cardiac: well perfused
- Abdomen: soft, nontender, nondistended
- Extremities: no edema, pulses palpated
- Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Unable to reliably give
history, unable to perform days of week backwards, mildly
dysarthric, language is overall fluent but with decreased speech
output, repetition intact, follow simple as well as cross body
commands, naming intact to pen but afterwards perseverates on
pen
called watch "pen", called knuckles "pen".
-Cranial Nerves:
I: Olfaction not tested.
II: Left pupil nonreactive post surgical, right pupil pinpoint
and minimally reactive
III, IV, VI: Disconjugate gaze right eye esotropic, right gaze
preference but able to cross midline, does not fully aDDuct
either eye, impaired upgaze, Unable to assess visual fields by
confrontation.
V: Facial sensation intact to light touch.
VII: Left facial droop (chronic)
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, increased tone in BUE, unable to asses
drift
[Delt] [Bic] [Tri] [FFlex] [IP] [Quad] [Ham] [TA] [Gas]
[C5] [C5] [C7] [C8] [L2] [L3] [L5] [L4] [S1]
L 3 4 4 4 4 4- 4 5 5
R 3 4- 4- 5- 4 4- 4 5 5
- Sensory - decreased sensation to light touch right hemibodi
(new)
-DTRs:
[Bic] [Tri] [___] [Quad]
L 3+ 3+ 3+ 0
R 3+ 3+ 3+ 0
Plantar response flexor b/l
-Coordination: Unable to assess
-Gait: deferred
===========================================
DISCHARGE PHYSICAL EXAM
General: ill-appearing
HEENT: no conjunctival injection
Neck: supple, no meningismus
CV: skin warm, well-perfused
Lungs: rales at left base otherwise clear
Abdomen: soft, NT, ND
Ext: pain with leg, L shoulder movement.
Skin: ecchymosis over lateral L upper arm, no rashes.
Neuro:
MS- EO to verbal stimuli. regards examiner with encouragement.
No commands.
CN- L pupil postsurgical, irregular, nonreactive. R pupil 1mm
and
minimally reactive. Gaze midline (at times gaze to Rt). L facial
droop. blinks to lash stim bilaterally, but less briskly on L.
Sensory/Motor- Increased tone BUE. RUE moves spontaneously, LUE
no movement to noxious. BLE withdraws
Coordination- UTA
Pertinent Results:
___ 07:00PM BLOOD WBC-7.6# RBC-4.46 Hgb-13.0 Hct-39.7
MCV-89 MCH-29.1 MCHC-32.7 RDW-15.9* RDWSD-51.5* Plt Ct-83*
___ 07:00PM BLOOD Neuts-60.4 ___ Monos-8.7 Eos-0.0*
Baso-0.1 Im ___ AbsNeut-4.56 AbsLymp-2.30 AbsMono-0.66
AbsEos-0.00* AbsBaso-0.01
___ 07:06AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
___ 07:00PM BLOOD ___ PTT-34.0 ___
___ 07:00PM BLOOD Glucose-116* UreaN-26* Creat-1.1 Na-137
K-4.4 Cl-99 HCO3-23 AnGap-19
___ 07:00PM BLOOD ALT-55* AST-52* AlkPhos-154* TotBili-0.5
___ 07:00PM BLOOD cTropnT-<0.01
___ 07:06AM BLOOD cTropnT-<0.01
___ 07:00PM BLOOD Albumin-4.0 Calcium-9.9 Phos-2.9 Mg-1.9
___ 07:06AM BLOOD tacroFK-<2.0*
___ 07:46PM BLOOD ___ pO2-34* pCO2-44 pH-7.40
calTCO2-28 Base XS-1
___ 08:15PM URINE Blood-TR Nitrite-NEG Protein-300
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-SM
___ 08:15PM URINE RBC-8* WBC-36* Bacteri-FEW Yeast-NONE
Epi-0
IMAGING:
___: NCHCT: Acute right thalamic parenchymal hemorrhage with
interventricular blood. Focal mass effect with 4 mm of leftward
midline shift of the septum pellucidum.
___ CT Abd/Pelvis:
1. No acute intra-abdominal abnormality on non contrast
examination.
2. Subacute right superior and inferior pubic rami fractures.
___ NCHCT: 1. Motion limited exam.
2. No significant change in right thalamic hemorrhage.
3. Slightly increased blood in the occipital horns of lateral
ventricles, with
stable small amount of blood in the right frontal horn and in
the fourth
ventricle.
4. Increased dilatation of the third and lateral ventricles.
MRI brain ___: 1. Right thalamic hemorrhage with bone of the
septum to the left. There is trace postcontrast enhancement,
likely venous. No definite underlying mass lesion identified.
However, follow-up examination after resolution of hemorrhage
can be performed to document resolution of enhancement.
2. Dilation of the occipital horns with layering blood products,
similar in size and distribution.
3. Diminutive caliber of left M3 branch of the MCA with
reconstitution of the M4 branches. This is felt to be most
likely artifactual in nature as this finding was not visualized
on prior examination of ___. Otherwise, unremarkable
MRA head.
4. Sequela prior micro hemorrhages in the basal ganglia and
bilateral
cerebellar hemispheres, potentially secondary to hypertension.
5. Diffuse heterogeneous signal of the calvarium which is
thickened,
potentially representing renal osteodystrophy or possibly
fibrous dysplasia.
___ CXR
ET tube tip is in appropriate position, 3.5 cm above the
carinal. Heart size is enlarged, the patient is in mild vascular
congestion although no overt pulmonary edema.
___ NCHCT:
Severely limited study due to patient motion and hardware
artifacts. Within these limits, interval enlargement of
bilateral lateral ventricles. Evaluation for acute infarction
is limited. No evidence of new or enlarging hemorrhage.
___ ___:
1. Mildly motion limited, portable exam.
2. Stable right thalamic hemorrhage with stable intraventricular
extension.
3. Stable position of the left frontal approach EVD catheter.
Allowing for differences in patient head position, there is no
significant change in the size of the ventricles.
___ CXR:
Mild interstitial edema. Unchanged position of tracheostomy tube
tip and right PICC.
___ CXR:
In comparison with the study ___, there is little change.
Monitoring support devices are stable, as is the enlargement of
the cardiac silhouette with mild elevation of pulmonary venous
pressure. Retrocardiac opacification is again consistent with
volume loss in the left lower lobe and small pleural effusion.
___ MRI Brain
No significant change in right thalamic hematoma compared to the
___llowing for differences in modalities.
Allowing for thick rim of T1 hyperintense blood products, there
is no evidence for an underlying mass. Stable compression of the
third ventricle and stable dilatation of the lateral ventricles.
Blood products are again seen along the prior left frontal
ventriculostomy tract. Numerous chronic microhemorrhages are
again demonstrated in the cerebellum,
brainstem, basal ganglia, and gray/white matter junction,
compatible with a combination of hypertensive etiology and
amyloid angiopathy.
COMMENT:
Since no evidence for right thalamic mass was seen on the ___ MRI, and given the presence of numerous
above-described chronic micro hemorrhages, the present right
thalamic hemorrhage is likely related to hypertension rather
than an underlying mass
Brief Hospital Course:
#R thalamic IPH: Ms. ___ was admitted to the TSICU under the
stroke service. She underwent interval NCHCT at 12 hours after
her initial scan which showed no change in the IPH. She then
underwent MRI which showed no underlying infarct and no abnormal
enhancement, and extensive microbleeds, which was thought to be
the etiology of her IPH. MRA showed diminutive caliber of left
M3 branch of the MCA with reconstitution of the M4 branches, and
was otherwise unremarkable.
On the morning after presentation, her exam remained stable and
given this along with her stable imaging, she was transferred to
the ___. The following morning, she was noted to be
increasingly somnolent, with worsening left-sided weakness.
NCHCT showed no change in the IPH, but some increase in the size
of the lateral ventricles. Given the location of the IPH and the
local mass effect and cerebral compression, it was felt that the
IPH led to obstructive hydrocephalus and therefore her worsening
exam and mental status. Neurosurgery was consulted and EVD was
placed ___. EVD was kept at 15, and was subsequently clamped on
___. Repeat imaging on ___ and on ___ showed stable
hydrocephalus. EVD was removed on ___.
It was also felt likely that her numerous chronic brain injuries
(multiple prior ischemic infarcts, chronic microvascular
ischemia, and numerous microhemorrhages diagnostic of amyloid
angiopathy) magnified the amplitude of the severity of this
acute injury. Additionally, thalamic injuries themselves can
cause a pseudo-dementia or somnolence. Decision was made to hold
Apixiban indefinitely. She was staretd on ASA 81 mg. She
received HSQ at a reduced dose of 2500mg BID.
Given association of bleeding risk with SSRI, decision was made
to wean the home sertraline from 50mg daily to 25mg daily, with
plan to keep on it for one more week and then stop (end date
___.
#Seizures: Given Ms. ___ history of seizures, she was
monitored on cvEEG x48 hours after the decline in mental status.
This showed slowing but no seizures. She was maintained on her
home AED throughout her admission.
#ID:
Her admission CXR was c/f infection, she was started on
cefepime, vanc and metronidazole and completed a 8 day course.
Transplant nephrology also recommended to check HSV which was
negative and CMV IgG which was positive, but IgM negative,
indicating previous infection. Her UA was c/f for UTI. She was
already covered with cefepime for PNA which covered her UTI as
well. Her urine culture also grew yeast, which per infectious
disease did not require any treatment. She was also noted to
have an elevated EBV viral load which was thought to be due to
reactivation of past infection. Transplant nephrology recommend
MRI Brain w/wo contrast to assess for underlying lymphoma as
cause of her IPH. MRI brain showed no underlying lesion/mass.
She was noted to have diarrhea, C-diff was initially negative
and she was started on immodium, and opioid tincture for her
diarrhea. Repeat C-diff testing returned positive and she was
started on PO vancomycin 125mg q6h. Per ID, she will need to
complete a 14 day course (end of treatment ___. Immodium and
opium tincture were discontinued.
#HTN: Her SBP was maintained below 150. Her home labetalol was
uptitrated and she remained on her home amlodipine.
#Renal transplant: Transplant nephrology followed and titrated
tacrolimus as necessary. She was discharged on tacrolismus 3mg
BID as well her home prednisone 5mg daily. On evening of ___
patient was noted to have gross hematuria. UA with >180 rbc. CBC
and coags stable. ___ called to make sure that they will
accept patient. Per renal transplant, hematuria most likely from
pulling on Foley. Recommended bladder irrigation, and monitor
for clots. Should she develop clots she would need to be seen by
a urologist. UA also noted to have >180 wbc and large ___, few
bacteria and no nitrites. Per renal transplant hold will hold
off on ABX until Ucx is back.
#Pulmonary:
Patient was intubated for acute respiratory failure. Patient
underwent TRACH on ___. She was unable to be weaned from the
VENT. She was noted to have acute pulmonary edema and was
diuresed with Lasix prn (goal -500). Albuterol/atrovent nebs
were added. She underwent a bronchoscopy which did not show any
gross abnormality. She was weaned to Trach collar on ___ and
tolerated it well.
#Derm:
She was noted to have a raised, hypertrophic lesion on her RUE.
Derm was consulted and took a biopsy of it. Low likelihood that
this represents a malignant mass. She will follow up in ___
clinic.
#GI:
She has a PEG and was maintained on TF glucerna 1.2 @65ml/HR
#MSK:
She was found to have a rami fx subacute diagnosed on admission.
Orho was consulted and recommended - Weight bearing and activity
as tolerated and follow up in orthopaedic trauma clinic 4 weeks.
Transitional issues:
-Needs to complete 14 day course of PO vanc 125mg q6h (End of
treatment ___
-Per renal transplant needs her tacrolismus level, CBC and
Chemistry drawn tmrw (___). Please forward result to:
___ - Nephrology Transplant -> Attn: ___, MD
___ Floor
___ ___
Phone ___
Fax ___
-Neurology outpatient F/U
-Renal transplant outpatient f/u
-F/U urine culture
-F/U EBV viral load
-Patient was noted to have a raised, hyperthrophic appearing
lesion on her RUE. Derm
was consulted and took a biopsy she will need to follow up with
Dermatology as an
outpatient.
-Orthopedics outpatient f/u
-Stop sertraline ___
-Continue bladder irrigation for hematuria until resolved.
Should she develop clots
in her urine please have her be seen by Urology
Medications on Admission:
1. Apixaban 5 mg PO BID
2. Atorvastatin 40 mg PO QPM
3. LevETIRAcetam 1500 mg PO Q12H
4. Sertraline 50 mg PO DAILY
5. Vancomycin Oral Liquid ___ mg PO Q6H Duration: 7 Days
6. Labetalol 300 mg PO Q8H
7. LACOSamide 100 mg PO BID
8. Tacrolimus Suspension 1 mg PO Q12H
9. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
10. amLODIPine 10 mg PO DAILY
11. Docusate Sodium 100 mg PO BID
12. Dorzolamide 2% Ophth. Soln. 1 DROP RIGHT EYE TID
13. Heparin 5000 UNIT SC BID
14. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
15. melatonin 1 mg oral QHS
16. Multivitamins 1 TAB PO DAILY
17. Omeprazole 20 mg PO BID
18. Pilocarpine 4% 1 DROP RIGHT EYE TID
19. PredniSONE 5 mg PO DAILY
20. Saccharomyces boulardii 250 mg oral BID
21. Senna 17.2 mg PO QHS:PRN Constipation
22. HELD- Lisinopril 20 mg PO DAILY This medication was held.
Do not restart Lisinopril until told to by your doctor ___
your creatine returns to normal)
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing,
shortness of breath
2. Aspirin 81 mg PO DAILY
3. Multivitamins W/minerals Liquid 15 mL PO DAILY
4. Pantoprazole (Granules for ___ ___ 40 mg PO DAILY
5. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
6. Acetaminophen 650 mg PO Q4H:PRN pain or temp > ___
7. Heparin 2500 UNIT SC BID
8. Labetalol 600 mg PO Q6H
9. Sertraline 25 mg PO DAILY Duration: 7 Days
10. Tacrolimus 3 mg PO Q12H
11. amLODIPine 10 mg PO DAILY
12. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES TID
13. LACOSamide 100 mg PO BID
14. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
15. LevETIRAcetam 1500 mg PO BID
16. melatonin 1 mg oral qhs
17. PredniSONE 5 mg PO DAILY
18. Vancomycin Oral Liquid ___ mg PO Q6H
19. HELD- Atorvastatin 40 mg PO QPM This medication was held.
Do not restart Atorvastatin until outpatient neuology follow up
20. HELD- Saccharomyces boulardii 250 mg oral BID This
medication was held. Do not restart Saccharomyces boulardii
until you follow up with your PCP
___:
Extended Care
Facility:
___
Discharge Diagnosis:
right basal ganglia intraparenchymal hemorrhage
acute obstructive hydrocephalus
midline shift
local mass effect and cerebral compression
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Dear ___
you were admitted to ___ for confusion. Your head imaging
showed a large brain bleed. We think this was due to many
previous small bleeds in your brain. Your MRI did not show any
underlying lesion. We stopped your apixiban indefinitely. Please
take your medication as prescribed. Please follow up as
mentioned below.
It was a pleasure taking care of you.
Best,
Your ___ care team
Followup Instructions:
___
|
19585869-DS-30
| 19,585,869 | 20,565,298 |
DS
| 30 |
2152-04-01 00:00:00
|
2152-04-01 17:14:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Ampicillin / Benadryl / Codeine / Bactrim / Zantac
/ pineapple
Attending: ___.
Chief Complaint:
Hypoxic respiratory failure
Major Surgical or Invasive Procedure:
TTE ___
PICC ___
History of Present Illness:
HISTORY OF PRESENTING ILLNESS:
Patient is a ___ year old patient with history subdural
hematoma s/p fall on ___ followed by subsequent acute on
chronic SDH s/p evacuation on ___, seizures on lacosamide
and levitiracetam, atrial fibrillation not on AC, and ESRD s/p
DDRT, and recent right thalamic IPH who presents from rehab to
___ for hypoxia and transferred to ___ for continuity
of care.
On ___, she was noted to be in respiratory distress by her
long-term care facility. Her vitals demonstrated a RR of 28 with
O2 sat of 40%, so she was placed on trach mask 60%. A large
mucous plug was suctioned and per report, her O2 saturations
improved. She was then transferred to ___.
At ___, initial vitals showed T 99.1, HR 122, BP 108/58, RR
16, O2 100% on AC 400x16, PEEP 5, FiO2 40%. Labs demonstrated
WBC 11.97, Cr 0.75, AG 16, ALT 52, AST 29, Lactate 2.6, ABG
7.41/48/242, and proBNP 1424. Due to concern for septic shock
given tachycardia and tachypnea with suspected pulmonary source,
she was started on vanc/cefepime and transferred to ___ for
continuity of care.
At ___ ___, initial vitals showed T 98.2, HR 70-125, BP
100-150/60s, RR 20, O2 100% on AC 400x16, PEEP 5, FiO2 50%. Labs
showed WBC 12.2 with 67.1% neutrophils, Cr 0.8, Lactate 1.8, VBG
7.36/56. CXR showed pulmonary vascular congestion and mild
pulmonary edema with a retrocardiac opacification that could be
atelectasis. She was admitted to ___.
On arrival to the ___, she is calm and in no respiratory
distress.
Past Medical History:
THROMBOCYTOPENIA
CONSTIPATION
CORONARY ARTERY DISEASE
DEPRESSION
END-STAGE RENAL DISEASE s/p RENAL TRANSPLANT
ESOPHAGEALDYSMOTILITY
GASTROPARESIS (R/O)
GERD/DYSPHAGIA
HYPERTENSION
INC ALK PHOS
OSTEOARTHRITIS
OSTEOPENIA
VITAMIN D DEFICIENCY
GLAUCOMA
COLON POLPYS
INSOMNIA
URINARY INCONTINANCE
PRE-DIABETES
SUBDURAL HEMATOMA s/p craniotomy
with Dr. ___ on ___
H/O SHINGLES
Social History:
___
Family History:
Multiple family members with DM2, Mom with HTN
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: Reviewed in metavision
GENERAL: Lying in bed, calm, trach in place, ventilated
HEENT: Sclera anicteric, MMM, significant oral thrush
NECK: 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
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: Warm
NEURO: Able to follow commands, increased tone in the upper
extremities, does not move left extremity
Pertinent Results:
ADMISSION LABS:
===============
___ 05:25AM BLOOD WBC-12.2* RBC-3.49* Hgb-10.1* Hct-32.6*
MCV-93 MCH-28.9 MCHC-31.0* RDW-16.1* RDWSD-54.6* Plt ___
___ 05:25AM BLOOD Glucose-134* UreaN-36* Creat-0.8 Na-141
K-4.7 Cl-102 HCO3-28 AnGap-11
___ 05:25AM BLOOD proBNP-1613*
IMAGING/STUDIES:
================
ECHOCARDIOGRAM ___:
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size, and global systolic function are normal
(LVEF>55%). Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets are mildly thickened (?#). There is no aortic valve
stenosis. Trace aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Trivial mitral regurgitation is
seen. There is borderline pulmonary artery systolic
hypertension. There is an anterior space which most likely
represents a prominent fat pad.
Suboptimal study due to patient on the ventilator and not
cooperating. Grossly normal biventricular function wihtout
significant valvular abnormalities.
Compared with the prior study (images reviewed) of ___, no
significant change is noted.
CHEST XRAY ___:
1. Pulmonary vascular congestion and mild pulmonary edema.
2. Retrocardiac opacification likely secondary to atelectasis
and probable
small left pleural effusion.
CHEST XRAY ___:
The tip of the right PICC is within the right atrium. Pulmonary
venous
congestion. Cardiomegaly.
Brief Hospital Course:
SUMMARY: ___ y/o woman with history subdural hematoma s/p fall on
___ followed by subsequent acute on chronic SDH s/p
evacuation on ___, seizures on lacosamide and
levitiracetam, atrial fibrillation not on AC, and ESRD s/p DDRT,
and recent right thalamic IPH who presents from rehab to
___ for hypoxia and transferred to ___ for continuity
of care.
FICU COURSE
===========
# Hypoxic respiratory failure: Developed new acute hypoxia on
___ with report of O2 sat 40%. She was placed on AC at ___
___ and continued here with improved ventilation and oxygenation.
Chest xray showed retrocardiac opacity concerning for pneumonia
and she likely mucous plugged in the setting of her infection.
Improved with mechanical ventilation. Treated for HCAP given
history of resistant organisms with vancomycin + ceftazidime for
planned 14 day course (last day ___. Weaned to trach mask ___
# C. difficile colitis: Developed frequent watery diarrhea. C.
difficile PCR positive. Started on PO vancomycin with planned
course to continue for 2 weeks after stopping antibiotics for
pneumonia (last day ___. Given recurrent c. diff could
consider treatment with fidaxomicin.
# Seizure disorder:
- Continued home keppra and lacosamide
# ESRD s/p DDT: Maintained on home tacrolimus and prednisone
# HTN:
- Holding home labetalol, amlodipine, and lisinopril as
normotensive without. Please evaluate whether these medications
need to be restarted
# GERD:
- Continued home omeprazole
# CAD:
- Continued home aspirin
TRANSITIONAL ISSUES:
====================
[] Continue vancomycin 750mg q12h for HCAP, last day ___
[] Please recheck vancomycin level prior to ___ dose of
vancomycin ___
[] Continue ceftazidime 2g q12h for HCAP, last day ___
[] Please continue PO vancomycin 125mg q6h for c. difficile,
last day ___
[] Consider fidaxomicin for treatment of recurrent c. difficile
[] Home amlodipine, labetalol, and lisinopril held during
admission. Normotensive without these medications. Please
evaluate if these should be restarted.
[] Given recurrent pneumonias, consider goals of care
conversation with family members.
[] tacrolumus level pending at discharge
Name of health care proxy: ___
Relationship: Daughter
Phone number: ___
___ on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen 650 mg PO Q4H:PRN pain or temp > ___
2. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES TID
3. Heparin 2500 UNIT SC BID
4. Labetalol 600 mg PO Q6H
5. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing,
shortness of breath
6. Aspirin 81 mg PO DAILY
7. Multivitamins W/minerals Liquid 15 mL PO DAILY
8. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
9. melatonin 1 mg oral qhs
10. Saccharomyces boulardii 250 mg oral BID
11. amLODIPine 10 mg PO DAILY
12. LACOSamide 100 mg PO BID
13. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
14. LevETIRAcetam 1500 mg PO BID
15. PredniSONE 5 mg PO DAILY
16. Tacrolimus 0.5 mg PO Q12H
17. Omeprazole 20 mg PO DAILY
18. Nystatin Oral Suspension 5 mL PO QID
19. Lisinopril 20 mg PO DAILY
Discharge Medications:
1. CefTAZidime 2 g IV Q12H
last day ___. vancomycin 125 mg oral Q6H
last day ___ (2 weeks after antibiotics completion)
3. Vancomycin 750 mg IV Q 12H
last day ___. Heparin 5000 UNIT SC BID
5. Tacrolimus 4 mg PO Q12H
6. Acetaminophen 650 mg PO Q4H:PRN pain or temp > ___
7. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing,
shortness of breath
8. Aspirin 81 mg PO DAILY
9. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES TID
10. LACOSamide 100 mg PO BID
11. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
12. LevETIRAcetam 1500 mg PO BID
13. melatonin 1 mg oral qhs
14. Multivitamins W/minerals Liquid 15 mL PO DAILY
15. Nystatin Oral Suspension 5 mL PO QID
16. Omeprazole 20 mg PO DAILY
17. PredniSONE 5 mg PO DAILY
18. Saccharomyces boulardii 250 mg oral BID
19. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
20. HELD- amLODIPine 10 mg PO DAILY This medication was held.
Do not restart amLODIPine until your doctor tells you to
21. HELD- Labetalol 600 mg PO Q6H This medication was held. Do
not restart Labetalol until your doctor tells you to
22. HELD- Lisinopril 20 mg PO DAILY This medication was held.
Do not restart Lisinopril until your doctor tells you to
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Pneumonia
Clostridium difficile colitis
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for at ___
___!
WHY YOU WERE ADMITTED:
-You were admitted to the hospital because you were having
difficulty breathing. Your oxygen level was also low.
WHAT HAPPENED IN THE HOSPITAL:
-You were diagnosed with a pneumonia and treated with
antibiotics.
-You briefly required a breathing machine to assist with your
breathing.
-You were having diarrhea and tested positive for c. difficile.
You were started on antibiotics for this.
WHAT YOU SHOULD DO AT HOME:
-Continue taking your antibiotics for the pneumonia, the last
day will be ___.
-Please continued taking oral vancomycin for your c. difficile
for two weeks after completing your pneumonia treatment, last
day ___.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Your ___ Team
Followup Instructions:
___
|
19585869-DS-31
| 19,585,869 | 20,562,280 |
DS
| 31 |
2152-04-12 00:00:00
|
2152-04-17 18:14:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Ampicillin / Benadryl / Codeine / Bactrim / Zantac
/ pineapple
Attending: ___.
Chief Complaint:
Hypoxic respiratory failure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HISTORY OF PRESENTING ILLNESS:
___ with extensive PMHx of chronic respiratory failure s/p
tracheostomy, seizure disorder, afib (not on AC), ESRD s/p DDRT,
multiple CVAs (Rt thalamic IPH ___, ___ ___, and recent
hospitalization ___ for hypoxemic resp failure iso HAP and
mucus plug s/p removal who now presents as transfer from ___
after presenting with respiratory distress found to have copious
secretions with improvement after suctioning now satting well on
trach mask
Pt was recently admitted ___ for hypoxemic respitory
failure after presenting to ___ from long-term SNF. She was
found to have PNA and mucus plug s/p removal at OSH and was
transferred to FICU. Sputum cx ___ had sparse GNR growth. She
was treated with AC ventilation and antibiotics for HAP given
history of resistant organisms with vancomycin + ceftazidime.
She improved and was weaned to trach mask. She was discharged on
vanc/cefepime with plan for 14 day course (last day ___.
Per ED chart, pt was at LT SNF, when found to be tachypneic with
increased work of breathing. She was taken to ___,
placed on the ventilator with improvement of her symptoms. While
at ___ she had suction that was notable for copious amounts
of white sputum and secretions. She was also found to have a
possible new right lower lung opacity with concern for pneumonia
and was treated with cefepime. Patient was transferred here for
further evaluation as she was still requiring ventilator
assistance. Per report from nursing facility patient has no
other focal complaints and is at her baseline mental status
which is nonconversant but reacting to verbal stimuli.
In the ED, intial VS were HR 107, BP 150/91, RR 25, SpO2 100% on
Trach Mask.
Labs were at baseline
VBG showed 7.42/45
CXR showed retrocardiac opacity similar to prior.
She was given doses of her home antibiotics on since discharge
___ 08:45 IV Vancomycin 1000 mg
- ___ 08:45 IV CefePIME 2 g
She was transferred to ___ for respiratory distress. On arrival
to the FICU, she was calm and in no respiratory distress.
Ms. ___ ICU course is as follows: Patient was admitted to
___ for acute hypoxic respiratory failure. She was suctioned,
which improved her status. CXR with bilateral fluffy opacities,
Vanc level 19.6 from OSH, EKG with sinus tachycardia. Ddx for
acute respiratory distress was recurrent mucous plugging, flash
pulmonary edema given intermittent hypertension and vascular
congestion. She received vanc/cefepime, which had been her
previous discharge antibiotics. Diuresed in FICU, restarted
labetalol for BP control. Received PO vanc for recent CDiff
infection dx'd ___. Vancomycin switched to linezolid, as had
grown enterococcus on home vanc. Cefepime switched to
ceftazadime. Continued to receive home tacrolimus. Dc'd foley.
Stopped ceftazidime. Continued SQH despite thrombocytopenia as
stable. CTAP negative for abscess or obvious GI source of
infection. Started oral diuretic for goal I:O even. Weaned off
vent.
Family meeting held ___, patient is full code per daughter.
Per daughter after ___ ___, eventually reached a baseline
that was reasonably functional, including all BADLs and some
IADLS, at long term rehab. Then after ___ in ___ pt had not
recovered to that 'new' baseline and was bedbound, non-verbal,
but had shown improvement 2 weeks PTA, including being A&Ox2,
and
communicating through lip reading. Pt's daughter ___
reiterated that prior to ___ in ___, pt expressed wishes to
remain full code and believes that at this time with uncertain
recovery, would wish to remain full code.
ID had followed the patient for enterococcal bacteremia, signed
of ___, had recommended vanc change to linezolid, as bacteremia
had occurred on vanc. Source unclear - potential urinary vs GI,
though may be contaminant. ___ lab was still
speciating as of ___. ID recommended, removing picc line,
treat
for 7d total course with po linezolid, discontinue ceftazadime.
Nephrology is following patient for hx ESRD s/p DDRT on
tacrolimus/prednisone. Most recent recs: Recommended
decreasing
diuresis due to moderate creatinine elevation to 0.8, decreasing
tacrolimus dose due to elevated trough to a tacrolimus night
dose
of 3 mg (the dose would be 4 and 3mg), with goal around 5 to 6
(last trough 9.4 ___, and to draw tacrolimus trough level
tomorrow morning. Ideally,it should be checked at 12 hours after
the night dose, before morning dose. Continue prednisone home
dose. Avoid nephrotoxin, contrast, NSAID, overdiuresis. For Na
at 140-143, recommended to increase water flush 500 ml/day.
Per FICU report, the patient was relatively stable over ___
hours prior to transfer to the Medicine floor.
She had minimal secretions and suction requirements
with strong cough and was afebrile.
VS reviewed on transfer: T98.6, P81, BP 155/76, RR 26,
Labs reviewed, of note: hgb 10.3, stable, plt 104. stable,
creatinine 1.0, has been rising from 0.8 on admit with diuresis,
glucose 145. Blood cultures negative here at ___, but
positive
with vanc resistant enterococcus at ___. Most recent BCx
___.
ROS: Unable to evaluate ROS, patient unresponsive/nonverbal
Past Medical History:
THROMBOCYTOPENIA
CONSTIPATION
CORONARY ARTERY DISEASE
DEPRESSION
END-STAGE RENAL DISEASE s/p RENAL TRANSPLANT
ESOPHAGEALDYSMOTILITY
GASTROPARESIS (R/O)
GERD/DYSPHAGIA
HYPERTENSION
INC ALK PHOS
OSTEOARTHRITIS
OSTEOPENIA
VITAMIN D DEFICIENCY
GLAUCOMA
COLON POLPYS
INSOMNIA
URINARY INCONTINANCE
PRE-DIABETES
SUBDURAL HEMATOMA s/p craniotomy
with Dr. ___ on ___
H/O SHINGLES
Social History:
___
Family History:
Multiple family members with DM2, Mom with HTN
Physical Exam:
FICU ADMISSION EXAM
===================
PHYSICAL EXAM:
VITALS: HR 100, BP 139/83, RR 26, SpO2 100% on trach mask
GENERAL: Non verbal, following commands, A&Ox1
HEENT: Sclera anicteric, Dry MMM thrush
NECK: JVP difficult to interpret
LUNGS: Course breath sounds b/l, trach in place with thick,
clear secretions
CV: Irregular, difficult to hear given breath sounds
ABD: soft, non-tender, non-distended
EXT: Warm, well perfused, 2+ pulses, trace ___ edema
SKIN: Many
NEURO: A&Ox1, Not moving extremities spontaneously, RUE
intrinsic hand ___, LLE wiggling toes
ACCESS: Rt PICC, Lt PEG,
DISCHARGE EXAM
==============
VITALS: Tmax 98.3, HR ___ BP 120s-140s/80; SpO2 100% on 35%
FiO2
GENERAL: Nonverbal, breathing room air comfortably, makes eye
contact to voice
EYES: Anicteric, pupils equally round
CV: Regular rate, irregularly irregular rhythm, no S3, no S4.
No
JVD.
RESP: Coarse upper airway sounds, rhonchi bilaterally
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present.
SKIN: No rashes or ulcerations noted
NEURO: nonverbal, face symmetric, gaze conjugate with EOMI, does
not participate with exam
Pertinent Results:
___ 08:48PM GLUCOSE-141* UREA N-36* CREAT-0.8 SODIUM-141
POTASSIUM-4.5 CHLORIDE-102 TOTAL CO2-24 ANION GAP-15
___ 08:48PM CALCIUM-9.9 PHOSPHATE-3.4 MAGNESIUM-1.9
___ 02:58AM ___ PO2-34* PCO2-45 PH-7.42 TOTAL CO2-30
BASE XS-3
___ 02:58AM O2 SAT-59
___ 02:16AM LACTATE-1.9
___ 02:00AM GLUCOSE-120* UREA N-35* CREAT-0.8 SODIUM-138
POTASSIUM-4.3 CHLORIDE-102 TOTAL CO2-23 ANION GAP-13
___ 02:00AM estGFR-Using this
___ 02:00AM CK(CPK)-44
___ 02:00AM CK-MB-4
___ 02:00AM CALCIUM-9.5 PHOSPHATE-2.5* MAGNESIUM-2.0
___ 02:00AM VANCO-19.6
___ 02:00AM tacroFK-4.9*
___ 02:00AM URINE HOURS-RANDOM
___ 02:00AM URINE UHOLD-HOLD
___ 02:00AM WBC-9.5 RBC-3.38* HGB-9.8* HCT-31.2* MCV-92
MCH-29.0 MCHC-31.4* RDW-15.5 RDWSD-51.6*
___ 02:00AM NEUTS-58.4 ___ MONOS-12.8 EOS-0.1*
BASOS-0.2 IM ___ AbsNeut-5.54 AbsLymp-2.65 AbsMono-1.21*
AbsEos-0.01* AbsBaso-0.02
___ 02:00AM ___ PTT-20.6* ___
___ 02:00AM PLT COUNT-100*
___ 02:00AM URINE COLOR-Yellow APPEAR-Hazy* SP ___
___ 02:00AM URINE BLOOD-TR* NITRITE-NEG PROTEIN-300*
GLUCOSE-NEG KETONE-TR* BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-LG*
___ 02:00AM URINE RBC-2 WBC-108* BACTERIA-FEW* YEAST-FEW*
EPI-10
___ 02:00AM URINE HYALINE-5*
___ 02:00AM URINE WBCCLUMP-MANY* MUCOUS-RARE*
Discharge Labs:
___ 05:55AM BLOOD WBC-4.9 RBC-3.49* Hgb-10.1* Hct-32.2*
MCV-92 MCH-28.9 MCHC-31.4* RDW-15.0 RDWSD-50.4* Plt Ct-86*
___ 05:55AM BLOOD Glucose-192* UreaN-57* Creat-0.9 Na-143
K-3.8 Cl-96 HCO3-30 AnGap-17*
___ 09:27AM BLOOD tacroFK-5.8
Micro:
Blood cultures:
___: no growth
Urine culture (___): YEAST. >100,000 CFU/mL.
Sputum cx (___): RESPIRATORY CULTURE (Final ___:
SPARSE GROWTH Commensal Respiratory Flora.
Imaging:
CXR, ___: IMPRESSION:
Retrocardiac opacity could be due to atelectasis and/or
pneumonia.
CXR ___: IMPRESSION:
No definitive evidence for new pneumonia. Decreased lung
volumes bilaterally,
otherwise no significant cardiopulmonary change from previous.
CT abd/pelvis WO contrast, ___: IMPRESSION:
1. No fluid collection within the abdomen or pelvis.
2. 0.8 cm left lower lobe opacity, likely round atelectasis.
3. Chronic moderate T9 compression deformity. No retropulsion.
4. Findings suggestive of renal osteodystrophy.
5. Nonobstructing stones within left iliac fossa transplant
kidney. No
hydronephrosis.
CXR, ___: IMPRESSION:
Compared to chest radiographs ___ through ___.
Lungs are low in volume but clear of focal abnormality.
Moderate to severe
cardiomegaly is exaggerated by low lung volumes, probably
worsened. No
pulmonary edema or pleural effusion. No pneumothorax.
Tracheostomy tube midline. Right PIC line ends in the region of
the superior
cavoatrial junction.
CXR, ___: IMPRESSION:
PE of ___, there is little overall change in the
monitoring and support
devices and overall appearance of the heart and lungs.
Cardiomediastinal
silhouette is stable and there again are low lung volumes. No
definite acute
focal pneumonia or pulmonary vascular congestion.
Brief Hospital Course:
BRIEF HPI/FICU COURSE
====================
___ with extensive PMHx of chronic respiratory failure s/p
tracheostomy, seizure disorder, afib (not on AC), ESRD s/p DDRT,
multiple CVAs (Rt thalamic IPH ___, ___ ___, and recent
hospitalization ___ for hypoxemic resp failure iso HAP and
mucus plug s/p removal who was transferred from ___ after
presenting with respiratory distress found to have copious
secretions with improvement after suctioning. On transfer pt was
satting well on trach mask. CXR with volume overload. Diuresed
with IV Lasix 160 mg until euvolemic and then switched to
torsemide 80 mg daily. Also continued treatment of HAP with
vanc/cefepime x8d ending ___. Also during admission OSH blood
cx ___ with enterococcus in ___ bottles on vanc. ID consulted
and recommended treating with 7d course of linezolid and
removing PICC line. On transfer to medicine floor, PICC line
remained for access but planned to be pulled prior to discharge.
ACTIVE PROBLEMS:
# Acute on chronic hypoxemic respiratory failure:
# HFpEF
# PNA
Pt has trach at baseline and recent PNA, admitted on treatment
with vanc/cefepime. Pt developed resp distress at home on Abx
with improvement s/p suctioning at OSH. BNP at OSH also elevated
above baseline. Etiology includes acute on chronic HFpEF vs
mucus plugging iso of resolving PNA or MDR PNA. Diuresed with IV
Lasix 160 mg until euvolemic and then switched to torsemide 80
mg daily. Continued treatment with vanc/ceftazidime for 8d
course ___.
# Enterococcus bacteremia: OSH (___) blood cx ___ with
enterococcus in ___ bottles on vanc. Source is likely
from urine or GI tract. CTAP was negative for source. ID
consulted and recommended treating with 7d course of linezolid
and removing PICC line. On transfer to medicine floor, PICC line
remained for access but was pulled prior to discharge. She
completed the full 7 days of linezolid prior to discharge.
# C diff: Recent CDI on ___. Continued PO vanc 125mg q6h until
14d post-antibiotics (last day ___
# Afib: persistent, CHADS2VASC 6. Not on AC given IPH ___.
Continued home asa 81. Originally continued home labetalol 600
q6h for rate control and then switched to metoprolol 50 mg q6h
in order to provide room for diuresis as above. Prior to
discharge, diuretics were discontinued and her home labetalol
was resumed.
# Concern regarding fluid overload, TTE ___ without systolic
CHF, possibly increased left ventricular filling pressure,
aortic
valve leaflets mildly thickened, no AS, borderline pulmonary
artery systolic hypertension. She was diuresed to euvolemia with
Lasix and torsemide.
She was not discharged on diuretics.
# ___ - Cr peaked at 1.2 from baseline 0.8, likely due to
overdiuresis. Her Cr returned to normal after diuretics were
stopped.
# ESRD s/p DDT: Maintained on prednisone 5 mg. Her tacrolimus
dose was adjusted (to 4mg qam/3mg qpm) due to supra therapeutic
tacrolimus troughs. On discharge, her tacrolimus troughs were
within goal range.
# Thrush noted in mouth, likely related to immunosuppression for
ESRD w/ DDRT on tacrolimus and prednisone. She was treated with
Nystatin oral suspension.
# Thrombocytopenia: Plts stable at discharge, continued on ___
for DVT ppx.
CHRONIC ISSUES:
# Seizure disorder: Continued home lancosamide and levitaracetam
# HTN: Continued labetalol then switched to metop as above. Held
home amlodipine, and lisinopril as normotensive without. Her
home labetalol was resumed prior to discharge.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen 650 mg PO Q4H:PRN pain or temp > ___
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing,
shortness of breath
3. Aspirin 81 mg PO DAILY
4. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES TID
5. LACOSamide 100 mg PO BID
6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
7. LevETIRAcetam 1500 mg PO BID
8. Nystatin Oral Suspension 5 mL PO QID
9. PredniSONE 5 mg PO DAILY
10. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
11. Tacrolimus 4 mg PO Q12H
12. melatonin 1 mg oral qhs
13. Multivitamins W/minerals Liquid 15 mL PO DAILY
14. Omeprazole 20 mg PO DAILY
15. Saccharomyces boulardii 250 mg oral BID
16. Heparin 5000 UNIT SC BID
17. CefTAZidime 2 g IV Q12H
18. vancomycin 125 mg oral Q6H
19. amLODIPine 10 mg PO DAILY
20. Labetalol 600 mg PO Q6H
21. Lisinopril 20 mg PO DAILY
22. Vancomycin 750 mg IV Q 12H
Discharge Medications:
1. GuaiFENesin 10 mL PO Q6H
2. Metoprolol Tartrate 50 mg PO Q6H
3. Pantoprazole (Granules for ___ ___ 40 mg G TUBE DAILY
4. Vancomycin Oral Liquid ___ mg PO Q6H Duration: 12 Days
5. Tacrolimus 3 mg PO QPM
6. Tacrolimus 4 mg PO DAILY
7. Acetaminophen 650 mg PO Q4H:PRN pain or temp > ___
8. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing,
shortness of breath
9. Aspirin 81 mg PO DAILY
10. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES TID
11. Heparin 5000 UNIT SC BID
12. Labetalol 600 mg PO Q6H
13. LACOSamide 100 mg PO BID
14. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
15. LevETIRAcetam 1500 mg PO BID
16. melatonin 1 mg oral qhs
17. Multivitamins W/minerals Liquid 15 mL PO DAILY
18. Nystatin Oral Suspension 5 mL PO QID
19. PredniSONE 5 mg PO DAILY
20. Saccharomyces boulardii 250 mg oral BID
21. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
22. HELD- amLODIPine 10 mg PO DAILY This medication was held.
Do not restart amLODIPine until systolic blood pressures are
consistently higher than 130
23. HELD- Lisinopril 20 mg PO DAILY This medication was held.
Do not restart Lisinopril until Systolic blood pressures are
consistently greater than 130
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Acute on chronic hypoxemic respiratory failure due to mucous
plugging, pulmonary edema due to hypertension, and
healthcare-associated pneumonia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Ms. ___,
You were admitted to the hospital for low oxygen levels. This
was thought to be most likely due to mucous plugging and flash
pulmonary edema (water in the lungs) due to high blood pressure.
Your oxygen status returned to normal after suctioning of the
mucous plugging, diuresis, and with continuing antibiotics
(since you were still completing treatment for pneumonia. Your
hospital course was also complicated by bacteria in your
bloodstream (noted on cultures from ___, which was treated
with antibiotics. You also have C.diff colitis and you are
continuing antibiotics for that. You developed injury to your
kidneys because you were diuresed too much. Your tacrolimus dose
adjusted because the levels were too high.
Followup Instructions:
___
|
19585869-DS-32
| 19,585,869 | 23,187,610 |
DS
| 32 |
2152-05-01 00:00:00
|
2152-05-01 19:52:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Ampicillin / Benadryl / Codeine / Bactrim / Zantac
/ pineapple
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
___ placed
History of Present Illness:
___ with extensive PMHx of chronic respiratory failure s/p
tracheostomy, multiple intracranial bleedings in the past year
including traumatic subdural hemorrhage with resultant
encephalopathy and seizures, afib (not on AC), CAD, ESRD s/p
DDRT (on tacrolimus), recurrent C. Diff infections, who presents
to the ED with fever and dyspnea. Per her daughter, she was
having shortness of breath over the past 2 days and her LTACH
(___) was concerned about her O2 saturations. CXR at
outside facility (___) showed RUL infiltrate and she was
prescribed Ceftriaxone IM for presumed pneumonia.
She continued to have worsening tachypnea at ___ and was
brought to the ED. On arrival she was diffusely rhonchorous,
tachypneic with RR to 40, and somnolent. RT performed suction
with no improvement in respiratory status. She was subsequently
placed on ventilator and started on Vanc/Cefepime.
Of note, she has had multiple admissions for similar complaints
including recent hospitalization ___ for hypoxemic resp
failure with HAP and mucous plugging s/p mucous plug removal and
vancomycin + ceftazidime x 14 days. She was re-admitted ___
for similar complaints.
In the ED, initial vitals: HR: 89 RR: 30 BP: 160/116 SpO2: 100
on 12L
humidified trach mask
Exam notable for: tachypnea, with diffusely rhonchorous
respirations bilaterally even after deep tracheal suctioning
Labs notable for:
Respiratory acidosis: pH 7.27 pCO2 73 pO2 28 HCO3 35
Lactate:1.9
Hgb:8.8
Hct:30.2
WBC:10.4
Plt:70
K+: 5.4
proBNP: ___
ALT: 46 AP: 133 Tbili: 0.5 Alb: 3.9 AST: 40
Trop-T: 0.01
tacroFK: Pnd
Imaging:
- CXR (___) from outside facility:
Infiltrate in the R upper lobe
- CXR (___):
Left midlung and basilar parenchymal opacities as well as less
conspicuous right lung parenchymal opacities. Findings may
represent multifocal pneumonia though edema would be possible.
- EKG (___): RBBB, no evidence of ischemia
Patient received:
___ 13:45 IV CefePIME 2g
___ 14:25 IV Vancomycin 1500mg
Consults: None
Vitals on transfer:
Upon arrival to ___, patient is alert. She understands that she
is in the hospital and can mouth words to me. She denies any
fevers/chills, shortness of breath, chest pain, abdominal pain,
N/V.
Past Medical History:
THROMBOCYTOPENIA
CONSTIPATION
CORONARY ARTERY DISEASE
DEPRESSION
END-STAGE RENAL DISEASE s/p RENAL TRANSPLANT
ESOPHAGEALDYSMOTILITY
GASTROPARESIS (R/O)
GERD/DYSPHAGIA
HYPERTENSION
INC ALK PHOS
OSTEOARTHRITIS
OSTEOPENIA
VITAMIN D DEFICIENCY
GLAUCOMA
COLON POLPYS
INSOMNIA
URINARY INCONTINANCE
PRE-DIABETES
SUBDURAL HEMATOMA s/p craniotomy
with Dr. ___ on ___
H/O SHINGLES
Social History:
___
Family History:
Multiple family members with DM2, Mom with HTN
Physical Exam:
ADMISSION PHYSICAL EXAM
=========================
VITALS: T: 99.0 HR: 88 BP:165/92 RR:22 SpO2:99% on CMV
GENERAL: Ill appearing woman in NAD.
HEENT: Tracheostomy. Sclera anicteric, MMM. Has noticeable white
hyper-keratinization vs. thrush in oropharynx.
NECK: JVP not elevated, no LAD
LUNGS: Diffuse rhonchi bilaterally with expiratory wheezes
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. Surgical scar
over mid abdomen.
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
NEURO: Grossly intact
ACCESS: R PICC
DISCHARGE PHYSICAL EXAM
=========================
VITALS: Reviewed in Metavision
GENERAL: Ill appearing woman in NAD.
HEENT: Tracheostomy. Sclera anicteric, MMM. Has noticeable white
hyper-keratinization vs. thrush in oropharynx.
NECK: JVP not elevated, no LAD
LUNGS: Diffuse rhonchi bilaterally with end expiratory wheezes
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. Surgical scar
over mid abdomen s/p DDRT.
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
NEURO: Grossly intact
ACCESS: R PICC
Pertinent Results:
ADMISSION LABS
==============
___ 12:01PM BLOOD WBC-10.4*# RBC-3.10* Hgb-8.8* Hct-30.2*
MCV-97 MCH-28.4 MCHC-29.1* RDW-16.7* RDWSD-58.3* Plt Ct-70*
___ 12:01PM BLOOD Neuts-69.0 Lymphs-14.7* Monos-15.6*
Eos-0.1* Baso-0.1 NRBC-0.3* Im ___ AbsNeut-7.19*#
AbsLymp-1.53 AbsMono-1.63* AbsEos-0.01* AbsBaso-0.01
___ 12:34PM BLOOD ___ PTT-21.0* ___
___ 12:01PM BLOOD Glucose-149* UreaN-43* Creat-1.0 Na-143
K-5.0 Cl-101 HCO3-29 AnGap-13
___ 12:01PM BLOOD ALT-46* AST-40 AlkPhos-133* TotBili-0.5
___ 12:01PM BLOOD cTropnT-0.01 proBNP-6909*
___ 12:01PM BLOOD Albumin-3.9 Calcium-10.1 Phos-4.5 Mg-2.0
RADIOLOGIC STUDIES
==================
CXR ___:
Left midlung and basilar parenchymal opacities as well as less
conspicuous
right lung parenchymal opacities. Findings may represent
multifocal pneumonia though edema would be possible.
MICROBIOLOGY
=================
Blood cultures ___ - pending
URINE CULTURE (Final ___:
YEAST. >100,000 CFU/mL.
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Cepheid nucleic
acid
amplification assay.
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN
GRAM STAIN (Final ___:
<10 PMNs and <10 epithelial cells/100X field.
2+ ___ per 1000X FIELD): GRAM POSITIVE ROD(S).
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Final ___:
SPARSE GROWTH Commensal Respiratory Flora.
GRAM NEGATIVE ROD(S). SPARSE GROWTH.
MRSA SCREEN (Final ___: No MRSA isolated.
Respiratory Viral Culture (Final ___:
No respiratory viruses isolated.
Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
1,2 & 3, and Respiratory Syncytial Virus..
Detection of viruses other than those listed above will
only be
performed on specific request. Please call Virology at
___
within 1 week if additional testing is needed.
Respiratory Viral Antigen Screen (Final ___:
Negative for Respiratory Viral Antigen.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
and RSV by immunofluorescence.
Refer to respiratory viral culture and/or Influenza PCR
(results
listed under "OTHER" tab) for further information..
DISCHARGE LABS
==============
___ 03:54AM BLOOD WBC-7.0 RBC-2.87* Hgb-8.1* Hct-27.3*
MCV-95 MCH-28.2 MCHC-29.7* RDW-16.4* RDWSD-57.0* Plt Ct-79*
___ 03:02AM BLOOD Neuts-60.6 ___ Monos-18.0*
Eos-0.4* Baso-0.1 Im ___ AbsNeut-4.10 AbsLymp-1.39
AbsMono-1.22* AbsEos-0.03* AbsBaso-0.01
___ 03:54AM BLOOD Plt Ct-79*
___ 03:02AM BLOOD ___ PTT-33.4 ___
___ 11:08AM BLOOD Glucose-158* UreaN-39* Creat-1.0 Na-146
K-3.8 Cl-101 HCO3-31 AnGap-14
___ 11:08AM BLOOD Calcium-10.0 Phos-4.0 Mg-2.2
___ 09:03AM BLOOD tacroFK-6.0
Brief Hospital Course:
Ms. ___ is a ___ year-old lady with extensive PMH including
chronic respiratory failure s/p tracheostomy, multiple
intracranial bleedings in the past year, seizure disorder, afib,
CAD, ESRD s/p DDRT (on tacrolimus/prednisone), recurrent C. Diff
infections, who was admitted to the FICU with fever and dyspnea
c/f HAP.
=============
ACTIVE ISSUES
=============
# Acute on chronic mixed hypercarbic and hypoxemic respiratory
failure
# HCAP
# Volume overload
# S/p previous tracheostomy
Fever, leukocytosis, and RUL infiltrate on chest X-ray most
consistent with developing pneumonia. Treated initially with
vancomycin/cefepime. Vanc was discontinued when MRSA was
negative. Cefepime was continued for 8 day ___,
PICC placed ___. She was treated with nebulizers, and diuresed
with Lasix 160mg IV q6h with good effect. Legionella, flu
negative. Discharged on torsemide 40mg daily with plans to
uptitrate as needed.
# Recurrent C. Diff Infections
Developed frequent watery diarrhea during last admission. C.
difficile PCR positive (along with multiple other positive
stools). Repeat C. diff negative. Given recurrent c. diff
infection while on antibiotics, current immunosuppression, and
persistent diarrhea, continued prophylactic treatment on
antibiotics. Started on PO vancomycin with planned course to
continue through last day of Cefepime, ___.
=================
CHRONIC ISSUES
=================
# Seizure Disorder
Continued home lacosamide, keppra
# HTN
Continued home labetalol 300mg Q6 for BP control. Stopped
Metoprolol
# Atrial Fibrillation (not on AC)
In A fib, rates 70-100. Held home metoprolol as HRs decreased to
___
# ESRD s/p DDRT
Continued home prednisone and tacrolimus.
# CAD
Continued home ASA 81mg
# Thrombocytopenia/Anemia
No evidence of bleeding
# Esophageal Dysmotility and Gastroparesis s/p G tube
Continued tube feeds
# GERD
Continued home pantoprazole
===================
TRANSITIONAL ISSUES
===================
- Will need to complete one more dose of IV Cefepime (___) to
complete 8 day course for healthcare associated pneumonia
(___)
- Discharged on Torsemide 40mg po given need for Lasix 160mg IV
for diuresis. Please uptitrate as needed and check BMP at least
twice weekly. Discharge weight: 75.7kg
- Continue PO Vancomycin antibiotics for prophylaxis given
recurrent C Diff until ___ (last day of Cefepime).
- Discharged on decreased dose of tacrolimus (3mg BID) due to
elevated levels while admitted.
- Discharged on labetalol for HTN. Held metoprolol given normal
rates and normotensive here. Trying to avoid using 2 beta
blockers simultaneously.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing,
shortness of breath
2. Aspirin 81 mg PO DAILY
3. Labetalol 600 mg PO Q6H
4. LACOSamide 100 mg PO BID
5. LevETIRAcetam 1500 mg PO BID
6. Nystatin Oral Suspension 5 mL PO QID
7. PredniSONE 5 mg PO DAILY
8. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
9. Tacrolimus 3 mg PO QPM
10. Tacrolimus 4 mg PO DAILY
11. Pantoprazole (Granules for ___ ___ 40 mg G TUBE DAILY
12. Metoprolol Tartrate 50 mg PO Q6H
13. GuaiFENesin 10 mL PO Q6H
14. Acetaminophen 650 mg PO Q4H:PRN pain or temp > ___
15. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES TID
16. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
17. melatonin 1 mg oral qhs
18. Multivitamins W/minerals Liquid 15 mL PO DAILY
19. Heparin 5000 UNIT SC BID
20. Ipratropium-Albuterol Neb 1 NEB NEB Q2H
Discharge Medications:
1. CefePIME 1 g IV Q12H Duration: 1 Dose
2. Torsemide 40 mg PO DAILY
3. Vancomycin Oral Liquid ___ mg PO BID Duration: 1 Day
Last day ___. Tacrolimus 3 mg PO Q12H
5. Acetaminophen 650 mg PO Q4H:PRN pain or temp > ___
6. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing,
shortness of breath
7. Aspirin 81 mg PO DAILY
8. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES TID
9. GuaiFENesin 10 mL PO Q6H
10. Heparin 5000 UNIT SC BID
11. Ipratropium-Albuterol Neb 1 NEB NEB Q2H
12. Labetalol 600 mg PO Q6H
13. LACOSamide 100 mg PO BID
14. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
15. LevETIRAcetam 1500 mg PO BID
16. melatonin 1 mg oral qhs
17. Multivitamins W/minerals Liquid 15 mL PO DAILY
18. Nystatin Oral Suspension 5 mL PO QID
19. Pantoprazole (Granules for ___ ___ 40 mg PO DAILY
20. PredniSONE 5 mg PO DAILY
21. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
PRIMARY DIAGNOSES
=================
Acute on Chronic Mixed Hypercarbic Hypoxemic Respiratory Failure
Pneumonia
SECONDARY DIAGNOSES
===================
Recurrent C Diff Infections
Seizure disorder
HTN
ESRD s/p DDRT
Atrial Fibrillation
CAD
Discharge Condition:
Activity Status: Bedbound.
Level of Consciousness: Lethargic but arousable.
Mental Status: Confused - always.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital with fever and shortness of
breath, and you were put on a machine to help you breathe. You
were probably having trouble breathing because there was an
infection and fluid in your lungs. We treated your infection
with antibiotics for 8 days. You will need one more dose of your
antibiotic on ___ to complete your treatment. We also gave you
pills that helped you get fluid out of your lungs. You will have
to take a new medication, called torsemide, everyday to keep
this fluid out of your lungs. It will also be helpful to weigh
yourself every morning. If your weight increases by more than 3
pounds, you should call your doctor.
It was a pleasure to care for you,
Your ___ Team
Followup Instructions:
___
|
19585869-DS-33
| 19,585,869 | 25,381,596 |
DS
| 33 |
2152-05-17 00:00:00
|
2152-05-19 10:32:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Ampicillin / Benadryl / Codeine / Bactrim / Zantac
/ pineapple
Attending: ___.
Chief Complaint:
Cardiac Arrest
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with extensive PMHx of chronic respiratory failure s/p
tracheostomy, multiple intracranial bleedings in the past year
including traumatic subdural hemorrhage with resultant
encephalopathy and seizures, afib (not on AC), CAD, ESRD s/p
DDRT (on tacrolimus), recurrent C. Diff infections who presents
as transfer from ___ after cardiac arrest which occurred
most likely in setting of trach dislodgment and hypoxemia.
Past Medical History:
THROMBOCYTOPENIA
CONSTIPATION
CORONARY ARTERY DISEASE
DEPRESSION
END-STAGE RENAL DISEASE s/p RENAL TRANSPLANT
ESOPHAGEALDYSMOTILITY
GASTROPARESIS (R/O)
GERD/DYSPHAGIA
HYPERTENSION
INC ALK PHOS
OSTEOARTHRITIS
OSTEOPENIA
VITAMIN D DEFICIENCY
GLAUCOMA
COLON POLPYS
INSOMNIA
URINARY INCONTINANCE
PRE-DIABETES
SUBDURAL HEMATOMA s/p craniotomy
with Dr. ___ on ___
H/O SHINGLES
Social History:
___
Family History:
Multiple family members with DM2, Mom with HTN
Physical Exam:
=======================
ADMISSION PHYSICAL EXAM
=======================
VITALS: Reviewed in metavision
GENERAL: trached on ventilator, unresponsive
HEENT: pinpoint R pupil, L fixed surgical pupil, neither pupil
reactive, symmetric face, oropharynx clear and MMM
NECK: supple, JVP not able to visualize
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs
ABD: PEG without e/o infection, no guarding or rigidity
EXT: Warm, well perfused, thread ___ pulses and 2+ radial pulses,
no edema
NEURO: Pupils as above, no movements, not withdrawing from pain.
=======================
DISCHARGE PHYSICAL EXAM
=======================
GENERAL: trached on ventilator, unresponsive
HEENT: pinpoint R pupil, L fixed surgical pupil, neither pupil
reactive, symmetric face, oropharynx clear and MMM
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs
NEURO: Pupils as above, no movements, not withdrawing from pain
Pertinent Results:
============================
ADMISSION LABORATORY STUDIES
============================
___ 08:56AM ___ 08:56AM ___ PTT-25.3 ___
___ 08:56AM WBC-17.8* RBC-3.10* HGB-8.8* HCT-29.7* MCV-96
MCH-28.4 MCHC-29.6* RDW-16.2* RDWSD-56.1*
___ 08:56AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 08:56AM CALCIUM-9.8 PHOSPHATE-4.6* MAGNESIUM-2.3
___ 08:56AM cTropnT-0.06*
___ 08:56AM LIPASE-22
___ 08:56AM UREA N-58* CREAT-1.4*
___ 09:03AM freeCa-1.19
___ 09:03AM HGB-9.5* calcHCT-29 O2 SAT-96 CARBOXYHB-3 MET
HGB-0
___ 09:03AM GLUCOSE-175* LACTATE-4.3* NA+-144 K+-4.1
CL--106
___ 11:35AM WBC-15.4* RBC-3.05* HGB-8.6* HCT-29.0* MCV-95
MCH-28.2 MCHC-29.7* RDW-16.2* RDWSD-55.9*
___ 11:35AM GLUCOSE-278* UREA N-60* CREAT-1.3* SODIUM-145
POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-23 ANION GAP-18
============================
DISCHARGE LABORATORY STUDIES
___ 02:25AM BLOOD WBC-10.1* RBC-2.61* Hgb-7.2* Hct-24.4*
MCV-94 MCH-27.6 MCHC-29.5* RDW-15.9* RDWSD-53.5* Plt Ct-83*
___ 02:25AM BLOOD Plt Ct-83*
___ 02:25AM BLOOD Glucose-133* UreaN-61* Creat-1.0 Na-144
K-4.0 Cl-111* HCO3-18* AnGap-15
___ 02:25AM BLOOD Calcium-9.6 Phos-4.6* Mg-2.0
___ 09:30AM BLOOD tacroFK-7.1
___ 11:01AM BLOOD tacroFK-3.4*
___ 10:25AM BLOOD tacroFK-4.1*
___ 02:39AM BLOOD ___ Temp-36.4 pO2-47* pCO2-37
pH-7.35 calTCO2-21 Base XS--4
===============
IMAGING STUDIES
===============
---- ___ CT Head Without Contrast ----
IMPRESSION:
1. Likely mild pulmonary vascular congestion denoted by mild
cardiomegaly and prominence of the interstitial lung markings.
2. No focal consolidation.
3. The tracheostomy tube terminates 4.4 cm above the carina.
--___ EEG---------------
IMPRESSION: This telemetry captured no pushbutton activations.
It showed an
extremely low voltage background throughout, indicative of a
severe
encephalopathy and unchanged from previous recordings. There
were no focal
abnormalities or epileptiform features. There were no
electrographic seizures.
--___ Cxray --------------
IMPRESSION:
In comparison with the study of ___, the monitoring and
support
devices are unchanged. Cardiomediastinal silhouette is stable
with mild
elevation in pulmonary venous pressure. Retrocardiac
opacification is
consistent with volume loss in left lower lobe and there is
blunting of both costophrenic angles.
No definite focal consolidation. However, in the appropriate
clinical
setting, it would be difficult to unequivocally exclude
superimposed
pneumonia/aspiration, especially in the absence of a lateral
view.
Brief Hospital Course:
___ with extensive PMHx of chronic respiratory failure s/p
tracheostomy, multiple intracranial bleedings in the past year
including traumatic subdural hemorrhage with resultant
encephalopathy and seizures, afib (not on AC), CAD, ESRD s/p
DDRT (on tacrolimus), recurrent C. Diff infections who presented
as transfer from ___ after cardiac arrest which occurred
most likely in setting of trach dislodgment and hypoxemia.
# Cardiac arrest:
Most likely hypoxemic arrest I/s/o trach being dislodged.
However, given discrepencies in documentation which document
possible increasing respiratory distress overnight prior to the
incident and increasing secretions also consider aspiration and
PNA. Low trop and nonconcerning EKG. She was found to have a non
occlusive thrombus seen in the right popliteal vein found on
ultrasound on ___. CBC stable without evidence of bleeding.
Considered obtaining a VQ scan to evaluate for PE (in order to
avoid contrast) and IVC filter, but ultimately did not pursue
this given her non-resolution of mental status. She should have
repeat labs within 1 week of discharge: recommend CBC, BMP,
LFTs.
#AMS:
The patient presented to us non-responsive after her ROSC. She
was cooled and rewarmed after 24 hours. We waited for 72 hours
for repeat neuro examination. Despite being able to breath on
her own, the patient maintained no other brainstem reflexes.
Neurology was consulted and saw no signs of brain activity on
EEG. The pt was maintained on her home lacosamide and keppra.
Family meeting was held between primary MICU team, consulting
neurology team, and patient's family members - daughter/HCP and
granddaughter - to discuss prognosis and care plan. It was
shared with family that given the minimal EEG activity and
clinical exam lacking in multiple basic brainstem reflexes,
there was minimal change for
any significant recovery. Patient's daughter and granddaughter
voiced appropriate understanding of this and explained that
after discussion with other family members, decision was made to
not withdraw any care and to continue supporting Ms. ___
through mechanical ventilation and medical therapies. They did
re-affirm that she was to remain DNR.
#ESRD s/p renal transplant:
The patient developed ___ on CKD with decreased urine output.
Differential included prerenal vs. ATN I/s/o arrest. Renal
transplant followed the pt throughout her admission. She was
kept on her rejection meds and was dosed daily. Other
medication was renally dosed. Her Cr improved towards discharge.
Her discharge Cr was 1.0. HER DISCHARGE TACROLIMUS DOSE WAS 4MG
BID AFTER SOME ADJUSTMENT. PLEASE REPEAT TACRO LEVEL IN 1 WEEK.
___ CLINIC WILL BE IN CONTACT TO FOLLOW-UP THE LEVEL AND
ADJUST DOSING AS NEEDED.
#HEMATURIA
Hematuria noted in foley day prior to discharge, no significant
clots and small amount. Good urine output. Cleared with
irrigation. Recommend urology follow-up.
#Possible E. Coli Pneumonia:
The pt began to have a fever, worsening white count and e. coli
on sputum culture ___. We treated the pt for a time with for a
VAP with a course of Meropenem, but eventually discontinued
antibiotics due to patient being afebrile with clinical
improvement. Subsequently stable. Abx discontinued ___.
#Hypernatremia:
Urine studies not consistent with DI. Her sodium levels
responded well to changing feeds to nepro and increasing free
water flushes. SEE DISCHARGE NUTRITION RECS BELOW.
#Recent ICH:
Hx of subdural hematoma after fall which required evacuation,
recently with R thalamic IPH ___ with significant neuro
deficits at baseline.
- Labetolol 600mg PO CHANGED TO q8H
=================
CHRONIC ISSUES
=================
# Seizure Disorder
- home lacosamide, keppra at new dose (500 BID)
# Atrial Fibrillation (not on AC)
- Currently in sinus rhythm, not on a/c given multiple had
bleeds.
# CAD
- home ASA 81mg
# Thrombocytopenia/Anemia: currently stable, would CTM for now.
- Recommend repeat labs as above
# GERD
- home pantoprazole
TRANSITIONAL ISSUES:
- She should have repeat labs within 1 week of discharge:
recommend CBC, BMP, LFTs.
- HER DISCHARGE TACROLIMUS DOSE WAS 4MG BID AFTER SOME
ADJUSTMENT. PLEASE REPEAT TACRO LEVEL IN 1 WEEK. ___ CLINIC
WILL BE IN CONTACT TO FOLLOW-UP THE LEVEL AND ADJUST DOSING AS
NEEDED.
- Discharged on Nystatin for thrush, continue until ___ or
until clinical improvement
- Discharge nutrition recs:
Continuous tubefeeding: Nepro; Full strength
Tube Type: Orogastric tube (OGT); Placement confirmed.
Starting rate: 10 ml/hr; Advance rate by 10 ml q6h Goal rate: 40
ml/hr
Residual Check: Not indicated for tube type
Flush w/ 30 mL water Per standard
Free water amount: 100 mL; Free water frequency: Q4H
- Check BMP every other day for first week after discharge,
particular attention to sodium levels with adjustment of free
water as needed
- Labetolol 600mg PO CHANGED TO q8H
- Keppra at new dose (500 BID)
- HELD torsemide as she was not needing diuresis, please
re-assess volume status and decide if need to restart torsemide
- FOLLOW-UP WITH UROLOGY for hematuria without obstruction or
significant clots (foley irrigated and cleared prior to
discharge)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q4H:PRN pain or temp > ___
2. Aspirin 81 mg PO DAILY
3. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES TID
4. GuaiFENesin 10 mL PO Q6H
5. Heparin 5000 UNIT SC BID
6. Ipratropium-Albuterol Neb 1 NEB NEB Q2H:PRN SOB
7. Labetalol 600 mg PO Q6H
8. LACOSamide 100 mg PO BID
9. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
10. LevETIRAcetam 1500 mg PO BID
11. Nystatin Oral Suspension 5 mL PO QID
12. Pantoprazole (Granules for ___ ___ 40 mg PO DAILY
13. PredniSONE 5 mg PO DAILY
14. Tacrolimus 3 mg PO Q12H
15. Torsemide 20 mg PO BID
16. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing,
shortness of breath
17. melatonin 1 mg oral qhs
18. Multivitamins W/minerals Liquid 15 mL PO DAILY
19. Acetylcysteine 20% ___ mL NEB Q6H:PRN increased secretions
20. Bisacodyl 10 mg PR QHS:PRN constipation
21. Fleet Enema (Saline) ___AILY:PRN constipation
Discharge Medications:
1. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
2. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
3. LevETIRAcetam 500 mg PO Q12H
4. Tacrolimus 4 mg PO Q12H
5. Acetaminophen 650 mg PO Q4H:PRN pain or temp > ___
6. Acetylcysteine 20% ___ mL NEB Q6H:PRN increased secretions
7. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing,
shortness of breath
8. Aspirin 81 mg PO DAILY
9. Bisacodyl 10 mg PR QHS:PRN constipation
10. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES TID
11. Fleet Enema (Saline) ___AILY:PRN constipation
12. GuaiFENesin 10 mL PO Q6H
13. Heparin 5000 UNIT SC BID
14. Ipratropium-Albuterol Neb 1 NEB NEB Q2H:PRN SOB
15. Labetalol 600 mg PO Q6H
16. LACOSamide 100 mg PO BID
17. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
18. melatonin 1 mg oral qhs
19. Multivitamins W/minerals Liquid 15 mL PO DAILY
20. Nystatin Oral Suspension 5 mL PO QID
21. Pantoprazole (Granules for ___ ___ 40 mg PO DAILY
22. PredniSONE 5 mg PO DAILY
23. HELD- Torsemide 20 mg PO BID This medication was held. Do
not restart Torsemide until your doctor tells you
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
#Cardiac arrest due to hypoxia
#Hypernatremia
#Anemia
#Ventilator associated pneumonia
Discharge Condition:
Mental status/Level of consciousness: No signs of neurologic
recovery after cardiac arrest
Activity Status: Bedbound.
Discharge Instructions:
Ms. ___,
You were admitted to ___ because you did not get enough oxygen
and your heart stopped.
While you are here:
-You were treated for pneumonia
-You are treated for low blood counts
-We treated you for high blood salt levels or "hypernatremia"
-We supported your breathing with a ventilator machine
-Unfortunately you did not show signs of brain recovery
When you go home:
-Continue all medications as directed
-Follow-up with all of the listed doctors
-___ yourself every morning, call MD if weight goes up more
than 3 lbs.
We wish you the best,
Your ___ care team
Followup Instructions:
___
|
19585991-DS-16
| 19,585,991 | 26,913,244 |
DS
| 16 |
2114-10-17 00:00:00
|
2114-10-17 20:49:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
codeine
Attending: ___
Chief Complaint:
Fever, nausea
Major Surgical or Invasive Procedure:
___ left ureteral stent placement
History of Present Illness:
History obtained via chart review as patient unable to give
detailed history.
___ with history of DM2 and CKD presents from ___ memory unit
for
altered mental status. She was seen by the physician on the day
of admission and noted to be off from her baseline feeling that
she did not look well and was endorsing fevers, achiness and
dyspnea.
She was sent to ___ where her work up revealed negative
flu PCR. Her labs were notable for a Cr of 5.4 with a K of 6.3
and a grossly positive UA. She was given CTX for her UTI in
addition to calcium and NaHCO3 and transferred to ___ for
further management.
Of note, the patient has two MRNs at ___ and her electronic
data was lost upon trying to merge the two MRNs.
Labs in the ED showed hyperkalemia and ___, and a renal u/s
showed b/l renal stones with left pelvic and proximal ureter
fullness, recommend CTU. She was treated with insulin and
dextrose for hyperkalemia, as well as antibiotics for suspected
UTI, and admitted to the medical floor.
REVIEW OF SYSTEMS: 10 point ROS reviewed and negative except as
per HPI
Past Medical History:
PAST MEDICAL AND SURGICAL HISTORY:
DM2
HLD
CKD III
UC s/p colostomy
Renal calculi
Dementia
Social History:
___
Family History:
Family history of renal calculi son and daughter
also have them.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 97.9 BP 132/57 HR 76 R 18 SpO2 97 Ra
GEN: NAD
HEENT: Dry mucous membranes
___: RRR No MRG
RESP: CTAB
ABD: NTND Ostomy in RLQ with brown stool output
EXT: Warm no edema
DISCHARGE PHYSICAL EXAM
24 HR Data (last updated ___ @ 1411)
Temp: 98.4 (Tm 98.4), BP: 121/65 (121-165/65-82), HR: 71
(66-71), RR: 16 (___), O2 sat: 94% (82-97)
GEN: NAD, resting calmly in bed
HEENT: Moist membranes, conjunctiva w/o pallor, no
lymphadenopathy
___: RRR No MRG
RESP: CTAB, no excess muscle use
ABD: NTND Ostomy in RLQ with brown/green stool/gas output, soft,
non-tender, non-distended, normal bowel sounds.
EXT: Warm no edema
SKIN: no rashes or cyanosis
GU: no foley
Pertinent Results:
ADMISSION LABS:
===============
___ 07:40PM BLOOD WBC-17.2* RBC-3.80* Hgb-13.0 Hct-40.0
MCV-105* MCH-34.2* MCHC-32.5 RDW-13.5 RDWSD-51.6* Plt ___
___ 07:40PM BLOOD Neuts-77.8* Lymphs-6.8* Monos-12.2
Eos-2.3 Baso-0.3 Im ___ AbsNeut-13.36* AbsLymp-1.17*
AbsMono-2.09* AbsEos-0.40 AbsBaso-0.05
___ 07:40PM BLOOD Glucose-71 UreaN-56* Creat-3.3* Na-140
K-6.2* Cl-106 HCO3-19* AnGap-15
___ 07:40PM BLOOD Albumin-3.3* Calcium-8.6 Phos-4.6* Mg-2.1
___ 12:31AM BLOOD ___ pO2-46* pCO2-48* pH-7.29*
calTCO2-24 Base XS--3 Comment-GREEN TOP
RELEVANT LABS:
==============
___ 07:40PM BLOOD VitB12-1073* Folate->20
___ 12:20AM BLOOD Hapto-299*
DISCHARGE LABS:
===============
___ 06:50AM BLOOD WBC-11.3* RBC-4.06 Hgb-13.9 Hct-42.3
MCV-104* MCH-34.2* MCHC-32.9 RDW-13.7 RDWSD-52.3* Plt ___
___ 06:50AM BLOOD Glucose-147* UreaN-28* Creat-1.4* Na-147
K-5.0 Cl-111* HCO3-22 AnGap-14
___ 06:50AM BLOOD Calcium-8.3* Phos-2.7 Mg-1.7
RELEVANT IMAGING:
=================
___ Renal US
IMPRESSION:
1. Bilateral renal stones, the largest measuring 1.2 cm in the
left kidney.
Mild left pelvic and proximal ureter fullness without frank
hydronephrosis.
Consider CT urography to assess for left distal ureteral
calculus.
2. Cyst arising from the interpolar region of the left kidney
with layering
debris measuring 7.2 x 4.6 x 7.3 cm, but no internal vascularity
or solid
elements. Other cysts in the kidneys appear simple.
___ CXR
IMPRESSION:
Lungs are low volume with bibasilar atelectasis. Right hilum is
prominent.
Cardiomediastinal silhouette is unchanged. No pneumothorax is
seen.
___ CTU Abd/Pel w/o contrast
IMPRESSION:
Bilateral renal and bladder calculi. 8 mm obstructing left mid
ureteral
calculus resulting in proximal left hydronephrosis and likely
atrophy of the
left kidney.
Age-indeterminate T10 vertebral compression fracture and
additional incidental
findings as above.
Brief Hospital Course:
___ with history of dementia and nephrolithiasis presents with
concern for altered mental status and found to have acute renal
failure with hyperkalemia.
#Acute Renal Failure
#Hyperkalemia
#Urinary Tract Infection:
#Renal Calculi
Cr reportedly 5.7 at ___ with elevated K of 6.3.
Baseline CR ___. No reported ECG changes. Received insulin,
calcium, kayexalate and NaHCO3. Labs improved w/ foley
placement. Now s/p OR procedure for stent on the left side to
relieve obstruction seen on CTU. Urine studies after stent sent
for further evaluation, but culture was negative at ___
prior to presentation. Given ceftriaxone while inpatient and
discontinued when all cultures were negative. Will follow up
with urology for lithotripsy. Cr and K improved.
#Concern for Toxic Metabolic Encephalopathy
#Hx dementia
On discussing further with family, she was not altered, and
remained at her baseline with dementia.
#HTN
-held ACEi given ___. Advised to have BP's rechecked at facility
and resume when creatinine normalizes.
#HLD
-continued atorvastatin
#DM2-on lantus and Janumet at home
-held oral agents ___ ___
-held lantus given renal failure and normal blood sugars
-treated with Humalog sliding scale which was later changed to
novolog ___ inability to obtain Humalog
-daughter in law/HCP advised to call MD/NP on call from facility
if blood glucose rises, with plans to initiate basal insulin if
needed
TRANSITIONAL ISSUES:
==================
[] Please follow glucose levels with insulin sliding scale,
restart home lantus slowly (25 would be half prior home dose) if
sugars increasing. Do not restart Janumet until Cr improves to
baseline ___ given the risk of lactic acidosis from metformin
in kidney injury.
[] Urology ___ get lithotripsy as an outpatient
[] Please get a repeat urine analysis in 1 week to check for
hematuria
[] Please get chemistry panel in 3 days to check for improvement
in Cr and potassium
[] Consider restarting lisinopril if kidney function has
returned to baseline
[] Check hemoglobin a1c with next lab check to evaluate status
of her diabetes
Discharge Cr: 1.4
Discharge K+: 5.0
Code status: DNR/DNI (ok for procedures), MOLST will travel w/
patient
HCP: Daughter-in-law ___
Time spent coordinating the discharge of this patient: 50
minutes
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 80 mg PO QPM
2. Lisinopril 5 mg PO DAILY
3. Janumet (SITagliptin-metformin) 50-500 mg oral DAILY
4. Aspirin 81 mg PO DAILY
5. Vitamin D ___ UNIT PO DAILY
6. Glargine 50 Units Bedtime
Discharge Medications:
1. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using HUM Insulin
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Vitamin D ___ UNIT PO DAILY
5. HELD- Janumet (SITagliptin-metformin) 50-500 mg oral DAILY
This medication was held. Do not restart Janumet until
creatinine improves
6. HELD- Lisinopril 5 mg PO DAILY This medication was held. Do
not restart Lisinopril until creatinine improves to baseline
___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
==============
Obstructing renal calculi
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital because you were having fevers
and abdominal pain.
What did we do for you while you were here?
- You received antibiotics because there was concern you had a
urinary tract infection, but we found no infection so the
antibiotics were discontinued
- A ultrasound of your kidneys and a CT scan of your kidneys
showed dilation of your left kidney and concern for a stone
blocking your urine from being able to enter your bladder
- You went to the operating room to have a left stent placed
inside your bladder to allow urine to drain.
What do you need to do when you go home?
- Follow up with your doctors as ___
- ___ your medications as scheduled.
It was a pleasure taking care of you!
Your ___ Care Team
Followup Instructions:
___
|
19586186-DS-11
| 19,586,186 | 24,861,560 |
DS
| 11 |
2156-06-09 00:00:00
|
2156-06-09 13:05:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Ciprofloxacin / Bactrim / Percocet
Attending: ___.
Chief Complaint:
Vision loss, right arm weakness
Major Surgical or Invasive Procedure:
Lumbar puncture
History of Present Illness:
Mr. ___ is a ___ year-old right-handed man with a history of
hypertension and recent diagnosis of sarcoidosis (biopsy proven)
who presents with 2 weeks of right eye blurring and
retro-orbital
pressure, and 1 day of right-sided weakness and transient right
arm numbness.
He initially presented in early ___ with cough and was
then found to have mediastinal, bilateral hilar, and right
supraclavicular lymphadenopathy, and granulomas in the RUL. He
underwent mediastinal endoscopy on ___ at ___. The cough
for which he initially presented improved on Flovent.
About 1 week later, ___, he noticed monocular blurring of
vision in his right eye. A few days later he developed a
pressure
sensation behind his right eye and cheek. It was initially only
noticeable, but has become progressively more painful. He
describes the facial pain as "something wanting to explode out
of
my head". It is not exacerbated by laying flat, bending over,
coughing or bearing down. It is present constantly throughout
the
day, though he is able to fall asleep despite it. His vision
continued to worsen as well, and on ___ he was seen by an
ophthalmologist who told him he had optic nerve swelling and
hemorrhages on the right. He recommended an MRI of the orbits to
be done as an outpatient.
Yesterday, while he was at work on the ___ floor of a ___, he attempted to move a dishwashing machine -- something
he
had done many times -- and felt that his right arm was not as
strong as usual. He favors his right arm and leg, but was unable
to use his right arm to move the machine, and couldn't rely on
that leg as well. This new weakness, in addition to the
progressively worsening facial pain, and delays in scheduling an
outpatient MRI, are what led him to the ED today. On his way to
the emergency department, he developed numbness in his right arm
which onset over the course of ~1 minute, seeming to start from
the wrist and go up his arm.
He does have a history of migraine, however these occur once
every few years, are associated with lateralized throbbing pain
and phonophobia. He has never had any focal neurological
symptoms
with his migraines, and the facial pain he currently describes
is
completely unlike his migraines.
Neuro ROS: As per HPI.
Past Medical History:
PMHx:
BPH
HTN
PSHx:
___ Laser vaporization of the prostate.
Social History:
___
Family History:
non-contributory
Physical Exam:
On admission:
-Vitals: T:98 BP:184/90 HR:80 RR:18 SaO2:100%
-General: Awake, cooperative, NAD.
-HEENT: NC/AT. No scleral icterus noted. MMM. No lesions noted
in
oropharynx.
-Neck: Supple.
-Cardiac: Well perfused.
-Pulmonary: Breathing comfortably on room air.
-Abdomen: Soft, NT/ND.
-Extremities: No cyanosis, clubbing, or edema bilaterally.
-Skin: No rashes or other lesions noted.
NEUROLOGIC EXAM:
-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 are no paraphasic errors.
Speech is not dysarthric. Able to follow both midline and
appendicular commands. Able to register 3 objects and recall ___
at 5 minutes. Had good knowledge of current events. There is no
evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. Right eye ___ acuity, and
inferior altitudinal field cut (unlikely significant given
intraocular pathology). Unable to visualize fundus.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Slightly decreased (80% of normal) to LT,PP,T in right V2,V3
VII: No facial droop, facial musculature symmetric. Mild Rt.
enophthalmus.
VIII: Hearing intact to finger rub.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline and equal strength bilaterally.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
No
asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ ___ 5 5 5
R 4 4+ 4+ ___- 5- 4+ 4+ 4+
* Right give-way weakness (?sensory vs volitional).
-Sensory: Slightly decreased (80-90% of normal) sensation to
LT,PP,T in right-sided extremities. Proprioception intact at
bilateral great toes and index fingers. Vibration detected for
>15 seconds at medial malleoli bilaterally. No extinction to
DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2+ 1 2+ 2 2
R 2+ 1 2+ 2 2
* Pectoral jerks present bilaterally
* Plantar response was mute bilaterally
-Coordination: Mild intention tremor bilaterally on FNF. Able to
continue FNF with eyes closed. No dysmetria on FNF or HKS. No
dysdiadochokinesia. Rapid finger tapping intact and with good
speed.
-Gait: Deferred.
====
On discharge:
OBJECTIVE
Physical exam
VS: reviewed in OMR, afebrile
Gen: NAD, patient sitting outside of room
HEENT: NCAT, small ~5mm R anterior cervical LN
CV: Well perfused, S1 S2, no m/r/g
RESP: Normal work of breathing on RA, CTAB
ABD: Soft, NT, slightly distended
EXT: Warm, no edema, ___, +DP
Neuro exam
MS: Alert and oriented to person, place, and time. Able to
relate
history without difficulty. Attentive to conversation. Speech is
fluent with full sentences, intact repetition, and intact verbal
comprehension. No paraphasias. No dysarthria. Normal prosody.
No
evidence of hemineglect. No left-right confusion.
CN: PERRL.
II, III, IV, VI - right eye ___ at 6 feet, near vision right
eye ___. Right eye blind spot similar to examiner, improved
compared to previously. PERRL. EOMI. VFs full to moving
fingers.
No nystagmus. R eye papilledema.
V - not tested
VII - No facial droop, facial musculature symmetric. Rt./ mild
enophthalmus continues.
VIII - Hearing loss to high, but not low, frequency on R at <1
inch. L finger rub ~18 inches.
IX, X - Palate elevates symmetrically.
XI - SCM/Trapezius strength ___ b/l.
XII - Tongue midline.
Motor: Normal bulk and tone. No drift. Low amplitude, low
frequency intention tremor R > L. No asterixis. Improved R sided
motor function.
[___]
L 5 5 5 5 ___ 5 ___ 5
R 5 5- 5 5- ___ 5 ___ 5
Reflexes: deferred today, ___:
[Bic] [Tri] [___] [Quad] [___]
L 2 2 2 2 2
R 2 2 2 2 2
Plantar response flexor bilaterally
Sensation: deferred
Coordination: No dysmetria with finger to nose testing b/l.
Gait: Normal initiation. Narrow base. Normal stride length and
arm swing. Stable without sway. Intact heel and toe walking,
intact tandem gait.
Pertinent Results:
___ 05:30AM BLOOD WBC-9.7 RBC-4.73 Hgb-13.0* Hct-39.3*
MCV-83 MCH-27.5 MCHC-33.1 RDW-13.6 RDWSD-41.3 Plt ___
___ 09:45PM BLOOD Neuts-54.3 ___ Monos-9.2 Eos-6.9
Baso-0.4 Im ___ AbsNeut-3.91 AbsLymp-2.08 AbsMono-0.66
AbsEos-0.50 AbsBaso-0.03
___ 05:30AM BLOOD Glucose-128* UreaN-17 Creat-0.7 Na-143
K-4.0 Cl-103 HCO3-26 AnGap-14
___ 09:45PM BLOOD ALT-12 AST-20 AlkPhos-72 TotBili-0.5
___ 09:45PM BLOOD Lipase-26
___ 05:15AM BLOOD Calcium-9.3 Phos-3.4 Mg-2.2
___ 09:45PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
CSF:
WBC 0 RBC 0 Poly 0 Lymph 0 Protein 33 Glucose 70
NCHCT: No evidence of mass, hemorrhage or infarction. Normal
head CT
MRI C-spine:
1. No abnormal enhancement or signal of the cord to suggest
sarcoidosis or
other process.
2. Mild multilevel cervical spondylosis, most prominent at C5-C6
where
degenerative changes and congenital shortening of the pedicles
results in
moderate spinal canal narrowing, remodeling the ventral aspect
of the cord. There is also bilateral mild neural foraminal
narrowing secondary to
uncovertebral and facet arthropathy.
3. Mild to moderate left C6-C7 neural foraminal narrowing is
also visualized.
4. Additional findings as described above.
MRI brain and orbits:
1. Findings compatible with mild right optic neuritis and
___. Mild right orbital fatty inflammatory stranding
is noted. Overall the findings are compatible with given
history of sarcoidosis. Clinical correlation is recommended.
2. The left orbit, bilateral cisternal orbital nerves, optic
chiasm and optic tracts are unremarkable.
3. There is no evidence of intracranial abnormal enhancement.
No acute
infarct.
4. Minimal periventricular and subcortical T2/FLAIR white matter
hyperintensities are nonspecific, but compatible with chronic
microangiopathy in a patient of this age.
5. Paranasal sinus disease as described above.
MRI IAC with and without contrast:
1. No abnormal vestibulocochlear or labyrinthine enhancement.
2. Paranasal sinus disease.
CXR: No acute intrathoracic process.
CTA head/neck:
1. Normal head and neck CTA.
2. Multiple enlarged conglomerate mediastinal lymph nodes
measuring up to 3.8 x 2.2 cm likely correlate with the patient's
recent diagnosis of sarcoidosis.
3. Moderate inflammatory changes of the ethmoid air cells and
left frontal
sinus.
Brief Hospital Course:
Mr. ___ is a pleasant ___ right handed man with
recently diagnosed biopsy proven sarcoid who presents with right
eye vision loss and right sided weakness.
A few months ago, he developed a cough. CXR was negative and he
was given a steroid pack, which improved the cough. Cough
returned, and a CT chest was obtained that showed hilar
lymphadenopathy. A subclavicular lymph node and hilar lymph node
were biopsied and revealed noncaseating granulomas suggestive of
sarcoid. He denies any recent travel. ___ years ago, he worked
with insulation and was exposed to fiberglass and cellulose.
Endorses weight loss of 5 pounds over months, and it was
intentional.
On ___, he developed floaters in his vision that worsened after
several days. He felt like a piece of wax paper was covering his
right eye. His vision deteriorated over ___ days. Developed
pressure on the right side of her head without eye pain. Wife
noted right eye ptosis 3 days prior to admission.
He then felt as though his right side was weak the day prior to
admission. For example, he was trying to move a dishwasher at
work with his right arm but was unable to. Able to do so with
his
left arm. Later that night, he felt that his right arm was numb
from his wrist to his elbow. This is what brought him to the
emergency room. The sensation of numbness resolved on arrival to
the ED.
For PMH, PSH, FHx, medications, and allergies, please see
neurology admission note by Dr. ___.
On initial exam, mental status was unremarkable. On cranial
nerve
exam, he had decreased vision in his right eye to where he was
unable to make out the letter E on the vision card. R
papilledema, some blurring of optic disc margins on L but no
frank edema. ?R NLFF that activates symmetrically, unclear if
this is baseline. Decreased hearing on the right to high
frequency sounds, intact to low frequency sounds. Subtle R
pronator drift, and RUE/RLE were slightly weaker than LUE/LLE in
UMN (5- on the right vs 5 on the left). Sensation, coordination,
and gait were intact.
MRI brain/orbit/c-spine/IAC were performed and showed mild optic
neuritis and ___ with right orbital fatty inflammatory
stranding compatible with sarcoidosis. C spine was unremarkable.
A lumbar puncture was performed that showed 0 WBC, 0 RBC, 33
protein, 70 glucose. CSF ACE was negative. An IEP showed 0
bands.
He was given 5 days of IV methylprednisolone and tolerated this
well. Developed some mild hypertension that was managed with
7.5mg amlodipine. He also required small amounts of sliding
scale
insulin from hyperglycemia ___ steroids. Also was irritable and
restless in the setting of steroids, which improved with Ativan.
His vision improved to ___- in his right eye on distance
testing
at 6ft. Has an enlarged blind spot in the right eye that is
improving and another blind spot infero-laterally. Right
hemiparesis significantly improve in Rt. UE and resolve in Rt.
___.
Rt. facial numbness was revealed to have been incurred at the
time
of dental surgery and was therefore thought to be irrelevant.
Rt. hearing loss came up during the hospitalization as he
recalled a
recent abrupt onset. It was found to involve the higher
frequencies.
IAC MRI w/wo unrevealing and W/U of probable sarcoid-related
hearing loss otherwise deferred to the out patient setting.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fluticasone Propionate 110mcg 2 PUFF IH BID
2. Omeprazole 20 mg PO DAILY
3. amLODIPine 5 mg PO DAILY
4. Benzonatate 200 mg PO TID
5. Vitamin B Complex 1 CAP PO DAILY
Discharge Medications:
1. LORazepam 0.5 mg PO QAM
RX *lorazepam 0.5 mg 1 tab by mouth twice a day Disp #*60 Tablet
Refills:*0
2. PredniSONE 100 mg PO DAILY Duration: 2 Doses
Start: Tomorrow - ___, First Dose: First Routine
Administration Time
This is dose # 1 of 3 tapered doses
RX *prednisone 20 mg ___ tablet(s) by mouth daily Disp #*105
Tablet Refills:*3
3. PredniSONE 80 mg PO DAILY Duration: 7 Doses
Start: After 100 mg DAILY tapered dose
This is dose # 2 of 3 tapered doses
4. PredniSONE 70 mg PO DAILY Duration: 7 Doses
Start: After 80 mg DAILY tapered dose
This is dose # 3 of 3 tapered doses
5. PredniSONE 60 mg PO DAILY
Start: After last tapered dose completes
This is the maintenance dose to follow the last tapered dose
6. amLODIPine 7.5 mg PO DAILY
RX *amlodipine 2.5 mg 3 tablet(s) by mouth daily Disp #*90
Tablet Refills:*3
7. Benzonatate 200 mg PO TID
8. Fluticasone Propionate 110mcg 2 PUFF IH BID
9. Omeprazole 20 mg PO DAILY
10. Vitamin B Complex 1 CAP PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Neurosarcoidosis and orbital sarcoidosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted because of right eye vision loss and right
sided weakness. Because of your recently diagnosed sarcoid, we
feel like the two processes are related and you likely have
sarcoid affecting your eye. We performed an MRI of your brain
and cervical spine, showed a right optic neuritis and
___ consistent with an inflammatory process such as
sarcoidosis. Your MRI of your cervical spine was unremarkable.
We also performed a lumbar puncture, which was normal. ACE level
in your CSF was normal.
You were treated with 5 days of IV steroids, and your vision
improved. You were seen by the rheumatologists and
opthalmologists and will need to follow up with them as an
outpatient.
With regards to your steroid taper (please take your steroids in
the morning!):
___: 100mg prednisone daily (5 20mg tablets)
___: 80mg prednisone daily (4 tablets)
___: 70mg prednisone daily (3.5 tablets)
___: 60 prednisone daily unless rheumatology/pulmonary
disagrees (3 tablets)
While you are on steroids, please continue to take omeprazole
20mg to protect your stomach. You can also take Ativan as needed
for your mood. Try not to take it if you do not need it.
Your blood pressure medication amlodipine was increased from 5mg
to 7.5mg. Please follow up with your primary care physician for
further titration.
For your radiology images, please remember to call ___
on ___.
It was a pleasure taking care of you, and we wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19586428-DS-16
| 19,586,428 | 26,510,351 |
DS
| 16 |
2161-11-11 00:00:00
|
2161-11-11 21:59:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Compazine
Attending: ___.
Chief Complaint:
Gastroparesis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo M with history of longstanding type I diabetes with severe
gastroparesis, currently undergoing work up for pancreas
transplant, CAD s/p MI and stenting in ___, Grave's Disease and
depression is transferred from the ___ for nausea
and vomiting x6 weeks. The patient was admitted to ___ from
___ for abdominal pain and gastroparesis, discharged, and
was feeling better until today when he had a couple sandwiches
and again developed intractable abdominal pain and
nausea/vomiting. He returned to the ___, where he was
given zofran, reglan, and ativan, then transferred to ___ ___
for higher level of care and continuing with his GI doctors ___
(___).
In the ___, initial VS were 97, 112, 124/62, 18, 97% Room Air.
EKG with normal sinus rhythm 98, LAD, NI, New TWI in inf leads.
Labs notable only for mild baseline anemia, troponin negative.
Given IVF, zofran, and dilaudid in the ___. Of note, the patient
was not given narcotics at ___ due to concern that he was being
admitted too frequently for narcotic administration.
On arrival to the floor, patient is back in severe pain, rates
it a ___. Not feeling very nauseated. No other new complaints,
denies chest pain.
Past Medical History:
# T1DM - w/ recurrent DKA and diagnosed ___ yrs ago, being
evaluated for pancreas transplant
# Multiple recent hospitalizations for severe gastroparesis
# CAD s/p multiple stents and multiple MIs (one secondary to
cocaine abuse), last in ___
# Depression
# Benign Hypertension
# Diabetic nephropathy
# Hyperthyroidism
# Hyperlipidemia
# GERD
# hiatal hernia
# Erosive esophagitis
Social History:
___
Family History:
One cousin with diabetes.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS T 98.0, BP 140/87, HR 96, RR 18, O2 sat 100% RA
GEN middle aged male lying in bed, obviously in pain, eyes
closed
HEENT NCAT MMM EOMI sclera anicteric, OP clear
NECK supple, no JVD
PULM Good aeration, CTAB no wheezes, rales, ronchi
CV Mildly tachycardic, normal S1/S2, no mrg
ABD soft ND normoactive bowel sounds. Diffusely mild tender to
light palpation, no distension or mass over epigastrium, no r/g
EXT WWP 2+ pulses palpable bilaterally, no c/c/e
NEURO CNs2-12 intact, motor function grossly normal
SKIN no ulcers or lesions
Discharge Physical Exam:
VS: 98.4, 81, 126/78, 18, 98% RA
GEN Well built man appearing stated age. Alert, oriented, no
acute distress, laying in bed not appearing to be in pain
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, mildly tender in upper epigastrum, ND, normoactive
bowel sounds, no r/g. Small scar in epigastrum from J tube in
years past.
EXT WWP 2+ pulses palpable bilaterally, no c/c/e
NEURO CNs2-12 intact, motor function grossly normal
SKIN no ulcers or lesions
Pertinent Results:
Admission Labs:
___ 05:34PM LACTATE-1.3
___ 05:25PM GLUCOSE-266* UREA N-6 CREAT-0.7 SODIUM-133
POTASSIUM-3.9 CHLORIDE-98 TOTAL CO2-27 ANION GAP-12
___ 05:25PM ALT(SGPT)-14 AST(SGOT)-12 ALK PHOS-123 TOT
BILI-0.5
___ 05:25PM LIPASE-10
___ 05:25PM cTropnT-<0.01
___ 05:25PM WBC-6.0 RBC-4.46* HGB-13.1* HCT-38.3* MCV-86
MCH-29.4 MCHC-34.3 RDW-13.9
___ 05:25PM NEUTS-74.8* ___ MONOS-4.5 EOS-1.1
BASOS-0.7
Relevant Labs:
___ 16:10
BUN 8 Cr 0.8 Na 130* k 4.7 Cl 96 Bicarb 26
___ 11:00
BUN 7 Cr. 0.8 Na 132* K 5.3* Cl 93* Bicarb 32
CPK ISOENZYMES CK-MB cTropnT
___ 04:15 1 <0.011
Source: Line-PICC
___ 05:40 1 <0.011
Source: Line-PICC
___ 02:44 1 <0.011
___ 17:25 <0.011
URINE CHEMISTRY UreaN Creat Na K Cl
___ 09:12 271 63 95 31 91
Discharge Labs:
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
___ 04:55 ___ 134 4.5 97 33* 9
Pertinent Micro/Path:
none
Pertinent Imaging:
___ 39 ___
Cardiovascular ReportECGStudy Date of ___ 6:06:42 ___
Sinus rhythm. Inferior wall myocardial infarction of uncertain
age.
Compared to the previous tracing of ___ no diagnostic
interval change.
Brief Hospital Course:
Patient is ___ year old male with past medical history of prior
mycardial infarction and difficult to control diabetes mellitis
type 1 with gastroparesis.
Active Diagnosis:
#1 Gastroparesis: The patient was transferred to this
institution to establish specialist care after the third
hospitalization in 6 weeks at an outside institution. He was
kept NPO for the first day and treated with IV dilauded for pain
and zofran and ativan for nausea. The patient declined reglan
when it was offered, stating that he did not feel that it helped
him. After the first day his diet was advanced to clear liquids
and then to full liquids and his medications were transitioned
to PO. He tolerated this well and was advanced to a full diet
with good control of pain and nausea. He was continued on his
home nortriptyline. At discharge, he was given a prescription
for a brief course of oxycodone for pain control in the
outpatient setting.
#2 Diabetes Mellitus type I: The patient is with end organ
effects of gastroparesis and neuropathy. He was placed on
Lantus 25 BID and sliding scale (home regimen) with reduction in
lantus dosing when NPO. He was also continued on home
gabapentin.
#3 CAD: Patient is status post myocardial infarction in ___
(possibly in the setting of cocaine use). There were T wave
inversions in the area of the prior infarct but no dynamic EKG
changes or chest pain. Serial troponins and CK-MB were
negative. He was continued on home metoprolol, lisinopril, and
simvastatin and aspirin was started.
#4 Electrolye abnormalities: During his hospitalization, the
patient was found to be slightly hyponatrimic. Urine analysis
did not reveal any obvious etiology. This likely represented
pseudohyponatremia in the setting of hyperglycemia. His sodium
level normalized by the time of discharge.
Chronic Diagnosis:
#5 Depression: The patient stated that his mood was down and was
without active suicidal ideation. Reports stress in recent
breakup of his marriage. Home cymbalta was continued. He was
seen by social work during his admission.
Transitional Issues:
The patient was with poor glycemic control that will need
aggressive management in the outpatient setting.
The patient was set up with outpatient GI followup to further
investigate his gastroparesis flairs.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient med records.
1. Duloxetine 30 mg PO DAILY
2. Gabapentin 600 mg PO TID
3. Lisinopril 5 mg PO DAILY
4. Metoprolol Tartrate 25 mg PO BID
5. Nortriptyline 25 mg PO HS
6. Simvastatin 20 mg PO DAILY
7. Glargine 25 Units Breakfast
Glargine 25 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
8. Metoclopramide 10 mg PO QIDACHS
Not currently taking
9. Ondansetron 4 mg PO Q6H:PRN nausea, vomiting
10. Omeprazole 20 mg PO BID
Discharge Medications:
1. Duloxetine 30 mg PO DAILY
2. Gabapentin 600 mg PO TID
3. Glargine 25 Units Breakfast
Glargine 25 Units Dinner
4. Lisinopril 5 mg PO DAILY
5. Metoclopramide 10 mg PO QIDACHS
Not currently taking
6. Metoprolol Tartrate 25 mg PO BID
7. Nortriptyline 25 mg PO HS
8. Omeprazole 20 mg PO BID
9. Simvastatin 20 mg PO DAILY
10. Ondansetron 4 mg PO Q6H:PRN nausea, vomiting
11. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
hold for sedation, RR<10
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*15 Tablet Refills:*0
12. insulin
please resume prior sliding scale
Discharge Disposition:
Home
Discharge Diagnosis:
Gastroparesis
Diabetes Mellitus type I
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 while you were in the
hospital. As you know, you were admitted for your
gastroparesis. We gave you pain and nausea medication in your
IV and by mouth that seemed to help your symptoms. We slowly
advanced your diet and by the second day you were here you were
able to eat solid foods without too much pain or nausea.
Because you were able to eat, we think that it is safe for you
to go home and continue your treatment as an outpatient.
We also found that your potassium and sodium blood levels were
not normal yesterday. We watched you overnight and tested your
urine and found no concerning reason why this was. Your blood
levels are now normal.
We made the following changes to your medicines:
STARTED Oxycodone as needed for pain
Followup Instructions:
___
|
19586428-DS-17
| 19,586,428 | 23,487,748 |
DS
| 17 |
2161-12-16 00:00:00
|
2161-12-17 10:28:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Com___
Attending: ___.
Chief Complaint:
nausea/vomiting
Major Surgical or Invasive Procedure:
right internal jugular catheter placement
Esophagogastroduodenoscopy with botox injection of pylorus
History of Present Illness:
___ male with pmhx of T1DM complicated by gastroparesis who has
been almost constantly in the hospital for the past 6 months.
The patient was transferred to ___ in the middle of ___ after 6 week hospitalization at ___, he was then
discharged on ___ and was re-admitted to ___ the
following day. He was discharged from that hospitalization the
day prior to admission at ___. The patient says that he was
having a UGIB at ___, but he did not have any treatment and
no scopes. He says that "they were not doing anything for me
there," so when he was discharged, he had a hamburger, which he
tolerated fine. He then had a tomato soup for dinner, which was
also well tolerated. He then was up all night having nausea and
vomiting and came to the ___ ED today. He says that he has
abdominal pain which is radiating to his back. He says that this
episode is very similar to prior episodes. In the ED, he did
endorse burning chest pain but he denied this on examination in
the MICU.
In the ER, the patient had an EKG which revealed sinus
tachyardia. He had a CXR to confirm line placement after a RIJ
was placed. He received 5L in the ED but only had 200cc of urine
out (per patient report). He received pantoprazole for GERD. He
also received insulin. His troponin was negative.
In the ED, initial VS were:
96.6 141 132/94 16 100% RA
11:18 ___ 22 100%
11:41 10 118 151/84 22 100%
12:25 10 140 149/91 24 100%
12:44 8 138 22 100%
13:10 ___ 10 ___ 16 100%
15:13 9.5 97 124 149/91 14 100%
15:59 8 124 125/84 14 100%
___ 120 120/80 14 100%
___ 120 120/80 14 100%
On arrival to the MICU, the patient appeared in pain. He was
having hiccups. He was alert, oriented and appropriate.
Past Medical History:
# T1DM - w/ recurrent DKA and diagnosed ___ yrs ago, being
evaluated for pancreas transplant
# Multiple recent hospitalizations for severe gastroparesis
# CAD s/p multiple stents and multiple MIs (one secondary to
cocaine abuse), last in ___
# Depression
# Benign Hypertension
# Diabetic nephropathy
# Hyperthyroidism
# Hyperlipidemia
# GERD
# hiatal hernia
# Erosive esophagitis
Social History:
___
Family History:
One cousin with diabetes.
Physical Exam:
ADMISSION EXAM
Vitals: T:98.7 BP: 176/98 P: 130 R: 21 O2: 100%
General: Alert, oriented, appears in pain but in no acute
respiratory distress.
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: RIJ
CV: Regular rhythm, tachycardia, normal S1 + S2, no murmurs,
rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, gait deferred
DISCHARGE EXAM:
Afebrile, stable vital signs, normotensive.
General: Alert, oriented, lying in bed in no apparent distress
Neck: RIJ in place, no erythema
Chest: RRR, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, nontender, non-distended, bowel sounds present,
no organomegaly
Ext: IV line R anterior shoulder. warm, well perfused, 2+
pulses, no clubbing, cyanosis or edema
Pertinent Results:
ADMISSION STUDIES
___ 11:50AM BLOOD WBC-6.9 RBC-4.74 Hgb-13.9* Hct-41.0
MCV-87 MCH-29.4 MCHC-34.0 RDW-13.6 Plt ___
___ 11:50AM BLOOD Neuts-81.2* Lymphs-11.2* Monos-6.9
Eos-0.4 Baso-0.3
___ 06:42PM BLOOD ___ PTT-33.0 ___
___ 11:50AM BLOOD Glucose-398* UreaN-9 Creat-0.8 Na-136
K-3.3 Cl-92* HCO3-28 AnGap-19
___ 11:50AM BLOOD ALT-18 AST-15 AlkPhos-105 TotBili-0.6
___ 11:50AM BLOOD Lipase-9
___ 11:50AM BLOOD cTropnT-<0.01
___ 11:50AM BLOOD Albumin-3.6 Calcium-7.9* Phos-2.4* Mg-1.7
___ 12:04PM BLOOD Type-ART Temp-36.9 pO2-103 pCO2-30*
pH-7.56* calTCO2-28 Base XS-5 Intubat-NOT INTUBA
___ 12:02PM BLOOD Lactate-1.3
___ BLOOD CULTURE X2 PENDING
___ CXR : Multiple AP chest radiograph demonstrates a right
internal jugular catheter terminating in the low SVC. The left
PICC is no longer present. There is no pneumothorax. The lungs
are clear. The cardiomediastinal silhouette is normal.
INTERVAL/DISCHARGE STUDIES:
___ 09:54AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-1000 Ketone-40 Bilirub-NEG Urobiln-2* pH-8.5* Leuks-NEG
___ 09:54AM URINE RBC-2 WBC-1 Bacteri-NONE Yeast-NONE
Epi-<1
___ 09:54AM URINE Color-Yellow Appear-Clear Sp ___
___ 09:54AM URINE Mucous-RARE
___ 9:54 am URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: <10,000 organisms/ml.
___ 07:30AM BLOOD %HbA1c-8.8* eAG-206*
EGD REPORT ___:
Findings: Esophagus:
Mucosa: Diffuse moderate erythema was noted in the esophagus
consistent with moderate esophagitis. Streaks of white plaques
were noted, which had the appearance of ___. Cold forceps
biopsies were performed for histology at the middle third of the
esophagus.
Stomach:
Contents: A significant amount of undigested food was noted in
the stomach consistent with history of gastroparesis.
Mucosa: Normal mucosa was noted in the stomach. 4 cc of Botox
was injected (1 cc in each quadrant) at the pylorus given
history of severe gastroparesis.
Duodenum:
Mucosa: Normal mucosa was noted in the bulb.
Impression: Diffuse moderate esophagitis with streaks of plaques
with appearance suggestive of ___. (biopsy)
Food in the stomach
Normal mucosa in the stomach. 1cc of botox injected into each
quadrant of pylorus (total of 4ccs) (injection)
Otherwise normal EGD to duodenal bulb
Recommendations: Follow up biopsy results from esophagus.
Recommend empiric fluconazole for treatment.Continue management
from inpatient GI team.
___ 05:18AM BLOOD WBC-8.1 RBC-4.25* Hgb-12.6* Hct-36.9*
MCV-87 MCH-29.7 MCHC-34.1 RDW-14.0 Plt ___
___ 05:18AM BLOOD Glucose-285* UreaN-6 Creat-0.7 Na-135
K-4.5 Cl-97 HCO3-32 AnGap-11
Pathology Report Tissue: GI BX (1 JAR) Procedure Date of
___
Report not finalized.
PENDING AT DISCHARGE:
1) Blood cultures x2
2) Pathology of EGD biopsy
Brief Hospital Course:
Mr ___ is a ___ male with pmhx T1DM, CAD, gastroparesis,
pancreatitis and hx of frequent DKA presenting with
nausea/vomiting, tachycardia and abdominal pain.
ACTIVE ISSUES:
# Tachycardia: Patient initially admitted to ICU for narrow
complex, sinus tachycardia, likely multifactorial including
dehydration, possible pancreatitis, abd pain, this improved with
IV boluses. He was initially admitted to the MICU for
tachycardia to 140s, which improved to the 120s with 4L NS and
then to the 110s with 2 more liters.
#Gastroparesis: Patient hospitalized frequently for
gastroparesis. The patient's home medications from the prior
hospitalizations include Zofran and Reglan, which per prior
discharge summaries, he has not taken in the past because he
says that it does not help. Patient continued on Reglan and
Zofran. Gastroenterology was consulted regarding options for
treatment and performed EGD with Botox injections of the
pyloris, as patient reported good results with that in the past.
A nutrition consult was placed as patient has not been compliant
with diet. Patient was educated and given handouts that explain
diet. He was put on a clear liquid diet and advanced to regular
diet by day of discharge.
# ?Esophageal Candidiasis: EGD findings were concerning for
candiasis, so patient was started on daily fluconazole for
empiric treatment until biopsy results return. Risk factors for
this patient are his diabetes. HIV testing as an outpatient may
be warranted.
# Abdominal pain: Patient presented with abdominal pain.
Initial differential included pancreatitis, DKA, PUD,
gastroparesis. Patient stated that pain was compatible with
usual pancreatitis pain. Lipase low on admission, but likely
due to 'burnt-out' pancrease with little parenchyma left to
generate elevation in lipase. Pain also may have been secondary
to gastroparesis and vomiting prior to admission. Patient was
treated conservatively with clear liquid diet and advanced as
tolerated.
CHRONIC ISSUES:
# Diabetes: Patient did not have signs of DKA on admission
without a gap and with normal blood sugars. The patient was
initially continued on his home Lantus sliding scale, half dose
lantus while NPO. ___ was consulted for poor blood sugar
control on current regimen and he was discharged on an adjusted
regimen.
#) CAD: The patient had no active CP on admission. His troponins
were negative. His EKG did not show signs of acute ischemia.
Continued home metoprolol, lisinopril and simvastatin.
#) Depression: Continued home Cymbalta. Social Work saw patient
for coping with multiple stressors and frequent
hospitalizations.
#) Chronic normocytic anemia, possibly ACD vs anemia secondary
to acute blood loss: -Early this admission his HCT dropped from
39-->35 earlier this admission. Likely due to dilution from IV
hydration, but may also have slow GI bleed (blood apparently
observed in vomit at OSH). There were no signs of active
bleeding here, and patient hemodynamically stable. Patient
remained clinically stable by day of discharge.
TRANSITIONAL ISSUES:
1) HIV testing given finding of esophageal candidiasis.
2) Patient did not have his appointments finalized by time of
discharge, and was instructed to have close follow up with Dr.
___ his diabetes and Dr. ___ PCP.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Lisinopril 5 mg PO DAILY
hold for SBP < 90
2. Gabapentin 600 mg PO TID
3. Duloxetine 30 mg PO DAILY
4. Glargine 25 Units Breakfast
Glargine 25 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
5. Metoprolol Tartrate 25 mg PO BID
hold for SBP < 90, HR < 55
6. Omeprazole 20 mg PO Q12H
7. Metoclopramide 10 mg PO QIDACHS
8. Nortriptyline 25 mg PO HS
Discharge Medications:
1. Duloxetine 30 mg PO DAILY
2. Gabapentin 600 mg PO TID
3. Glargine 25 Units Breakfast
Glargine 25 Units Bedtime
Humalog 8 Units Breakfast
Humalog 8 Units Lunch
Humalog 8 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
4. Lisinopril 5 mg PO DAILY
hold for SBP < 90
5. Metoclopramide 10 mg PO QIDACHS
6. Metoprolol Tartrate 25 mg PO BID
hold for SBP < 90, HR < 55
7. Nortriptyline 25 mg PO HS
8. Fluconazole 200 mg PO Q24H
RX *fluconazole [Diflucan] 200 mg 1 tablet(s) by mouth daily
Disp #*28 Tablet Refills:*0
9. Omeprazole 20 mg PO Q12H
10. Simvastatin 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: gastroparesis, diabetes type I, uncontrolled; candidal
esophagitis
Secondary: hypertension, coronary artery disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with a gastroparesis flare (sluggish stomach).
You were evaluated by the GI team and had an endoscopy with
botox injection, which provided relief. You were able to
tolerate small and frequent meals. It is very important to
adjust your eating habits to prevent further flares.
The diabetes team was also involved in your care given high
blood sugars. You were provided with a new insulin scale. You
should follow-up with ___ Diabetes for further care.
It was also discovered that you had fungus in your esophagus.
You will take a medication called fluconazole for this
condition.
Followup Instructions:
___
|
19586697-DS-11
| 19,586,697 | 20,130,759 |
DS
| 11 |
2175-01-16 00:00:00
|
2175-01-16 15:25:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Latex / Topamax
Attending: ___.
Chief Complaint:
Left lower extremity pain and heaviness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old right handed female with past
medical history remarkable for multiple sclerosis, sciatica, and
migraines who presents today with ___ day history of difficulty
with cognition described as word finding difficulty as well as
sudden onset on the morning of presentation of left anterior leg
pain 2-3cm rostral from the ankle which she described as
alternating in character from sharp stabbing to burning
initially static and then after ~1 hour radiating up the
anterior aspect of the shin across the lateral aspect of the
thigh and into the lateral left lumbar region of the back. Of
note, the patient reports the pain distribution has been
relatively constant with some amelioration over the course of
the day and exacerbation mostly noted in the initial location of
complaint and in the lateral left lumbar region of the back.
She notes this is not consistent with previous MS flares, the
last she notes was in ___ timeframe which was treated
with steroids; also, this pain is inconsistent with her sciatic
pain in character,
distribution, and duration. She also reports some abdominal
pain which feels musculoskeletal in character and is congruent
with the pain in the left lumbar back. In terms of her left
lower extremity, around midday she noted an "increase in
heaviness" noting the initial pain caused some "weakness because
of the stinging" which changed to more "heaviness, like the leg
is too
heavy to lift".
She was diagnosed with multiple sclerosis and treated with
steroids in ___ and also in ___ she started Rebif, did well,
only with a couple of injection site problems. On ___
she started having neck pain and headaches associated with neck
problem. MRI of the C-spine on ___ showed C5
demyelinating and nonenhancing lesions. She had another
exacerbation in ___ and was treated with steroids.
She had been followed by Dr. ___ her MS from ___ to ___,
now by ___ MD. On ___, she had a flare of
ascending numbness to her trunk which was thought to be
transverse myelitis
and no steroids were given.
In ___ she began to experience right sciatica and right
hip pain. She was diagnosed with right sacroiliitis at possible
right S1 radiculopathy and she has been getting epidural steroid
injections at this location. Most recent L-spine MRI was
___ showed DJD at T11-T12 and mild bilateral articular
joint facet hypertrophy at L4-L5 and mild disc bulge at L5-S1,
slight to the right. Most recent MRI of the brain was
___ showing mild progression of FLAIR bright lesions in
the pericallosal and periventricular white matter. There are
multiple T1 holes.
On neuro ROS, the pt notes headache along the ___
midline axis milder in character than her other complaints and
inconsistent with previous migraines, as well as some loss of
vision due to odd left eye visual deficit on lateral aspect. She
denies, diplopia, dysarthria, dysphagia, lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies difficulties
producing or comprehending speech. Denies numbness and
parasthesiae. No bowel or bladder incontinence or retention.
On general review of systems, the pt reported some shortness of
breath relieved after 5 uses of Ventolin inhaler (uses rarely
per pt). Denies recent fever or chills. No night sweats or
recent weight loss or gain. 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:
PAST MEDICAL & SURGICAL HISTORY:
1. migraine Headaches
2. multiple sclerosis (diagnosed in ___ last dose of steroids
in ___ followed by Dr. ___ - decreased her dose of
Rebif to 22 mcg MWF as she was not able to tolerate Rebif 44
mcg)
3. chronic low back pain
Social History:
___
Family History:
Two brothers and a cousin with MS. ___ with stroke,
father with epilepsy and hypertension.
Physical Exam:
Tc/max=98.6F, HR=100, BP=128/94, RR=18, SaO2=98% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: CTABL
Cardiac: RRR, no murmurs
Abdomen: soft, nondistended, TTP in central abdomen
Extremities: no edema, pulses palpated
Skin: excoriation over anterior aspect of left shin, no other
specific lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to spell chair forwards,
not
backward "RAIC". 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. The pt. had
good
knowledge of current events. There was no evidence of apraxia
or
neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 5 to 2mm and brisk. VFF to confrontation. Funduscopic
exam revealed no papilledema, exudates, or hemorrhages.
III, IV, VI: EOMI without nystagmus. Normal saccades. Pain
elicited with lateral gaze
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5- 5 5- 5- 5- 5-
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: Inconsistent report of sensation throughout body to
light touch, pinprick noted dull where not, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Not assessed ___ pain and weakness per patient.
Pertinent Results:
___ 02:04PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 02:04PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-4* PH-7.0
LEUK-NEG
___ 02:04PM URINE RBC-0 WBC-1 BACTERIA-FEW YEAST-NONE
EPI-6 TRANS EPI-<1
___ 06:00AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 05:56AM GLUCOSE-85 UREA N-14 CREAT-0.6 SODIUM-136
POTASSIUM-3.8 CHLORIDE-104 TOTAL CO2-24 ANION GAP-12
___ 05:56AM ALT(SGPT)-15 AST(SGOT)-14 LD(LDH)-123 ALK
PHOS-45 TOT BILI-0.7
___ 05:56AM ALT(SGPT)-15 AST(SGOT)-14 LD(LDH)-123 ALK
PHOS-45 TOT BILI-0.7
___ 05:56AM ALBUMIN-4.0 CALCIUM-8.9 PHOSPHATE-3.5
MAGNESIUM-2.0
___ 05:56AM VIT B12-255 FOLATE-19.8
___ 05:56AM TSH-2.2
___ 05:56AM WBC-7.5 RBC-4.74 HGB-14.0 HCT-40.3 MCV-85
MCH-29.5 MCHC-34.6 RDW-12.6
___ 05:56AM ___ PTT-32.1 ___
___ 01:30AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 01:30AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 01:05AM GLUCOSE-78 UREA N-14 CREAT-0.6 SODIUM-139
POTASSIUM-3.9 CHLORIDE-104 TOTAL CO2-28 ANION GAP-11
___ 01:05AM BLOOD Creat-0.6
Abdominal XRay:
IMPRESSION: Normal bowel gas pattern with no evidence of ileus
or obstruction.
MRI Brain / MRI C-Spine:
No new progression of MS, no new flare, interval resolution of
prior flare.
Brief Hospital Course:
# NEUROLOGICAL:
The patient was admitted for further workup of a suspected flare
given her atypical distribution of weakness. Initially given
some disparity in her day to day symptoms, it was unclear
whether this was a presentation of MS ___ which she last
experienced a flare in ___ or if this was lower extremity
pain and some bloating causing her distress. After attempts to
control her pain with Ketorolac for 3 days which per the patient
was minimally helpful for her LLE pain, left lumbar and
abdominal pain, as well as headache of which all symptom
severity was out of proportion with presentation, an MRI Brain
and C-Spine were obtained which demonstrated no new active flare
which could explain her symptoms.
While inpatient, Ms. ___ was maintained on her home dosages
of clonezepam for anxiety.
# GASTROINTESTINAL:
Ms. ___ noted abdominal pain initially was not typical of
stomach pain, or normal GI distention, however as time
progressed, the patient endorsed her pain to be severe and
bloating in character. An abdominal plain film was obtained
which showed a normal bowel gas pattern and no obvious
intraabdominal process. To treat her pain - simethicone,
calcium carbonate, and tramadol were used.
# GENITOURINARY:
Ms. ___ noted some pelvic discomfort on discharge, but was
recommended to follow up with her PCP if complaints continue.
Medications on Admission:
- CLONAZEPAM - 1 mg Tablet - one Tablet(s) by mouth q8hrs as
needed for anxiety
- CYCLOBENZAPRINE - 5 mg Tablet - 1 Tablet(s) by mouth three
times a day as needed for back pain
- INTERFERON BETA-1A [REBIF] - 22 mcg/0.5 mL Syringe - 22mcg
sub-cut ___
- SUMATRIPTAN [IMITREX] - 5 mg/Actuation Spray, Non-Aerosol - 1
dose nasal q2h as needed for headaches up to 8 doses daily, up
to 15 doses monthly
Discharge Medications:
1. Simethicone 40-80 mg PO QID:PRN GI upset / gas
2. TraMADOL (Ultram) 50 mg PO Q4H:PRN Pain
3. Multivitamins 1 TAB PO DAILY
4. Calcium Carbonate 500 mg PO QID:PRN heartburn
5. Clonazepam 1 mg PO TID:PRN anxiety
per home dosing
6. Cyanocobalamin 50 mcg PO DAILY
7. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Lower extremity pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
___ were evaluated at ___
your issue with lower extremity pain which progressed into your
left lumbar back and abdomen, with subsequent Left leg weakness.
We performed a abdominal X-ray to rule out any intra-abdominal
process, and performed an MRI study of your head and cervical
spine. Both of these studies did not demonstrate any new
exacerbation of your MS. ___ should follow up with your PCP
regarding your vaginal discomfort if it continues to be an
issue.
Followup Instructions:
___
|
19586697-DS-13
| 19,586,697 | 26,803,405 |
DS
| 13 |
2176-05-25 00:00:00
|
2176-05-25 17:19:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Latex / Topamax / adhesive
Attending: ___.
Chief Complaint:
CC: HA, back pain
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ PMH multiple sclerosis, migraine headaches, sciatica,
anxiety/depression, presents with worsening headache and back
pain. She is a long-time HA sufferer, but this current HA has
been worsening x2wks. Per ED comments, patient describes HA as
tight compression, from occiput and temples down the spine. One
episode of feeling cold today, but no rigors, or fevers. Feels
nausea. No photophobia / phonophobia which are common in her
migraines. No subjective vision changes, weakness, numbness,
balance changes which occur during her MS flares. She has taken
fiorricet, imitrex, valium, flexeril for pain with minimal
relief.
Patient saw neurologist earlier this week, who did not recommend
additional therapy for her HA past sumitriptan. He also
commented that flexeril was sufficient for her back pain. She
has previously had flares of back pain and HA dating to ___,
some of which were temporally linked to spinal lesions seen on
MRI. Last MRI ___ commented that extent of MS was stable w/o
new or enhancing lesions compared to ___ ("diffuse high
signal throughout the cervical cord in keeping with sequelae of
demyelinating disease" but no focal lesions).
On ROS, patient endorsed to ED increased asthma symptoms, for
which she used her inhaler three times prior to arrival. She
continued to feel wheezy. Speaking full sentences in the ED. VS
on presentation were: 97.8 103 137/89 100%RA. Initially received
fioricet, ketorolac, ondansetron, and morphine 5mg IV. At ___
she developed crushing epigastric pain. Troponin negative x2.
AST/ALT/AP/TB/Lipase wnl. UA neg. EKG sinus rhytm w/o ischemic
changes. Received additional dilaudid 1mg IV x2, fioricet,
flexeril 5mg PO, fluoxetine, omeprazole, ondansetron x2, and
methylprednisolone 125mg x1. Last ED vitals were 98.2 82 132/77
18 99%RA.
On arrival to the floor, patient reports that she had chronic HA
for her entire life, and had HAs preceeding her current severe
HA. These previous HA took a variety of forms and were generally
controlled with fioricet and imitrex. However, her current
severe HA started 3d ago and could not be controlled with her
home meds. She describes severe behind-the-L-eye pain with
associated numbness and fierce sharp pain of her L face. The
pain generalized to a pressure throughout her entire head and
then radiated down her spine. She has had bitemperol pressure
pains with back pain since then. She endorses nausea and SOB as
above, but no other neurologic, infectious or other sx. She
denies sick contacts, trauma, change in appetite or mood, social
stressors, f/c, vision or hearing changes, n/v, rhinorrhea,
cough, congestion, CP, abdominal pain, bowel or urinary sx, new
or unusual lesions, numbness or paresthesias, muscle or joint
pain other than described above. She has had some chills here.
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:
1. Multiple sclerosis.
2. Asthma.
3. Tobacco abuse.
4. Reflux.
5. Anxiety/Depression
6. Migraine headaches
Social History:
___
Family History:
Two brothers and a cousin with MS.
___ with stroke, father with epilepsy and hypertension.
There is a family history of migraines as well as lupus.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS - 98.3 130/94 81 18 99%RA
General: Pleasant, conversational, oriented x3, NAD
HEENT: NCAT, no skin lesions, symmetric, EOMI w/o pain, pain
with palpation of the head however, clear OP, MMM, no LAD
Neck: supple, no LAD
CV: RRR, no r/g/m
Lungs: CTA b/l
Abdomen: Soft, NT, ND, +BS
GU: no Foley
Ext: WWP, no edema
Neuro: c/o pain with Kernig's and Brudzinski's but w/o neck or
hip flexion, face symmetric, visual fields intact b/l, CN II-XII
grossly intact, ___ strength ___, intact light touch sensation
upper & lower extremities, seen ambulating normally into the
room
Skin: as above, no lesions, some removal residue on the upper
chest (appears like dried adhesive)
DISCHARGE PHYSICAL EXAM:
========================
VS - 97.8 124/83 76 18 100%RA
General: Comfortable-appearing, NAD
HEENT: clear OP, MMM
CV: RRR, no r/g/m
Lungs: CTA b/l
Abdomen: Soft, NT, ND, +BS
GU: no Foley
Ext: WWP, no edema
Pertinent Results:
ADMISSION LABS:
===============
___ 06:15PM BLOOD WBC-5.5 RBC-4.84 Hgb-13.7 Hct-41.9 MCV-87
MCH-28.4 MCHC-32.8 RDW-12.3 Plt ___
___ 06:15PM BLOOD Neuts-67.0 ___ Monos-5.6 Eos-2.0
Baso-0.9
___ 06:15PM BLOOD Glucose-75 UreaN-13 Creat-0.5 Na-139
K-4.2 Cl-102 HCO3-28 AnGap-13
___ 06:15PM BLOOD ALT-22 AST-22 AlkPhos-50 TotBili-0.3
___ 06:15PM BLOOD Lipase-36
___ 06:15PM BLOOD Albumin-4.5 Calcium-9.3 Phos-3.5 Mg-2.0
OTHER LABS:
===========
___ 06:15PM BLOOD cTropnT-<0.01
___ 01:05AM BLOOD cTropnT-<0.01
DISCHARGE LABS:
===============
___ 07:00AM BLOOD WBC-7.3 RBC-4.55 Hgb-12.8 Hct-39.3 MCV-86
MCH-28.1 MCHC-32.6 RDW-12.3 Plt ___
___ 07:00AM BLOOD Glucose-114* UreaN-16 Creat-0.5 Na-140
K-3.7 Cl-105 HCO3-25 AnGap-14
___ 07:00AM BLOOD Calcium-9.0 Phos-3.5 Mg-1.9
IMAGING:
========
___ NCHCT: IMPRESSION: No acute intracranial process.
Brief Hospital Course:
___ PMH multiple sclerosis, migraine headaches, sciatica,
anxiety/depression, presents with worsening headache and back
pain.
ACTIVE ISSUES:
==============
# HA/Back Pain muscle strain/atypical migraine: Complained her
headache and back pain were worse than her typical pains, which
are typically controlled on her home pain medications (Fioricet,
Imitrex, Flexeril and Valium). Non-contrast head CT was
reassuring she did not have SAH; her clinical exam and CBC were
reassuring that she did not have infectious process,
particularly meningitis. She did not describe neurologic
complaints such as motor or sensory weakness consistent with an
MS flare. Neurology was consulted, and agreed with this
assessment. In consultation with her outpatient Neurologist Dr
___ recommended a regimen that would reduce pains
associated with musculoskeletal tension or inflammation,
particularly at the neck. She will also be started on
nortriptyline. The primary Medical team will give her a short
script of narcotics that did help her pain this admission until
she can see her outpatient Primary Care Physician.
CHRONIC ISSUES:
===============
# Multiple Sclerosis: Continued Tecfidera.
# Asthma: No exacerbation or symptoms this hospitalization.
Continued home Albuterol and Advair.
# Depression/Anxiety: The patient declined her home fluoxetine,
which she does not take anyway (she does not endorse depression,
and feels the medication makes her feel poorly besides). She was
continued on her home dose of Ativan.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen-Caff-Butalbital 1 TAB PO Q4H:PRN headache
2. Cyclobenzaprine 5 mg PO TID:PRN back pain
3. Diazepam 5 mg PO Q8H:PRN muscle ache, backache
4. Fluoxetine 20 mg PO DAILY
5. Fluticasone Propionate NASAL 1 SPRY NU DAILY
6. Lorazepam 1 mg PO DAILY:PRN anxiety
7. SUMAtriptan 5 mg/actuation nasal Q2H:PRN Headache
8. Aspirin 81 mg PO BID:PRN headache
9. Vitamin D ___ UNIT PO DAILY
10. LOPERamide 2 mg PO BID:PRN diarrhea
11. Multivitamins 1 TAB PO DAILY
12. Tecfidera (dimethyl fumarate) 240 mg oral BID
13. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB, wheezing
14. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
Discharge Medications:
1. Acetaminophen-Caff-Butalbital 1 TAB PO Q4H:PRN headache
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB, wheezing
3. Cyclobenzaprine 5 mg PO TID:PRN back pain
4. Diazepam 5 mg PO Q8H:PRN muscle ache, backache
5. Fluticasone Propionate NASAL 1 SPRY NU DAILY
6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
7. LOPERamide 2 mg PO BID:PRN diarrhea
8. Lorazepam 1 mg PO DAILY:PRN anxiety
9. Multivitamins 1 TAB PO DAILY
10. Tecfidera (dimethyl fumarate) 240 mg oral BID
11. Vitamin D ___ UNIT PO DAILY
12. Aspirin 81 mg PO BID:PRN headache
13. SUMAtriptan 5 mg/actuation nasal Q2H:PRN Headache
no more than 8 doses daily, no more than 15 doses monthly
14. Nortriptyline 10 mg PO HS
RX *nortriptyline 10 mg 1 capsule by mouth at bedtime Disp #*30
Capsule Refills:*0
15. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN pain Duration: 10
Doses
Do NOT take with alcohol. Do NOT take before or while driving or
operating heavy machinery.
RX *hydromorphone 2 mg 1 tablet(s) by mouth every six (6) hours
Disp #*10 Tablet Refills:*0
16. MEDrol (Pak) (methylPREDNISolone) 4 mg oral daily Duration:
5 Days
take 8 tablets Day1, 5 Day2, 4 Day3, 2 Day4, 1 Day5, then stop
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Headache, Muscular Back Strain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms ___,
It was a pleasure to care for you at the ___
___. You were admitted for headache and back pain.
Your evaluation here was reassuring that you do not have an
infection or bleed, nor is this a flare of your multiple
sclerosis. Your case was discussed with the ___ Consult
Team, who also spoke with Dr. ___. We will follow their
recommendations on discharge, including prescribing you
medications to reduce muscular inflammation and pain sensation,
as well as a brace to stabilize your neck.
Please see below for your medications and appointments. Thank
you for allowing us to participate in your care.
Followup Instructions:
___
|
19586697-DS-14
| 19,586,697 | 23,097,306 |
DS
| 14 |
2177-02-02 00:00:00
|
2177-02-08 16:52:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Latex / Topamax / adhesive
Attending: ___
Chief Complaint:
lower extremity pain, hand/foot/lip parasthesias
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ yo woman with history of MS diagnosed in
___ on tecfidera (followed by Dr. ___ who presents with
worsening chronic low back and bilateral leg pain as well as
numbness/tingling of the fingertips, toes, and lips for the past
4 days. Neurology is consulted for concern for MS flare and
question of further imaging.
She reports that she has had chronic mild low back pain and pain
in both legs over the past ___ months. She describes a
"crushing
pressure all over" in both legs extending from her low back down
both legs into her feet. This is different from the left-sided
sciatica which is chronic. Although painful, her symptoms do
not
cause functional limitations and she is independent with all
ADLs. She has tolerated symptoms with home motrin, valium, and
flexeril but in the past week the pain is much worse. It keeps
her up at night. In the past she has had MS flares ___ below)
with similar neck/back/leg pain which have responded to
steroids.
In addition to worsening pain, the patient endorses tingling of
her fingertips, feet and lips during the past 4 days. This
started in the right hand, then 1 day later progressed to the
left hand and feet. She describes a "pins and needles
sensation"
mostly in the fingertips and toes. These symptoms are also
similar to prior flares.
To briefly review the MS history, the patient was diagnosed with
MS in ___, with initial presenting symptoms of left optic
neuritis. She also had episodic vertigo, foot numbness and
clumsiness of the hands at that time. She was treated with IV
steroids with good response and was started Rebif injections. By
___ she developed new posterior neck pain and
headaches
and MRI C-spine showed a C5 non-enhancing lesion. Her disease
remained largely stable between ___ and then in ___, she had a flare of progressive ascending numbness/tingling
from her legs to her trunk which was thought to be transverse
myelitis (so she was not given steroids), and this eventually
resolved spontaneously. Subsequent flares include an episode of
bliateral leg numbness, left hand numbness/pain in ___
when MRI showed a new C4 enhancing lesion. She was treated with
3
days IV MP. Most recent MRI brain ___ shows T2 pericallosal
and periventricular white matter lesions with multiple T1 black
holes. Her last MS flare was ___ with symptoms of groin
numbness, gait instability and pain treated with 3d IVMP. After
that time she was switched to oral tecfidera 240mg BID as
therapy
for MS.
___ of MS ___ per recent Dr. ___ ___ Clinic Note)
Onset: ___
Diagnosis: ___
Flair history:
1. ___: L>R ON, treated with IVMP
2. ___: neck pain, headache, L optic neuritis, treated with
IVMP
3. ___: pain (head, neck, back), treated with IVMP
4. ___: transverse myelitis, no treatment
5. ___: new cord lesion and B leg numbness, left hand
numbness/pain, IVMP
6. ___: groin numbness, gait change; treated with 3d IVMP
TREATMENT AND RESULTS OF TREATMENT:
1. Rebif (___)
2. Vitamin D (___)
3. Tecfidera (___)
On neuro ROS today, the pt denies headache, loss of vision,
blurred vision, diplopia, dysarthria, dysphagia,
lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies difficulties
producing or comprehending speech. Denies focal weakness. 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:
1. MS
2. migraines
3. depression/anxiety
4. asthma
5. left sciatica
Social History:
___
Family History:
Two brothers and a cousin with MS.
___ with stroke, father with epilepsy and hypertension.
There is a family history of migraines as well as lupus.
Physical Exam:
ADMISSION EXAMINATION:
Physical Exam:
Vitals: 98.2 114 124/80 16 98% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. 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. The pt had good
knowledge of current events. There was no evidence of apraxia or
neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. Left RAPD. VFF to confrontation.
No abnormality of color vision. Funduscopic exam shows flat
optic
disks, sharp margins, left sided pallor.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: She reports decreased pinprick in the arms from the
forearm distally and in the legs from the midshin distally. She
reports decreased light touch and temperature in the same
distribution. Vibration and proprioception are intact.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: Slight intention tremor (L>R), some slowness with
___ (L>R). Slightly uncoordinated FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem without difficulty. Romberg
absent.
DISCHARGE EXAMINATION: (largely stable vs admission examination)
- afebrile and with stable vital signs during admission
- General exam: middle aged F, pleasant and cooperative, NAD
- MSK: pain w palpation of B/L greater trochanters
Neurological Exam
- MS: A&Ox3, language fluent, comprehension intact, good fund of
knowledge
- CN: ?L RAPD, poor accomodation of R eye; facial motor and
sensation intact
- Motor: strength is full but there is give way weakness on
exam;
- Sensory: painful parasthesias in B/L L5 distribution
- DTRs: 2 in UEs, 3 at patellas, 2 ankle jerks
- Coord: FNF intact B/L, mild slowing of RAM bilaterally
Pertinent Results:
___ 06:25AM BLOOD WBC-7.0 RBC-4.66 Hgb-13.4 Hct-39.7 MCV-85
MCH-28.7 MCHC-33.8 RDW-13.1 Plt ___
___ 07:30PM BLOOD Neuts-74.7* Lymphs-16.6* Monos-4.1
Eos-4.0 Baso-0.6
___ 09:23AM BLOOD Glucose-132* UreaN-17 Creat-0.5 Na-138
K-4.3 Cl-102 HCO3-23 AnGap-17
___ 09:23AM BLOOD ALT-153* AST-46* AlkPhos-68
___ 07:30PM BLOOD CK-MB-1 cTropnT-<0.01
___ 09:23AM BLOOD Calcium-9.3 Phos-2.7 Mg-2.0
___ MR ___ SPINE W/O CONTRAST
L5-S1 disc bulge contacting, but not deforming, the exiting L5
nerve roots, bilaterally.
Brief Hospital Course:
___ F w PMHx of MS ___ tecfidera ___ year) presents with subacute
worsening of chronic back and bilateral lower extremity pain.
Ms. ___ also reports new parasthesias of the fingers, toes,
and lips which she associates with an MS flair. Exam is notable
for chronic MS deficits ___ loss of pinprick, temp and
light touch in the distal arms and legs) but preserved strength
and normal reflexes. Per Dr. ___, there is clinical evidence
of bilateral L5 radiculopathy and hip bursitis. Of note, Ms.
___ does of a PMHx of left sciatic nerve pain which was well
controlled with a presumed glucocorticoid injection ___ years
ago. Ms. ___ states that her pain was initally well
controlled following that injective but has worsened over the
past several months.
We will admit for treatment of bilateral L5 radiculopathy with
concurrent hip bursitis. Treatment with IV steroids x2days and
predinsone 60mg PO x3 days. MRI L-spine shows modest L4/5 and
L5/S1 disc protrusion as well as facet arthropathy and
narrowing. We will also refer Ms. ___ to the ___ pain
clinic for outpatient treatment.
Of note, Ms. ___ had elevated LFTs on admission of uncertain
etiology. LFTs trended down throughout admission, but remained
elevated at time of d/c. Recommend outpatient follow up to
verify complete normalization.
DIAGNOSIS: B/L L5 radiculopathic pain precipitating mild MS
flare
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Tecfidera (dimethyl fumarate) 240 mg oral twice a day
2. Acetaminophen-Caff-Butalbital 1 TAB PO Q6H:PRN headache
3. Cyclobenzaprine 5 mg PO TID:PRN back pain
4. Diazepam 5 mg PO Q8H:PRN muscle ache, back ache
5. Lorazepam ___ mg PO Q6H:PRN anxiety
6. Omeprazole 40 mg PO DAILY
7. Imitrex (SUMAtriptan;<br>SUMAtriptan succinate) 5
mg/actuation nasal q2hrs PRN headache
8. Aspirin 81 mg PO DAILY
9. Vitamin D ___ UNIT PO DAILY
10. Simethicone 80 mg PO DAILY:PRN gas
11. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Acetaminophen-Caff-Butalbital 1 TAB PO Q6H:PRN headache
2. Aspirin 81 mg PO DAILY
3. Cyclobenzaprine 5 mg PO TID:PRN back pain
4. Lorazepam ___ mg PO Q6H:PRN anxiety
5. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*3
6. Simethicone 80 mg PO DAILY:PRN gas
7. Tecfidera (dimethyl fumarate) 240 mg oral twice a day
8. Vitamin D ___ UNIT PO DAILY
9. Diazepam 5 mg PO Q8H:PRN muscle ache, back ache
10. Imitrex (SUMAtriptan;<br>SUMAtriptan succinate) 5
mg/actuation nasal q2hrs PRN headache
11. Multivitamins 1 TAB PO DAILY
12. TraZODone 25 mg PO HS:PRN sleep
RX *trazodone 50 mg 0.5 (One half) tablet(s) by mouth nightly,
as needed Disp #*4 Tablet Refills:*0
13. PredniSONE 60 mg PO DAILY Duration: 2 Doses
RX *prednisone 20 mg 3 tablet(s) by mouth daily Disp #*6 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Bilateral L5 radiculopathy
Secondary: multiple sclerosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were hospitalized for symptoms of lower extremity pain
likely secondary to a small disc protrusion in your lower back.
We are treating this condition which steroids, which should also
help with the mild MS flare that may have accompanied your pain.
Your condition does not require any further inpatient
management. We will discharge you home on a short course of oral
prednisone. Please follow up in your pain clinic to discuss pain
control for your radiculopathy, another joint injection may be
warranted.
It was a pleasure caring for you during this hospitalization.
Followup Instructions:
___
|
19586780-DS-20
| 19,586,780 | 27,902,920 |
DS
| 20 |
2130-02-26 00:00:00
|
2130-02-26 19:08:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Prazosin / Sulfa(Sulfonamide Antibiotics) / morphine
Attending: ___
Chief Complaint:
right arm and leg weakness
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
___ yo M with hx of stroke with mild residual RUE weakness, afib
on anticoag, seizure disorder who presents with sudden onset HA,
right hemiparesis, and garbled speech. The patient was at his
PCP's office for a regularly scheduled appointment when he
developed first the headache, followed by the right arm and leg
weakness and garbled speech. The time course for these events is
unclear, the patient reports that they happened within a minute.
The headache is constant over his left forehead area. He's never
had a similar headache in the past. He reports that he has mild
right arm weakness since his remote stroke but never this
severe.
He also reports difficulty getting the words he wants to say
out.
He denies any trouble understanding language. Since the onset,
there has been no progression or improvement in his symptoms. He
vomited once a few hours ago at ___ and again feels
nauseated.
On neuro ROS, the pt loss of vision, blurred vision, diplopia,
dysphagia, vertigo, or hearing difficulty. Denies focal
numbness, parasthesiae.
On general review of systems, the pt reports increased cough and
sputum production over the past week. He reports fevers 3 weeks
ago, now with chills at night. He reports chronic right knee
pain. He denies shortness of breath. Denies chest pain or
tightness, palpitations. Denies diarrhea, constipation or
abdominal pain.
Past Medical History:
- Parkinsism - ? tremor from DPA
- Atrial fibrillation on rivaroxaban
- ?Seizure disorder - per patient, he loses consciousness and
comes to on the floor. Frequency is 1/yr. Never injures himself
or has incontinence. Previously on depakote but this was stopped
___ after 24 hrs of EEG without epileptiform activity.
- Pt reports stroke in ___ at ___. Per ___ records pt presented
with R sided weakness, got tPA at OSH but no stroke on MRI.
Again presented with left sided weakness in ___ with no stroke
on MRI.
- T2DM
- COPD
- OSA
- HTN
- HL
- Depression
- Skin cancer (basal and squamous)
- GERD
-Bells palsy
Social History:
___
Family History:
Mother with HTN and a-fib.
Physical Exam:
Vitals: T: 98.3 P: 83 BP:155/77 RR: 24 SaO2:100% on 2___
General: Awake, cooperative. Mildly distress by symptoms.
HEENT: NC/AT, no scleral icterus, MMM, clear oropharynx
Neck: Supple, no nuchal rigidity. No carotid bruits
Pulmonary: Decreased breath sounds throughout. Otherwise lungs
CTA bilaterally without R/R/W
Cardiac: irreg irreg, no M/R/G
Abdomen: soft, obese, NT/ND, normoactive bowel sounds.
Extremities: Chronic venous stasis changes in b/l LEs to the
knee. Trace edema. 2+ radial, 1+ DP pulses bilaterally.
Skin: multiple keratotic skins lesions on head
Neurologic:
___ Stroke Scale score was: 11
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: 3
6a. Motor leg, left: 0
6b. Motor leg, right: 3
7. Limb Ataxia: 0
8. Sensory: 2
9. Language: 1
10. Dysarthria: 1
11. Extinction and Neglect: 0
-Mental Status: Alert, oriented x 3. Attentive, able to relate
history with difficulty only in speech articulation. Speech is
hesistant and studdering with prolonged holding on various
syllables in words, not typical for dysarthria. Language slow
but
fluent, with intact repetition and comprehension. Normal
prosody
but at times he whispers. There were no paraphasic errors. Pt.
was able to name both high frequency objects but had some
difficulty with low frequency. Able to follow both midline and
appendicular commands. The pt. had good knowledge of current
events. There was no evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF testing is difficult as the
patient inconsistently reports being unable to see fingers in
first left visual field, but then was unable to see in right
upper visual field and left was intact. Funduscopic exam
revealed
no papilledema, exudates, or hemorrhages.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch bilaterally.
VII: Very mild right N-L flattening
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue initially appeared to be weak on the right but when
re-examined 20 minutes later, it had symmetric strength.
-Motor: Normal bulk, tone throughout. Resting tremor of right
hand. No movement of the right hemibody to command with the
exception of right finger flexors ___, but patient held right
arm
antigravity in response to noxious. Positive Hoovers sign with
RLE hip extension during LLE hip flexion. Full strength in left
upper and lower limbs.
-Sensory: Patient reports no light touch, cold, or pin sensation
on right hemibody (excluding face). However when asked to reply
"yes" or "no" to touch, he repeatedly hesitated before saying
"no" after being touched on left. He then reported normal
vibration and proprioception at b/l great toes. He felt pain at
the right finger, knee, and toe.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: No dysmetria on FNF or HKS on the left side,
unable to complete on right.
-Gait: Unable due to weakness. Attempted sitting up but stopped
due to headache pain.
Pertinent Results:
___ 07:30PM URINE HOURS-RANDOM
___ 07:30PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 07:30PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 07:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 07:30PM URINE RBC-1 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-1
___ 07:30PM URINE MUCOUS-RARE
___ 03:40PM ___ COMMENTS-GREEN TOP
___ 03:40PM GLUCOSE-95 NA+-142 K+-3.8 CL--105 TCO2-25
___ 03:30PM CREAT-0.5
___ 03:30PM UREA N-14
___ 03:30PM estGFR-Using this
___ 03:30PM ALT(SGPT)-15 AST(SGOT)-32 ALK PHOS-74 TOT
BILI-0.6
___ 03:30PM cTropnT-<0.01
___ 03:30PM ALBUMIN-4.1
___ 03:30PM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
___ 03:30PM WBC-9.2 RBC-4.50*# HGB-14.3 HCT-42.6# MCV-95
MCH-31.8 MCHC-33.6 RDW-13.0
___ 03:30PM PLT COUNT-197
___ 03:30PM ___ PTT-34.5 ___
MRI ___:
There is no evidence of infarct or hemorrhage. There are
scattered T2/FLAIR
hyperintensities throughout the periventricular and subcortical
white matter
which are nonspecific but likely related to chronic
microangiopathy. There is
prominence of the extra-axial CSF spaces and ventricles
representing global
cerebral volume loss.
There is no evidence of midline shift, mass effect, or
hydrocephalus.
There is mild mucosal thickening of the maxillary sinuses with a
right mucus retention cyst. There is mild mucosal thickening of
the ethmoid air cells.
CT head noncontrast: There is no evidence of hemorrhage. There
are scattered
low-attenuation areas in the periventricular and subcortical
white matter
which are nonspecific but likely related to chronic
microangiopathy. There is
prominence of the extra-axial CSF spaces and ventricles likely
related to
global cerebral volume loss. There is no evidence of midline
shift, mass
effect, or hydrocephalus.
A mucus retention cyst is visualized in the right maxillary
sinus.
The soft tissues are unremarkable.
There is mild atherosclerotic calcification of the cavernous and
supraclinoid
segments of the internal carotid arteries.
CTA head and neck: There is a 3 vessel arch. The origins of
the common
carotid arteries are patent. There is a tiny focus of
calcification at the
origin of the right vertebral artery, however the origin is
widely patent.
The origin of the left vertebral artery is patent. Both
vertebral arteries
are patent throughout the neck. The common carotid arteries
appear patent.
There is calcified and noncalcified plaque at the carotid bulbs
without
stenosis with the atherosclerotic plaque extending into the
right internal
carotid artery. An ulcerated plaque is noted in the right
carotid bulb. There
is minimal narrowing of the origin of the right internal carotid
artery,
however both internal carotid arteries are patent throughout the
neck without
evidence of stenosis by NASCET criteria.
The intracranial internal carotid arteries are patent. There is
mild
atherosclerotic calcification of the cavernous and supraclinoid
segments of
the internal carotid arteries without stenosis. The anterior
and middle
cerebral arteries appear patent without stenosis or aneurysms
with normal
branching pattern.
The intracranial vertebral arteries and basilar artery are
patent. The right
posterior cerebral artery is patent with normal branching
pattern. The left
posterior cerebral artery is smaller than the right but patent.
There are ground-glass and denser opacities in both visualized
lungs likely
reflecting a combination of scarring and atelectasis.
CT perfusion: There is no evidence of ischemia or infarct.
Brief Hospital Course:
This is a ___ year old man with a history of HTN, HL, depression,
DM, and afib on xarelto presenting with sudden onset of right
arm and leg weakness with numbness. The patient has a functional
exam and no acute stroke seen on MRI. Thus, it is most likely
that his functional weakness and his speechmotor impairment are
due to a conversion syndrome.
NEURO: The patient was admitted to the stroke service for
concern for a stroke. He had an MRI overnight which showed no
acute stroke. He was continued on his home dose of rivaroxaban
for atrial fibrillation. The patient's strength returned on day
2 of admission. Prior records were obtained from ___ which
revealed no prior history of stroke but at least two similar
presentations with weakness and negative MRIs. A possible
diagnosis of migraine with hemiplegia was suggested in discharge
paperwork. Stroke risk factors were checked including A1c (5.5)
and LDL (63). Patient walked independently with nursing and
physicians. He uses a cane or walker at baseline.
PSYCH: The patient had a functional exam, appeared upset and
expressed suicidal thoughts so pscyhiatry was consulted. They
diagnosed him with Depression and PTSD. He admitted to them that
his weakness was probably "pscyhological" and began moving the
right side. He was placed on 1:1 for SI with ___. He was
continued on his home dose of seroquel.
CARDS: The patient was continued on his home dose of statin,
metoprolol and rivaroxaban. He was monitored on telemetry and no
events were noted. He had an episode of chest pain on ___ but
had a normal EKG and negative cardiac enzymes. This was likely
due to anxiety.
PULM: The patient was continued on his home nebulizers. He had a
cough and initially was on oxygen. He had a chest xray on
admission which appeared fluid overloaded. He received 20mg of
PO lasix with good effect and no longer needed oxygen. Fluid
overload was likely due to IV fluids.
HEME: Patient had a drop in HCT on admission but initial HCT was
significantly higher than baseline so this is likely dilutional.
HCT was rechecked and was stable.
Patient is medically cleared for discharge to Deaconess 4.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Budesonide Nasal Inhaler *NF* .5 mg/2ml Other BID
2. formoterol fumarate *NF* 20 mcg/2 mL Inhalation BID
3. Glargine 20 Units Bedtime
4. MetFORMIN (Glucophage) 500 mg PO BID
5. Metoprolol Succinate XL 50 mg PO DAILY
6. Metoprolol Succinate XL 37.5 mg PO HS
7. Omeprazole 20 mg PO DAILY
8. Rivaroxaban 20 mg PO DAILY
9. Simvastatin 20 mg PO DAILY
10. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN SOB
11. Bisacodyl 10 mg PR HS:PRN constipation
12. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN leg
pain
13. FoLIC Acid 1 mg PO DAILY
14. Quetiapine Fumarate 25 mg PO BID
15. Magnesium Oxide 400 mg PO DAILY
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN SOB
2. Bisacodyl 10 mg PR HS:PRN constipation
3. formoterol fumarate *NF* 20 mcg/2 mL Inhalation BID
4. Glargine 15 Units Bedtime
Insulin SC Sliding Scale using REG Insulin
5. Magnesium Oxide 400 mg PO DAILY
6. Metoprolol Succinate XL 25 mg PO DAILY
7. Omeprazole 20 mg PO DAILY
8. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN leg pain
9. Quetiapine Fumarate 25 mg PO BID
10. Rivaroxaban 20 mg PO DAILY
11. Simvastatin 20 mg PO DAILY
12. Diltiazem Extended-Release 120 mg PO DAILY
13. Budesonide Nasal Inhaler *NF* 0.5 mg/2ml OTHER BID
14. FoLIC Acid 1 mg PO DAILY
15. MetFORMIN (Glucophage) 500 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Depression, PTSD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Functional right arm and leg weakness, resolved
Discharge Instructions:
You came to the hospital for right sided weakness and numbness.
You had an MRI which did not show any acute stroke and your
strength returned. We have found no physical cause for your
symptoms so we expect that you will continue to improve. You
were seen by psychiatry who felt that you had depression and
PTSD and were concerned for your safety to you have been
discharged to a psychiatric facility.
Followup Instructions:
___
|
19587039-DS-11
| 19,587,039 | 28,195,205 |
DS
| 11 |
2143-06-11 00:00:00
|
2143-06-12 16:13:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right intertrochanteric femur fracture
Major Surgical or Invasive Procedure:
___ right short TFN
History of Present Illness:
___ F s/p CABG with AS (ECHO ___ 45% EF), HLD, HTN, DMII s/p
fall with Right Intertrochanteric femur fracture. On exam she is
closed and
neurovascularly intact. X-rays demonstrate a comminuted
intertrochanteric femur fracture on the right side, CT head
reveals only a scalp hematoma, CT of abdomen with with possible
stercoral colitis. After discussion with the family, taking
into
account to the family's goals, this is an operative fracture
which would benefit the patient and morbidity mortality to be
done within the first 48 hours. Given the patient's history of
aortic stenosis and CABG would recommend that medicine clear the
patient for surgery. Also awaiting acute care surgery
recommendations for stercoral colitis.
Past Medical History:
CORONARY BYPASS SURGERY
HYPERTENSION
AORTIC STENOSIS
DIABETES TYPE II
HYPERLIPIDEMIA
PULMONARY NODULE
MILD COGNITIVE IMPAIRMENT
OSTEOPOROSIS
OSTEOARTHRITIS
CATARACTS
HEARING LOSS
HEMORRHOIDS
WELLNESS VISITS
H/O RETINAL DETACHMENT
Social History:
___
Family History:
n/a
Physical Exam:
General: Well-appearing, breathing comfortably
MSK: RLE
Sleeping comfortably this AM, did not awaken due to geriatric
protocol
gross motor intact
foot wwp
Pertinent Results:
see omr
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopaedic surgery team. The patient was found
to have right intertrochanteric femur fracture and was admitted
to the orthopaedic surgery service. The patient was taken to the
operating room on ___ for short TFN, which the patient
tolerated well. For full details of the procedure please see the
separately dictated operative report. The patient was taken from
the OR to the PACU in stable condition and after satisfactory
recovery from anesthesia was transferred to the floor. The
patient was initially given IV fluids and IV pain medications,
and progressed to a regular diet and oral medications by POD#1.
The patient was given ___ antibiotics and
anticoagulation per routine. The patient's home medications were
continued throughout this hospitalization. The patient worked
with ___ who determined that discharge to rehab was appropriate.
The ___ hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
weightbearing as tolerated in the right lower extremity
extremity, and will be discharged on Lovenox for DVT
prophylaxis. The patient will follow up with Dr. ___
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course
including reasons to call the office or return to the hospital,
and all questions were answered. The patient was also given
written instructions concerning precautionary instructions and
the appropriate follow-up care. The patient expressed readiness
for discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. DiphenhydrAMINE 40 mg PO QHS
2. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
3. Alendronate Sodium 70 mg PO QTHUR
4. amLODIPine 7.5 mg PO DAILY
5. Atorvastatin 40 mg PO QPM
6. Ferrous GLUCONATE 324 mg PO DAILY
7. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit oral DAILY
8. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
3. Enoxaparin Sodium 30 mg SC Q24H
RX *enoxaparin 30 mg/0.3 mL 1 syringe subcutaneous once a day
Disp #*28 Syringe Refills:*0
4. Pantoprazole 40 mg PO Q24H
5. Senna 8.6 mg PO BID
6. TraMADol 25 mg PO Q6H:PRN pain
partial fill ok. no driving/machinery. wean as tolerated.
RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth every 4
hours as needed Disp #*25 Tablet Refills:*0
7. Alendronate Sodium 70 mg PO QTHUR
8. amLODIPine 7.5 mg PO DAILY
9. Aspirin 81 mg PO DAILY
10. Atorvastatin 40 mg PO QPM
11. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit oral DAILY
12. DiphenhydrAMINE 40 mg PO QHS
13. Ferrous GLUCONATE 324 mg PO DAILY
14. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right intertrochanteric femur fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please
follow your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
-Weightbearing as tolerated right lower extremity
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This
is an over the counter medication.
2) Add tramadol as needed for increased pain. Aim to wean
off this medication in 1 week or sooner. This is an example on
how to wean down:
then 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per state regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you
should drink eight 8oz glasses of water daily and continue
following the bowel regimen as stated on your medication
prescription list. These meds (senna, colace, miralax) are over
the counter and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your
physicians at discharge.
8) Continue all home medications unless specifically
instructed to stop by your surgeon.
ANTICOAGULATION:
- Please take Lovenox daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever greater than 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
FOLLOW UP:
Please call ___ to schedule a follow up with your
Orthopaedic Surgeon, Dr. ___. You will have follow up with
___, NP in the Orthopaedic Trauma Clinic 14 days
post-operation for evaluation. Call ___ to schedule
appointment upon discharge.
Please follow up with your primary care doctor regarding this
admission within ___ weeks and for any new medications/refills.
THIS PATIENT IS EXPECTED TO REQUIRE >30 DAYS OF REHAB
Physical Therapy:
Activity: Activity: Out of bed w/ assist
Right lower extremity: Full weight bearing
Left lower extremity: Full weight bearing
Encourage turning, deep breathing and coughing qhour when awake.
Treatments Frequency:
Your incision is closed with staples that will be taken out at
your 2-week postoperative visit.
If the dressing falls off on its own three days after surgery,
no need to replace the dressing unless actively draining.
Followup Instructions:
___
|
19587039-DS-12
| 19,587,039 | 21,549,168 |
DS
| 12 |
2143-06-15 00:00:00
|
2143-06-15 21:25:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ F s/p CABG with AS (ECHO ___ 45% EF), HLD, HTN, DMII,
recently admitted for fall with right intertrochanteric femur
fracture (___) s/p right short TFN ___ with
orthopedics, who presents 1 day after discharge with altered
mental status.
Patient was discharged from the hospital yesterday after
surgical
repair to rehab. Daughters went to see her this morning, noted
her to be confused, alert and oriented x1. Patient also has new
urinary retention and is status post Foley from rehab. Patient
is
reporting right knee pain. Patient denies chest pain, difficulty
breathing, abdominal pain or dysuria.
In terms of her recent admission, the patient was taken to the
operating room on ___ for short TFN, which the patient
tolerated well. She was treated with IV fluids and pain
medications (tylenol, tramadol). She was treated with
___ antibiotics (IV ceazolin) and lovenox for DVT
prophylaxis x 4 weeks. She was discharged to rehab ___.
Past Medical History:
CORONARY BYPASS SURGERY
HYPERTENSION
AORTIC STENOSIS
DIABETES TYPE II
HYPERLIPIDEMIA
PULMONARY NODULE
MILD COGNITIVE IMPAIRMENT
OSTEOPOROSIS
OSTEOARTHRITIS
CATARACTS
HEARING LOSS
HEMORRHOIDS
WELLNESS VISITS
H/O RETINAL DETACHMENT
Social History:
___
Family History:
n/a
Physical Exam:
GENERAL: Alert and interactive. In no acute distress.
EYES: NCAT. PERRL, EOMI. Sclera anicteric and without injection.
ENT: MMM. Thyroid is normal in size and texture, no nodules. No
cervical lymphadenopathy. No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2.
+systolic murmur loudest over right sternal border
RESP: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
MSK: No bruising or other changes over right hip. No clubbing,
cyanosis, or edema. Pulses DP/Radial 2+ bilaterally.
SKIN: Warm. Cap refill <2s. No rash.
NEUROLOGIC: Oriented to person only. Follows commands. Non-focal
neuro exam
PSYCH: AOx3 today. Appropriate mood and affect
Pertinent Results:
___ 11:17PM URINE HOURS-RANDOM CREAT-116 SODIUM-<20
POTASSIUM-54 CHLORIDE-21
___ 11:17PM URINE OSMOLAL-624
___ 03:34PM LACTATE-2.0
___ 03:32PM URINE HOURS-RANDOM
___ 03:32PM URINE UHOLD-HOLD
___ 03:32PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 03:32PM URINE BLOOD-TR* NITRITE-NEG PROTEIN-30*
GLUCOSE-1000* KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-SM*
___ 03:32PM URINE RBC-0 WBC-7* BACTERIA-NONE YEAST-NONE
EPI-<1
___ 03:32PM URINE GRANULAR-1* HYALINE-1*
___ 03:32PM URINE MUCOUS-RARE*
___ 03:20PM GLUCOSE-261* UREA N-23* CREAT-0.7 SODIUM-134*
POTASSIUM-4.8 CHLORIDE-99 TOTAL CO2-22 ANION GAP-13
___ 03:20PM ALT(SGPT)-10 AST(SGOT)-34 ALK PHOS-74 TOT
BILI-0.8
___ 03:20PM LIPASE-42
___ 03:20PM ALBUMIN-3.0* CALCIUM-8.3* PHOSPHATE-2.3*
MAGNESIUM-2.0
___ 03:20PM WBC-12.3* RBC-3.40* HGB-8.1* HCT-26.6*
MCV-78* MCH-23.8* MCHC-30.5* RDW-13.5 RDWSD-38.9
___ 03:20PM NEUTS-74.3* LYMPHS-14.7* MONOS-9.8 EOS-0.2*
BASOS-0.2 IM ___ AbsNeut-9.14* AbsLymp-1.81 AbsMono-1.21*
AbsEos-0.03* AbsBaso-0.02
___ 03:20PM PLT COUNT-236
___ 03:20PM ___ PTT-21.9* ___
___ 05:57AM WBC-12.6* RBC-3.08* HGB-7.4* HCT-24.3*
MCV-79* MCH-24.0* MCHC-30.5* RDW-13.5 RDWSD-38.4
___ 05:57AM PLT COUNT-153
Brief Hospital Course:
SUMMARY
=========
___ F s/p CABG with AS (ECHO ___ 45% EF), HLD, HTN, DMII,
recently admitted for fall with right intertrochanteric femur
fracture (___) s/p right short TFN ___ with
orthopedics, who presents 1 day after discharge with altered
mental status.
ACTIVE ISSUES
==============
#Altered mental status
Patient presented with waxing and waning levels of
consciousness, as well as variable orientation consistent with
delirium. She did not have focal neurological deficits on exam,
and head CT performed in the ED was negative. UA was contained
trace leukocyte esterase, negative nitrites, grew Klebsiella
oxytoca. Although she was initially placed on broad spectrum
antibiotics, these were discontinued because she was
hemodynamically stable and afebrile. We treated her with 2 days
Bactrim DS. She also had urinary retention with full bladder,
requiring intermittent straight catheterization.
In summary, her delirium was likely multifactorial related to
delirium from recent hospital stay with new pain medications,
urinary retention, and urinary tract infection. We avoided
giving her opioid medications for pain, and discontinued
Benadryl and tramadol, which were on her medication list at
discharge from the last hospitalization.
#Urinary retention
Had Foley placed in rehab for urinary retention. Likely
secondary to anesthesia and opioids during recent
hospitalization, although urinalysis contained small leukocyte
esterase and grew Klebsiella oxytoca. We treated her with
Bactrim DS BID for two days, and she received intermittent
straight catheterization thereafter. She will require q6h
bladder scans with intermittent straight catheterization at
rehab.
# Right intertronchanteric fracture s/p right short fixation
Patient's pain was managed with standing Tylenol and lidocaine
patches. Did not require opioids during stay. Was continued on
Lovenox 30mg daily, which was started for DVT prophylaxis, which
she will continue for a total of 4 weeks (started during
hospitalization ___ post-operatively). She was seen by
orthopedic surgery, who evaluated her wound, which appeared
clean, dry and intact.
CHRONIC ISSUES
===============
#Constipation
- Senna PRN
- Bisacodyl prn
#CAD
- home ASA
- home atorvastatin 40mg nightly
#HTN
- amlodipine 7.5 mg daily
#Insomnia
- hold home Benadryl 40mg nightly iso AMS
#T2DM
- HISS while inpatient
- held home metformin XR 500mg PO daily
#Iron deficiency anemia
- held home ferrous gluconate 324 mg daily while inpatient
#Osteoporosis
- held home alendronate and calcium as inpatient
CORE MEASURES:
==============
#CODE: Full (presumed)
#CONTACT: daughter, ___ ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 7.5 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Ferrous GLUCONATE 324 mg PO DAILY
5. Acetaminophen 1000 mg PO Q8H
6. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
7. Senna 8.6 mg PO BID
8. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
9. DiphenhydrAMINE 40 mg PO QHS
10. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit oral DAILY
11. Alendronate Sodium 70 mg PO QTHUR
12. Pantoprazole 40 mg PO Q24H
13. Enoxaparin Sodium 30 mg SC Q24H
14. TraMADol 25 mg PO Q6H:PRN pain
Discharge Medications:
1. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 1 Dose
2. Acetaminophen 1000 mg PO Q8H
3. Alendronate Sodium 70 mg PO QTHUR
4. amLODIPine 7.5 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 40 mg PO QPM
7. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
8. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit oral DAILY
9. Enoxaparin Sodium 30 mg SC Q24H
10. Ferrous GLUCONATE 324 mg PO DAILY
11. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
12. Pantoprazole 40 mg PO Q24H
13. Senna 8.6 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
=================
Acute Toxic-metabolic encephalopathy d/t medications
Urinary tract infection
Right intertrochanteric femur fracture
SECONDARY DIAGNOSES:
====================
Coronary artery disease
Type 2 Diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you while you were in the
hospital. Here is some information and instructions for when you
are discharged from the hospital.
WHY WERE YOU ADMITTED?
You were in rehab after your hip fracture recovering from your
surgery. You were brought in to the hospital because you were
confused and difficult to wake up.
WHAT DID WE DO FOR YOU?
We checked your blood and urine for an infection. We found
bacteria growing in your urine, so we treated you with
antibiotics. We also changed your pain medications. We think
that you were oversedated from getting too many pain medications
at rehab.
WHAT SHOULD YOU DO WHEN YOU ARE DISCHARGED?
You should take the medications that we prescribe for you. You
should participate in physical therapy at rehab. You should also
go to your medical appointments.
WHAT SHOULD YOU LOOK OUT FOR?
You should tell the health care providers at rehab if you have
chest pain, difficulty breathing, lightheadedness, or severe
pain in your hips/knees not controlled by your current pain
regimen.
Be well,
Your ___ Care Team
Followup Instructions:
___
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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
atorvastatin / Levofloxacin
Attending: ___.
Chief Complaint:
R arm pain
Major Surgical or Invasive Procedure:
___:
ORIF right intra-articular distal humerus fracture.
History of Present Illness:
___ LHD s/p mechanical fall today. She was opening the door
after having lunch with her grandchildren when she fell backward
and landed on her right side. She isn't sure if she hit her
head.
She did not lose consciousness. She had severe pain in her R
arm.
Films at ___ showed R distal humerus fracture.
transferred to ___. Denies pain anywhere else. Denies N/T.
Past Medical History:
PMH: HTN, hypothyroidism, concussion, anxiety
Social History:
___
Family History:
Non contributory
Physical Exam:
PE: 97.2 92 157/88 16 98% RA
NAD
A&Ox3
RUE: skin intact
WWP, + radial and ulnar pulses
+edema and ecchymoses at elbow
+EPL OP DIO
SILT R/M/U
Pertinent Results:
___ 09:20PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 09:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-MOD
___ 09:20PM URINE RBC-1 WBC-17* BACTERIA-FEW YEAST-NONE
EPI-1 TRANS EPI-<1
___ 08:40PM GLUCOSE-120* UREA N-15 CREAT-1.0 SODIUM-140
POTASSIUM-4.0 CHLORIDE-101 TOTAL CO2-30 ANION GAP-13
___ 08:40PM estGFR-Using this
___ 08:40PM WBC-9.1 RBC-3.86* HGB-11.8* HCT-34.6* MCV-89
MCH-30.6 MCHC-34.3 RDW-13.5
___ 08:40PM NEUTS-84.0* LYMPHS-11.3* MONOS-4.0 EOS-0.4
BASOS-0.4
___ 08:40PM NEUTS-84.0* LYMPHS-11.3* MONOS-4.0 EOS-0.4
BASOS-0.4
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have R distal humerus fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for open reduction internal fixation,
which the patient tolerated well (for full details please see
the separately dictated operative report). The patient was taken
from the OR to the PACU in stable condition and after recovery
from anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient was given perioperative antibiotics and anticoagulation
per routine. The patients home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to rehab was appropriate.
Of note, the patient experienced post operative delerium. She
was closely followed by the Psychiatry and Geriatric Teams.
There recommendations for medication changes were implemented.
It is recommended that the patient follow up with her
Neurologist regarding her medication regimen following discharge
from the hospital to further discuss any additional changes.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is non weight bearing in the right
upper extremity, and will be discharged on aspirin for DVT
prophylaxis. The patient will follow up in two weeks per
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course, and
all questions were answered prior to discharge.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
___ distal humerus fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please continue to take Aspirin as prescribed.
WOUND CARE:
- You can get the wound wet/take a shower starting 3 days after
your surgery. You may wash gently with soap and water, and pat
the incision dry after showering.
- No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
ACTIVITY AND WEIGHT BEARING:
- Non WBing
Physical Therapy:
Non Weight Bearing Right Arm
Treatments Frequency:
Please keep splint clean and dry until follow up.
Followup Instructions:
___
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2174-06-29 22:50:00
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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Fall
Past Medical History:
Allergic rhinitis, bronchitis, cataracts, colon polyps, HTN,
HLD, lumbar radiculopathy, peripheral neuropathy, urinary
incontinence, ___ disease, restless legs syndrome,
osteoarthritis,
Past Surgical History:
Right TKA in ___
Social History:
___
Family History:
Not obtained
Physical Exam:
Physical Exam on Admission
VS: 98.0, 98, 124/65, 13, 99% 1L NC
HEENT: no lacerations, opens eyes to name, ___, CN intact
CV: RRR
Pulm: CTA b/l
Abd: no scars. soft, nondistended, notender
Ext: some left distal arm tenderness and left hip tenderness.
Moving all extremities to command. decreased sensation left
side. b/l palpable DP
Neuro: GCS 14 (loses 1 point for eye opening)
Back: some spinal tenderness, no stepoffs, no bruising
DISCHARGE PHYSICAL EXAM
VITALS: 24 HR Data (last updated ___ @ 1058)
Temp: 98.9 (Tm 98.9), BP: 119/61 (111-173/47-73), HR: 85
(81-96), RR: 18, O2 sat: 94% (92-95), O2 delivery: Ra
Fluid Balance (last updated ___ @ 1058)
Last 8 hours Total cumulative -530ml
IN: Total 420ml, PO Amt 420ml
OUT: Total 950ml, Urine Amt 950ml
Last 24 hours Total cumulative -1420ml
IN: Total 780ml, PO Amt 780ml
OUT: Total 2200ml, Urine Amt 2200ml
HEENT: Anicteric, ___, EOM intact, mucous membranes dry,
oropharynx without erythema or exudate
Neck: no JVD
CV: RRR, S1/S2 noted, no murmurs/gallops
Pulm: Clear bilaterally
GI: +BS, NT, ND, no organomegaly
GU: No foley
Skin: ecchymosis in upper extremities and bilateral flanks
appears stable from prior
MSK: Warm, no edema, 1+ pedal pulses. Left arm in cast.
Neuro: no focal deficits
Pertinent Results:
Imaging
___ CT ABDOMEN PELVIS WITHOUT CONTRAST
CT ABDOMEN PELVIS ___
Redemonstration of multiple pelvic fractures and small amount of
pelvic hemorrhage. No new retroperitoneal hemorrhage.
___ (CT HEAD W/O CONTRAST)
IMPRESSION:
1. Grossly stable right frontal subarachnoid hemorrhage with
slight interval redistribution into the left frontal extra-axial
space. Continued follow-up is recommended.
2. No new acute intracranial process.
___ CT CHEST/ABD/PELVIS W/
IMPRESSION:
1. Multiple pelvic fractures. There is a nondisplaced fracture
at the right inferior pubic ramus. There are two nondisplaced,
minimally comminuted fractures at the medial and lateral portion
of the right parasymphyseal region. There is a displaced,
comminuted angulated fracture at the left inferior pubic ramus.
There is a possible nondisplaced fracture at the left
parasymphyseal region. There is a fracture of the left anterior
acetabulum. There is no associated hematoma, soft tissue
stranding, or bladder injury.
2. The major organs within the abdomen and pelvis are without
evidence of
traumatic focal lesion or laceration. There is no evidence of
mesenteric
injury.
3. The urinary bladder is distended. There is a small amount of
nonspecific free fluid within the pelvis.
4. Esophagus is distended and fluid-filled without evidence of
hiatal hernia or wall thickening.
5. Thickening of the left lower bronchus as well as
consolidation in the left lung base which may represent
atelectasis versus a component of aspiration in the setting of
esophageal distention.
6. Tortuous gallbladder without evidence of wall thickening or
pericholecystic fluid.
7. Known left distal ulnar fracture is re-demonstrated.
___ CT HEAD W/O CONTRAST
IMPRESSION: Right frontal subarachnoid hemorrhage without
evidence of mass effect.
___ CT HEAD W/O CONTRAST
IMPRESSION: Right frontal subarachnoid hemorrhage without
evidence of mass effect.
___ CT C-SPINE W/O CONTRAST
IMPRESSION:
1. No evidence of cervical spine fracture or malalignment.
2. Multilevel, multifactorial degenerative changes throughout
the cervical spine, grossly unchanged since the prior
examination and more significant from C2-C3 through C6-C7
levels.
___ FOREARM (AP & LAT) LEFT
IMPRESSION: An oblique fracture of the distal left ulnar
diaphysis with 3 mm of ulnar displacement and mild dorsal apex
angulation is minimally changed.
___ ELBOW (AP, LAT & OBLIQUE)
IMPRESSION: No evidence of fracture or dislocation.
ADMISSION LABS
==============
___ 10:45PM BLOOD WBC-7.1# RBC-3.94 Hgb-13.0 Hct-39.1
MCV-99* MCH-33.0* MCHC-33.2 RDW-12.8 RDWSD-46.7* Plt ___
___ 10:45PM BLOOD Plt ___
___ 10:45PM BLOOD Glucose-107* UreaN-18 Creat-1.0 Na-141
K-4.3 Cl-104 HCO3-24 AnGap-13
___ 10:25AM BLOOD Calcium-8.3* Phos-2.9 Mg-1.9
___ 11:03PM BLOOD Lactate-1.3
NOTABLE LABS
============
___ 10:25AM BLOOD WBC-6.9 RBC-2.64*# Hgb-8.8*# Hct-25.9*#
MCV-98 MCH-33.3* MCHC-34.0 RDW-12.9 RDWSD-46.1 Plt Ct-79*
___ 10:25AM BLOOD Plt Smr-VERY LOW* Plt Ct-79*
___ 07:07AM BLOOD ALT-11 AST-26 LD(LDH)-409* AlkPhos-55
TotBili-1.7* DirBili-0.4* IndBili-1.3
___ 07:07AM BLOOD Albumin-3.3* Calcium-8.4 Phos-2.9 Mg-2.4
Iron-55
___ 07:07AM BLOOD calTIBC-251* VitB12-319 Hapto-<10*
Ferritn-262* TRF-193*
DISCHARGE LABS
==============
___ 07:54AM BLOOD WBC-8.0 RBC-3.10* Hgb-10.6* Hct-31.6*
MCV-102* MCH-34.2* MCHC-33.5 RDW-14.1 RDWSD-49.8* Plt ___
___ 07:58AM BLOOD Glucose-136* UreaN-16 Creat-0.9 Na-137
K-4.6 Cl-100 HCO3-25 AnGap-12
Brief Hospital Course:
The patient presented to Emergency Department on ___
following a fall. The Acute Care Surgery team was asked to
evaluate the patient. She was found to have the following
injuries: R frontal subarachnoid hemorrhage, left ulnar
fracture, right inferior pubic ramus fracture, multiple pelvic
fractures, left acetabular fracture. For this reason the
following consults were obtained:
1) Neurosurgery consult for the subarachnoid hemorrhage. They
recommended repeat head CT scan that was completed and showed a
stable right frontal SAH with no mass effect. They recommended
to hold aspirin for seven days and to aim for a sBP< 160
2) Orthopedic surgery also saw the patient who indicated that
her injuries are non-op. They placed her left arm in a sling and
recommended weight bearing activity as tolerated for the left
lower extremity.
During hospital day two the patient developed abnormal mouth
movements and for this reason a neurology consult was obtained
as well as a repeat head CT. Repeat head CT scan was stable and
neurology indicated that the abnormal mouth movements were most
likely tremors. During her hospital course the patient
experienced delirium. Geriatrics was consulted who recommended
to give 25mg Seroquel.
The patient was transferred to medicine for a full syncope
workup and further management.
MEDICINE COURSE:
Ms. ___ is an ___ year old woman with a history of
hypertension, hyperlipidemia, lumbar radiculopathy, and
___ disease who present with a fall resulting in a
traumatic right frontal subarachnoid hemorrhage, left ulnar
fracture, right pubic ramus fracture, and left acetabular
fracture with course complicated by delirium found to have
anemia and thrombocytopenia with stable pelvic hematoma.
ACUTE/ACTIVE PROBLEMS:
# Delirium
Baseline is intermittent confusion at home with inability to
perform ADL or IADL. Agitated earlier this hospitalization that
improved on Seroquel. Waxing and waning orientation is
consistent with delirium. Etiology is likely secondary to
hospitalization, pain, frustration with communication secondary
to the language barrier, narcotic pain medications. Urine with
mixed flora. No other signs of infection. Geriatrics has been
consulted and recommended seroquel in the setting of delirum.
Delirium was well controlled with seroquel and the presence of
her family in the room. She continued trazodone QHS.
# Anemia
Baseline Hb 13 fell to 8.8 nadir this admission. Labs notable
for low haptoglobin and mildly elevated bili and LDH. In the
setting of pelvic hematoma noted on CT scan ___ that is stable
on repeat CT scan ___ with now improving Hb, these values
likely reflect RBC breakdown in the setting of bleed. There is
no change over the past 5 days in the bleeding and she has no
hemodynamically significant changes. Discharge Hb 10.6.
# Thrombocytopenia
New onset thrombocytopenia. Etiology not clear. Likely
consumptive in setting of bleed as above. But again, there is no
clear history of bleed. HIT is low probability with 4T score of
3. Platelet nadir 79, improved to 196 at discharge.
# Falls
Patient with reports of multiple falls over the past few years.
Etiology is potentially related to dysautonomia from
___. Cardiac syncope appears less likely. She was
monitored on telmetry with sinus rhythm for over 24 hours.
Physical therapy was consulted and recommended rehab.
# Polytrauma
Non-operative fractures in the pubic ramus, left ulna, left
acetabulum. - Left arm sling. 2 weeks ortho follow up with LUE
xray. Pain control with standing tylenol, standing oxycodone,
prn oxycodone.
# SAH
Nonoperative SAH stable on head CT. No focal neurologic
deficits. Aspirin held ___ to discharge. Systolic blood
pressure kept less than 160.
# Hypertension
Patient with history of hypertension, exacerbated here in the
setting of delirium. She continued metoprolol.
CHRONIC/STABLE PROBLEMS:
# ___ Disease:
Continued Carbidopa-Levodopa (___) 2 TAB PO/NG QID. She
missed multiple doses at the beginning of the hospital course
when she was acutely confused in the setting of delirium.
# Allergic rhinitis
Continued cetirizine
# Peripheral neuropathy
Continued Gabapentin 600 mg PO/NG BID, Gabapentin 900 mg PO/NG
QHS
TRANSITIONAL ISSUES
# NEW MEDICATIONS
- OxyCODONE (Immediate Release) 2.5-5 mg PO/NG Q4H:PRN Pain -
Moderate
Give pain meds before transferring/moving patient
- OxyCODONE (Immediate Release) 2.5 mg PO/NG Q6H
hold for RR <12 hold for sedation
- Polyethylene Glycol 17 g PO/NG DAILY
- QUEtiapine Fumarate 25 mg PO/NG QHS schedule at ___
- QUEtiapine Fumarate 12.5 mg PO/NG QHS:PRN agitation
# CHANGED MEDICATIONS
- Carbidopa-Levodopa (___) 2 TAB PO/NG QID
Four times daily 7am, 11am, 3pm, 7pm
- Gabapentin 600 mg PO/NG BID
Gabapentin 900 mg PO/NG QHS
[] Monitor for delirium and up-titrate or down-titrate Seroquel
and gabapentin as needed to controls symptoms while minimizing
over-sedations
[] monitor pain and decrease oxycodone as able
[] please perform voiding trial on ___ and attempt to remove
foley. it was placed because the patient had pain with moving to
urinate but should NOT remain indwelling long term
[] Ensure follow up with orthopedics with left ulnar x-ray in 2
weeks
[] Held aspirin since the fall which was on ___. This was
held at discharge. Risk/benefit can be addressed by her
outpatient physicians. OK per neurosurgery to restart on ___.
[] Wean seroquel as tolerated when in her normal surroundings
[] Discuss home services with patient and her family vs.
facility for long term care
- Surrogate/emergency contact: Name of health care proxy: ___
Relationship: daughter
Cell phone: ___
___ on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild
2. Atorvastatin 10 mg PO QPM
3. Carbidopa-Levodopa (___) 3 TAB PO TID
4. Carbamide Peroxide 6.5% ___ DROP BOTH EARS BID
5. Cephalexin 500 mg PO ONCE
6. Cetirizine 5 mg PO DAILY
7. Docusate Sodium 100 mg PO BID
8. Gabapentin 300 mg PO BID
9. Metoprolol Succinate XL 25 mg PO DAILY
10. Multivitamins 1 TAB PO DAILY
11. Polymyxin B ___ ___ UNIT PO TID
12. TraZODone 50 mg PO QHS:PRN insomnia
Discharge Medications:
1. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth every four
(4) hours Disp #*20 Tablet Refills:*0
2. OxyCODONE (Immediate Release) 2.5 mg PO Q6H
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth every six
(6) hours Disp #*14 Tablet Refills:*0
3. Polyethylene Glycol 17 g PO DAILY
4. QUEtiapine Fumarate 25 mg PO QHS
5. QUEtiapine Fumarate 12.5 mg PO QHS:PRN agitation
6. Carbidopa-Levodopa (___) 2 TAB PO QID
7. Gabapentin 600 mg PO BID
RX *gabapentin 600 mg 1 tablet(s) by mouth twice a day Disp #*20
Tablet Refills:*0
8. Gabapentin 900 mg PO QHS
RX *gabapentin 600 mg 1.5 tablet(s) by mouth at bedtime Disp
#*14 Tablet Refills:*0
9. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild
10. Atorvastatin 10 mg PO QPM
11. Carbamide Peroxide 6.5% ___ DROP BOTH EARS BID
12. Cetirizine 5 mg PO DAILY
13. Docusate Sodium 100 mg PO BID
14. Metoprolol Succinate XL 25 mg PO DAILY
15. Multivitamins 1 TAB PO DAILY
16. Polymyxin B ___ ___ UNIT PO TID
17. TraZODone 50-100 mg PO QHS:PRN insomnia
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Right frontal subarachnoid hemorrhage
Left ulnar fracture
Right inferior pubic ramus fracture
Multiple pelvic fractures
Left acetabular fracture
Delirium
Anemia
Thrombocytopenia
Secondary:
___ Disease
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. ___,
You were admitted to ___ after a fall. You were found to have
fractures in the arm and hip. You had a bleed into the brain.
The surgery team evaluated these injuries and did not perform
any operations. You were given medications to help control your
confusion while in the hospital.
You had a new anemia from a small bleed into the pelvis. This
was stable at the time of discharge.
You should work with physical therapy as you are able after
discharge.
It was a pleasure taking care of you. We wish you the best in
your health.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
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2164-03-11 15:58:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Penicillins / codeine / hydrochlorothiazide / cephlasporins /
oxycodone
Attending: ___.
Chief Complaint:
left hip pain
Major Surgical or Invasive Procedure:
left cephalomedullary nail
History of Present Illness:
___ female presents with the above fracture s/p symcopal fall.
Patient awoke, ambulating to bathroom, felt weak and fell. No
HS/LOC. No nausea/vomiting. No focal neuro changes or chest
pain. On presentation, patient complaining only of left hip pain
with no distal numbness or tingling.
Past Medical History:
Hypertension
Social History:
___
Family History:
non-contributory
Physical Exam:
Exam on Discharge
No acute distress
Unlabored breathing
Abdomen soft, non-tender, non-distended
Dressing is clean/dry/intact with no erythema or discharge,
minimal ecchymosis
Left lower extremity fires ___
Left lower extremity SILT sural, saphenous, superficial
peroneal, deep peroneal and tibial distributions
Left lower extremity dorsalis pedis pulse 2+ with distal digits
warm and well perfused
Pertinent Results:
noncontributory
Brief Hospital Course:
Hospitalization Summary (ED Admit)
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left intertrochanteric femur fracture and was admitted
to the orthopedic surgery service. The patient was taken to the
operating room on ___ for a left ceaphlomedullary nail,
which the patient tolerated well. For full details of the
procedure please see the separately dictated operative report.
The patient was taken from the OR to the PACU in stable
condition and after satisfactory recovery from anesthesia was
transferred to the floor. The patient was initially given IV
fluids and IV pain medications, and progressed to a regular diet
and oral medications by POD#1. The patient was given
___ antibiotics and anticoagulation per routine. The
patient's home medications were continued throughout this
hospitalization. The patient worked with ___ who determined that
discharge to rehab was appropriate. The ___ hospital
course was complicated by atrial fibrillation with rapid
ventricular response. that began in the ___ setting.
The patient remained hemodynamically stable despite a heart rate
in the 130's to 150s. The patient was started on diltiazem and
resumed normal sinus rhythm. She was also found to have a
urinary tract infection on presentation. Urinary cultures grew
enterococcus and she was treated with a three day course of
vancomycin. Medicine was consulted and agreed with these
changes.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
full weight bearing in the left lower extremity with no hip
precautions, and will be discharged on Lovenox for DVT
prophylaxis. The patient will follow up with Dr. ___
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course
including reasons to call the office or return to the hospital,
and all questions were answered. The patient was also given
written instructions concerning precautionary instructions and
the appropriate follow-up care. The patient expressed readiness
for discharge.
I provided an opioid prescription with a notation that it can be
filled at a lower amount. I discussed with the patient regarding
the quantity of the opioid prescribed and the option to fill the
prescription in a lesser quantity. I also discussed the risks
associated with the opioid prescribed. Prior to prescribing the
opioid, I utilized the ___ Prescription
Awareness Tool) to review the patients previous prescriptions.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Influenza Vaccine Quadrivalent 0.5 mL IM NOW X1
Start: ___, First Dose: Next Routine Administration Time
2. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
3. Calcium Carbonate 500 mg PO DAILY
4. Vitamin D 1000 UNIT PO DAILY
5. Lisinopril 20 mg PO DAILY
6. GuaiFENesin 10 mL PO Q4H:PRN cough
Discharge Medications:
1. Diltiazem Extended-Release 180 mg PO DAILY
RX *diltiazem HCl [DILT-XR] 180 mg 1 capsule(s) by mouth once a
day Disp #*30 Capsule Refills:*0
2. Docusate Sodium 100 mg PO BID
use while taking narcotic pain medication
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
3. Enoxaparin Sodium 40 mg SC DAILY
RX *enoxaparin 30 mg/0.3 mL 1 syringe subcutaneously daily Disp
#*28 Syringe Refills:*0
4. Senna 8.6 mg PO DAILY
use while taking narcotic pain medicaiton
RX *sennosides [senna] 8.6 mg 1 tablet by mouth once a day Disp
#*30 Tablet Refills:*0
5. TraMADol 50 mg PO Q4H:PRN Pain - Moderate
RX *tramadol 50 mg 1 tablet(s) by mouth every four (4) hours
Disp #*16 Tablet Refills:*0
6. Acetaminophen 650 mg PO 5X/DAY
7. Calcium Carbonate 500 mg PO DAILY
8. GuaiFENesin 10 mL PO Q4H:PRN cough
9. Lisinopril 20 mg PO DAILY
10. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
left, closed intertrochanteric femur fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- weight bearing as tolerated on the left lower extremity.
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take enoxaparin daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Please remain in your dressing and do not change unless it is
visibly soaked or falling off. If it becomes soaked it can be
redressed as needing for drainage. If the incision is dry it may
be left open to air.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
Physical Therapy:
weight bearing as tolerated with no hip precautions.
Treatments Frequency:
The dressing should not be changed unless it is visibly soaked
or falling off. If it becomes soaked it can be redressed as
needing for drainage. If the incision is dry it may be left open
to air.
Followup Instructions:
___
|
19588064-DS-18
| 19,588,064 | 23,264,099 |
DS
| 18 |
2192-05-06 00:00:00
|
2192-05-07 20:29:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
dyspnea, lower extremity edema
Major Surgical or Invasive Procedure:
Attempted TEE/cardioversion - received sedation; unable to pass
probe into mouth
History of Present Illness:
___ female with a history of severe diastolic heart
failure and atrial fibrillation who presents with worsening
weakness, dyspnea, orthopnea. The daughter has noted worsening
dyspnea and increased swelling in her lower legs over the past
three days. Orthopnea became so severe yesterday that the
___ daughter increased her dose of Lasix to 20 twice daily
starting yesterday. The ___ daughter also states that for
the past three days, her mother has suddenly become
unable/unwilling to stand, has been less lucid (does not
recognize family, mumbling non-sensical words), and has had
decreased appetite. No chest pain, palpitations, syncope or
presyncope, fevers, or productive cough.
.
Of note, the patient was last seen on ___ with complaints of
feeling severely fatigued with increased dyspnea on exertion.
At this time, she was noted to be in atrial fibrillation/flutter
with a heart rate in the 80's. Dr. ___ the ___
Amiodarone to 200mg. She was referred for TEE/CV, but required
cancellation of the procedure for subtherapeutic INR. The
concern for subtherapeutic INR is hightened due to one year of
increasing wordfinding difficulties/confusion, with question of
cardioembolic strokes. The patient was seen by a neurologist,
and CT scan showed severe atrophy with evidence of small-vessel
ischemic disease.
.
In the ED, initial vital signs 97.6 101 116/86 26 100% . The
patient underwent CXR that showed moderate cardiomegaly
(stable), Pleural effusions (trace), no overt pulmonary edema.
BNP 13000's. A foley catheter was placed for UOP monitoring.
.
On arrival to the floor, patient unable to participate in
history or exam. Per daughter, mumbling to herself in
non-sensical syllables. Daughter states that she continues to
have mild dyspnea. Per daughter, edema improved with additional
doses of lasix.
.
REVIEW OF SYSTEMS
On review of systems, she denies any prior history of deep
venous thrombosis, pulmonary embolism, bleeding at the time of
surgery, myalgias, joint pains, cough, hemoptysis, black stools
or red stools. No recent fevers, chills or rigors. All of the
other review of systems were negative.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes (non-insulin dependent),
Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
- Paroxysmal atrial fibrillation
- Severe diastolic congestive heart failure.
- Pulmonary hypertension.
- Moderate-to-severe mitral regurgitation.
- Moderate tricuspid regurgitation.
- Question of restrictive cardiomyopathy.
-PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
- Osteoporosis.
- Glaucoma.
- Gout.
- Appendicitis with septic shock.
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
Admission Physical Exam:
VS: T=95 BP= 126/88 HR= 54 RR= 20 O2 sat= 100%3L
GENERAL: frail woman, laying in bed; appears mildly dyspneic;
occasionally mumbling non-sensical words
HEENT: NCAT. Sclera anicteric. Conjunctiva pink, no pallor or
cyanosis of the oral mucosa.
NECK: Supple with JVD to mid neck
CARDIAC: Irregularly irregular S1, S2 with prominant pulmonary
component; holosystolic murmur best heard at apex. No thrills,
lifts. No S3 or S4.
LUNGS: Resp were unlabored, no accessory muscle use. Mild
bibasilar crackles.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: Trace pedal edema
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
NEURO: Slight left sided facial droop - but smile symmetric,
patient unable to participate in EOM, increased tone in upper
extremities bilaterally; ___ grasp bilaterally; bilateral +
babinskis; patient unable to stand independently
PULSES:
Right: Carotid 2+ DP 1+ ___ 1+
Left: Carotid 2+ DP 1+ ___ 1+
.
Discharge Physical Exam:
VS: 97.5 129/86 80 18 97%RA
GENERAL: frail woman, laying in bed; appears comfortable
NECK: Supple without JVD
CARDIAC: Irregularly irregular S1, S2 with prominant pulmonary
component; holosystolic murmur best heard at apex. No thrills,
lifts. No S3 or S4.
LUNGS: Resp unlabored, no accessory muscle use. Clear to
auscultation bilaterally
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: Trace pedal edema
PULSES:
Right: Carotid 2+ DP 1+ ___ 1+
Left: Carotid 2+ DP 1+ ___ 1+
Pertinent Results:
Admission labs:
___ 04:55PM BLOOD WBC-7.9 RBC-3.76* Hgb-12.3 Hct-38.4
MCV-102* MCH-32.8* MCHC-32.1 RDW-13.9 Plt ___
___ 04:55PM BLOOD ___ PTT-47.2* ___
___ 04:55PM BLOOD Glucose-251* UreaN-32* Creat-1.2* Na-143
K-3.3 Cl-103 HCO3-25 AnGap-18
___ 04:55PM BLOOD ___
___ 04:55PM BLOOD cTropnT-0.02*
___ 06:05AM BLOOD Calcium-9.2 Phos-3.9 Mg-2.5
.
Discharge Labs:
___ 08:05AM BLOOD WBC-7.8 RBC-3.79* Hgb-12.5 Hct-38.1
MCV-100* MCH-32.9* MCHC-32.8 RDW-13.8 Plt ___
___ 08:05AM BLOOD ___ PTT-49.2* ___
___ 08:05AM BLOOD Glucose-128* UreaN-42* Creat-1.2* Na-141
K-3.8 Cl-102 HCO3-28 AnGap-15
___ 08:05AM BLOOD Calcium-8.8 Phos-4.6* Mg-2.5
.
CXR ___: FINDINGS: Single AP upright portable view of the
chest was obtained. There has been interval removal of a
right-sided PICC. Moderate to marked cardiomegaly persists.
There is blunting of the left costophrenic angle suggesting a
combination of pleural effusion and atelectasis. There may also
be a trace right pleural effusion. No overt pulmonary edema is
seen. There is no pneumothorax. Mediastinal contours are stable.
.
IMPRESSION: Persistent, stable moderate to marked cardiomegaly
with small left and possibly trace right bilateral pleural
effusions with overlying
atelectasis.
.
Head CT (non-contrast) ___:
FINDINGS: No acute intracranial hemorrhage, edema, masses, or
mass effect is seen. The gray-white matter differentiation is
preserved. The ventricles and sulci are moderately enlarged,
consistent with moderate involutional changes. The basal
cisterns are normal. Bilateral periventricular white matter
hypodensities suggest small vessel ischemic disease. Extensive
vascular calcification is seen in both cavernous internal
carotid arteries. The imaged paranasal sinuses and mastoid air
cells are clear.
.
IMPRESSION: No acute intracranial pathology. Moderate to severe
atrophy and small vessel ischemic disease.
.
Attempted transesophageal ECHO ___: Patient was unable to
cooperate with exam even with the assistance of a translator,
esophageal intubation was unsuccessful. If indicated, a repeat
study with anesthesia support is suggested.
Brief Hospital Course:
___ female with a history of severe diastolic heart
failure and atrial fibrillation admitted with worsening
weakness, dyspnea, orthopnea; found to have acute on chronic
diastolic heart failure.
.
# Acute on chronic diastolic heart failure: Patient has a
history of severe diastolic heart failure. Last EF > 55%.
Symptoms of worsening dyspena, orthopnea, peripheral edema
concerning for excacerbation. Unclear precipitant for
exacerbation, but loss of atrial kick from atrial fibrillation
may have worsened forward flow. During admission, the patient
was diuresed with Lasix 20 mg IV daily. She was then
transitioned to home Lasix 20 mg PO upon reaching euvolemia. As
atrial fibrillation likely contributing to symptoms, the patient
underwent attempted TEE/cardioversion as below. Patient unable
to tolerate procedure. Will attempt cardioversion as outpatient
in 3 weeks with continued therapeutic INR.
.
# Atrial fibrillation/RHYTHM: Patient is in atrial
fibrillation, on coumadin and amiodarone. Concern that lack of
atrial kick is contributing to CHF symptoms. During admission,
the patient underwent attempted TEE/cardioversion. However, she
would not tolerate swallowing the TEE probe. The patient was
maintained on coumadin with INR ___. She should remain on
coumadin with therapeutic INR on discharge. If INR maintained
between ___, patient will undergo cardioversion as an outpatient
in 3 weeks. The patient should undergo continued INR monitoring
twice a week as an outpatient.
.
# Cognitive decline: Per daughter, patient with slow cognitive
decline over 6 months. For three days prior to admission, the
patient was not lucid at all - mumbles to herself, confusing
friends and family, not oriented to place or time. CT head
without contrast without acute findings. During admission,
patient returned to baseline. She was monitored for evidence of
infection as source of delirium - no evidence of UTI or
pneumonia.
.
# CORONARIES: No known history of CAD. She was continued on
ASA 81mg throughout admission.
.
# Diabetes: Type II, on metformin. Metformin was held while
the patient was in the hospital. The patient was continued on
an insulin sliding scale during admission. She should resume
metformin as an outpatient.
.
# OSTEOPOROSIS: Patient has a history of severe osteoporosis.
She was continued on vitamin D and calcium while in house. She
should resume weekly alendronate as an outpatient.
.
CODE: DNR/DNI, discussed with health care proxy
Medications on Admission:
ALENDRONATE [FOSAMAX] - (Prescribed by Other Provider) - 35 mg
Tablet - one Tablet(s) by mouth once weekly ___
AMIODARONE - (Prescribed by Other Provider) - 200 mg Tablet - 1
Tablet(s) by mouth daily
FUROSEMIDE - 20 mg Tablet - one Tablet(s) by mouth daily
METFORMIN - (Prescribed by Other Provider) - 500 mg Tablet -
0.5
(One half) Tablet(s) by mouth every morning
POLYETHYLENE GLYCOL 3350 - (Prescribed by Other Provider) - 17
gram Powder in Packet - 1 by mouth daily as needed
WARFARIN - (Prescribed by Other Provider) - 1 mg Tablet - one
Tablet(s) by mouth daily
ASPIRIN - (Prescribed by Other Provider; OTC) - 81 mg Tablet,
Delayed Release (E.C.) - one Tablet(s) by mouth once daily in
p.m.
CALCIUM - (Prescribed by Other Provider) - 500 mg Tablet - one
Tablet(s) by mouth once daily at noon
MULTIVITAMIN - (Prescribed by Other Provider) - Tablet - one
Tablet(s) by mouth once daily in p.m.
Discharge Medications:
1. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
3. metformin 500 mg Tablet Sig: 0.5 Tablet PO once a day.
4. warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
___: Take 1 tablet ___ take 1.5 tab ___,
___.
5. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily).
6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Calcium 500 + D (D3) 500-125 mg-unit Tablet Sig: One (1)
Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagonsis: Acute on chronic diastolic heart failure;
atrial fibrillation
Secondary diagnoses: type II diabetes, non-insulin dependent,
controlled; dementia
Discharge Condition:
Mental Status: Confused - most of time
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair (baseline
prior to admission, ambulatory with walker)
Discharge Instructions:
Ms. ___,
.
You were admitted to the hospital for worsening shortness of
breath related to your heart failure. We gave you lasix IV to
help remove excess fluid from your body. You also underwent
attempted TEE/cardioversion for your atrial fibrillation;
however you were unable to tolerate the procedure. You were
maintained on therapeutic coumadin throughout your admission.
You were discharged to rehabilitation. You should continue to
take your coumadin to maintain a therapeutic INR between ___
daily. You may follow up in the coming weeks to attempt
cardioversion again, once therapeutic on your coumadin for a
month. If you do attempt cardioversion, it will be important
for you to remain therapeutic on coumadin for at least a month
following the procedure.
.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
.
Medications changed this admission:
Please take coumadin 1 mg daily ___
Please take coumadin 1.5 mg daily ___
Followup Instructions:
___
|
19588075-DS-16
| 19,588,075 | 27,413,631 |
DS
| 16 |
2167-03-12 00:00:00
|
2167-03-12 15:37:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Keflex
Attending: ___.
Chief Complaint:
abd pain
Major Surgical or Invasive Procedure:
EUS with FNA of ampulla
History of Present Illness:
___ yo female with history of recurrent pancreatitis presents
with abodminal pain for 1 week. Pain is L sided, exacberated
with movement, breathing, and eating. +Nausea, no emesis. Pt
reports steatorrhea about 5 days ago but has since resolved. Of
note, pt was admitted at ___ on ___, CT there
showed dilated CBD but otherwise was within normal limits.
Patient was admitted to ___ for further work
up but left AMA before any evaluation could be done. She then
was referred by Dr. ___ to ___ ___ after initial evaluation
in clinic.
In ___ pt had normal labs and RUQ US, and patient was admitted
for further evaluation. She was given morphine, zofran, viscous
lidocaine, maalox, pantoprazole and donnatol.
On arrival to floor pt reports that this is similar to her prior
episodes when she was diagnosed with pancreatitis. Her most
recent flare prior to this was ___ years ago. States her enzymes
are usually mildly elevated. She thinks this episode was brought
on by taking oxycodone for recent surgery after a fall.
ROS: as noted above, otherwise reviewed and negative
Past Medical History:
GERD
- s/p Nissen fundoplication in ___
MS
___
- s/p CCY
Recurrent pancreatitis
RLS
Hypothyroid
Social History:
___
Family History:
___ w/pancreatitis, colon ca
Physical Exam:
Vitals: T:98.4 BP:111/69 P:69 R:18 O2:99%ra
PAIN: 6
General: nad
Lungs: clear
CV: rrr no m/r/g
Abdomen: bowel sounds present, soft, nd, tender LUQ
Ext: no e/c/c
Skin: no rash
Neuro: alert, follows commands
Discharge exam:
afebrile, VSS
Abdomen- non-tender to light palpation, mildly tender to deep
palpation
ambulatory without assistance
remainder of exam as above
Pertinent Results:
GLUCOSE-98 UREA N-11 CREAT-1.0 SODIUM-140 POTASSIUM-3.8
CHLORIDE-107 TOTAL CO2-23 ANION GAP-14
ALT(SGPT)-22 AST(SGOT)-18 ALK PHOS-100 TOT BILI-0.4
LIPASE-45
ALBUMIN-4.5
WBC-4.9 RBC-4.47 HGB-12.8 HCT-38.4 MCV-86 MCH-28.6 MCHC-33.2
RDW-13.2
NEUTS-67.1 ___ MONOS-5.4 EOS-1.3 BASOS-0.7
PLT COUNT-306
URINE UCG-NEG
COLOR-Yellow APPEAR-Hazy SP ___
BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG
BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-TR
RBC-1 WBC-2 BACTERIA-NONE YEAST-NONE EPI-2
Discharge labs:
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
5.0 3.99 11.3 34.6 87 28.3 32.7 13.0 247
Glucose UreaN Creat Na K Cl HCO3
92 10 0.8 143 4.2 112 25
ALT AST AlkPhos TotBili
18 13 87 0.2
Imaging:
RUQ ultrasound:
IMPRESSION:
1. Mild dilatation of the CBD which can be seen post
cholecystectomy. However, as the distal CBD was not visualized,
if there is continued concern for CBD stones, further assessment
with MRCP is recommended. No intrahepatic biliary dilatation.
2. The pancreas is not well visualized due to overlying bowel
gas.
MRCP:
Dilated main pancreatic duct, measuring up to 9 mm in diameter
with increased enhancement in the major papilla suggesting an 8
mm mass, highly concerning for an ampullary tumor. Mild intra
and extrahepatic duct dilation down to the level of the ampulla.
No biliary tract calculi are identified. ERCP is recommended
for further evaluation.
Endoscopic ultrasound:
Esophagus: Minimal exam of the esophagus was normal with the
echoendoscope.
Stomach: Exam of the stomach was normal with the echoendoscope;
no ulcers or erosions were seen.
Duodenum: Exam of the duodenum was normal with the
echoendoscope.
- The head and uncinate pancreas were imaged from the duodenal
bulb and the second / third duodenum. The body and tail
[partially] were imaged from the gastric body and fundus.
- The parenchyma in the uncinate, head, body and tail of the
pancreas was homogenous, with a normal salt and pepper
appearance.
- The pancreas duct was dilated. It measured 6.5 mm in maximum
diameter in the head of the pancreas and 2.2 mm in maximum
diameter in the body of the pancreas. The duct was normal in
echotexture and contour. No intra-ductal stones were noted. No
dilated side-branches were noted.
- The bile duct was imaged at the level of the porta-hepatis,
head of the pancreas and ampulla. The maximum diameter of the
bile duct was 11.2 mm. The bile duct was dilated but no
intrinsic stones or sludge were noted.
- Portal vein, splenic vein and porto-splenic confluence were
imaged and appeared normal. The imaged superior mesenteric vein
and artery were imaged and appeared normal.
- Ampulla appeared normal endoscopically but appeared fuller in
appearance when compated to normal endosonographically. All 4
EUS layers were well preserved. PD appeared to end at the
duodenal wall margin. No adjacent lymphadenopathy was noted.
There was no evidence of a malignant process, pancreatic head
mass or chronic pancreatitis to explain dilation of the PD and
CBD.
- Because ampulla appeared fuller, FNA was done with a 25-gauge
needle. Two needle passes were made into the ampulla. Aspirate
was sent for cytology, pending at time of discharge
Brief Hospital Course:
Abdominal Pain: broad differential- gastritis vs. PUD vs. acute
pancreatitis vs. chronic pancreatitis vs. biliary obstruction.
Patient treated empirically for gastritis- continued PPI, added
high dose H2 blocker for 2 weeks. Acute pancreatitis not
evidence on labs, and pancreas as imaged on EUS was normal,
ruling out chronic pancreatitis. No evidence of hepatic
dysfunction on labs. Recent CT abdoman/pelvis reassuring, only
noted dilated CBD (common after cholecystectomy). Thus,
evaluation focused on biliary tree. MRCP as noted above raised
concern for obstruction at the level of the ampulla. EUS as
noted above did not show evidence of ampullary mass or
stricture, and a less dilated pancreatic duct then suggested on
MRCP, all of which was reassuring. FNA of redundant ampullary
tissue was performed, cytology pending at time of discharge.
Patient was tolerating a regular, low residue diet on day of
discharge, and will follow up closely with PCP and
gastroenterologist in the coming weeks. Should symptoms
persist, consideration will be given to ERCP for evaluation of
intermittent ampullary stenosis. Patient was given a short
course of fentayl patch (started by PCP earlier this week) upon
discharge, and advised not to drive while using the patch.
GERD: as above, continued PPI, added H2 blocker
MS: continued Tecfidera
RLS: continuted home medications
FULL CODE
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 100 mcg PO DAILY
2. Tecfidera (dimethyl fumarate) 240 mg oral BID
3. Gabapentin 600 mg PO TID
4. Duloxetine 30 mg PO BID
5. Topiramate (Topamax) 200 mg PO DAILY
6. Dexilant (dexlansoprazole) 30 mg oral daily
7. Mirapex (pramipexole) 0.5 mg oral qhs
8. Fluoxetine 20 mg PO DAILY
9. Fentanyl Patch 12 mcg/h TD Q72H
Discharge Medications:
1. Duloxetine 30 mg PO BID
2. Fentanyl Patch 12 mcg/h TD Q72H
RX *fentanyl 12 mcg/hour apply to skin Q72 hours Disp #*2 Unit
Refills:*0
3. Fluoxetine 20 mg PO DAILY
4. Gabapentin 600 mg PO TID
5. Levothyroxine Sodium 100 mcg PO DAILY
6. Mirapex (pramipexole) 0.5 mg oral qhs
7. Tecfidera (dimethyl fumarate) 240 mg oral BID
8. Topiramate (Topamax) 200 mg PO DAILY
9. Dexilant (dexlansoprazole) 30 mg oral daily
10. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*3
11. Ranitidine 150 mg PO BID Duration: 7 Days
RX *ranitidine HCl [Zantac] 150 mg 1 tablet(s) by mouth twice a
day Disp #*14 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
abdominal pain
"fuller" ampulla, no mass or obstruction, biopsy obtained
Secondary diagnosis:
multiple sclerosis
GERD
depression/anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with abdominal pain. An MRCP
revealed possible dilated pancreatic duct. You then underwent
an endoscopic ultrasound, which showed a normal pancreas, no
stomach ulcers, and mildly dilated pancreatic duct. A biopsy
was performed, and will return next week.
You tolerated a regular, low residue, low fat diet without
worsening symptoms prior to returning home.
Please see below for your follow up appointments.
The only medication change will be the addition of ranitidine
150 mg PO BID x 7 days and docusate, a stool softener.
Followup Instructions:
___
|
19588182-DS-18
| 19,588,182 | 21,472,953 |
DS
| 18 |
2133-09-01 00:00:00
|
2133-09-01 21:39:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right lower extremity claudication
Major Surgical or Invasive Procedure:
___
1. Ultrasound-guided access to left common femoral artery with
placement of ___ sheath.
2. Selective catheterization of the posterior tibial artery on
the right ___ order vessel.
3. Abdominal aortogram.
4. Right lower extremity arteriogram.
5. Placement of 20 cm infusioning ___ catheter and
initiation of lysis.
___
1. Selection of right posterior tibial artery ___ vessel.
2. Right lower extremity imaging.
3. AngioJet thrombectomy of distal posterior tibial artery.
4. Closure of access with ___ Perclose device.
History of Present Illness:
The patient is a ___ gentleman with past medical history
significant for hypertension and BPH, who presents with a 3-day
history of worsened right lower extremity claudication. He had
some intermittent paleness and coolness of the foot as well. He
was seen in an outside hospital where an ultrasound showed an
occluded popliteal artery. He was started on heparin and
transferred to our institution.
Past Medical History:
BPH, HTN, diverticulosis, GERD, carpal tunnel syndrome
Past surgical history:
Appendectomy, bilateral cataract surgery, bronchoscopy with
removal of food particle, bilateral knee arthroscopies, dilation
of esophageal stricture
Social History:
___
Family History:
Positive for hypertension.
Physical Exam:
On admission,
Vital signs: 98.4 59 136/68 18 98% RA
Constitutional: well-appearing, in NAD, AAOx3
Cardiopulmonary: RRR, normal S1 and S2. No murmurs, rubs or
gallops. CTAB, no respiratory distress
Abdomen: Soft, non-tender, non-distended
RLE: warm to touch, no erythema or edema, motor and sensory
intact
LLE: warm to touch, no erythema or edema, motor and sensory
intact
Pulses: Bilateral palpable femoral and popliteal. Dopplearable
(weak) right DP, and dopplearable left DP and ___ bilateral.
On discharge,
General: AVSS, well-appearing, in no acute distress.
Cardiopulmonary: RRR, normal S1 and S2. No murmurs, rubs or
gallops. CTAB, no respiratory distress
Abdomen: Soft, non-tender, non-distended
Neurologic: Grossly intact. AAO x 3
Pulses: Palpable femoral, popliteal, ___ and DP bilateral.
Pertinent Results:
___ 07:30AM BLOOD WBC-7.7 RBC-4.37* Hgb-13.5* Hct-41.8
MCV-96 MCH-30.9 MCHC-32.3 RDW-11.6 Plt ___
___ 02:15AM BLOOD ___ PTT-74.2* ___
___ 07:30AM BLOOD Glucose-100 UreaN-18 Creat-1.1 Na-141
K-4.2 Cl-107 HCO3-25 AnGap-13
___ 07:30AM BLOOD Calcium-8.4 Phos-3.3 Mg-1.8
___ 07:30AM BLOOD %HbA1c-5.8 eAG-120
Right lower extremity arterial duplex (___)
Occlusion of the right popliteal and perineal arteries
Echocardiography (___)
Normal biventricular function, with estimated let ventricular EF
>55%. Biatrial enlargement is noted. Mild aortic insufficiency
and mild-moderate mitral and tricuspid insufficiency are presen.
Mild dilation of the ascending aorta. Mild pulmonary
hypertension. No pericardial effusion.
CT Urogram (___)
1. Mild perinephric fat stranding, particularly surrounding the
lower poles of both kidneys. No concerning renal lesions. No
hydronephrosis. No radiopaque urinary tract calculi.
2. Unusual soft tissue density adjacent to the right
ureterovesical junction within the bladder which likely
represents clot, although a tumor cannot be outruled.
3. Non-opacified vessels in the right lower lobe. Although
suspicion for PE is low, it cannot be outruled. CTA chest is
recommended for further evaluation.
4. Soft tissue stranding and a small amount of hematoma within
the left groin related to the recent surgery.
5. Trace bilateral pleural effusions. Chronic interstitial
changes in both lung bases.
6. Enlarged prostate gland with a volume of approximately 67 cc.
7. Subcentimeter enhancing lesion within segment V of the liver
that likely represents a small hemangioma.
8. Severe mitral valve calcification.
Brief Hospital Course:
Mr ___ presented with a 3-day history of right lower
extremity claudication. Imaging studies performed at outside
hospital were consistent with right popliteal artery occlusion,
for which purpose he max started on a heparin drip and
transferred to our institution for further evaluation and
management. Decision was made to take the patient to the
operating room for angiography/angioplasty. Findings were
consistent with right popliteal artery occlusion with distal
reconstitution of anterior and posterior tibial arteries. A
___ catheter was placed and initiation of lysis was
performed (see Operative Note for further details). Patient was
taken back to the ward after a brief uneventful stay in the
PACU. After overnight lysis, he was taken back to the operating
room for lysis check. A patent popliteal artery with 2-vessel
runoff through AT and ___ confirmed success of the lysis
treatment. All hardware was removed. A ___ Perclose was
placed for hemostasis, and the patient returned to the floor
after a brief PACU stay. Heparin drip was continued and warfarin
therapy started.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was managed appropriately with oral
medications. A noticeable improvement in pain was reported after
the procedure. CV: The patient remained stable from a
cardiovascular standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization. Findings on CT consistent
with non-opacified vessels in right lower lobe were concerning
-even with low suspicion- for pulmonary embolism. Given
patient's reassuring clinical status, further studies were not
pursued. GI/GU/FEN: The patient's diet was advanced sequentially
to a regular diet, which was well tolerated. Patient's intake
and output were closely monitored. Urine output on POD#1 from
initial surgery was noted to be grossly bloody, which was
attributed to the recent administration of thrombolytics. Given
persistence of hematuria, a Urology consult was requested on
POD#2 and heparin drip was discontinued. Recommendation was made
to start continuous bladder irrigation overnight, urine analysis
and cytology, as well as a CT urography (refer to Reports for
details). Findings were reassuring, although an unusual density
within the bladder (likely a clot) prompted recommendation for
outpatient follow-up. Hematuria cleared and CBI was stopped
after overnight treatment. Three-way Foley catheter was removed
and patient voided with no issues. ID: The patient's fever
curves were closely watched for signs of infection, of which
there were none. HEME: The patient's blood counts were closely
watched for signs of bleeding, of which there were none.
Prophylaxis: The patient was started on warfarin on POD#1 of the
second procedure and bridging with enoxaparin was initiated.
Arrangements were made prior to discharge for anticoagulation
management.
At the time of discharge, Mr ___ 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.
Medications on Admission:
vitB12, atenolol 25mg qday, oxybutynin 5mg qday
Discharge Medications:
1. Atenolol 25 mg PO DAILY
2. Docusate Sodium 100 mg PO BID constipation
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice daily
Disp #*40 Capsule Refills:*0
3. Enoxaparin Sodium 60 mg SC BID
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 60 mg/0.6 mL 60 mg subcutaneous every ___ hours
Disp #*10 Syringe Refills:*0
4. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 capsule by mouth once daily Disp
#*30 Capsule Refills:*0
5. Tamsulosin 0.4 mg PO HS
RX *tamsulosin 0.4 mg 1 capsule,extended release 24hr(s) by
mouth once daily Disp #*30 Capsule Refills:*0
6. Warfarin 5 mg PO DAILY16
RX *warfarin 5 mg 1 tablet(s) by mouth once a day Disp #*10
Tablet Refills:*0
7. Acetaminophen 500 mg PO Q6H:PRN pain
RX *acetaminophen 500 mg 1 tablet(s) by mouth every six (6)
hours Disp #*40 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Right lower extremity claudication
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr ___,
It was a pleasure taking care of you here at ___
___. You were admitted to our institution
after undergoing a procedure to clear an occlusion in your right
lower extremity that was causing you pain. After a brief
hospital stay and successful recovery, we now feel comfortable
discharging you home, provided you follow these recommendations.
Division of Vascular and Endovascular Surgery
Lower Extremity Angioplasty Discharge Instructions
MEDICATION:
Take new medications as instructed: Coumadin and Lovenox
Continue all other medications you were taking before surgery,
unless otherwise directed
You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
WHAT TO EXPECT:
It is normal to have slight swelling of the legs:
Elevate your leg above the level of your heart with pillows
every ___ hours throughout the day and 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:
When you go home, you may walk and use stairs
You may shower (let the soapy water run over groin incision,
rinse and pat dry)
Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area
No heavy lifting, pushing or pulling (greater than 5 lbs) for 1
week (to allow groin puncture to heal)
After 1 week, you may resume sexual activity
After 1 week, gradually increase your activities and distance
walked as you can tolerate
No driving until you are no longer taking pain medications
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
SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site)
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:
___
|
19588182-DS-19
| 19,588,182 | 24,036,110 |
DS
| 19 |
2134-06-28 00:00:00
|
2134-06-28 22:18:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Progressive dyspnea
Major Surgical or Invasive Procedure:
Nuclear Stress test
History of Present Illness:
___ with h/o HTN and popliteal embolus (on Coumadin) last year,
referred to the ED after stress test today showed new onset
atrial fibrillation and ischemic pattern. He reports a two-week
h/o dyspnea and chest pressure on exertion, without other
associated features. Was seen by his PCP last week, an EKG and
CXR at that time were unremarkable and he was scheduled for
today's stress test.
Any kind of incline causes dyspnea/CP for him after
approximately 10 min, resolves with rest. No rest symptoms. This
has been present for at least 2 weeks, but he wonders if it has
been more insidious, having to stop swimming over the ___ bc
of dyspnea. He has given swimming up bc of SOB over the summer.
On today's stress test, he was noted to have escalating
angina/DOE with minimal exertion, activity related 02
desaturation to 93%. He was noted to have ___epressions
inferolaterally. He received ASA 325 mg.
In the ED intial vitals were: T97.8 P60 BP126/72 RR16 O2 sat
96%. Labs were notable for normal CBC, Cr 1.3 (baseline 1.0-1.2)
and INR 3.4. Troponin was negative x 1. CXR was unremarkable. He
was chest pain free. Patient was then admitted to Cardiology for
further management.
Vitals on transfer: T98.2 P72 BP 136/83 RR18 O2 sat 97% RA
On the floor the pt is w/o complaints
ROS: On review of systems, he denies any prior history of
stroke, TIA, bleeding at the time of surgery, myalgias, joint
pains, cough, hemoptysis, black stools or red stools. He denies
recent fevers, chills or rigors. He denies exertional buttock or
calf pain. All of the other review of systems were negative.
Cardiac review of systems is notable for absence of paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope
or presyncope.
Past Medical History:
BPH, HTN, diverticulosis, GERD, carpal tunnel syndrome
Past surgical history:
Appendectomy, bilateral cataract surgery, bronchoscopy with
removal of food particle, bilateral knee arthroscopies, dilation
of esophageal stricture
Social History:
___
Family History:
Positive for hypertension.
Physical Exam:
Admission Physical:
VS: 98.5 132/78 43 18 95% RA Wt 71.2
GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP at angle of mandible at 30 deg.
CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Discharge Physical:
VS: 97.9 110s-120s/60s-70s ___ 97%O2 RA
GENERAL: in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. No xanthelasma.
NECK: Supple with JVP of 7-8 cm.
CARDIAC: Normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 2+ ___ 2+
Left: DP 2+ ___ 2+
Pertinent Results:
Admissions Labs:
___ 01:00PM BLOOD WBC-7.5 RBC-4.78# Hgb-15.1# Hct-45.1#
MCV-94 MCH-31.7 MCHC-33.6 RDW-13.1 Plt ___
___ 02:13PM BLOOD ___ PTT-40.2* ___
___ 01:00PM BLOOD Glucose-88 UreaN-25* Creat-1.3* Na-138
K-4.8 Cl-106 HCO3-22 AnGap-15
___ 05:45AM BLOOD Calcium-8.8 Phos-3.3 Mg-1.9
___ 01:00PM BLOOD cTropnT-<0.01
___ 03:59AM BLOOD CK-MB-3 cTropnT-<0.01
___ 05:45AM BLOOD CK-MB-3 cTropnT-<0.01
Discharge Labs:
___ 05:30AM BLOOD WBC-6.5 RBC-4.14* Hgb-13.3* Hct-40.2
MCV-97 MCH-32.1* MCHC-33.1 RDW-12.7 Plt ___
___ 05:30AM BLOOD ___ PTT-29.6 ___
___ 05:30AM BLOOD Glucose-99 UreaN-22* Creat-1.3* Na-141
K-4.4 Cl-110* ___ AnGap-9
___ 05:30AM BLOOD Calcium-8.5 Phos-3.1 Mg-1.9
Nuclear stress test:
Echo (___):
Severe left atrial enlargement. Mild symmetric left ventricular
hypertophy with normal cavity size and regional/global systolic
function. Mild aortic regurgitation. Mild pulmonary artery
hypertension. Mildly dilated thoracic aorta. Findings c/w
hypertensive heart disease.
Compared with the prior study (images reviewed) of ___ the
left ventricular wall thickness measures mildly increased.
Atrial fibrillation is now present. Other findings are similar.
IMPRESSION: Average/good exercise tolerance for age. Anginal
symptoms
with borderline ischemic ST segment changes. Blunted systolic
blood
pressure response to exercise. Appropriate heart rate response.
Nuclear
report sent separately.
Perfusion study (___)
1. Probably normal myocardial perfusion. Fixed defects most
consistent with
attenuation.
2. Normal left ventricular cavity size.
Brief Hospital Course:
___ with h/o HTN and popliteal embolus (on Coumadin) last year,
referred to the ED after stress test on the day of admission
showed new onset atrial fibrillation and ischemic pattern.
#Progressive Dyspnea: The patient had a positive stress
prompting a trip to the emergency room and subsequent admission
for catheterization. Nuclear stress test did not show ischemia
and thus the patient did not undergo catheterization. While
admitted, the patient was started on atorvastatin, and
isosorbide dinitrate. None of these medications were continued
on discharge. 81 mg Aspirin was the only new medication started
since it was thought that the patient likely had some minor
degree of CAD but not significant enough to warrant a statin
without knowing what is lipid panel looked like.
#Bradycardia: The patient intermittently had rates in the ___
during his first day of hospitalization. He was asymptomatic
during these episodes. His atenolol was held and his rates
eventually improved to the ___. His beta blocker was not
restarted on discharge.
#Afib: The patient's rates were with normal limits during
admission. His warfarin was held during this stay in
anticipation of a procedure. He was instructed to take warfarin
upon returning home on the day of discharge. He was also told to
have his INR checked on ___.
# HTN: The patient's BP Was stable while admitted. His atenolol
was discontinued (see above).
# Pulmonary nodules: Stable on current CXR as compared to CXR
from ___. Could consider a nonurgent chest CT as
outpatient to better to define these abnormalities
# History of popliteal embolus: The patient's warfarin was held
during this admission (see above).
# CKD: Stable. At baseline Creatinine.
# BPH: Stable. Continued home tamsulosin.
#GERD: Continued home PPI.
Transitional issues:
-Atenolol was stopped during this admission for bradycardia
-The patient's warfarin was held during this admission in
anticipation of a procedure but he was instructed to restart it
upon discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 25 mg PO DAILY
2. Tamsulosin 0.4 mg PO DAILY
3. Omeprazole 20 mg PO DAILY
4. Cyanocobalamin 1000 mcg PO DAILY
5. Warfarin 5 mg PO 3X/WEEK (___)
6. Warfarin 3.75 mg PO 4X/WEEK (___)
Discharge Medications:
1. Cyanocobalamin 1000 mcg PO DAILY
2. Omeprazole 20 mg PO DAILY
3. Tamsulosin 0.4 mg PO DAILY
4. Warfarin 5 mg PO 3X/WEEK (___)
Please adjust your warfarin dose according to your doctor's
instructions.
5. Warfarin 3.75 mg PO 4X/WEEK (___)
Please adjust your warfarin dose according to your doctor's
instructions.
6. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: Progressive Dyspnea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital because you stress test showed
signs of cardiac ischemia and your doctor wanted it investigated
further. You had a nuclear stress test which did not confirm the
findings of your outpatient stress test thus it was decided not
to pursue any further interventions.
Please go to the lab to have your INR checked on ___ so
that we can monitor your coumadin blood levels.
You are now ready to be discharged. Please follow up with the
providers listed below.
It was a pleasure taking care of you!
Your ___ Care Team
Followup Instructions:
___
|
19588353-DS-15
| 19,588,353 | 26,496,421 |
DS
| 15 |
2194-07-14 00:00:00
|
2194-07-14 22:44:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
Colonscopy
History of Present Illness:
___ with ___ disease, sacral pressure ulcer and chronic
constipation ___ yrs. Presenting with BRBPR. Pt was seen with
him and his wife at the bedside. Pt with BRBPR this AM wihtout a
bowel movement. Last BM ___.
.
Pt was hospitalized last week at ___ for fevers to
102 at which time he wa treated for cellulitis of LLE up to his
thigh. The wife states this is now "much better" with redness to
foot. While he in the hospital, pt was given a suppository last
___, following which had BRBPR, in toilet bowl.
Pt discharged from the hospital ___ and had more BRBPR
___ and ___ (both in bowl and on tissue). Constipation
for past ___ years, baseline once every ___ days but maybe
worsening in last few weeks. Last colonoscopy ___ years ago.
No NSAIDs or alcohol use. Only on aspirin.
.
-In the ED, initial VS: 97.9 73 148/78 19 100% ra
-Exam notable for: guaiac positive
-Labs notable for: Hct 42 cr 1.3, LFTs wnl, lipase of 61
-The pt underwent: CXR
-The pt received: Vanco for ___ cellulitis
-The pt was seen by: GI
-Vitals prior to transfer: Afebrile, 80, RR: 16, BP: 146/82,
.
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, dysuria, hematuria. All
other ROS negative.
Past Medical History:
# Gluteal Pressure ulcer
# ___
# DMII
# Constipation
Social History:
___
Family History:
Mother: ___ CA in her ___.
Physical Exam:
Admission Exam:
VS: Afebrile 163/90 65 18 100%RA
GENERAL: Elderly Male in NAD.
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear.
Masked.
NECK: Supple.
HEART: Bradycardic. Irregular. no MRG.
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored.
ABDOMEN: Soft/NT/ND, no masses or HSM, no rebound/guarding.
EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses.
SKIN: right gluteal ulceration healing
LYMPH: No cervical LAD.
NEURO: Awake, A&Ox3, Resting tremor.
.
Discharge Exam:
AVSS
Abdomen Benign
Pertinent Results:
Admission Labs:
___ 01:00PM WBC-9.8 RBC-4.42* HGB-14.4 HCT-42.0 MCV-95
MCH-32.6* MCHC-34.3 RDW-14.0
___ 01:00PM NEUTS-79.1* LYMPHS-13.9* MONOS-3.5 EOS-2.5
BASOS-0.9
___ 01:00PM PLT COUNT-199
___ 01:00PM ALBUMIN-3.9
___ 01:00PM LIPASE-61*
___ 01:00PM ALT(SGPT)-22 AST(SGOT)-28 ALK PHOS-70 TOT
BILI-0.3
___ 01:00PM GLUCOSE-126* UREA N-24* CREAT-1.3* SODIUM-140
POTASSIUM-4.2 CHLORIDE-103 TOTAL CO2-25 ANION GAP-16
.
Discharge Labs:
___ 06:05AM BLOOD WBC-7.8 RBC-4.24* Hgb-13.6* Hct-40.2
MCV-95 MCH-32.2* MCHC-33.9 RDW-13.8 Plt ___
___ 06:05AM BLOOD Plt ___
___ 06:05AM BLOOD Glucose-104* UreaN-16 Creat-1.3* Na-142
K-4.1 Cl-108 HCO3-26 AnGap-12
___ 01:00PM BLOOD Lipase-61*
___ 01:00PM BLOOD Albumin-3.9
___ 01:00PM BLOOD cTropnT-<0.01
.
KUB:
ABDOMINAL RADIOGRAPH: There is moderate-to-significant fecal
loading
throughout the ___. A few prominent loops of small bowel are
noted
centrally, but without suspicious air-fluid level. There is no
evidence of
free air. Significant degenerative changes are noted in the
lower spine with
rotatory levoconvex scoliosis.
IMPRESSION: Moderate-to-significant fecal loading in the ___.
No specific
evidence of small bowel obstruction.
.
Procedure:The procedure, indications, preparation and potential
complications were explained to the patient, who indicated his
understanding and signed the corresponding consent forms. A
physical exam was performed. Moderate sedation was initiated by
the physician. Continuous pulse oximetry and cardiac and blood
pressure monitoring were used throughout the procedure.
Supplemental oxygen was used. The patient was placed in the left
lateral decubitus position.The digital exam was normal. The
colonoscope was introduced through the rectum and advanced under
direct visualization until the cecum was reached. The
appendiceal orifice and ileo-cecal valve were identified.
Careful visualization of the ___ was performed as the
colonoscope was withdrawn. The colonoscope was retroflexed
within the rectum. The procedure was not difficult. The quality
of the preparation was good. The patient tolerated the procedure
well. There were no complications.
Findings:
Mucosa:Segmental continuous ulceration, granularity, friability
and erythema with contact bleeding were noted in the distal 6-8
cm of rectum. This is most likely severe mucosal prolapse
injury, but biopsies were done to rule out a neoplastic lesion.
Cold forceps biopsies were performed for histology at the distal
rectum.
Protruding LesionsA single sessile 5 mm polyp of benign
appearance was found in the proximal transverse ___. A
single-piece polypectomy was performed using a cold snare in the
proximal transverse ___. The polyp was completely removed.
Impression:Polyp in the proximal transverse ___ (polypectomy)
Ulceration, granularity, friability and erythema in the distal
rectum (biopsy)
Otherwise normal colonoscopy to cecum
Recommendations:Follow-up with Dr ___ 1 week for
pathology report
Follow-up with referring physician as necessary
___ Fiber, low fat Diet
Increase fluid intake
Brief Hospital Course:
___ with parkinsons, recently treated for cellulitis presenting
with episodes of BRBPR.
.
# BRBPR: Pt presented hemodynamically stable with stable HCT.
+Guaiac in ED. DDx internal hemorrhoid, diverticular, less
likely colitis or swift upper GIB. The pt was prepped over the
course of two days due to severe constipation. On colonoscopy,
ulceration, granularity, friability and erythema was found in
the distal rectum. This may have been secondary to constipation
or from intermittent rectal prolapse from straining.
**Biopsies pending at the time of discharge**
**Pt instructed to take miralax daily to improved constipation**
.
# 2nd Degree AV Block (Mobitz I): Pt with lengthening PR
intervals followed by occasional dropped QRS on telemetry.
Narrow complex. Visualized p waves. Clinically stable. Follow-up
as outpatient.
.
# Parkinsons: Clinically stable. Continued on home medications.
Continued Cab/Levo, Zonegran.
.
# Chronic Pressure Ulcer: Pt evaluated by wound care while in
house for chronic right gluteal wound 1.0x0.5cm. Should continue
would care at home.
# Hypothyroidism: Cont Levoxyl
.
# Cellulitis: Continuing to improve per patients wife. The pt
completed a total of 10 days (per the wife) including his stay
while in house. His foot should be re-evaluated as an
outpatient. He remained afebrile without leukocytosis while in
___.
.
# DMII: Pt was to continued on Byetta while in house.
.
TRANSITIONAL ISSUES:
* Pt was discharged without services and instructed to go for
outpatient ___. Will need an outpatient prescription from his
PCP.
* Will need to have GI biopsies followed up
* An appointment was made for the patient to follow-up with his
PCP ___. Direct verbal signout provided to the PCP prior to
___.
Medications on Admission:
Synthroid ___
Oxybutynin 10mg BID
Pronebecid ___
Vitamin D 1000 Units
MVI
Glucosamine
EFA
Coenzyme Q 50mg
Requip 2mg BID
Lipitor 10mg
Byetta 10mg
Carb/Levo ___ TID
Zonegran 100mg BID
ASA 81mg
Augementin 500mg BID
Discharge Medications:
1. levothyroxine 137 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. oxybutynin chloride 10 mg Tablet Extended Rel 24 hr Sig: One
(1) Tablet Extended Rel 24 hr PO twice a day.
3. probenecid ___ mg Tablet Sig: One (1) Tablet PO once a day.
4. Vitamin D 1,000 unit Capsule Sig: One (1) Capsule PO once a
day.
5. multivitamin Tablet Sig: One (1) Tablet PO once a day.
6. Glucosamine Oral
7. Requip 2 mg Tablet Sig: One (1) Tablet PO twice a day.
8. Lipitor 10 mg Tablet Sig: One (1) Tablet PO once a day.
9. carbidopa-levodopa ___ mg Tablet Sig: One (1) Tablet PO
three times a day.
10. zonisamide 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
11. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
12. Byetta 10 mcg/0.04 mL Pen Injector Sig: One (1) ML
Subcutaneous Daily ().
13. Miralax 17 gram/dose Powder Sig: One (1) PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
- Rectal Ulceration
- Parkinsons
- Chronic Pressure Ulcer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital with bright red blood in your
stool. For this you underwent a colonoscopy that reveal an
ulcer. You were also noted to have a heart rhythm called
Wenckebach.
.
Please continue to take all of your medications.
We have STOPPED Augmentin. Please have your foot evaluated by
your PCP on ___.
Please TAKE Miralax everyday.
.
Please keep all of your appointments
Followup Instructions:
___
|
19588353-DS-18
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DS
| 18 |
2197-01-26 00:00:00
|
2197-01-27 19:15:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
s/p fall and right flank pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HISTORY OF PRESENT ILLNESS:
Mr. ___ is a ___ y/o male with a history of ___
disease, DM, gout, hypothyroidism, and CKD (reported basline Cr
1.5) with congenital one kidney who presents after a fall 1
night ago. The patient ___ symptoms have recently been
stable with no fall in the last 6 months. However, last night
the patient experienced a mechanical fall when trying to reach
his medications. He denies associated lightheadedness/dizziness,
CP, or SOB. When he fell he hit his right flank on a crock pot
and the floor. He denies head strike and LOC. He was seen by EMS
overnight to assist getting him off the floor but refused to be
brought in at that time. However, today the patient began
experiencing more pain over his right flank and given concern
for ?nephritic injury in setting of absent left kidney the wife
brought the patient to the ED today.
He denies head or neck pain. He has no other associated
symtpoms. No N/V or diarrhea. No cough. No dysuria (although has
a chronic indwelling foley). No fever/chills. No confusion.
In the ED initial vitals were: 98.6 73 142/70 18 95% ra
- Labs were significant for Cr 1.8, plt 134, and UA with 4 RBC,
58 WBC, and few bacteria.
- CT head was negative for acute process. CT abd/pelvis showed
no renal injury but did show non-displaced fracture of the
posterior 11th rib.
- Patient foley was changed. He was given 2L IVF, tylenol and
oxycodone for pain.
Vitals prior to transfer were: 98.0 66 148/67 16 98% RA
On the floor, the patient reports that he is feeling better with
only ___ pain since receiving medications in ED.
Review of Systems:
(+) per HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
- ___ disease
- DMII
- CKD stage 3 (baseline Cr ~1.5), only has right kidney
(congenital absence of left)
- h/o Gluteal Pressure ulcer
- 2nd Degree AV Block (Mobitz I)
- Hypothyrodism
- Chronic Constipation
- Gout
- urinary incontinence
- Secondary hyperparathyroidism (of renal origin), previously on
Vit D 2 50,000u monthly. On this x ___ years.
Social History:
___
Family History:
Mother: ___ CA in her ___
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
============================
PHYSICAL EXAM:
Vitals - T: 98.0 BP: 155/77 HR: 64 RR: 18 02 sat: 97% RA
GENERAL: elderly male in NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, conjunctiva with
injection on left eye, MMM
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, soft ___ systolic murmur heard at LUSB, no
gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
BACK: no tenderness on thoracic cage compression, tenderness
over inferior left flank over area of ecchymosis
EXTREMITIES: trace edema ___ to mid shin, moving
all 4 extremities with purpose, no tenderness to pelvic
compression, able to bear weight ___ without pain
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, strength ___ in upper extremities,
proximal strength ___ limited by pain in left flank but distal
strength ___, sensation intact to light touch, mild tremor
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
PHYSICAL EXAM ON DISCHARGE:
==============================
Vitals - T: 98.0 BP: 155/77 HR: 64 RR: 18 02 sat: 97% RA
GENERAL: elderly male in NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, conjunctiva with
injection on left eye, MMM
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, soft ___ systolic murmur heard at LUSB, no
gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
BACK: no tenderness on thoracic cage compression, tenderness
over inferior left flank over area of ecchymosis, no evidence of
retroperitoneal hematoma
EXTREMITIES: trace edema ___ to mid shin, moving
all 4 extremities with purpose, no tenderness to pelvic
compression, able to bear weight ___ without pain
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, strength ___ in upper extremities,
proximal strength ___ limited by pain in left flank but distal
strength ___, sensation intact to light touch, mild tremor
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
LABS ON ADMISSION:
===============
___ 03:50PM BLOOD WBC-7.1 RBC-4.67 Hgb-15.0 Hct-44.4 MCV-95
MCH-32.1* MCHC-33.7 RDW-14.2 Plt ___
___ 03:50PM BLOOD Neuts-72.5* Lymphs-15.6* Monos-9.0
Eos-2.0 Baso-0.9
___ 03:50PM BLOOD Glucose-143* UreaN-32* Creat-1.8* Na-136
K-4.6 Cl-100 HCO3-27 AnGap-14
LABS ON DISCHARGE:
================
___ 10:55AM BLOOD WBC-6.2 RBC-4.41* Hgb-14.1 Hct-41.9
MCV-95 MCH-32.0 MCHC-33.6 RDW-14.1 Plt ___
___ 10:55AM BLOOD Plt ___
___ 10:55AM BLOOD Na-138 K-4.0 Cl-100
___ 07:15AM BLOOD Glucose-128* UreaN-25* Creat-1.5* Na-137
Cl-103 HCO3-24 AnGap-15
Time Taken Not Noted Log-In Date/Time: ___ 6:44 pm
URINE TAKEN SPECIMEN ___ @ 1844.
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
OF TWO COLONIAL MORPHOLOGIES.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ 8 S
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 32 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
STUDIES:
=======
CT abdomen/pelvis ___:
IMPRESSION:
Nondisplaced fracture of the posterior ___ right rib.
Within the limits of a noncontrast study, no right kidney injury
was
identified. The left kidney is absent.
CT head ___:
FINDINGS:
There is no acute intracranial hemorrhage,acute infarction, mass
or midline
shift. There is no hydrocephalus. The ventricles and sulci are
mildly
enlarged consistent with mild atrophy. There are minimal
periventricular white
matter hypodensities most consistent with sequelae of chronic
small vessel
ischemic disease. Mild aerosolized secretions in the sphenoid
sinus,
otherwise the visualized paranasal sinuses and mastoid air cells
are clear.
There is no fracture.
IMPRESSION:
No evidence of acute intracranial process.
Brief Hospital Course:
Mr. ___ is a ___ y/o male with a history of ___
disease, DM, gout, hypothyroidism, and CKD (reported basline Cr
1.5) with congenital one kidney who presented after a fall 1
night ago with right flank pain found to have urinary tract
infection.
# Fall: Patient's fall primarily mechanical in nature and
associated with reaching for an object while in bed. Head CT was
without acute process. CT abd/pelvis showed no kidney injury but
did show rib fracture (see below). Orthostatics also negative.
Patient did endorse feeling less steady over last last 2 weeks.
___ be secondary to progression of Parkinsonian effects on gait
as well vs. underlying UTI. Neurology appointment upcoming and
can be evaluated at that time. Patient ambulated with walker
prior to discharge without difficulty.
# Complicated UTI with indwelling catheter: Patient with
leukocytes, positive nitrites, and large leukocytes on UA s/p
foley change. Patient treated with ciproflaxacin 500 mg Q12
hours for 10 days, day 1 day 1 ___.
Culture with evidence of growth of E. coli that is ciprofloxacin
susceptible (see results section).
# Acute on Chronic CKD: last record in ___ with baseline of
1.3-1.5
Cr 1.8 on admission, that improved to 1.5 prior to discharge
with 2L IV fluids. All medications were renally dosed and
nephrotoxic medications avoided.
# Right Flank Pain: Patient found to have ecchymosis over
inferior right flank with pain on palpation. CT abdomen pelvis
without evidence of any kidney injury.
# ___ Posterior Right Rib Fracture:
Patient with ___ posterior rib fracture following fall from
bed. ___ need further bone density evaluation as outpatient as
this was not a high impact fall and resulted in a fracture.
# Parkinsons Disease:
Potentially thought to be at baseline though patient did report
some unsteadiness in gait over last 2 weeks. ___ be secondary to
UTI as above. Patient continued on ropinirole and
carbidopa/levodopa. Has upcoming outpatient Neuro appointment.
# DM:
History of DM currently diet controlled.
# Gout:
No active flare. Continued probenecid.
# Hypothyroidism:
Continued synthroid.
# HLD:
Continued pravastatin.
TRANSITIONAL ISSUES:
=======================
-consider adjusting Parkinsonian medications as patient has
endorsed worsening gait symptoms over the last few weeks.
Patients fall prior to admission was from bed and not from
standing position.
-please ensure resolution of patient's UTI
-please confirm and review patient's indication and dose of
mesalamine
-chem 7 to evaluate renal function and to ensure stabilization
or improvement.
-consider bone density evaluation as patient had rib fracture
from a relatively low impact fall
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 137 mcg PO DAILY
2. Apriso (mesalamine) 0.375 gram oral 4x daily
3. Probenecid ___ mg PO TID
4. Vitamin D 1000 UNIT PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Flax, Fish & Borage Oil (fish oil-vit E-fat acid5-___)
400-5 mg-unit oral daily
7. Ropinirole 2 mg PO BID
8. Carbidopa-Levodopa (___) 1 TAB PO TID
9. Aspirin 81 mg PO DAILY
10. Pravastatin 10 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Levothyroxine Sodium 137 mcg PO DAILY
3. Multivitamins 1 TAB PO DAILY
4. Pravastatin 10 mg PO DAILY
5. Probenecid ___ mg PO TID
6. Ropinirole 2 mg PO BID
7. Vitamin D 1000 UNIT PO DAILY
8. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth twice daily Disp
#*18 Tablet Refills:*0
9. Apriso (mesalamine) 0.375 gram oral 4x daily
10. Carbidopa-Levodopa (___) 1 TAB PO TID
11. Flax, Fish & Borage Oil (fish oil-vit E-fat acid5-hb137)
400-5 mg-unit oral daily
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Urinary Tract Infection
___ disease
Secondary Diagnosis:
DMII
CKD stage 3 (congenital absence of left)
2nd Degree AV Block (Mobitz I)
Hypothyrodism
Chronic Constipation
Gout
Urinary incontinence
Secondary hyperparathyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___. You were admitted
because of a fall when reaching for your medications. As a
result of your fall you were found to have a rib fracture. We
also found an infection in your urine. We will treat you with a
medication called ciproflaxacin for 10 full days. It is very
important for you to take this medication until it is finished.
Sincerely,
Your ___ team
Followup Instructions:
___
|
19588353-DS-19
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| 19 |
2197-05-28 00:00:00
|
2197-05-28 18:10:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fevers, Malaise, decreased PO intake
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with history of DM, Hypothyroidism, ___ disease with
chronic indwelling Foley presenting with fevers, malaise,
decreased PO intake. Patient has not felt well since last ___
and has been getting progressively worse. He has his indwelling
Foley exchanged every month and was due on ___, his usual
nurse could not come so he had a different ___. Per patient, the
exchange of his foley was traumatic at that time. Per his wife,
the Foley ___ seem to be draining properly and had to be
readjusted by ___ after which he had ___ L rapid UOP. He has
been having cough, often in setting of drinking fluids. Cough is
productive of yellow sputum. Had fever. Denies significant SOB
but does feel that he has been more tachypnic recently.Patient
states that initially he was having suprapubic pain, but this is
currently resolved.
In the ED, initial vitals: ___ 18 96% on RA.
Labs notable for: Na 132, BUN/Cr 38/1.7, glucose 240, WBC 14.7
with 91.5% PMN's, lactate 1.5, UA with large leuks, many
bacteria, WBC>182. Pt was given: vancomycin 1gm IV/Zosyn,
tylenol, and 3L NS. Foley was exchanged.
On arrival to the MICU, VS are: 98.4, 99, 135/69, RR 27, 100%
non-rebreather
Past Medical History:
- ___ disease
- DMII
- CKD stage 3 (baseline Cr ~1.5), only has right kidney
(congenital absence of left)
- h/o Gluteal Pressure ulcer
- 2nd Degree AV Block (Mobitz I)
- Hypothyrodism
- Chronic Constipation
- Gout
- urinary incontinence
- Secondary hyperparathyroidism (of renal origin), previously on
Vit D 2 50,000u monthly. On this x ___ years.
Social History:
___
Family History:
Mother: ___ CA in her ___
Physical Exam:
ADMISSION PE:
==================
Vitals- 98.4, 99, 135/69, RR 27, 100% non-rebreather
GENERAL: Alert, oriented, mild distress, rigoring
HEENT: Sclera anicteric,
NECK: supple, JVP not elevated, no LAD
LUNGS: Course breath sounds bilaterally with diffuse inspiratory
and expiratory wheezes.
CV: Tachycardic, normal S1 S2, no murmurs, rubs, gallops
appreciated
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Bilateral ___, R>>L. Warm, well perfused
SKIN: per nurse, 11cmx11cm sacral decub that appears to be
healing with mild open areas. No visible purulent drainage.
NEURO: A&Ox3. Moving all extremities.
DISCHARGE PE:
=================
Vitals: Temp. 97.9, BP 151/69, HR 67, RR 18, 96% RA
UOP: +1000 since midnight
0 loose stools
GENERAL: Alert, oriented X 4, comfortable, masked facies, good
eye contact
HEENT: Sclera anicteric
NECK: supple, JVP not elevated, no LAD
LUNGS: Crackles in left lung base, diminished breath sounds in
right base. Clear to auscultation otherwise.
CV: RRR, normal S1 S2, no murmurs, rubs, gallops appreciated
ABD: soft, tender to palpation in suprapubic region, bowel
sounds present, no rebound tenderness or guarding, no
organomegaly
EXT: Bilateral 1+ edema to midshins (patient's noted baseline)
SKIN: Denuding of gluteal folds (present at time of admission)
mild open areas. No visible purulent drainage.
NEURO: CN II-XII intact, bilateral pill rolling tremor (improved
from ___, +dysdiadokinesia, ___ strength in upper
extremities, ___ strength in lower extremities
Pertinent Results:
ADMISSION LABS:
=================
___ 10:50PM BLOOD WBC-14.7*# RBC-4.03* Hgb-12.7* Hct-37.6*
MCV-93 MCH-31.6 MCHC-33.9 RDW-14.5 Plt ___
___ 10:50PM BLOOD Neuts-91.5* Lymphs-3.1* Monos-5.0 Eos-0.3
Baso-0.1
___ 10:50PM BLOOD Plt ___
___ 10:50PM BLOOD Glucose-240* UreaN-38* Creat-1.7* Na-132*
K-3.9 Cl-97 HCO3-24 AnGap-15
___ 05:26AM BLOOD ALT-22 AST-36 LD(LDH)-208 AlkPhos-83
TotBili-0.8
___ 10:50PM BLOOD Calcium-8.6 Phos-2.2* Mg-1.8
___ 10:56PM BLOOD Lactate-1.5
___ 05:00AM BLOOD Ferritn-484*
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
KLEBSIELLA PNEUMONIAE. FINAL SENSITIVITIES.
Cefazolin interpretative criteria are based on a dosage regimen
of 2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Anaerobic Bottle Gram Stain (Final ___: GRAM NEGATIVE
ROD(S).
C. diff negative
Blood cultures from ___ and ___ pending at time of discharge
DISCHARGE LABS:
==================
___ 06:10AM BLOOD WBC-7.8 RBC-3.74* Hgb-11.5* Hct-34.8*
MCV-93 MCH-30.7 MCHC-33.0 RDW-15.1 Plt ___
___ 05:00AM BLOOD Neuts-79.4* Lymphs-12.1* Monos-7.5
Eos-0.6 Baso-0.4
___ 06:10AM BLOOD Glucose-192* UreaN-41* Creat-1.6* Na-146*
K-4.2 Cl-110* HCO3-26 AnGap-14
___ 06:10AM BLOOD Calcium-8.8 Phos-4.1 Mg-1.8
STUDIES/IMAGING:
CXR: Trace right greater than left pleural effusions. Otherwise
unremarkable study.
Brief Hospital Course:
___ with history of DM, Hypothyroidism, ___ disease with
chronic indwelling Foley presenting with fevers, malaise,
decreased PO intake consistent with sepsis.
#Urosepsis
Patient met ___ SIRS criteria on presentation to the emergency
room. The patient appeared to be rigoring. The course was
thought to most ___ secondary to urosepsis given patient's
history of chronic indwelling foley and history of prior urinary
tract infections. In addition patient was noted to have RLL
layering effusion on CXR in setting of mild respiratory distress
wheezing and need for non-rebreather initially. Patient was
started on vancomycin, zosyn, and levofloxacin to cover both
urinary and pulmonary sources. Urinary legionella was sent and
found to be negative. The patient was transfered to the medical
floor within 24 hours and narrowed to cefepime and levofloxacin.
Urinary cultures showed no growth though urine was presumed
source of infection. Blood cultures showed klebsiellae
pneumoniae and patient was initially transitioned to
ceftriaxone. He remained afebrile for 24 hours and was
transitioned to PO ciprofloxacin for total 14 day course to be
completed on ___. Repeat blood cultures were pending at
time of discharge though preliminarily without growth. Foley
catheter was exchanged on ___.
#Acute on chronic kidney injury (baseline of 1.3-1.5)
Patient with history of only right kidney (congenital absence of
left). FeNa noted to be 0.45%, suggestive of prerenal etiology
in addition to BUN/Cr ratio greater than 20, and improvement
with IVF in setting of decreased PO intake and sepsis.
Creatinine improved to 1.6 at time of discharge. Chem-7 should
be repeated on ___ to ensure that renal function is stable.
#Hypernatremia
Patient noted to be hypernatremia with approximate 2.5 L free
water defecit. Sodium on day of discharge was 146 and improved.
Should recheck chem-7 on ___ and encourage free water
intake.
#Normocytic Anemia 11.9/35.4
Appeared to be new with likely some component of hemodilutional
effect in setting of IVF in the ICU. Ferritin noted to be
elevated >400 thought to be from anemia of chronic disease.
Hg/Hct remained stable throughout hospital course.
CHRONIC ISSUES
#Denuded bilateral gluteals with bleeding tissue
Wound consult obtained with following recommendations:
Continue with sacral Mepilex - change q 3 days and prn
Continue with use of no lift equipment and recommend this to
home agency or ECF for prevention of increased skin breakdown
from friction
Chair cushion for sitting - limit to 1 hour each time
Turn and reposition off back q 2 hours and prn
# ___ disease
Patient with pill rolling tremor and masked facies throughout
hospital course. These symptoms improved when ropinirole and
carbidopa-levadopa was restarted after the patient was
stabilized and moved to the medical floor.
# DMII
Insulin sliding scale was continued during hospital course. He
was transitioned back to home regimen prior to discharge.
# HLD
- Pravastatin continue
# Hypothyrodism
- Levothyroxine continued
# Gout
- Probenacid initially held given it's interaction with cefepime
though restarted at time of discharge.
# Secondary hyperparathyroidism (of renal origin), previously on
Vit D 2 50,000 u monthly.
- continued on Vitamin D 1000 UNIT PO DAILY
# Concern for aspiration: There was initial concern that Mr.
___ had evidence of aspiration. Video swallow evaluation
showed that penetration and intermittent aspiration with thin
liquids, which resolved following chin-tuck technique. He was
instructed to use the chin-tuck method throughout his hospital
course with thin liquids and should continue this going forward.
# ? Indication for Mesalamine
Mesalamine for now (0.375gm QID) unclear why patient is on this
medication. When it was held Mr. ___ was noted to develop
diarrhea that improved after re-initiation of mesalamine. It was
unclear to primary team why he was on this medication as he has
no history of IBD and denied this history as well. C. diff was
negative. Primary team attempted to get in touch with patient's
PCP though she was out of the office for the week.
TRANSITIONAL ISSUES:
=====================
-ciprofloxacin started this hospital course to be continued for
total 14 days until ___
-please check renal function and sodium on ___ with chem-7
to ensure it is stable
-indication for mesalamine (no known history of IBD)
-please assess patient's gluteal skin breakdown (wound care
instructions above)
-follow up pending blood cultures from this admission
-patient should tuck chin to chest with thin liquids per video
swallow recommendation to prevent aspiration
-foley catheter exchanged on ___. Should be changed once
monthly per patient and wife
___ on ___:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Levothyroxine Sodium 137 mcg PO DAILY
3. Multivitamins 1 TAB PO DAILY
4. Pravastatin 10 mg PO DAILY
5. Probenecid ___ mg PO TID
6. Ropinirole 2 mg PO BID
7. Vitamin D 1000 UNIT PO DAILY
8. Apriso (mesalamine) 0.375 gram oral 4x daily
9. Carbidopa-Levodopa (___) 1 TAB PO TID
10. Flax, Fish & Borage Oil (fish oil-vit E-fat acid5-hb137)
400-5 mg-unit oral daily
11. Lipoic Acid (alpha lipoic acid;<br>alpha lipoic acid (bulk))
300 mg oral daily
12. Tradjenta (linagliptin) 5 mg oral daily
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Carbidopa-Levodopa (___) 1 TAB PO TID
3. Levothyroxine Sodium 137 mcg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Pravastatin 10 mg PO DAILY
6. Ropinirole 2 mg PO BID
7. Vitamin D 1000 UNIT PO DAILY
8. Flax, Fish & Borage Oil (fish oil-vit E-fat acid5-hb137)
400-5 mg-unit oral daily
9. Lipoic Acid (alpha lipoic acid;<br>alpha lipoic acid (bulk))
300 mg oral daily
10. Probenecid ___ mg PO TID
11. Tradjenta (linagliptin) 5 mg oral daily
12. Apriso (mesalamine) 0.375 gram oral 4x daily
13. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth twice
a day Disp #*18 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Urosepsis
Community Acquired Pneumonia
Acute on chronic kidney injury
Secondary:
Bilateral gluteal skin breakdown
___ disease
Type II Diabetes
CKD stage 3 (baseline Cr ~1.5), only has right kidney
(congenital absence of left)
h/o Gluteal Pressure ulcer
2nd Degree AV Block (Mobitz I)
Hypothyrodism
Chronic Constipation
Gout
Urinary incontinence
Secondary hyperparathyroidism (of renal origin), previously on
Vit D 2 50,000u monthly. On this x ___ years.
Secondary
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 because you had a fever and
did not feel like yourself. You were found to have an infection
of your urinary tract and blood stream. You were transferred to
the intensive care unit and placed on antibiotic therapy. You
were continued on antibiotics until you improved and were
transitioned to a pill form of the medication. It is very
important you take all of this medication until it is completed.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19588353-DS-20
| 19,588,353 | 20,941,575 |
DS
| 20 |
2198-03-13 00:00:00
|
2198-03-15 22:46:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fall
Major Surgical or Invasive Procedure:
___ - L-sided dual chamber PPM placement
History of Present Illness:
Mr. ___ is a ___ gentleman w/ ___ Disease, DM, CKD
stage III, and hypothyroidism p/w ___ transferred to ___
for possible nodal blockade.
Patient was walking at home and acutely felt lightheaded then
fell backwards and struck his head. Taken by EMS to ___
___ where he was bradycardic to ___ for 2 hours
with normal CT head and neck. EKG shows 2:1 AV block with
ventricular rate of 44bpm and variable 1:1 conduction. Patient
was lightheaded while HR ___. Bradycardia resolved spontaneously
without intervention and he was transferred to ___ for further
care.
In the ED initial vitals were: 98.2F, HR96, BP116/81, RR14, 96%
RA
EKG: NSR w/ 1:1 conduction.
Labs/studies notable for: WBC 9.5, Cr 1.3, Negative trop/CK, INR
1.1, UA mod bacteria, ___ Nitrite
Patient was given: Carbidopa-Levodopa
CXR was normal
ROS:
On review of systems, denies any prior history of stroke, TIA,
deep venous thrombosis, pulmonary embolism, bleeding at the time
of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. Denies recent fevers, chills or rigors.
Denies exertional buttock or calf pain. All of the other review
of systems were negative. Cardiac review of systems is notable
for absence of chest pain, dyspnea on exertion, paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope
or presyncope.
Past Medical History:
- ___ disease
- DMII
- dyslipidemia
- CKD stage 3 (baseline Cr ~1.5), only has right kidney
(congenital absence of left)
- h/o Gluteal Pressure ulcer
- 2nd Degree AV Block (Mobitz I)
- Hypothyrodism
- Chronic Constipation
- Gout
- urinary incontinence
- Secondary hyperparathyroidism (of renal origin), previously on
Vit D 2 50,000u monthly. On this x ___ years.
Social History:
___
Family History:
Mother: ___ CA in her ___
No family history of arrhythmia
Physical Exam:
====================
EXAM ON ADMISSION
====================
GENERAL: WDWN older white male with masked faces and minimal
movement.
NEURO: AOx3. Minimal facial expressions with slow responses,
quiet voice. No tremor
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple without JVD
CARDIAC: Nonpalpable PMI. RRR, normal S1, S2. No
murmurs/rubs/gallops. No thrills, lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, NTND.
EXTREMITIES: 1+ b/l ___ edema to knees. L knee scar c/w TKR. No
c/c. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, or xanthomas.
PULSES: Distal pulses palpable and symmetric
====================
EXAM ON DISCHARGE
====================
Vitals: 98.1, 82, 140/68, 18, 95%RA
I/O: 24 hours; ___ 8hrs - 240/650
Weight on admission: 106.4 kgs
Today's weight: 101.1 kg
General: Alert and oriented x3, NAD
HEENT: speech is dysarthric; JVD not elevated
Chest: surgical site with dressing. Crepitus surrounding
surgical site.
Lungs: CTAB on anterior exam; clear laterally as well
CV: rrr, widely split S2 with appropriate respiratory variation;
no murmurs
Abdomen: soft, nontender, nondistended
Ext: bilateral nonpitting edema
Pertinent Results:
========================
LABS ON ADMISSION
========================
___ 11:50PM BLOOD WBC-9.5 RBC-4.69# Hgb-14.3 Hct-43.6#
MCV-93 MCH-30.5 MCHC-32.8 RDW-14.3 RDWSD-48.2* Plt ___
___ 11:50PM BLOOD Neuts-85.8* Lymphs-6.4* Monos-6.2
Eos-0.9* Baso-0.4 Im ___ AbsNeut-8.13* AbsLymp-0.61*
AbsMono-0.59 AbsEos-0.09 AbsBaso-0.04
___ 11:50PM BLOOD ___ PTT-36.3 ___
___ 11:50PM BLOOD Glucose-267* UreaN-27* Creat-1.3* Na-136
K-4.2 Cl-98 HCO3-23 AnGap-19
___ 11:50PM BLOOD CK(CPK)-316
___ 06:20AM BLOOD LD(LDH)-168
___ 11:50PM BLOOD cTropnT-0.01
___ 06:20AM BLOOD Calcium-9.0 Phos-3.3 Mg-1.7
___ 06:20AM BLOOD TSH-4.1
========================
LABS ON DISCHARGE
========================
___ 06:30AM BLOOD WBC-7.0 RBC-4.08* Hgb-12.3* Hct-38.6*
MCV-95 MCH-30.1 MCHC-31.9* RDW-14.3 RDWSD-49.7* Plt ___
___ 06:30AM BLOOD Glucose-184* UreaN-34* Creat-1.6* Na-141
K-3.7 Cl-103 HCO3-25 AnGap-17
___ 06:30AM BLOOD Calcium-8.6 Phos-3.7 Mg-1.8
========================
MICROBIOLOGY
========================
___ Urine Culture - Mixed bacterial flora
========================
IMAGING
========================
___ Chest PA+Lat:
1. Progressive right lower lobe atelectasis raises concern about
bronchial patency and possibility of right hilar mass.
___ CT Chest w/ contrast:
1. No evidence of a mass lesion in the perihilar region or
within the tracheobronchial tree on this exam.
2. Large right pleural effusion with associated atelect
___ TTE - The left atrium is elongated. No atrial septal
defect is seen by 2D or color Doppler. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF 55%). There is no ventricular septal defect. The
right ventricular cavity is mildly dilated with normal free wall
contractility. The ascending aorta is mildly dilated. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. Trace aortic regurgitation is seen. The mitral
valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. There is
borderline pulmonary artery systolic hypertension. There is no
pericardial effusion.
___ Chest PA+Lat:
Interval placement of a pacemaker, with leads terminating in the
low right atrium and right ventricle.
Brief Hospital Course:
Mr. ___ is a ___ gentleman w/ ___ Disease, DM, CKD
stage III, and hypothyroidism p/w ___ transferred to ___
for possible nodal blockade.
#Symptomatic Bradycardia w/ variable conduction: Mr. ___
presented from an OSH with variable 2:1 AV block with an
instance of syncope. EP was consulted to see the patient and
review his telemetry. He was found to have occasional dropped
QRS complexes, that he was generally conducting in a 1:1 fashion
and intermittently switching to a 2:1 conduction pattern despite
a fixed sinus rate. They felt that, in addition to the clear AV
node pathology (that we see in our system going back to at least
___, there was further evidence of infranodal disease.
Therefore, they felt that the patient had an indication for a
permanent pacemaker. However, the patient was also found to have
progressive atelectasis, concerning for a hilar mass, on chest
x-ray. He underwent a CT chest, which showed no masses or
evidence of malignancy. He was also noted to have bacturia, with
an indwelling foley. A urine culture showed only mixed bacterial
flora. Therefore, the patient was cleared for a pacemaker, which
was placed on ___. The patient tolerated the procedure
well. He received three days of post-op antibiotics, and was
discharged home with EP followup.
#Acute on chronic diastolic heart failure - While hospitalized,
the patient was noted to have nonpitting edema past his knees.
He also received 1L NS while in the hospital for pre- and
post-hydration for a CT (as above). On ___, the patient was
started on Lasix 40mg PO, with good urine output. He was
discharged home on lasix 40mg PO daily, and can further titrate
this with his primary care doctor in the outpatient setting.
___ disease: Continued home ropinirole and
carbidopa-levadopa
#HLD: Continued home pravastatin
#DMII: Home linagliptin while in hospital, and maintained on
ISS.
#Hypothyroid: Continued home levothyroxine
#Gout: Continued hoem probenacid
#Constipation/Diarrhea - Continued home mesalamine, which was
reported by patient to help regulate his bowel function.
==================================
TRANSITIONAL ISSUES
==================================
Discharge weight: 101.1kg
- The patient was noted to be fluid-overloaded on exam, and was
discharged on Lasix 40mg PO daily. His electrolytes should be
checked at his next primary care appointment on ___ and
Lasix dose titrated based on volume status
- Pacemaker placed: Dual chamber left sided ___ PPM
# CODE: Full
# CONTACT: ___ (wife) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Carbidopa-Levodopa (___) 1 TAB PO TID
3. Levothyroxine Sodium 137 mcg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Pravastatin 10 mg PO DAILY
6. Ropinirole 2 mg PO BID
7. Vitamin D 1000 UNIT PO DAILY
8. Flax, Fish & Borage Oil (fish oil-vit E-fat acid5-hb137)
400-5 mg-unit oral daily
9. Lipoic Acid (alpha lipoic acid;<br>alpha lipoic acid (bulk))
300 mg oral daily
10. Probenecid ___ mg PO TID
11. Tradjenta (linagliptin) 5 mg oral daily
12. Apriso (mesalamine) 0.375 gram oral 4x daily
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Carbidopa-Levodopa (___) 1 TAB PO TID
3. Levothyroxine Sodium 137 mcg PO DAILY
4. Pravastatin 10 mg PO DAILY
5. Probenecid ___ mg PO TID
6. Ropinirole 2 mg PO BID
7. Vitamin D 1000 UNIT PO DAILY
8. Tradjenta (linagliptin) 5 mg oral daily
9. Apriso (mesalamine) 0.375 gram oral 4x daily
10. Flax, Fish & Borage Oil (fish oil-vit E-fat acid5-hb137)
400-5 mg-unit oral daily
11. Lipoic Acid (alpha lipoic acid;<br>alpha lipoic acid (bulk))
300 mg oral daily
12. Multivitamins 1 TAB PO DAILY
13. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnoses:
- syncope/presyncope
- junctional rhythm with intermittent 2:1 conduction
Secondary Diagnoses:
- Parkinsons disease
- Diabetes Type II
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure being a part of your care team at ___
___. You were admitted because you were
found to have a slow heart rate after you fell. You were seen by
our heart electricity doctors ___ or EP), who
looked at your heart rhythm and thought that a pacemaker might
help stop this from happening in the future. A pacemaker was
placed on ___, and you were able to go home. We also saw
that you had some extra fluid in your legs, and so we gave you
medication to get rid of some of the fluid.
The extra fluid that you have is because your heart is not
working well. Please weigh yourself everyday and call your
cardiologist if your weight increases by more than 2 lbs in a
day. Since you do not yet have a cardiologist, for now call your
primary care doctor.
We would like for you to see your primary care doctor in the
next week, and we have also made appointments for you with the
EP Device Clinic to help you manage your new pacemaker. They
will help you make the next appointment with a cardiologist near
to your home.
It was very nice to meet you, and we wish you the best.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19588408-DS-10
| 19,588,408 | 29,987,961 |
DS
| 10 |
2172-11-06 00:00:00
|
2172-11-06 16:48:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Sulfa(Sulfonamide Antibiotics) / Heparin Agents
Attending: ___.
Chief Complaint:
confusion and right side weakness secondary to seizure
Major Surgical or Invasive Procedure:
LP: ___
Intubation: ___
History of Present Illness:
HPI:
The pt is a ___ year old right-handed woman with a history of
left
temporoparietal brain abcess s/p drainage and craniectomy who
presents with seizure activity followed by confusion and
right-sided weakness. The patient is unable to provide any
history currently. Her son, who is at bedside, reports that he
arrived home at 0100 this morning and noticed snoring
respirations as he walked by her room tonght. He thought this
was
odd so he went to check on her 5 minutes later. He found her
lying on the floor next to her bed, her right side on the
ground.
He then noticed that she had clonic movements of the right arm.
He called EMS. They gave her 2mg of versed, which stopped the
right arm movements. However after this she is no longer moving
her right arm and is very confused and agitated.
Previous to her son finding her this evening, she was last seen
normal at 10pm by her daughter. Her family all deny any recent
seizures. The only previous seizures she has had was a
generalized tonic-clonic event in the ED triage area in ___,
which lead to the original discovery of the brain abscess, as
well as odd behavior leading up to the ED visit that day such as
speech arrest and confusion. She has been taking Keppra 1250mg
po
bid prophylactically and the family is not aware of her missing
any doses. She has not endorsed any recent infectious symptoms
to
her family. She has been having low back pain for the past few
weeks and was subsequently diagnosed with a vertebral fracture,
for which she has been taking Percocet and muscle relaxants as
needed for pain. Otherwise there have no changes to her
medications.
In the ED the patient received 6mg IV ativan and haldol 2.5mg
for
severe agitation.
ROS: Unobtainable
Past Medical History:
PAST MEDICAL HISTORY:
- HTN
- HL
- Ulcerative colitis; not active
- femur fracture s/p ORIF (___)
- hyperplastic squamous tongue lesion negative for viral
inclusions and malignancy
- resected skin ca (unclear if melanoma vs other)
- s/p hysterectomy
- brain abscess (L temporoparietal) s/p stereotactic drainage
___ ___/b recurrence and L craniotomy and drainage
___ with 10 weeks of ABx for likely fusobacterium
- vertebral fracture - found ___ weeks ago
Social History:
___
Family History:
Unable to obtain from patient
Physical Exam:
Exam on admission:
Physical Exam:
Vitals: T (rectal): 99.6 P: 120s BP: 155/90 RR: 13 SaO2: 95
%
on 4L NC
General: Awake, agitated.
HEENT: NC/AT, no scleral icterus, dried blood around mouth
Neck: Supple, no nuchal rigidity.
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: tachycardic Reg Rhythm
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions
Neurologic:
___ Stroke Scale score was: 10
1a. Level of Consciousness: 1
1b. LOC Question: 2
1c. LOC Commands: 1
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: 1
7. Limb Ataxia: 0
8. Sensory: 0
9. Language: 3
10. Dysarthria: 0
11. Extinction and Neglect: 0
Neurologic:
-Mental Status: Eyes intermittent open. Thrashing, trying to get
up from bed. Intermittently attends to examiner. Gaze midline.
Will track to voice. Follow some simple commands intermittently.
Nonverbal. Difficult to assess but appears to have right
inattention > left.
-Cranial Nerves:
Pupils 3mm and reactive bilaterally. Corneals intact
bilaterally.
No clear facial asymmetry.
-Motor: Spontaneous, purposeful movement of left arm and leg.
Some antigravity movement of right leg. RUE withdraws to
noxious.
-Sensory: Withdraws to noxious in left and RLE > RUE
-DTRs: Unable to test due to thrashing
At the time of discharge she is awake, alert and oriented x3.
no focal weakness in motor exam
Pertinent Results:
EEG: pending
___ 06:35PM CEREBROSPINAL FLUID (CSF) PROTEIN-33
GLUCOSE-66
___ 06:35PM CEREBROSPINAL FLUID (CSF) WBC-3 RBC-4* POLYS-1
___ ___ 06:34AM GLUCOSE-125* UREA N-8 CREAT-0.5 SODIUM-136
POTASSIUM-3.6 CHLORIDE-100 TOTAL CO2-19* ANION GAP-21*
___ 06:34AM ALT(SGPT)-13 AST(SGOT)-23 ALK PHOS-129* TOT
BILI-0.5
___ 06:34AM ALBUMIN-4.3 CALCIUM-9.1 PHOSPHATE-3.0
MAGNESIUM-1.6
___ CXR:
FINDINGS: A portable supine frontal radiograph of the chest
demonstrates low
inspiratory lung volumes and scattered opacities in the lower
lung zones
likely reflecting subsegmental atelectasis. No focal
consolidation concerning
for pneumonia, significant pleural effusion, or pneumothorax is
detected. The
cardiac silhouette is normal in size. The mediastinum is
prominent with
unfolding of the thoracic aorta and would be better evaluated
with upright
conventional radiography. The trachea is midline. The
visualized upper
abdomen is relatively gasless.
CT head ___:
CT HEAD: Portions of the scan were repeated twice due to
motion.
There is a left parietal/occipital craniotomy. Adjacent left
occipital and
inferior parietal hypodensity with volume loss indicates
encephalomalacia.
There is no evidence of intra-axial or extra-axial hemorrhage,
edema, mass
effect or shift of normally midline structures. The ventricles
and sulci are
prominent, compatible with age-related global atrophy.
A mucous retention cyst is noted in the right maxillary sinus.
IMPRESSION:
S/p left parietal/occipital craniotomy with underlying
encephalomalacia. While
no evidence of acute intracranial abnormalities is seen on
noncontrast CT, MRI
would be more sensitive for detecting a seizure source or
recurrent infection.
CXR ___:
REPORT:
The patient has been extubated in the interval. NG tube courses
throughout
the mediastinum and its tip appears down in the left
hypochondrium.
There is overall poor inspiratory effort. There is atelectasis
at the left
base, probably some atelectasis in the right mid zone. There is
a degree of
pulmonary edema, slightly worsened from prior study.
No additional findings of note.
CONCLUSION: Bibasilar atelectasis with some pulmonary edema
noted.
MRI brain w/ & w/o contrast ___:
FINDINGS: A left parietal craniotomy is again noted. The area
of contrast
enhancement in the left inferior parietal/occipital region has
decreased in
extent. Surrounding high T2 signal has minimally decreased in
extent. No new
areas of contrast enhancement or high T2 signal are seen in the
brain. There
is no new diffusion abnormality. Multiple foci of high T2
signal are again
seen in the supratentorial white matter bilaterally, and in the
pons,
nonspecific but likely related to sequela of chronic small
vessel ischemic
disease. A small focus of encephalomalacia is again seen in the
right
posterior inferior cerebellar hemisphere, likely a chronic
infarct. The
ventricles are stable in size, with ex vacuo dilatation of the
occipital horn
of the left lateral ventricle again noted. There is no evidence
of new
intracranial blood products on gradient echo images. The major
arterial flow
voids are grossly preserved.
A nasogastric tube is noted. There is a small mucus-retention
cyst in the
right maxillary sinus.
IMPRESSION: Continued decrease in the extent of contrast
enhancement and high
T2 signal in the left inferior parietal/occipital region. No
evidence of new
intracranial abnormalities.
Brief Hospital Course:
___ year old right-handed woman with a history of left
temporoparietal brain abscess s/p drainage and craniectomy who
presented with seizure activity followed by confusion and
right-sided weakness.
Neurological exam initially w/significant confusion, agitation,
right-sided weakness/significant anterior tongue swelling,
likely secondary to biting during seizure. Admitted to ICU
___. Received PHT load in ED, then continued on PHT 100 mg
q8h in addition to home-dose LEV 1250 mg BID. EEG w/slowing L >
R, L breech rhythm, L occipital spikes, no seizures. Pt was
transiently intubated ___ in order to obtain MRI and LP. MRI
___ with improving inflammation surrounding abscess resection.
LP ___ w/o complications, CSF benign. On ___, with
significant improvement, minimal residual right-sided deficit.
Overall the patient appears to have had a seizure with
post-ictal agitation and ___ paralysis.
There are no clear precipitant of this breakthrough seizure: pt
appears to have been adherent to AED regimen (though awaiting
levetiracetam level from admission), no clear signs of infection
or metabolic derangement, no new intracranial abnormality.
Neuro:
- cont home levetiracetam 1250 mg BID; we checked Keppra level
at the time of admission but the result is not back
She was monitored with EEG which showed slowing L > R, L breech
rhythm, L occipital spikes but not epileptogenic discharge, Lp
result was benign and her MRI showed significant improvement.
ENT/Resp: She had crackles on exam with normal o2 saturation
likely secondary to atelectasis After using incentive spirometry
it was resolved. Her tongue swelling resolved without
intervention
___
- We cont home metoprolol 25mg po/ng bid, despite that she had
multiple episode of tachycardia and marginally high blood
pressure and she needs to be followed by her primary care doctor
in this regard,
ID: She stayed afebrile and we never had a positive culture
result her leukocytosis improved without intervention and we
thought it could be demargination secondary to seizure
Chronic medical issues:
- Depression -We restart citalopram after she was transferred
out of ICU
- hyperlipidemia We restart simvastatin after she was
transferred out of ICU
She was evaluated for swallowing and she was cleared for eating
regular consistency diet. as she was allergic to heparin and
cannot tolerate ASA due to GI effects and h/o ulcerative
colitis, we used pneumato boots for DVT PPX.
___:
After we saw the patient today she is at her baseline now . ___
cleared her for home discharge.
**TRANSITIONAL ISSUES:
**NEUROLOGY- follow up Keppra level from admission to determine
if dose should be increased. Consider taper off Dilantin on
follow up visit.
PCP- monitor BP for need for additional anti hypertensive.
Medications on Admission:
MEDICATIONS:
- celexa 20mg QD
- keppra 1250mg BID
- metoprolol 50mg BID
- omeprazole 40mg QD
- simvastatin 10mg QD
- recently started taking muscle relaxants and percocet for back
pain from vertebral fx
Discharge Medications:
1. Citalopram 20 mg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. LeVETiracetam 1250 mg PO BID
4. Metoprolol Tartrate 50 mg PO BID
5. Omeprazole 40 mg PO DAILY
6. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q6H back pain
7. Phenytoin (Suspension) 200 mg PO HS
RX *phenytoin [Dilantin Infatabs] 50 mg 200 mg by mouth at
bedtime Disp #*80 Tablet Refills:*1
8. Phenytoin (Suspension) 100 mg PO IN THE MORNING AND AT NOON
RX *phenytoin [Dilantin Infatabs] 50 mg 100 mg by mouth twice a
day in the morning and at noon Disp #*40 Tablet Refills:*1
9. Simvastatin 10 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Todds paralysis and confusion secondary to seizure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
She is awake, alert and oriented x3, no focal weakness or
sensory changes
Discharge Instructions:
Dear Ms ___, you were admitted here with confusion and right
side weakness, we did EEG, MRI, Lumbar puncture, which did not
show new abnormal findings. We think you had seizure that caused
weakness and confusion. We changed the dose of Keppra to 1500
mg every 12 hours and add phenytoin 100 inthe morning and at
noon and 200 mg night to control your seizure. You need to
contact your primary care doctor and check your dilantin level
in a week from now and by your neurologist in a week. For your
pain you can contact your primary care doctor. As you are at
risk of having another seizure you should avoid driving and
discuss it in your follow up visit.
Followup Instructions:
___
|
19588408-DS-8
| 19,588,408 | 22,378,165 |
DS
| 8 |
2172-04-03 00:00:00
|
2172-04-07 19:55:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Sulfa(Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Called by Emergency Department to evaluate
for confusion, subsequent seizure activity.
Major Surgical or Invasive Procedure:
intubation, extubation
History of Present Illness:
Ms. ___ is intubated and sedated; history obtained from
husband.
Ms. ___ is a ___ y/o woman with PMH significant for HTN,
HLD
and femur fx s/p surgery (___) who was brought to ED with
receptive language difficulties and who subsequently had GTC
seizure while in ED triage; she was intubated for airway
protection. According to her husband, she was last seen well at
2:55 ___ today. She went into another room to check email and she
came out at 3 ___ saying that the email was not working and that
she closed it. However, when her husband went to check on it, it
was still open. He was then asking her questions, but she was
not
responding appropriately. For example, he asked her what day is
it and her response was "this is ridiculous." She never answered
any questions correctly. He notes that her speech itself was
articulate (she was saying intelligible words, though unclear if
she ever reached true fluency); it was just that the things she
was saying was not relevant to what was being discussed. Her
husband also said that she appeared confused. EMS was called and
she was brought to ___, while at triage, she had GTC seizure
and subsequent extenor posturing noted in all extremities by ED.
She received Ativan 2 mg per EMS and was intubated by the ED for
airway protection; Etomidate and Succinylcholine was used for
intubation. Code Stroke was called because of her speech changes
prior to the seizure.
Past Medical History:
-HTN
-HLD
-Ulcerative colitis - per PCP/GI doc, trivial 15-30 cm of
colitis in distal sigmoid sparing rectum. Pathology showed mild
IBD. PCP/GI doc does not consider this UC.
-Femur fracture s/p rod + pins (___)
-viral tongue lesion (dx 1 month ago) - s/p biopsy and ~4 wks
abx
-left cheeck skin cancer s/p topical/surgical removal - unclear
if basal cell vs melanoma. PCP ___ recall melanoma hx but
does not have in records. Derm: Dr. ___ at ___
___ tests (per PCP/GI Dr. ___ - Pt often
refused.
- last colonoscopy ___ - focal ischemia, no polyps
- mammogram ___ - no abnl
- prev CXR ___
Social History:
___
Family History:
Unable to obtain from patient
Physical Exam:
At admission:
Vitals: T: 97 P: 84 R: 16 BP: 131/93 SaO2: 100% NRB
(subsequently intubated)
General: intubated, sedated
HEENT: NC/AT, no scleral icterus noted, MMM, there is blood on
her tongue
Neck: Supple
Pulmonary: anterior lung fieds cta b/l
Cardiac: RRR, S1S2
Abdomen: soft, nondistended, +BS
Extremities: warm, well perfused
Neurologic:
___ Stroke Scale score was: >20 (patient had just been intubated
with paralytics prior to assessment; so unable to obtain
accurate
NIHSS)
Neurologic Exam: she is intubated and sedated. No eye opening.
No
commands. PERRL 5-->3 mm. Eyes in midline. Unable to elicit
Doll's eyes. Unable to elicit corneals. + cough. She was having
intermittent pronation of UE b/l and adduction ___ b/l. No
purposeful spontaneous movements. No withdrawal or grimmace to
noxious stimuli. Unable to elicit any reflexes. Extensor plantar
response b/l.
PHYSICAL EXAM AT DISCHARGE:
VS: 98.6, 130/70's, ___'s, 18, 98% on RA
GEN: elderly woman sitting in bed, tearful
HEENT: OP clear, no tenderness at mouth when made to bite down
on tongue depressor
CV: RRR
PULM: CTAB
ABD: soft, NT, ND
EXT: trace edema
.
NEURO EXAM:
MS - patient intermittently tearful, sometimes refusing to
answer questions, but essentially cooperative
CN - L NLF flattening and mild R facial droop, EOMI, PERRL
MOTOR - pt moving all four extremities, not cooperative with
formal strength exam
SENSORY - intact to light touch throughout
GAIT - able to walk without assistance, narrow based gait
Pertinent Results:
___ 04:34PM WBC-14.0* RBC-4.54 HGB-12.4 HCT-41.2 MCV-91
MCH-27.2 MCHC-30.1* RDW-15.0
___ 04:34PM PLT COUNT-385
___ 04:34PM ___ PTT-30.6 ___
___ 04:34PM UREA N-11
___ 04:35PM GLUCOSE-116* NA+-139 K+-4.8 CL--99 TCO2-24
___ 04:37PM CREAT-0.6
___ 05:56PM TYPE-ART ___ TIDAL VOL-450 PEEP-5
O2-100 PO2-231* PCO2-48* PH-7.37 TOTAL CO2-29 BASE XS-2
AADO2-436 REQ O2-75 -ASSIST/CON INTUBATED-INTUBATED
___ 02:03AM BLOOD ALT-10 AST-20 AlkPhos-88 TotBili-0.4
___ 02:03AM BLOOD Albumin-3.6 Calcium-8.4 Phos-3.7 Mg-1.9
CXR - portable:
FINDINGS: There is pulmonary vasculature indistinctness
compatible mild
pulmonary edema. Cardiomediastinal silhouette is at the upper
limits of
normal. There is no evidence of pneumothorax or pleural
effusions.
Endotracheal tube tip is 4.5 cm from the carina, in standard
position, and an enteric tube tip is in the stomach.
IMPRESSION: Mild pulmonary edema. Standard positioning of the
endotracheal
and NG tubes.
CTA Head and Neck:
CT HEAD: A 15 x 15 mm measuring, fairly sharply demarcated area
of
hypoattenuation is identified in the left parietotemporal
junction. This
extends to the cortex and is wedge-shaped. The focus is
associated with
reduced blood flow and volume on perfusion imaging, but no
increase in transit time. This combination of findings suggests
that this likely represents a subacute infarct. There is no
associated hemorrhagic transformation or mass effect. The
cerebral sulci, ventricles, and extra-axial CSF-containing
spaces have normal size and configuration. There is no shift of
the midline structures. Otherwise, the gray-white matter
differentiation is well preserved and there is no evidence of
additional ischemic infarct. Confluent scattered periventricular
white matter low attenuation likely represents a sequela of
small vessel ischemic disease. The visualized paranasal sinuses
and mastoid air cells are clear.
PERFUSION IMAGING: As detailed above, the area of
hypoattenuation is
associated with reduced blood volume and flow, with no increase
in transit
time, suggesting subacute infarct.
CTA OF HEAD: The intracranial internal carotid, vertebrobasilar
and anterior, middle, and posterior cerebral arteries are patent
with normal contrast enhancement and branching pattern. There is
no evidence of stenosis, occlusion, aneurysm, or arteriovenous
malformation.
CTA OF THE NECK: The origins of the common carotid and vertebral
arteries are patent without significant stenosis. The common,
internal and external
carotid arteries are normal in appearance. There is no evidence
of
hemodynamically significant stenosis or dissection. The cervical
portions of the vertebral arteries demonstrate normal contrast
opacification.
Note is made of bilateral atelectatic changes in the dorsal
basal aspects of the lung apices.
IMPRESSION: Hypodense focus at the left parietotemporal junction
with reduced blood flow and volume and no increase in transit
time. While the CT presentation is compatible with subacute
infarct, the more recently obtained MRI suggestes intracranial
abcess or neoplasm. CTA of the head and neck is normal.
MRI/MRV Brain with contrast:
FINDINGS: There is a 10 x 10 mm ring enhancing lesion in the
left
parietotemporal junction with markedly slow diffusion. The focus
has an
enhancing leptomeningeal tail projecting toward the dura. There
is moderate perilesional vasogenic edema and no evidence of
hemorrhage. Mass effect is mild. The gray-white matter
differentiation is otherwise well preserved and there is no
evidence of additional enhancing foci. Scattered or confluent
periventricular, deep white matter, and subcortical FLAIR/T2
white matter abnormalities are in keeping with sequela of small
vessel ischemic disease. The ventricles, cerebral sulci, and
extra-axial CSF-containing spaces have age-appropriate size and
configuration. Bilateral T2 hyperintense cystic lesions in the
atria likely represent xantogranulomas. Flow voids of the major
intracranial arteries are preserved.
MRV HEAD: When judged from contrast enhancend images, the left
transverse and sigmoid sinus is patent. However, flow related
MRV and high signal on T2 suggested abnormally slow flow which
in unclear in etiology.
IMPRESSION:
1. Ring enhancing lesion with slow diffusion in the left
parietotemporal
junction. Giving the imaging features, the lesion is most
compatible with
intracranial abcess; however, neoplasm such as solitary
metastasis, GBM is
nonot excluded.
2. Slow flow in left transverse and sigmoid sinus without
evidence of
thrombosis.
CT HEAD ___: IMPRESSION: Known left parietal rim-enhancing
lesion and the surrounding vasogenic edema have progressed since
the prior study. These findings, in the context of those on MRI,
remain highly concerning for an abscess.
Dedicated multi- and single-voxel MR spectroscopy may be helpful
in further
characterization of this process.
CT HEAD ___: IMPRESSION: Status post stereotactic biopsy of
left parietal lobe lesion, with expected small air-fluid level
and minimal hemorrhage at the surgical site.
TTE ___: Conclusions
The left atrium is mildly dilated. The right atrium is
moderately dilated. Left ventricular wall thickness, cavity
size, and global systolic function are normal (LVEF 65%). Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Right ventricular chamber size and
free wall motion are normal. The aortic valve leaflets (3) are
mildly thickened. Flow acceleration along the axis of left
ventricular outflow is seen (2.4 m/sec). This is may be in part
due to an obstructive subaortic fibromuscular shelf (although
mild valvular aortic stenosis may be present) The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: Suboptimal image quality. No vegetations seen
TEE ___: Conclusions
No atrial septal defect is seen by 2D or color Doppler. Overall
left ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
ascending, transverse and descending thoracic aorta are normal
in diameter and free of atherosclerotic plaque to 30 cm from the
incisors. The aortic valve leaflets (3) are mildly thickened.
Trace aortic regurgitation is seen. The mitral valve leaflets
are mildly thickened. Mild to moderate (___) mitral
regurgitation is seen. There is no pericardial effusion.
IMPRESSION: No echocardiographic evidence of endocarditis. Mild
to moderate mitral regurgitation.
CT HEAD ___: IMPRESSION: Status post drainage of left
parietal abscess with expected postoperative changes and no
significant hemorrhage.
Brief Hospital Course:
Mrs. ___ is a ___ y/o woman with PMHx significant for HTN,
HLD and femur fx s/p surgery (___) who was brought to ED
with receptive language difficulties and who subsequently had
GTC seizure while in ED triage; she was intubated for airway
protection. Neurological exam on sedation was limited but
nonfocal. Inital CT imaging
was not conclusive. There was a left temporo-occipital
hypodensity with no flow limitiation noted on CTA, and decreased
blood volume in this location, with no evidence of increased MTT
on CTP. Given inconclusivity of CT data and as she was still in
time window for tpa, she underwent STAT MRI. This showed a
ring-enhancing mass lesion and a possible venous infarct with
diminished flow in left transverse sinus. The initial most
likely diagnosis was felt to be a metastatic lesion, however the
possibility of abscess was also brought up.
# NEURO: Patient was able to be extubated the morning after
admission and the sedation weaned. Repeat neurological exam off
sedation showed difficulty with naming and some commands. She
was put on keppra 1 gram BID for seizure prophylaxis that was
then increased to 1250mg BID. She underwent a CT torso to look
for malignancy and this was negative. She then had an LP which
showed 2 WBCs, with negative cytology. She then underwent a
brain biopsy, but on biopsy frank pus was aspirated, so the
abscess was drained. The fluid culture of her abscess showed
mixed anaeorobic growth, with fusobacterium species. She was
started on CTX, vancomycin and flagyl while awaiting the above
Cx retults. She was started on celexa 20mg QD as her hospital
course was c/b depression and emotional outbursts. Eventually
she was narrowed to just CTX and flagyl and was able to be sent
home with a PICC line for the CTX and oral flagyl. On
discharge, patient was intermittently tearful, and reporting
that she didn't want to leave the hospital, then changing her
mind and requesting to leave the hospital. Given her emotional
lability, we wanted to ensure that there was no change in her
head CT. She had a NCHCT, which showed expected post-surgical
changes but no bleeding or increased edema. Eventually, with
the help of her family, she decided that she would prefer to
complete her treatment at home.
# ID: Patient was put on antibiotics as above. Her HIV was
negative, TEE was negative for vegetations. She had a panorex
that did not show any abscesses. Her brain abscess grew out
fusobacterium as above, that was felt to likely have been from
her mouth infection that she had previously on her last
admission to rehab.
# ___: Pt has HTN, so we continued her home metoprolol and
statin.
# PULM: pt was extubated on the morning of ___, and had no
further pulmonary issues.
PENDING RESULTS:
None
TRANSITIONAL CARE ISSUES:
Patient and family were told that if her sx change at all or she
worsens or changes she should come to the ED for a CT scan to
ensure there is no bleeding or increased swelling of her lesion.
Medications on Admission:
-Metoprolol 50 mg bid
-Simvastatin 10 mg qhs
Discharge Medications:
1. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
2. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. levetiracetam 500 mg Tablet Sig: 2.5 Tablets PO BID (2 times
a day) for 2 weeks.
Disp:*75 Tablet(s)* Refills:*0*
4. ondansetron HCl 4 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours) as needed for nausea.
Disp:*180 Tablet(s)* Refills:*0*
5. loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed for diarrhea.
Disp:*120 Capsule(s)* Refills:*0*
6. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
7. ceftriaxone in dextrose,iso-os 2 gram/50 mL Piggyback Sig:
Two (2) grams Intravenous Q24H (every 24 hours): Infectious
Disease will determine the date of your final dose.
Disp:*30 doses* Refills:*1*
8. Outpatient Lab Work
CBC with differential, BMP, LFTs, ESR and CRP QWeekly until
Infectious Disease determines this can stop.
All laboratory results should be faxed to the ___
R.N.s at ___. All questions regarding outpatient
parenteral antibiotics should be directed to the ___
___ R.N.s at ___ or to the on-call ID fellow when
the clinic is closed.
ICD-9 Code is 324.00 for brain abscess.
9. oxycodone 5 mg Tablet Sig: 0.5 mg PO every six (6) hours as
needed for pain for 3 days.
Disp:*12 tablets* Refills:*0*
10. Celexa 20 mg Tablet Sig: One (1) Tablet PO once a day for 2
weeks.
Disp:*14 Tablet(s)* Refills:*0*
11. Celexa 20 mg Tablet Sig: One (1) Tablet PO once a day: This
Rx has been called into your mail order pharmacy.
12. Flagyl 500 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours: This Rx has been called into your mail order pharmacy.
13. Keppra 500 mg Tablet Sig: 2.5 Tablets PO twice a day: This
Rx has been called into your mail order pharmacy.
14. Flagyl 500 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours for 2 weeks.
Disp:*21 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Seizure
Brain Abscess
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were seen in the hospital for language difficulties and a
seizure. You were found to have had a brain abscess that was
causing your symptoms and you were treated with antibiotics.
You will need to be continued on antibiotics for at least one
month.
We made the following changes to your medications:
1) We STARTED you on KEPPRA 1250mg twice a day.
2) We STARTED you on CITALOPRAM 20mg once a day.
3) We STARTED you on FLAGYL 500mg every 8 hours. Infectious
Disease will determine when to stop this medication.
4) We STARTED you on CEFTRIAXONE 2 grams once every 24 hours
through your PICC line. Infectious Disease will determine when
to stop this medication.
5) We STARTED you on ZOFRAN 8mg every 8 hours as needed for
nausea while taking flagyl.
6) We STARTED you on LOPERAMIDE 2mg four times a day as needed
for diarrhea while you are taking flagyl.
7) We STARTED you on OXYCODONE 2.5mg every 6 hours as needed for
pain from your ___ line. This will decrease over the next ___
days and you will no longer need this medication.
Of note, your longer term medications (keppra, flagyl and celexa
have been called into your mail order pharmacy - confirmation #
___, and you have been written for a 14 day course of
them in addition to make sure you get them on discharge from the
hospital.
Please continue to take your other medications as previously
prescribed.
If you experience any of the below listed Danger Signs, please
contact your doctor or go to the nearest Emergency Room.
It was a pleasure taking care of you on this hospitalization.
Please follow these seizure safety guidelines:
SEIZURE SAFETY
________________________________________________________________
The following tips will help you to make your home and
surroundings as safe as possible during or following a seizure.
Some people with epilepsy will not need to make any of these
changes. Use this list to balance your safety with the way you
want to live your life.
Make sure that everyone in your family and in your home knows:
- what to expect when you have a seizure
- correct seizure first aid
- first aid for choking
- when it is (and isn't) necessary to call for emergency help
Avoid things that are known to increase the risk of a seizure:
- forgetting to take medications
- not getting enough sleep
- drinking a lot of alcohol
- using illegal drugs
In the kitchen:
- As much as possible, cook and use electrical appliances only
when someone else is in the house.
- Use a microwave if possible.
- Use the back burners of the stove. Turn handles of pans toward
the back of the stove.
- Avoid carrying hot pans; serve hot food and liquids directly
from the stove onto plates.
- Use pre-cut foods or use a blender or food processor to limit
the need for sharp knives.
- Wear rubber gloves when handling knives or washing dishes or
glasses in the sink.
- Use plastic cups, dishes, and containers rather than breakable
glass.
In the living room:
- Avoid open fires.
- Avoid trailing wires and clutter on the floor.
- Lay a soft, easy-to-clean carpet.
- Put safety glass in windows and doors.
- Pad sharp corners of tables and other furniture, and buy
furniture with rounded corners.
- Avoid smoking or lighting fires when you're by yourself.
- Try to avoid climbing up on chairs or ladders, especially when
alone.
- If you wander during seizures, make sure that outside doors
are
securely locked and put safety gates at the top of steep stairs.
In the bedroom:
- Choose a wide, low bed.
- Avoid top bunks.
- Place a soft carpet on the floor.
In the bathroom:
- Unless you live on your own, tell a family member ___
before you take a bath or shower.
- Hang the bathroom door so it opens outward, so it can be
opened
if you have a seizure and fall against it.
- Don't lock the bathroom door. Hang an "Occupied" sign on the
outside handle instead.
- Set the water temperature low so you won't be hurt if you have
a seizure while the water is running.
- Showers are generally safer than baths. Consider using a
hand-
held shower nozzle.
- If taking a bath, keep the water shallow and make sure you
turn off the tap before getting in.
- Put non-skid strips in the tub.
- Avoid using electrical appliances in the bathroom or near
water.
- Use shatterproof glass for mirrors.
At work:
___
Out and about:
- Carry only as many medications with you as you will need, and
2
spare doses.
- Wear a medical alert bracelet to let emergency workers and
others know that you have epilepsy.
- Stand well back from the road when waiting for the bus and
away from the platform edge when taking the subway.
- If you wander during a seizure, take a friend along.
- Don't let fear of a seizure keep you at home.
Sports:
- Use common sense to decide which sports are reasonable.
- Exercise on soft surfaces.
- Wear a life vest when you are close to water.
- Avoid swimming alone. Make sure someone with you can swim
well enough to help you if you need it.
- Wear head protection when playing contact sports or when there
is a risk of falling.
- When riding a bicycle or rollerblading, wear a helmet, knee
pads, and elbow pads. Avoid high traffic areas; ride or skate
on side roads or bike paths.
Driving:
- You may not drive in ___ unless you have been
seizure- free for at least 6 months.
- Always wear a seatbelt.
Parenting:
- Childproof your home as much as possible.
- If you are nursing a baby, sit on the floor or bed with your
back supported so the baby will not fall far if you should lose
consciousness.
- Feed the baby while he or she is seated in an infant seat.
- Dress, change, and sponge bathe the baby on the floor.
- Move the baby around in a stroller or small crib.
- Keep a young baby in a playpen when you are alone, and a
toddler in an indoor play yard, or childproof one room and use
safety gates at the doors.
- When out of the house, use a bungee-type cord or restraint
harness so your child cannot wander away if you have a seizure
that affects your awareness.
- Explain your seizures to your child when he or she is old
enough to understand.
Followup Instructions:
___
|
19588408-DS-9
| 19,588,408 | 21,584,312 |
DS
| 9 |
2172-05-07 00:00:00
|
2172-05-07 13:35:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
Sulfa(Sulfonamide Antibiotics) / Heparin Agents
Attending: ___.
Chief Complaint:
Enlarging brain abcess
Major Surgical or Invasive Procedure:
___ Left Craniotomy for evacuation of brain abscess
History of Present Illness:
Ms. ___ is a ___ y.o. RH female with PMH of HTN,
hyperlipidemia, ulcerative colitis and known left tempoparietal
brain abscess s/p stereotactic brain abscess drainage on ___
who presented to ED with multiple brain abscessed. She was
discharged on ceftriaxone, vancomycin and Flagyl. She was
followed by neurology and ID. She was recently found have
thrombocytopenia and ceftriaxone was changed to penicillin.
However, she was found to have Heparin-Induce Thrombocytopenia.
She was changed from Ceftriaxone to penicillin IV.
Now for the past several days, she has had increasing HAs,
agitation, nausea, vomiting and fevers. She had a head CT
yesterday which showed multiple ring enhancing lesion. Patient
presented to ED for further management. Neurosurgery consulted
for further management.
On review of systems patient reports chills and rigors. She has
no visual loss or paresthesia. No chest pain, abdominal pain or
SOB. All other systems are essentially non-contributory.
Past Medical History:
-HTN
-HLD
-Ulcerative colitis - per PCP/GI doc, trivial 15-30 cm of
colitis in distal sigmoid sparing rectum. Pathology showed mild
IBD. PCP/GI doc does not consider this UC.
-Femur fracture s/p rod + pins (___)
-viral tongue lesion (dx 1 month ago) - s/p biopsy and ~4 wks
abx
-left cheeck skin cancer s/p topical/surgical removal - unclear
if basal cell vs melanoma. PCP ___ recall melanoma hx but
does not have in records. Derm: Dr. ___ at ___
___ tests (per PCP/GI Dr. ___ - Pt often
refused.
- last colonoscopy ___ - focal ischemia, no polyps
- mammogram ___ - no abnl
- prev CXR ___
Social History:
___
Family History:
Unable to obtain from patient
Physical Exam:
ADMISSION PHYSICAL EXAM:
O: T: 101.0 103 146/73 22 97%
Gen: WD/WN, comfortable, NAD, warm to touch, with rigors
HEENT: head: incision well-healed, disheveled, eye; clear, no
jaundice, ears: hearing intact, no drainage Nose: patent, no
drainage
Neck: Supple.
Lungs: CTA bilaterally, no w/c/r.
Cardiac: RRR. S1/S2.
Abd: Soft, obese, NT, BS+
Extrem: Warm and well-perfused, no c/c/e
Neuro:
Mental status: Awake and alert, distressed and agitate.
Orientation: Oriented to person and hospital, thinks it is ___.
Language: Speech fluent with good comprehension, following
commands, able to repeat
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2
mm bilaterally, fundoscopic - no papilledema, 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
Reflexes: B T Br Pa Ac
Right 2+----------
Left 2+----------
No clonus
Toes downgoing bilaterally
Bilateral rigors on coordination exam, but appropriate
Handedness Right
On Discharge:
Stable
Pertinent Results:
ADMISSION LABS:
___ 04:05PM BLOOD WBC-9.2# RBC-4.29 Hgb-12.4 Hct-38.4
MCV-90 MCH-29.0 MCHC-32.4 RDW-14.2 Plt ___
___ 04:05PM BLOOD Neuts-84.8* Lymphs-12.5* Monos-2.1
Eos-0.4 Baso-0.3
___ 04:05PM BLOOD ___ PTT-27.4 ___
___ 04:05PM BLOOD Glucose-126* UreaN-3* Creat-0.6 Na-130*
K-4.1 Cl-96 HCO3-19* AnGap-19
___ 04:05PM BLOOD CRP-1.5
___ 04:20PM BLOOD Lactate-1.7
REPORTS:
CT HEAD ___: IMPRESSION: Four rim-enhancing left parietal
fluid collections encompassing a larger area in comparison to a
previously-seen single abscess at this location. The findings
are concerning for recurrent or expanding infection. MR could
be considered for further evaluation.
Cardiovascular Report ECG Study Date of ___ 3:45:24 ___
Sinus tachycardia. Possible prior septal myocardial infarction,
age
undetermined. Left ventricular hypertrophy with secondary
repolarization
changes. Compared to the previous tracing of ___ wave changes are more prominent on the current tracing.
Other findings are similar.
___ MR HEAD W & W/O CONTRAST
IMPRESSION:
1. Multiseptated, multiloculated peripherally enhancing lesion
in left
temporoparietal lobe is suggestive of an abscess with associated
significant perilesional edema causing mass effect on the atrium
and body of left lateral ventricle.
2. Enhancement along the atrium of left lateral ventricle which
likely
represents subependymal spread of infection.
3. Changes of chronic small vessel ischemic disease.
___ CHEST (PORTABLE AP) FINDINGS: The patient has received a
right PICC line. The course of the line is unremarkable, the
line appears to terminate in the mid SVC. There is no evidence
of complications, notably no pneumothorax.
MR HEAD W/O CONTRAST Study Date of ___ 11:51 AM
IMPRESSION:
1. Limited examination due to patient motion, functional MRI
sequences of the brain were cancelled due to lack of patient
cooperation.
2. DTI tractography images demonstrate significant deviation of
the
corticospinal fibers and association fibers; however, apparently
there is
evidence of cortical spinal tracts adjacent to this mass lesion.
3. In comparison with the prior examinations, no significant
changes are
visualized in the left occipital mass with persistent vasogenic
edema, slow diffusion and mass effect.
MR HEAD W/ CONTRAST Study Date of ___ 4:44 AM
IMPRESSION:
1. Pre-operative planning study with stable multiseptated,
multiloculated
peripherally enhancing lesion in left temporoparietal lobe with
associated
significant perilesional edema causing mass effect on the atrium
and body of left lateral ventricle.
2. Enhancement along the atrium of left lateral ventricle which
likely
represents subependymal spread of infection.
___ CT head postop: Status post craniotomy and drainage of left
parietal abscesses with small amount of post procedural
intraparenchymal and extra-axial hemorrhage and unchanged
vasogenic edema without evidence of significant mass effect.
___ Chest Xray: There is an endotracheal tube whose distal tip
is 5 cm above the carina at the level of the aortic knob and
appropriately sited. Cardiac silhouette is upper limits of
normal. There is mild prominence of the pulmonary interstitial
markings without overt pulmonary edema. No large pleural
effusions or pneumothoraces are seen. There is a right-sided
PICC line whose distal tip is at the cavoatrial junction,
unchanged from prior.
___ MR brain with & without Contrast:
IMPRESSION:
1. Post-surgical changes in the left parietal region, with
heterogeneous
enhancement in the left parietal lobe extend into the atrium of
the left
lateral ventricle with mild subependymal enhancement and
moderate surrounding edema. This is decreased since the
pre-operative study, with a few persistent blood products and
possible purulent material. Other details as above.
2. A faint focus of enhancement in the pons, likely represents
a capillary telangiectasia and is unchanged.
___ Transthoracic Echocardiogram
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). Tissue Doppler imaging suggests a normal
left ventricular filling pressure (PCWP<12mmHg). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No masses or vegetations are seen on
the aortic valve. Trace aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. No mass or vegetation is seen on the mitral valve.
Mild (1+) mitral regurgitation is seen. The estimated pulmonary
artery systolic pressure is normal. There is no pericardial
effusion.
IMPRESSION: No echocardiographic evidence of endocarditis.
Normal global and regional biventricular systolic function. Mild
mitral regurgitation.
Brief Hospital Course:
This is a ___ year old female with known left tempoparietal brain
abscess who presented with increased headaches,nausea, vomiting,
and agitation who presented on ___ with more enhancing
lesions (probable abcess) and cerebral edema. On ___ the
patient was admitted to the neurosurgery service to the SICU
additional evaluation and treatment. The patient had a brain MRI
with and without contrast to assess the extent ofthe multiple
brain abscesses which was consistent with multiseptated,
multiloculated peripherally enhancing lesion in left
temporoparietal lobe is suggestive of an abscess with associated
significant
perilesional edema causing mass effect on the atrium and body of
left lateral
ventricle. Enhancement along the atrium of left lateral
ventricle which likely
represents subependymal spread of infection.Changes of chronic
small vessel ischemic disease. A functional MRI was performed as
this lesion is near her motor and speech centers of her brain
because she is right-handed and left hemisphere dominate which
was consistent with limited examination due to patient motion,
functional MRI sequences of the brain were cancelled due to lack
of patient cooperation. DTI tractography images demonstrate
significant deviation of the corticospinal fibers and
association fibers; however, apparently there is evidence of
cortical spinal tracts adjacent to this mass lesion. In
comparison with the prior examinations, no significant changes
are visualized in the left occipital mass with persistent
vasogenic edema, slow diffusion and mass effect. The patient
exhibited "red man's syndrome" and was given benadryl.
On ___ Disease was consulted and recommendations
were as follows:The failure to resolve her brain abscess after a
long course of metronidazole and ceftriaxone suggests that
either her infection was polymicrobial at the outset or she
developed a superinfection, perhaps via an organism introduced
at the time of
her prior surgery. Would cover gram positive organismsby adding
vancomycin to her regimen, and would monitor vancomycin levels
and renal function. For now would continue metronidazole and
ceftriaxione, since she initially seemed to
improve. Based on the results of new brain aspiration, would
adjust antibiotics accordingly, possibly to cover more resistant
gram negative rods or to cover yeast or other atypical
pathogens. On exam, the patient's mental status was improved.
On ___, A Wand MRI was performed for OR planning. The patient
went to the OR for a left craniotomy for evacuation and washout
of the brain abscess. The patient tolerated the procedure well
and she was transferred intubated to the ICU. Postoperative
head CT demonstrated no postoperative hemorrhage.
She remained intubated until after a postoperative MRI could be
obtained on ___. Post extubation the patient remained
neurologically intact.
On ___ she was transferred to the regular floor. She was
repleted in the AM via IV for a Potassium of 2.8. Repeat
evening K was 3.4 for which she was repleted orally with a plan
to recheck in the AM. Vancomycin dosing was increased to 1250
IV BID per ID recommendations and a trough was scheduled for
prior to the 4th dose. On ___, she was screened for rehab and
ceftriaxone was changed to daily per ID. On ___, ID changed
flagyl to PO 500mg Q8H which patient could not tolerate due to
nausea so it was made IV once again. She continued to have
nausea around the administration of Flagyl and thus was managed
with oral and IV antiemetics. TTE was obtained on ___ which
demonstrated a normal EF of 55% with no evidence of vegetations.
She remained neurologically stable during her hospital stay and
at the time of discharge on ___ she was tolerating a regular
diet, ambulating with an assistive device, afebrile with stable
vital signs.
She is sheduled for follow up with ID in two weeks with a plan
to continue triple antibiotic therapy until then. Vancomycin
levels should be followed to maintain a goal trough level of
___.
Medications on Admission:
Penicillin 4 million units IV Q4h
CITALOPRAM [CELEXA] - (Prescribed by Other Provider) - 20 mg
Tablet - 1 Tablet(s) by mouth once a day This Rx has been called
into your mail order pharmacy
LEVETIRACETAM [KEPPRA] - (Prescribed by Other Provider) - 500
mg
Tablet - 2.5 Tablet(s) by mouth twice a day This Rx has been
called into your mail order pharmacy
LOPERAMIDE - (Prescribed by Other Provider) - 2 mg Capsule - 1
Capsule(s) by mouth four times a day as needed for diarrhea
METOPROLOL TARTRATE - (Prescribed by Other Provider) - 50 mg
Tablet - 1 Tablet(s) by mouth twice a day
METRONIDAZOLE [FLAGYL] - (Prescribed by Other Provider) - 500
mg
Tablet - 2 Tablet(s) by mouth two times a day and 1 tablet QHS
ONDANSETRON HCL - (Prescribed by Other Provider) - 4 mg Tablet
-
2 Tablet(s) by mouth every eight (8) hours as needed for nausea
SIMVASTATIN - (Prescribed by Other Provider) - 10 mg Tablet - 1
Tablet(s) by mouth DAILY (Daily)
heparin flushes - was discontinued prior to arrival
Discharge Medications:
1. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed for diarrhea.
3. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. insulin regular human 100 unit/mL Solution Sig: per insulin
sliding scale Units Injection ASDIR (AS DIRECTED).
6. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
7. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical BID
(2 times a day) as needed for irritation.
8. acetaminophen-codeine 300-30 mg Tablet Sig: ___ Tablets PO
Q4H (every 4 hours) as needed for Pain.
9. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. levetiracetam 500 mg Tablet Sig: 2.5 Tablets PO BID (2 times
a day).
11. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
12. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
13. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
14. Vancomycin 1250 mg IV Q 12H
15. Ondansetron 4 mg IV Q8H
Please give prior to flagyl dosing
16. CeftriaXONE 2 gm IV Q24H
17. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H
18. Ondansetron 4 mg IV Q4H:PRN nausea
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Cerebral Abcess
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
General Instructions
Have a friend/family member check your incision daily for
signs of infection.
Take your pain medicine as prescribed.
Exercise should be limited to walking; no lifting, straining,
or excessive bending.
You have dissolvable sutures. You may wash your hair.
Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
You have been discharged on Keppra (Levetiracetam) for seizure
prevention, you will not require blood work monitoring.
Clearance to drive and return to work will be addressed at
your post-operative office visit.
Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
New onset of tremors or seizures.
Any confusion or change in mental status.
Any numbness, tingling, weakness in your extremities.
Pain or headache that is continually increasing, or not
relieved by pain medication.
Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
Fever greater than or equal to 101.5° F.
Followup Instructions:
___
|
19588862-DS-12
| 19,588,862 | 28,355,894 |
DS
| 12 |
2188-09-03 00:00:00
|
2188-09-03 14:00:00
|
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, abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o female with metastatic intrahepatic cholangiocarcinoma
with
peritoneal carcinomatosis, recently admitted with constipation,
nausea, vomiting, dehydration, and pain d/t CT demonstrated
partial small bowel obstructions representing with with ___
colicky abdominal pain and inability to take PO and constipation
x1 week. Patient reports daily enemas without effect at home.
She attempted to eat Jello this morning but vomited it up.
Patient was discharged ___ after 6 day admission. In the ED,
vitals were stable. KUB suggestive of SBO. Surgery was consulted
who recommended no surgical intervention given ascitis, and
manage conservatively. NG decompression was done which has
resolved her symptoms somewhat.
On the floor, she endorses mild diffuse abdominal pain, nausea.
She has not vomited since coming to the hospital. She has still
not been able to pass gas or have BM.
Past Medical History:
1. Metastatic gallbladder CA. 2. Hypertension. 3. Shoulder
surgery. 4. Tubal ligation.
Onc Hx:
She initially presented with concurrent liver and pelvic masses
and underwent resection of the pelvic mass. Pathology showed a
large ovarian cystadenoma in conjunction with metastatic
adenocarcinoma.
Pathology was similar to that of her prior liver biopsy and
consistent with cholangiocarcinoma. She began gemcitabine/
cisplatin ___. She completed 14 cycles of chemotherapy
began a treatment break as of ___. She resumed
chemotherapy with single agent gemcitabine on ___.
Cisplatin was held on account of persistent and substantial
neuropathy.
Ms. ___ course more recently has been complicated by new
onset partial small-bowel obstructions.
Social History:
___
Family History:
no family history of colon cancer, uterine cancer, or other
types of cancers
Physical Exam:
VS: Tmax 98.1, BP 102/68, HR 98, RR 16, O2 Sat 97% RA,
GEN: A&O, NAD, pleasant, thin.
HEENT: Sclerae non-icteric, EOM intact, o/p clear, MM dry.
Neck: Supple, no thyromegaly, no cervical LAD.
CV: S1S2, RRR, no MRG.
RESP: CTAB, no rhonchi or wheezing.
ABD: Distended, protruding umbilical hernia, minimal abdominal
tenderness, cannot appreciate HSM, no inguinal LAD, normal bowel
sounds.
EXTR: No edema.
DERM: No rash.
Neuro: Strength ___, decreased sensation on soles of feet, no
other focal deficits.
Pertinent Results:
___ 08:54PM ___ COMMENTS-GREEN TOP
___ 08:54PM LACTATE-1.4
___ 07:20PM GLUCOSE-96 UREA N-18 CREAT-0.9 SODIUM-128*
POTASSIUM-3.2* CHLORIDE-86* TOTAL CO2-28 ANION GAP-17
___ 07:20PM estGFR-Using this
___ 07:20PM ALT(SGPT)-16 AST(SGOT)-40 ALK PHOS-76 TOT
BILI-0.5
___ 07:20PM LIPASE-15
___ 07:20PM ALBUMIN-3.5
___ 07:20PM WBC-6.9 RBC-4.26 HGB-14.5 HCT-45.4 MCV-107*#
MCH-34.0* MCHC-31.9 RDW-18.3*
___ 07:20PM NEUTS-65 BANDS-12* LYMPHS-16* MONOS-6 EOS-0
BASOS-0 ATYPS-1* ___ MYELOS-0
___ 07:20PM HYPOCHROM-2+ ANISOCYT-2+ POIKILOCY-2+
MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-1+ SPHEROCYT-OCCASIONAL
TARGET-2+ SCHISTOCY-OCCASIONAL HOW-JOL-OCCASIONAL
PAPPENHEI-OCCASIONAL ACANTHOCY-OCCASIONAL
___ 07:20PM PLT SMR-HIGH PLT COUNT-448*
.
___ 07:00AM BLOOD WBC-5.5 RBC-3.77* Hgb-12.6 Hct-38.2
MCV-101* MCH-33.3* MCHC-32.9 RDW-18.7* Plt ___
___ 07:30AM BLOOD Glucose-128* UreaN-17 Creat-0.7 Na-135
K-4.3 Cl-104 HCO3-25 AnGap-10
___ 07:00AM BLOOD Calcium-8.0* Phos-2.6* Mg-1.8
.
Brief Hospital Course:
___ woman with HTN and metastatic gallbladder cancer admitted
for nausea, vomiting, constipation, and SBO.
.
# metastatic cholangiocarcinoma complicated by SBO and abdominal
pain. Symptoms due to SBO seen on KUB. This is secondary to
peritoneal carcinomatosis.
.
She was managed with medical management. SHe was seen by
surgery who felt that she likely had multiple small obstructions
on account of her diffuse peritoneal carcinomatosis. In
addition, surgery and GI both said that she was not a candidate
for venting G tube as her malignant ascites would be a
contraindication.
.
She was seen by the palliative care team, who advised octreotide
to reduce secretions, decadron to reduce bowel wall edema and
reglan to promote motility. SHe had an NG tube placed, but KUB
showed no resolution of the obstruction. She did not want to be
discharged with an NG tube, so she had a clamping trial, which
she passed. Prior to discharge, patient decided that she wanted
to be discharged with hospice, but that she also wanted to
continue IVF at home.
.
She will be discharged to home to continue on hospice care, with
palliative fluid via SQ route, as well as Reglan, Dexamethasone,
and Octreotide to reduce gut secretions, promote gut motility
and decrease bowel edema in order to reduce her GI symptoms and
provide palliation. She will be followed by Good ___
Hospice. On day of discharge, she has tolerated clamped NGT x
72 hours, is passing small flatus and stool, and has not
required any PRN morphine, with pain being well controlled on
Fentanyl patch.
.
Transitional Issues:
1. She will be discharged to home with home hospice to follow
and manage her symptomatically.
.
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from webOMR.
1. Furosemide 80 mg PO DAILY Start: In am
2. Lorazepam 1 mg PO Q6H:PRN nausea, vomiting
3. Omeprazole 20 mg PO DAILY Start: In am
4. Ondansetron 8 mg IV Q8H:PRN nausea, vomiting
5. Spironolactone 50 mg PO DAILY
6. HYDROmorphone (Dilaudid) 0.5 mg IV Q4H:PRN pain
7. Aspirin 81 mg PO DAILY Start: In am
8. Bisacodyl ___AILY:PRN constipation Start: In am
Discharge Medications:
1. Octreotide Acetate 200 mcg SC Q8H
RX *octreotide acetate 200 mcg/mL 200 mcg sc three times a day
Disp #*30 Syringe Refills:*1
2. Morphine Sulfate (Concentrated Oral Soln) ___ mg PO Q1H:PRN
pain
RX *morphine concentrate 100 mg/5 mL (20 mg/mL) 1 ml by mouth q2
hours Disp #*1 Bottle Refills:*1
RX *morphine concentrate 100 mg/5 mL (20 mg/mL) 2 - 20 mg by
mouth q1 hour Disp ___ Milliliter Refills:*1
3. Fentanyl Patch 12 mcg/h TP Q72H
RX *fentanyl 12 mcg/hour 1 patch q72 hours Disp #*1 Box
Refills:*1
4. Dexamethasone 5 mg PO BID
RX *dexamethasone [Dexamethasone Intensol] 0.5 mg/0.5 mL 5
Drops(s) by mouth twice a day Disp #*1 Bottle Refills:*1
5. Metoclopramide 10 mg PO QIDACHS
RX *metoclopramide HCl 5 mg/5 mL 10 mg by mouth 4 x daily Disp
#*1 Bottle Refills:*1
RX *metoclopramide HCl 5 mg/5 mL 10 ml by mouth 4 x daily Disp
#*1 Bottle Refills:*1
6. IV fluid presciption (RX)
please dispense IV fluid, D5NS (dextrose and 0.9% normal
saline). to be infused at max rate of 42ml/hour (1000ml/24hour)
SQ. please dispense quantity sufficient.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Small Bowel Obstruction
Cholangiocarcinoma with peritoneal carcinomatosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with a small bowel obstruction. This has
happened because your cancer is compressing parts of the small
bowel, preventing secretions and other contents from passing
through your bowel.
Unfortunately, there are no surgical options or treatments for
this. You met with the palliative care team to focus on a
hospice approach to your symptoms, which involves goals of
comfort.
You had an NG tube in your stomach to remove contents, as they
were not able to pass through the small bowel because of the
obstructions. We also started you on medicines like octreotide
injection, steroids (decadron) and reglan to help your body
handle the secretions from the stomach and small bowel without
use of an NG tube. It appears that this approach is working,
and you will go home without an NG tube.
You will also go home on Subcutaneous fluid for comfort and to
prevent dehydration.
The hospice nurses and company will visit you at home daily to
make sure that you remain comfortable physically and
emotionally. They will also help administer medications. Dr.
___ primary oncologist, will also continue to follow
along.
Followup Instructions:
___
|
19589069-DS-20
| 19,589,069 | 24,622,111 |
DS
| 20 |
2178-03-18 00:00:00
|
2178-03-26 15:52:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Hydromorphone
Attending: ___
Chief Complaint:
Neck pain, blurry vision, gait instability, and vertigo
Major Surgical or Invasive Procedure:
lumbar puncture
History of Present Illness:
Ms. ___ is a ___ year-old woman with no significant PMH who
presents with 1 month of neck pain, unsteadiness, and 8 days of
worsening intermittent vertigo. She was also found to have
enlarged ventricles on outpt MRI, so was sent for expedited
evaluation by Dr. ___, who saw her for initial
evaluation today.
She reports that she was normal until ___, when she woke
up with severe headache and nausea, with about 15 episodes of
vomiting x3 times over 3 hours. Then these symptoms resolved.
She
felt herself until ___, when she began developing left
sided neck pain, which is not radicular. Pain is worse with
movement. She also felt that she was off balance and just did
not
quite feel herself.
She complained of these symptoms on ___, which was her
annual physical, and had a head CT done which showed enlarged
ventricles and possible chronic sinus changes. She was asked to
use neti pot, and developed headache after, and about 2 days
later, had a piece of plastic fall out of her right nostril,
which she thinks was part of neti pot. No headache since then.
She also took some antibiotics after that given concern for
sinusitis with foreign body, but developed diarrhea and stopped
it.
She also got a MRI of her brain as a follow up. Sometime in late
___, she also developed blurry vision, and since ___,
she
has had intermittent vertigo, described as feeling like she's on
a boat. Her gait has been unstable since this time, and she
feels
that she's walking towards right, though her wife has not
noticed
that pt's walking into things or people as she walks. No falls,
but she has developed new intermittent urinary urge
incontinence.
She may have had increasing moodiness associated with these
problems, but there has been no disorientation, confusion or
speech issues.
I spoke with Dr. ___ was able to see her outpt MRI,
which
he read as communicating hydrocephalus, and he felt this did not
represent an ex-vacuo type of hydrocephalus. No abnormal signal
on GRE to suggest hemorrhages.
On neuro ROS, the pt denies headache, loss of vision,
dysarthria,
dysphagia, lightheadedness, tinnitus or hearing difficulty.
Denies difficulties producing or comprehending speech. Denies
focal weakness, numbness, parasthesiae. No bowel retention.
On general review of systems, the pt denies recent fever or
chills. Recent weight gain after ankle surgery. Denies cough,
shortness of breath. Denies chest pain or tightness,
palpitations. Denies constipation or abdominal pain. No
dysuria. Denies rash.
Past Medical History:
PMHx:
- GERD
- history of esophageal ?spasm vs. stricture, s/p
dilatation/endoscopy
- high cholesterol
- multiple orthopedic surgeries: 2 shoulder x2, left shoulder
x1,
left ankle x1 and left knee x1.
- osgood schlatter disease R > L
Social History:
___
Family History:
Mother has osteoporosis, pulmonary embolism on
coumadin, died from lung cancer (smoker). She had 8 children,
?miscarriage. Father had rheumatic fever and subsequent valve
disease requiring multiple heart surgeries. Has 7 siblings - 2
of
the brothers had strokes in their ___, unclear if ischemic vs.
hemorrhagic. Sister had ___ palsy. No history of miscarriages
or clots.
Physical Exam:
==============
ADMISSION EXAM
==============
Vitals: 98.7 83 116/92 18 98% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: CTABL
Cardiac: RRR, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: no edema, pulses palpated
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. 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. The pt had good
knowledge of current events. There was no evidence of neglect.
There was no evidence of left-right confusion as the patient was
able to accurately follow the instruction to touch left ear with
right hand.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 2.5 to 2mm and brisk. VFF to finger counting in all
quadrants. Funduscopic exam revealed mild blurring of disc
bilaterally, nasal > temporal.
III, IV, VI: EOMI. With rightward gaze, pt has counterclockwise
beating rotatory nystagmus, not really observed in other
positions.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
- Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
No
asterixis noted.
Delt Bic Tri WrE FFl FE IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5
-Sensory: No deficits to light touch, cold sensation, vibratory
sense, proprioception throughout.
-DTRs: 1+ throughout, absent at the ankles. Toes downgoing.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Difficulty with tandem. Romberg absent. Does not seem
magnetic.
With untenberger, pt marches in place without turning, and then
complains of dizziness and steps backwards and sits down.
===============
DISCHARGE EXAM
===============
Vitals: Tc 98.7 Tm 98.7 BP 129/60 (122-129/68-81) HR ___ RR
___ SaO2 97/ra
Awake. Alert. Able to recall events of history. PERRL, 4->2 bl.
No nystagmus. Difficult to assess diplopia ___ poor visual
acuity. Sacaades intact. No skew deviation. Visual acuity ___
with reading glasses. No color desaturation. Face symmetric at
rest and with activation. SCM/Trap full strength. Strength ___
in upper and lower extremities. Reflexes 2+ throughout. - head
impulse. - ___. Big toe proprioception and vibration
sense intact bl, L>R. Positive Romberg. No dysmetria on FNF or
HTS bl. Mild vertical dysmetria on downward matching. No
dysdiadochokinesia. Slightly wide-basd gait. Heel and toe
walking in tact.
Pertinent Results:
==============
ADMISSION LABS
==============
___ 06:35PM BLOOD WBC-7.1 RBC-4.39 Hgb-13.5 Hct-40.1 MCV-91
MCH-30.8 MCHC-33.7 RDW-13.4 Plt ___
___ 06:35PM BLOOD Neuts-73.5* ___ Monos-4.9 Eos-1.7
Baso-0.6
___ 06:35PM BLOOD Plt ___
___ 06:35PM BLOOD Glucose-109* UreaN-13 Creat-0.6 Na-136
K-4.2 Cl-98 HCO3-26 AnGap-16
___ 06:35PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 10:51PM URINE Color-Straw Appear-Clear Sp ___
___ 10:51PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-MOD
___ 10:51PM URINE RBC-4* WBC-6* Bacteri-NONE Yeast-NONE
Epi-1 TransE-<1
___ 10:51PM URINE Mucous-RARE
___ 10:51PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
=================
PERTINENT RESULTS
=================
___ 04:00PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-0 Polys-PND
Lymphs-PND Monos-PND
___ 04:00PM CEREBROSPINAL FLUID (CSF) TotProt-26 Glucose-71
___ 04:00PM CEREBROSPINAL FLUID (CSF) TB - PCR-PND
___ 04:00PM CEREBROSPINAL FLUID (CSF) VARICELLA DNA
(PCR)-PND
___ 04:00PM CEREBROSPINAL FLUID (CSF) TREPONEMA PALLIDUM
ANTIBODY, IFA (CSF)-PND
___ 04:00PM CEREBROSPINAL FLUID (CSF) ANGIOTENSIN 1
CONVERTING ENZYME-PND
___ 04:00PM CEREBROSPINAL FLUID (CSF) ASPERGILLUS
GALACTOMANNAN ANTIGEN-PND
___ 04:00PM CEREBROSPINAL FLUID (CSF) VDRL-PND
___ 04:00PM CEREBROSPINAL FLUID (CSF) HERPES SIMPLEX VIRUS
PCR-PND
==============
DISCHARGE LABS
==============
___ 07:44AM BLOOD WBC-5.5 RBC-4.13* Hgb-13.0 Hct-38.0
MCV-92 MCH-31.4 MCHC-34.1 RDW-13.3 Plt ___
___ 07:44AM BLOOD Plt ___
___ 07:44AM BLOOD ___ PTT-29.3 ___
___ 07:44AM BLOOD Glucose-100 UreaN-17 Creat-0.8 Na-139
K-4.2 Cl-99 HCO3-29 AnGap-15
___ 07:44AM BLOOD Calcium-9.6 Phos-4.6*
=======
IMAGING
=======
CT HEAD (___): Prominence of ventricles and sulci.
MRI HEAD (___): Findings suggesting mild communicating
hydrocephalus with no evidence of transependymal CSF flow.
CTA/CTV HEAD (___): 1. Normal appearance of the vasculature of
the head and neck, without significant stenosis (by NASCET
criteria), dissection, or aneurysm. 2. No dural venous sinus
thrombosis. 3. No acute territorial infarct, space-occupying
lesion, or intracranial hemorrhage. 4. Mild global enlargement
of the lateral, third, and fourth ventricles, unchanged dating
back to CT on ___. When compared with MRI head from
___, the cerebral aqueduct also appears enlarged.
This pattern suggests extraventricular obstructive
hydrocephalus. 5. Prominence of the pulmonary veins suggesting
pulmonary venous congestion.
Brief Hospital Course:
This is a ___ year old woman who presents with a 1 month history
of gradually worsening neck pain, blurry vision, gait
instability, and vertigo. These symptoms began on ___ when
the patient awoke with a severe headache and several episodes of
vomiting. Since that point symptoms of neck pain and
unsteadiness have progressed slowly. Over the past 8 days, her
symptoms have worsened, with the development of blurry vision
and gait instability with tilting towards the right side. She
reports some new-onset urge incontinence over the past month. CT
imaging on ___ showed prominence of both the ventricles and
the sulci. MRI follow up ___ showed mild chronic compensated
hydrocephalus. Due to these findings and worsening symptoms, her
neurologist Dr. ___ her to the ___ ED for evaluation.
She was admitted to the neurology service for evaluation. Her
exam was notable for gait with difficulty tandem (sways) and
backward fall on Romberg. She was slightly disinhibited and very
restless. There were no other focal neurologic findings.
The etiology of her hydrocephalus is unclear. On imaging, it
does not appear to be obstructive. Communicating hydrocephalus
could have several different etiologies. Posthemorrhage or
venous congestion are unlikely given the results of her CTA and
CTV ( no evidence of dural venous sinus thrombosis or cerebral
artery aneurysm). Other etiologies include infectious (viral or
fungal), inflammatory, or neoplastic process.
A lumbar puncture was performed to evaluate opening pressure
(slightly elevated given body habitus). The opening pressure was
mildly elevated at 27 cmH2O. 20 mL of CSF was pulled off and
closing pressure was 18 cmH20. CSF labs are currently pending
and will be followed-up with Dr. ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 20 mg PO BID
2. Pravastatin 20 mg PO DAILY
3. Ranitidine 300 mg PO HS
4. Lorazepam 0.5 mg PO QHS:PRN sleep
5. Ibuprofen 200 mg PO Q8H:PRN pain
6. Vitamin D 50,000 UNIT PO DAILY
7. Fish Oil (Omega 3) 1000 mg PO DAILY
8. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation 2
puffs every 4 to 6 hours prn
Discharge Medications:
1. Omeprazole 20 mg PO BID
2. Pravastatin 20 mg PO DAILY
3. Ranitidine 300 mg PO HS
4. Lorazepam 0.5 mg PO QHS:PRN sleep
5. Ibuprofen 200 mg PO Q8H:PRN pain
6. Vitamin D 50,000 UNIT PO DAILY
7. Fish Oil (Omega 3) 1000 mg PO DAILY
8. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation 2
puffs every 4 to 6 hours prn
Discharge Disposition:
Home
Discharge Diagnosis:
elevated intracranial pressure
mild communicating hydrocephalus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms ___,
You were admitted with episodes of dizziness and veering to the
right with walking that began after a headache that woke you up
in the middle of the night on ___. You have not had
headaches since. Your vision has been poor and you think it may
have also gotten worse over this period. We looked at your
outside hospital MRI here - it showed evidence of mild
communicating hydrocephalus. We ended up doing a spinal tap
which also showed that you had mildly elevated pressure at 27
cmH20. We pulled off 20 mL of CSF and have sent it off for
several different labs that may help us figure out why you have
high intracranial pressure. You should follow up with your
outpatient neurologist regarding the results of our CSF tests
Followup Instructions:
___
|
19589138-DS-28
| 19,589,138 | 29,662,469 |
DS
| 28 |
2160-09-20 00:00:00
|
2160-09-21 00:02:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Gabapentin
Attending: ___.
Chief Complaint:
Back pain, shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is an ___ year old woman with h/o Lung cancer s/p RU
lobectomy,COPD, Gout, HTN, DM, CAD, HLP, and recently diagnosed
L3 compression fracture who presents with chief complaint of
back pain. The patient states that she has had sciatica for many
years but about 3 weeks ago started experiencing severe right
sided lumbar and right buttock pain radiating to the entire RLE.
The pain is described as severe and increases with activity. It
is associated with diffuse RLE numbness and subjective weakness.
The patient states that at the time of symptom onset, she went
to a plain clinic, where she was prescribed fentanyl patch w/o
relief. She then presented to the ED 10 days ago where she was
found to have an L3 compression fracture. She was discharged on
oral Dilaudid 2mg prn. She states that her pain has conitnued to
increase since that time. She denies associated fevers, chills,
weight loss, urinary incontinence. She presented to clinic today
for further evaluation and was referred to the ED.
.
Initial vitals in ED triage were 97 82 140/61 16 96%.
.
She was admitted to medicine for further management of back
pain.
On reaching the floor, she reported continued back pain and
discomfort. Her VS on arrival to the floor were: 97.8, 147/70,
86, 24, 94RA.
.
<B>REVIEW OF SYSTEMS:<B>
+ Per HPI
+ shortness of breath- the patient reports that this is her
baseline and has not increased recently.
+ cough- patient states chronic cough productive of clear to
yellow sputum is unchanged from baseline.
+ constipation- has not had bowel movement in three days despite
use of milk of magnesia, Senokot, and MiraLax.
+ orthopnea- patient reports sleeps on five pillows for the past
4 weeks has has increasing dyspnea in recumbent position.
+ ___ edema increasing over the past few weeks
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, chest pain, pressure, tightness, or
palpitations. Denies nausea, vomiting, diarrhea, or abdominal
pain. No dysuria or hematuria.
Past Medical History:
1. Hypertension.
2. Chronic obstructive pulmonary disease.
3. Type 2 diabetes mellitus with neuropathy
4. History of lung cancer.
5. Chronic back pain, R sciatica
6. History of anemia.
7. Hyperlipidemia.
8. Venous insufficiency with venous stasis ulcers.
9. Coronary artery disease s/p stent
___. Pulmonary hypertension.
11. gout
12. osteoarthritis
13. chronic diastolic heart failure
Social History:
___
Family History:
Brother- pancreatic CA
Mother- DM2
Sister- ___
Physical Exam:
ADMISSION
VS: 97 82 140/61 16 96%.
Gen: elderly female in NAD. Oriented x3.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. MMM, OP benign.
Neck: Supple, full ROM. no JVD. No cervical lymphadenopathy.
CV: RRR with normal S1, S2. No M/R/G. No S3 or S4.
Chest: Respiration unlabored, no accessory muscle use. some mild
expiratory wheezes, rhoncherous BS left mid lung fields
Abd: Normal bowel sounds. Soft, NT, ND. No organomegaly or
masses.
Ext: Digital cap refill <2 sec. 2+ peripheral edema ___ ___
Distal pulses not palpable due to edema, normal capillary refill
Skin: hyperpigmentation ___ lower legs, right shin: 2x3cm
erythematous area with bullae
Neuro: CN II-XII grossly intact. Strength ___ in all
extremities.
.
DISCHARGE
Gen: elderly female in NAD. Oriented x3.
HEENT: MMM
CV: RRR with normal S1, S2. No M/R/G. No S3 or S4.
Chest: Respiration unlabored, no accessory muscle use. Clear to
auscultation bilaterally with no w/r/r
Abd: Normal bowel sounds. Soft, NT, ND. No organomegaly or
masses.
Ext: Digital cap refill <2 sec. 2+ peripheral edema ___
(minimally improved)
Skin: hyperpigmentation ___ lower legs, right shin: 3x5cm bullae
w/ clear fluid; no significant surrounding erythema or warmth
Pertinent Results:
ADMISSION
___ 02:00PM BLOOD WBC-10.4 RBC-3.71* Hgb-10.9* Hct-35.4*
MCV-96 MCH-29.5 MCHC-30.9* RDW-15.7* Plt ___
___ 02:00PM BLOOD Neuts-86.0* Lymphs-9.7* Monos-2.5 Eos-1.4
Baso-0.4
___ 02:00PM BLOOD Glucose-297* UreaN-36* Creat-1.1 Na-139
K-4.2 Cl-99 HCO3-27 AnGap-17
___ 06:00AM BLOOD Calcium-8.5 Phos-4.2 Mg-2.2
.
DISCHARGE
___ 05:45AM BLOOD WBC-7.9 RBC-3.44* Hgb-10.2* Hct-32.2*
MCV-94 MCH-29.6 MCHC-31.5 RDW-16.0* Plt ___
___ 05:45AM BLOOD Glucose-170* UreaN-40* Creat-1.0 Na-140
K-4.0 Cl-98 HCO3-29 AnGap-17
___ 05:45AM BLOOD Albumin-3.6 Calcium-8.2* Phos-5.2* Mg-1.9
.
PERTINENT
___ 02:19PM BLOOD Lactate-3.2*
___ 01:40PM BLOOD Lactate-3.5*
___ 07:03AM BLOOD Lactate-2.0
___ 02:00PM BLOOD proBNP-___*
___ 2:00 pm BLOOD CULTURE Site: ARM
Blood Culture, Routine (Pending):
.
EKGs
Sinus rhythm with atrial premature beats. Non-specific lateral
ST-T wave
changes. Low QRS voltages in precordial leads. Compared to
tracing #2 sinus rhythm has been restored. Other findings are
similar to tracing #1.
TRACING #3
Intervals Axes
Rate PR QRS QT/QTc P QRS T
83 138 94 ___ 98
.
Narrow complex tachycardia suggestive of re-entrant rhythm. An
atrial
tachycardia cannot be excluded on the basis of this tracing.
Diffuse ST-T wave changes are likely due to repolarization
abnormalities. Compared to the tracing #1 the rhythm has changed
to a likely re-entrant rhythm and heart rate is increased.
Non-specific ST-T wave changes likely reflecting the heart rate
and/or retrograde P waves.
TRACING #2
Intervals Axes
Rate PR QRS QT/QTc P QRS T
152 0 80 288/449 0 41 -105
.
Sinus rhythm. Non-specific inferior and lateral T wave changes.
Low QRS voltage in precordial leads. Compared to the previous
tracing of ___ low QRS voltages are seen in the precordial
leads. Other findings are similar.
TRACING #1
Intervals Axes
Rate PR QRS QT/QTc P QRS T
81 122 82 ___ 100
.
CXR ___
CHEST, PA AND LATERAL: Again seen are changes of right upper
lobectomy with apical pleural thickening and elevation of the
right hemidiaphragm. There is a chronic, minimally displaced rib
fracture of the lateral right sixth rib, with adjacent pleural
thickening. No pneumothorax, pleural effusion, or focal
consolidation. On the left, there is mild lower lobe
atelectasis. Heart is normal in size, and the aorta is markedly
tortuous and calcified.
IMPRESSION:
1. No acute cardiopulmonary process.
2. Right upper lobectomy changes.
.
MRI ___
FINDINGS: Since the prior study, L3 is showing mildy progressive
loss of
height. There is also increasing dessication and height loss of
the L2/L3
intervertebral disc with more pronounced retrolisthesis of L2 on
L3 and more extensive ___ type 1 endplate changes.
For the remainder of the lumbar spine, bone marrow signal and
dorsal alignment are grossly preserved. Previously reported
multilevel degenerative changes are likewise stable and detailed
below:
At level L2/L3, the combination of disc bulging, facet joint
arthropathy and thickening of the ligamentum flavum is
associated with mild-to-moderate narrowing of the spinal canal.
There is also mild bilateral narrowing of the lateral recess as
well as moderate stenosis of the bilateral neural foramina due
to facet joint arthropathy.
At level L3/L4, the combination of broad-based disc bulge, facet
joint
arthropathy and thickening of the flavum ligament is causing
moderate-to-severe spinal canal stenosis. The bilateral neural
foramina are narrowed by facet joint arthropathy, mild on the
right and moderate on the left.
At level L4/L5, left eccentric disc bulge, facet joint
arthropathy and
thickening of the ligamentum flavum combine to cause mild spinal
canal
narrowing. The left neural foramen is mildly narrowed by facet
joint
osteophytes and disc material extending into the foramen.
At level L5/S1, there is bilateral narrowing of the neural
foramina due to
facet joint arthropathy, severe on the right and moderate on the
left. The
conus terminates at L1/L2 level. The cauda redemonstrate
clumping and
crowding, which is likely due to multilevel spinal canal
stenosis.
IMPRESSION:
1. Mildly progressive collapse of L3 vertebral body with
increasing
spondylosis and endplate erosion at the L2/L3 segment. No
evidence of acute
abnormality such as spondylodiskitis.
2. Otherwise, short-term stability of multilevel, multifactorial
degenerative
changes as detailed above.
Brief Hospital Course:
The patient is an ___ year old woman with h/o Lung cancer s/p RU
lobectomy,COPD, Gout, HTN, DM, CAD, HLP, and recently diagnosed
L3 compression fracture who was admitted for further management
of back pain.
#Back Pain, DJD, L3 compression fracture
The patient presented with a history of severe back pain
refractory to increasing doses of opioids. Given the patient's
previous history of malignancy, this was concerning for possible
metastatic disease. An MRI as performed which showed mildly
progressive collapse of L3 vertebral body with increasing
spondylosis and endplate erosion at the L2/L3 segment. No
evidence of acute abnormality such as spondylodiskitis. No
infiltrative bone process was noted. The patient was evaluated
by Orthopedic surgery who felt that no acute intervention was
necessary given that the patient was stable and ambulatory. No
activity limitations or back brace was recommended. The patient
will follow up with them in the outpatient setting. The patient
was started on calcium and vitamin D for bone health. It is
unclear whether she had been evaluated or treated for
osteoporosis/osteopenia in the past.
The patient's pain improved with increased dose of fentanyl. She
was discharged on a regimen consisting of Fentanyl patch for
basal pain, short acting hydromorphone, and standing tylenol.
While she did report modest improvement with this regimen,
further adjustments will have to be made in the outpatient
setting.
.
# COPD
While the patient appeared significantly dyspneic at the time of
admission, she repeatedly denied increased shortness of breath,
cough or sputum production. She was noted to have some slight
wheezes on exam. She was treated with ipratropium and albuterol
nebulizer treatments. She improved dramatically prior to
discharge.
.
# Chronic diastolic heart failure w/ EF 70 in ___:
The patient seemed dyspneic at presentation and reported
orthopnea and exertional dyspnea. While she had no significant
crackles on exam, she did have increasing ___ edema and mildly
elevated BNP compared to most recent value. Her presentation
seemed suggestive of a mild CHF exacerbation. She was given one
extra dose of torsemide on HD 2 with mild improvement in ___
edema and respiratory symptoms.
.
# GOUT
No acute flare throughout hospitalization. She was continued on
allopurinol and prednisone. She will follow up rheumatology upon
discharge.
.
# Venous stasis dermatitis with RLE blister
Patient RLE not appear particularly concerning for cellulitis at
this time.
-continue home diuretics for now
.
# constipation
Likely secondary to recent opioid use for pain. The patient was
given an aggressive bowel regimen with complete resolution. She
was discharged on senna, miralax, colace, and lactulose.
.
# Hypertension:
Continued on home regimen.
.
# Hyperlipidemia:
Patient was Continued on home statin.
.
# Diabetes, type 2 uncontrolled:
A1c ___ was 7.5 on oral hypoglycemics. Patient was found to
have significantly elevated BG likely secondary to recent
steroid use. No changes were made to home regimen. Should be
followed up in outpatient setting.
Medications on Admission:
ALLOPURINOL - 100 mg Tablet - 2 Tablet(s) by mouth once a day
FENTANYL - 12 mcg/hour Patch 72 hr - apply one patch Change
every
72 hours
FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 500 mcg-50 mcg/Dose
Disk
with Device - 1 inhalation po twice a day
GLIPIZIDE - 10 mg Tablet - 1 Tablet(s) by mouth twice a day
HYDROMORPHONE - 2 mg Tablet - 1 Tablet(s) by mouth tid prn
IPRATROPIUM-ALBUTEROL - 0.5 mg-3 mg (2.5 mg base)/3 mL Solution
for Nebulization - 1 inhalation po four times a day as needed
for
shortness of breath use as directed up to four times a day
IPRATROPIUM-ALBUTEROL [COMBIVENT] - 18 mcg-103 mcg (90
mcg)/Actuation Aerosol - 2 puff(s) ih four times a day
LIDOCAINE [LIDODERM] - 5 % (700 mg/patch) Adhesive Patch,
Medicated - apply as directed 12 hours on, 12 hours off
LOSARTAN - 25 mg Tablet - 1 Tablet(s) by mouth daily
METFORMIN - 1,000 mg Tablet - 1 Tablet(s) by mouth twice a day
METOPROLOL SUCCINATE - 25 mg Tablet Extended Release 24 hr - 1
Tablet(s) by mouth once a day
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s)
by mouth once a day
PREDNISONE - 2.5 mg Tablet - 1 Tablet(s) by mouth once a day -
No
Substitution
SIMVASTATIN - 80 mg Tablet - 1 Tablet(s) by mouth daily at
bedtime
TORSEMIDE - 20 mg Tablet - 2 Tablet(s) by mouth twice a day
Medications - OTC
ASPIRIN - (Prescribed by Other Provider) - 325 mg Tablet - 1
Tablet(s) by mouth once a day
BLOOD SUGAR DIAGNOSTIC [FREESTYLE LITE STRIPS] - Strip - Use
to
test glucose 4 times daily as needed
FERROUS SULFATE - (Prescribed by Other Provider) - Dosage
uncertain
IRON ASPGL & PS CM-VIT C-CA-SA [FERREX ___ PLUS] - 150 mg-50
mg-50 mg Capsule - 1 Capsule(s) by mouth once a day
SENNOSIDES [SENNA] - (Prescribed by Other Provider) - Dosage
uncertain
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. allopurinol ___ mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours): (last changed on ___
___.
Disp:*10 Patch 72 hr(s)* Refills:*0*
4. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) inhalation Inhalation BID (2 times a day).
5. glipizide 10 mg Tablet Sig: One (1) Tablet PO twice a day.
6. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
7. ipratropium-albuterol 0.5 mg-3 mg(2.5 mg base)/3 mL Solution
for Nebulization Sig: One (1) inhalation Inhalation every four
(4) hours as needed for shortness of breath or wheezing.
8. ipratropium-albuterol ___ mcg/Actuation Aerosol Sig: Two
(2) puffs Inhalation four times a day.
9. Lidoderm 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: as
directed Topical once a day: apply as directed 12 hours on, 12
hours off
.
10. losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day.
12. metoprolol succinate 25 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
13. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
14. prednisone 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. simvastatin 40 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)): total 80mg daily.
16. torsemide 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
17. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
18. Ferrex ___ Plus 150-50-50 mg Capsule Sig: One (1) Capsule PO
once a day.
19. polyethylene glycol 3350 17 gram/dose Powder Sig: Seventeen
(17) gram PO DAILY (Daily) as needed for constipation: Do not
take if you have if you have loose stools.
Disp:*qs gram* Refills:*2*
20. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
Disp:*240 Tablet(s)* Refills:*2*
21. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
22. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO BID (2 times a day).
Disp:*60 Tablet, Chewable(s)* Refills:*2*
23. senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis: Back pain, L3 compression fracture
Secondary Diagnosis: Chronic diastolic heart failure, chronic
obstructive pulmonary disease, constipation, diabetes mellitus
type 2
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 severe back pain. We took
an MRI picture of your back, which showed a compression
fracture. It also showed some arthritis where your bones may be
pressing on your nerves and causing some pain and weakness in
your legs. At this time, the spine doctors ___ not think there is
a need for surgery or any procedure because you are stable and
able to walk.
For your pain, we increased the dose of your Fentanyl patch and
started you on tylenol. Please take these medications regularly.
You can also continue to take the Dilaudid up to three times a
day if you continue to have pain. It may take some time to get
your pain regimen just right, but it is important to follow up
with your doctors after leaving the hospital so we can continue
to help you.
You were also feeling a little short of breath when you arrived.
This was probably because you had some extra fluid from your
heart failure and because of your lung disease. We gave you some
extra diuretic and took of some fluid, and we also treated you
with nebulizers. You felt better after this.
You were also very constipated when you arrived. This was
probably caused by your pain medications. We gave you some
medications to help with this, and you had a bowel movement. It
is important to continue taking these medications (colace,
senna, miralax)while you are using fentanyl and hydromorphone.
MEDICATION CHANGES
START docusate (colace) [for constipation]
START polyethylene glycol (miralax) [for constipation]
START acetaminophen (tylenol) [for pain]
START cholecalciferol (vitamin D) [for stronger bones]
START calcium carbonate [for stronger bones]
INCREASE senna [for constipation]
INCREASE fentanyl [for pain]
It was a pleasure taking care of you.
Followup Instructions:
___
|
19589138-DS-29
| 19,589,138 | 28,797,636 |
DS
| 29 |
2160-10-11 00:00:00
|
2160-10-11 14:50:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Gabapentin
Attending: ___.
Chief Complaint:
numbness, pain, weakness in left arm
Major Surgical or Invasive Procedure:
___: Left brachial artery embolectomy
History of Present Illness:
Patient is a ___ year old female with extensive PMH who
presented to the ED with 4 days of pain, numbness and
progressively increasing weakness in the left upper extremity,
which is her dominant arm. The arm has been cool from just below
the elbow distally. The numbness extends from just below the
elbow to the finger tips. Patient has never had a similar
episode
before. She is currently on ASA. She has a h/o coronary artery
stent for which she is no longer anticoagulated. She does not
have renal dysfunction. She has no history of embolism or
thrombus formation.
Past Medical History:
1. Hypertension.
2. Chronic obstructive pulmonary disease.
3. Type 2 diabetes mellitus with neuropathy - non compliant
with treatment. Refuses insulin
4. History of lung cancer.
5. Chronic back pain, R sciatica
6. History of anemia.
7. Hyperlipidemia.
8. Venous insufficiency with venous stasis ulcers.
9. Coronary artery disease s/p stent
___. Pulmonary hypertension.
11. gout
12. osteoarthritis
13. chronic diastolic heart failure
Social History:
___
Family History:
Brother- pancreatic CA
Mother- DM2
Sister- ___
Physical Exam:
98.5 88 139/60 94
Gen: Obese, ___ woman in ___. Alert and oriented x3
CV: RRR
Lungs: CTA bilat
Abd: Obese, soft no m/t/o
Extremities: Left arm, slightly edematous with ecchymosis @
brachial incision. Incision c/d/i. ___ with edema bilat. L shin
ulcer.
Pulses: L radial pulse palpable
Pertinent Results:
TTE (Complete) Done ___ at 2:52:08 ___
The left atrium is mildly dilated. The left atrium is elongated.
No atrial septal defect or patent foramen ovale is seen by 2D,
color Doppler or saline contrast with maneuvers. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. Due to suboptimal technical quality, a
focal wall motion abnormality cannot be fully excluded. Overall
left ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
number of aortic valve leaflets cannot be determined. There is
no aortic valve stenosis. No aortic regurgitation is seen. There
is moderate pulmonary artery systolic hypertension. There is an
anterior space which most likely represents a prominent fat pad.
IMPRESSION: poor technical quality due to patient's body
habitus. With this limitation, no cardiac source of embolism was
identified. Left ventricular function is probably normal, a
focal wall motion abnormality cannot be fully excluded. No
pathologic valvular abnormality seen. Moderate pulmonary artery
systolic hypertension.
CTA UPPER EXT W&W/O C & RECONS BILAT Study Date of ___ 4:54
___
1. Near occlusion of the left brachial artery at the level of
the distal
humerus. Distally, the brachial bifurcation and radial and ulnar
arteries are unremarkable.
2. Medialization of bilateral common carotids arteries with very
tight left common carotid artery stenosis.
___ Carotid Series:
Left Carotid tortous, 80-99% stenosis
Right 40-59% stenosis
COAGS:
___ 09:00AM BLOOD ___
___ 07:20AM BLOOD ___ PTT-29.7 ___
___ 01:20PM BLOOD ___ PTT-28.4 ___
Discharge Labs:
___ 07:20AM BLOOD WBC-9.6 RBC-3.32* Hgb-10.1* Hct-30.8*
MCV-93 MCH-30.2 MCHC-32.6 RDW-15.8* Plt ___
___ 09:00AM BLOOD Glucose-202* UreaN-39* Creat-1.2* Na-141
K-4.1 Cl-101 HCO3-28 AnGap-16
___ 09:00AM BLOOD Calcium-8.8 Phos-3.9 Mg-2.3
Other Pertinent labs:
___ 03:59AM BLOOD %HbA1c-8.3* eAG-192*
___ 02:55PM URINE Color-Straw Appear-Clear Sp ___
___ 02:55PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
Brief Hospital Course:
Ms. ___ was seen in the ED, started on heparin and sodium
bicarb gtts, and taken urgently from the ED to the OR where she
underwent left brachial embolectomy. Please see OMR for full
report. She tolerated the procedure well and was transfered to
the PACU for recovery. She was monitored closely and remained
hemodynamicaly stable. Her heparin gtt was held overnight. She
was transfered to the vascular floor where she continued to be
monitored closely and remained stable. Her heparin gtt was
resumed on POD 1. Her blood sugars were persistenly elevated,
and A1C was 8.3%. The ___ Diabetes team was consulted. They
recommended stopping her oral metformin d/t elevated SCr and
initiated a tight humalog sliding scale. They also discussed
diet and lifestyle changes with the patient. She told the
___ team, as well as the nursing staff and the vascular team
that she would absolutely not take insulin at home. She also was
adament that she would not change her eating habits. A TTE was
done to eval for source of emboli, no clot was found. She began
working with ___ and was found to be deconditioned and in need of
rehab after discharge. On POD 2 she was started on coumadin
5mg qhs. Her blood sugars were slightly better controlled but
she continued to eat high carb meals and snacks and refuse to
follow diabetic diet. On POD 4, her creatinine was trending
back down to baseline. She was seen by the nutritionist but
again refused diet changes. She continued to work with ___ and
was deemed stable for discharge to a rehab facility. Prior to
d/c her carotids were imaged after seeing significant L carotid
stenosis on CTA. The duplex showed 80-99% blockage of the left
carotid. She is currently asymptomatic, but should follow up
with her PCP and vascular surgery and be monitored closely. Her
PCP is quite involved in her care and will monitor her INR. At
the time of discharge the patient continues to verbalize her
understanding of need for better blood sugar control but
contniues to refuse appropriate diet and medical management.
Medications on Admission:
ALLOPURINOL - 100 mg Tablet - 2 Tablet(s) by mouth once a day
FENTANYL - 12 mcg/hour Patch 72 hr
ADVAIR DISKUS - 500 mcg-50 mcg/bid
GLIPIZIDE - 10 mg Tablet - 1 Tablet(s) by mouth twice a day
HYDROMORPHONE - 2 mg Tablet - 1 Tablet(s) by mouth tid prn
IPRATROPIUM-ALBUTEROL - 0.5 mg-3 mg (2.5 mg base)/3 mL Solution
for Nebulization - 1 inhalation po four times a day as needed
IPRATROPIUM-ALBUTEROL - 2 puff(s) ih four times a day
LIDOCAINE [LIDODERM] - 5 % (700 mg/patch) Adhesive Patch 12h on
, 12h off
LOSARTAN - 25 mg Tablet - 1 Tablet(s) by mouth daily
METFORMIN - 1,000 mg Tablet - 1 Tablet(s) by mouth twice a day
METOPROLOL SUCCINATE - 25 mg - 1 Tablet(s) by mouth once a day
OMEPRAZOLE - 20 mg Capsule 1 Capsule(s)by mouth once a day
PREDNISONE - 2.5 mg Tablet - 1 Tablet(s) by mouth once a day -
SIMVASTATIN - 80 mg Tablet - 1 Tablet(s) by mouth daily at
bedtime
TORSEMIDE - 20 mg Tablet - 2 Tablet(s) by mouth twice a day
ASPIRIN - 325 mg qday
BLOOD SUGAR DIAGNOSTIC [FREESTYLE LITE STRIPS] - Strip - Use
to test glucose 4 times daily as needed
FERROUS SULFATE IRON ASPGL & PS CM-VIT C-CA-SA [FERREX ___ PLUS]
- 150 mg-50 mg-50 mg Capsule - 1 Capsule(s) by mouth once a day
Discharge Medications:
1. allopurinol ___ mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation BID (2 times a day).
4. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours): this was a home med.
Disp:*10 Patch 72 hr(s)* Refills:*0*
7. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*10 Tablet(s)* Refills:*0*
8. losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
10. prednisone 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. torsemide 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
12. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed for sob/wheezing.
13. metoprolol succinate 25 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
14. collagenase clostridium hist. 250 unit/g Ointment Sig: One
(1) Appl Topical DAILY (Daily): to right shin ulcer.
15. lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO DAILY
(Daily) as needed for constipation.
16. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
17. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) mL
Injection TID (3 times a day).
18. glipizide 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
19. warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day: INR
goal 2.0-3.0
.
20. Humalog 100 unit/mL Solution Sig: sliding scale
Subcutaneous four times a day: see below
.
21. sliding scale
Breakfast Lunch Dinner Bedtime
Humalog Humalog Humalog Humalog
Glucose Insulin Dose
___ Proceed with hypoglycemia protocol
71-100mg/dL 0Units 0Units 0Units 0Units
101-150mg/dL 4Units 4Units 4Units 0Units
151-200mg/dL 6Units 6Units 6Units 0Units
201-250mg/dL 8Units 8Units 8Units 2Units
251-300mg/dL 10Units 10Units 10Units 4Units
301-350mg/dL 12Units 12Units 12Units 6Units
Instructons for NPO Patients: use bedtime ss when NPO
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left brachial artery embolus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Weigh yourself every morning,
call PCP/cardiologist if weight goes up more than 3 lbs.
What to expect when you go home:
1. It is normal to feel tired, this will last for ___ weeks
You should get up out of bed every day and gradually increase
your activity each day
Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have swelling of the arn you were operated
on:
Elevate your arm above the level of your heart (use ___
pillows or a recliner) every ___ hours throughout the day and at
night
3. It is normal to have a decreased appetite, your appetite will
return with time
You will probably lose your taste for food and lose some
weight
Eat small frequent meals
It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
No driving until post-op visit and you are no longer taking
pain medications
You should get up every day, get dressed and walk
You should gradually increase your activity
You may up and down stairs, go outside and/or ride in a car
No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
You may shower no direct spray on incision, let the soapy
water run over incision, rinse and pat dry
Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
Take all the medications you were taking before surgery. You
were started on several new medications here, including insulin
to help control your blood sugars and coumadin to prevent future
blood clots in your arteries
Take one full strength (325mg) enteric coated aspirin daily.
Keep your f/u appt in 2 weeks
What to report to office:
Redness that extends away from your incision
A sudden increase in pain that is not controlled with pain
medication
A sudden change in the ability to move or use your arm or the
ability to feel your arm
Temperature greater than 100.5F for 24 hours
Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions
What is warfarin?
Warfarin is the generic name for ___ (brand or trade
name).
___ belongs to a class of medications called
anticoagulants, which help prevent clots from forming in your
blood and or keep grafts open.
Why am I taking warfarin?
You are taking warfarin because you have a medical condition
that puts you at risk for forming dangerous blood clots, or to
keep open vessels that have stents and or vessels that allow
blood to flow for ischemic leg symptoms.
How do I take warfarin?
Warfarin is taken once daily at the same time every day,
preferably in the evening, with or without food.
If you miss ___ dose of warfarin, take the missed dose as soon as
possible on the same day. If you forget, do not double up the
next day! Write the day of your missed dose on your calendar and
let your health care provider know at your next visit.
Why is warfarin use monitored so carefully?
Warfarin is a medication that requires careful and frequent
monitoring to make sure that you are being adequately treated,
but not over- or under-treated. If you have too much warfarin in
your body, you may be at risk for bleeding. If you have too
little warfarin in your body, you may be at risk for forming
dangerous blood clots. Medications, food and alcohol can also
interfere with warfarin, making close monitoring even more
important.
What is INR?
INR, which stands for International Normalized Ratio, is a blood
test that helps determine the right warfarin dose for you.
The INR tells us how much warfarin is in your bloodstream and is
a measure of how fast your blood clots.
A high INR means you are more likely to bleed (your blood does
not clot very fast).
A low INR means you are more likely to form a clot (your blood
clots very fast).
All patients will have an INR goal depending on their medical
condition(s), yours is ___.
What are the possible side effects of warfarin?
The major side effect of warfarin is bleeding (especially when
your INR is too high). Here are some symptoms of bleeding to
look for and to report to your health care provider:
___ bruising or bruises that won't heal
Bleeding from your nose or gums
Unusual color of urine or stool (including dark brown urine, or
red or black/tarry stools)
What do I need to know about drug interactions with warfarin?
Many drugs can potentially interfere with warfarin and may cause
your INR to change, putting you at risk for bleeding or a clot.
These drugs include prescription medications, over-the-counter
medications (like aspirin, ibuprofen, naproxen), and dietary and
herbal supplements. They should be avoided unless otherwise
directed by health provider. You should take your Aspirin as
directed.
What role does my diet play?
The amount of vitamin K in your diet may affect your response to
warfarin. Certain foods (like green, leafy vegetables) have high
amounts of vitamin K and can decrease your INR. You do not have
to avoid foods high in vitamin K, but it is very important to
try to maintain a consistent diet every week.
What about alcohol?
Alcohol use also may affect your response to warfarin. Excessive
use can lead to a sharp rise in your INR. It is best to avoid
alcohol while you are taking warfarin.
Safety Tips
Carry a wallet ID card and/or wear an emergency alert bracelet
Tell all health care providers (physicians, nurses, pharmacists,
dentists, etc.) that you are taking warfarin, especially if you
have any planned surgeries or procedures.
Alert your health care provider if you are pregnant or become
pregnant while taking warfarin.
Plan ahead when traveling by having enough warfarin and arrange
for follow-up blood tests. It is also important to keep your
diet consistent.
Avoid any sport or activity that may result in a serious fall or
injury.
Use a soft-bristled toothbrush to protect your gums.
Use an electric razor if you are prone to cut yourself when
shaving.
Followup Instructions:
___
|
19589138-DS-30
| 19,589,138 | 22,184,569 |
DS
| 30 |
2160-12-17 00:00:00
|
2160-12-17 19:04:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Gabapentin
Attending: ___.
Chief Complaint:
Bilateral leg edema and erythema
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with past medical history notable for DMII, CAD s/p stent,
venous insufficiency with venous stasis ulcers, PAD, dCHF, COPD,
lung cancer s/p R upper lobectomy p/w two week history of
worsening BLE edema and erythema and blue discoloration of the
right foot.
She presented to ___'s office for urgent care visit 1d PTA for
symptoms of bilateral leg edema and erythema. Per PCP note, she
was started on Keflex for cellulitis for an area of concern on
the L anterior lower leg warmth and erythema about 10cm in
diameter. She has reportedly gained 1.5 pounds and not had any
increased shortness of breath over her baseline. Urgent care
physician recommended adding metolazone 2.5mg to her regimen
daily for 7 days, and she was instructed to restric Na intake.
Patient reports burning pain involving the anteromedial aspects
of bilateral sheens and the dorsum of the R foot. She denies
foot pain while sleeping. She denies improvement in pain when
dangling her feet off from the bed. She is frustrated because
she has not been able to walk due to bilateral leg pain since
yesterday. At baseline, she ambulates with a cane. Denies any
fevers or chills. She reports shorntess of breath, unchaged from
her baseline. Denies chest pain. She reports nausea. She also
complains of right hip pain, unchanged from her baseline.
Denies history of stroke/TIA.
Of note, she recently underwent L brachial embolectomy afer
presenting with LUE weakness, numbness, and impaired motor
function. She has been on coumadin and aspirin since discharge.
.
Initial VS in the ED: 98.7 95 109/35 20 97% RA.
CXR showed bibasilar atelectasis. Labs were notable for Na 132,
BUN/Creatinine 50/1.3, glucose 255, proBNP 865, WBC 11.4 (94%
PMNs), Hct 32.9. Patient was given a dose of vancomycin IV for
cellulitis. VS prior to transfer: 137/64, HR 80, T 97.4 oral,
O2 sat 97% RA, ___ pain, improved after morphine. She was
admitted to the medicine service for further evaluation and
management.
.
.
Review of systems:
(+) Per HPI
(-) Per HPI. Also denies headache, sinus tenderness, rhinorrhea
or congestion. Denied diarrhea, constipation or abdominal pain.
Past Medical History:
1. Hypertension.
2. Chronic obstructive pulmonary disease.
3. Type 2 diabetes mellitus with neuropathy - non compliant
with treatment. Refuses insulin
4. History of lung cancer s/p RUL VATS
5. Chronic back pain, R sciatica
6. History of anemia.
7. Hyperlipidemia.
8. Venous insufficiency with venous stasis ulcers.
9. Coronary artery disease s/p stenting of the right coronary
artery and the circumflex
___. Pulmonary hypertension.
11. gout
12. osteoarthritis
13. chronic diastolic heart failure
14. left brachial embolectomy ___ - started on warfarin
15. Carotid Artery Stenosis 80-99% on Left - ultrasound ___
16. cholecystectomy
Social History:
___
Family History:
Brother- pancreatic CA
Mother- DM2
Sister- ___
Physical Exam:
ADMISSION EXAM
Vitals: T: 97.8 BP: 128/58 P: 125 R: 26 O2: 95 2L ___ 262
General: Sleeping, arousable by gentle touching, alert,
interactive, laboured breathing but speaking in full sentence
HEENT: sclera anicteric, dry mucous membranes, oropharynx clear
Neck: supple, no LAD, no JVD, no carotid bruits
Lungs: coarse breath sounds bilaterally with good air movement,
no wheezing or rales, labored breathing with accessory muscle
use
CV: tachycardic but regular, normal S1 + S2, II/VI early
systolic and ___ diastolic murmur heard best at LUSB
Abdomen: bowel sounds present, obese, soft, non-tender,
non-distended
Ext:
LUE: 6cm well healed scar. Hand warm but numb to touch.
RUE: Hand warm to touch. Index finger DIP joint tender, warm,
edematous and erythematous.
BLE: 3+ pitting edema. Hyperpigmentation of venous stasis
involving the anteromedial aspect of L sheen (10x11cm) and
anteromedial aspect and surrounding the lateral and medial
maleoli of the RLE extending up to the mid-calf level on the
sheen. The majority of the dorsal aspect of the R foot
erythematous but not warm to touch with blue discoloration
involving the base of the great toe and the skin overlying all
five PIP joints. R foot numb to light touch. Light touch
sensation intact on L foot. Both feet cool to touch. No ulcers
or other open lesions.
Pulses:
Fem Pop DP ___ Rad Uln
Carot
R 1+ non-palp due to body habitus 1+ 1+ 2+ 1+ 2+
L 1+ non-palp due to body habitus 2+ 2+ 1+ 1+ 2+
Neuro: Alert and interactive, CN II-XII tested and intact. No
gross focal motor deficits. Sensation as above.
DISCHARGE EXAM
Vitals: 98 150/78 67 20 98 on 2L
General: Alert, interactive, non-laboured breathing speaking in
full sentence
HEENT: sclera anicteric, dry mucous membranes, oropharynx clear
Neck: supple, no JVD
Lungs: coarse breath sounds b/l with good air movement, no
wheeze, no crackles
CV: RRR, normal S1 + S2, II/VI early systolic and ___ diastolic
murmur heard best at ___
Abdomen: bowel sounds present, obese, soft, non-distended,
notnder, no gaurding, + BS
Ext: Multiple various sized ecchymosis patches on her four
extremities.
LUE: 6cm well healed scar over the medial aspect of the skin
over the biceps prior embolectomy incision. Hand warm but numb
to touch.
RUE: Hand warm to touch. Index finger DIP joint tender, warm,
edematous and erythematous.
BLE: ACE wrap BLE below the knees ; 3+ pitting edema on feet
(unwrapped), 1+edema b/l calves. Hyperpigmentation of venous
stasis involving the anteromedial aspect of L sheen (6x8cm) and
also involving the anteromedial aspect and the areas surrounding
the lateral and medial maleoli of the RLE extending up to the
lower ___ level on the sheen. Regressing from the marking made
in the ED ___. The majority of the dorsal aspect of the R foot
erythematous and warm to touch with blue discoloration involving
the base of the great toe and the skin overlying all five PIP
joints. The dorsolateral aspect of R foot with ecchymosis.
Purpuric lesions on the tips of the toes noted on ___ now
resolved. The R toes noticeably cooler than the foot. R foot
numb to light touch. Light touch sensation intact on L foot. No
ulcers or other open lesions. Pain illicited over the bilateral
erythematous areas lying over the tibia but improved from the
previous day.
Pulses:
Fem Pop DP ___ Rad Uln
Carot
R 1+ non-palp due to body habitus 1+ non-palp 2+ 1+
2+
L 1+ non-palp due to body habitus 2+ non-palp 1+ 1+
2+
Neuro: Alert and interactive, CN II-XII grossly intact. No gross
focal motor deficits. Sensation as above.
Pertinent Results:
___ 02:40PM WBC-11.4* RBC-3.67* HGB-11.3* HCT-32.9*
MCV-90 MCH-30.8 MCHC-34.3 RDW-16.3*
___ 02:40PM NEUTS-94.4* LYMPHS-2.5* MONOS-1.5* EOS-1.2
BASOS-0.3
___ 02:40PM ___
___ 02:40PM PLT COUNT-302
___ 11:42AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 11:42AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
___ 03:00PM URINE HOURS-RANDOM
___ 03:00PM URINE UHOLD-HOLD
___ 02:51PM LACTATE-2.3*
___ 02:40PM GLUCOSE-255* UREA N-50* CREAT-1.3*
SODIUM-132* POTASSIUM-4.4 CHLORIDE-93* TOTAL CO2-23 ANION GAP-20
___ 02:40PM proBNP-865*
___ 04:50AM BLOOD WBC-6.7 RBC-3.07* Hgb-9.3* Hct-27.8*
MCV-91 MCH-30.3 MCHC-33.4 RDW-15.9* Plt ___
___ 04:50AM BLOOD ___ PTT-86.4* ___
___ 04:50AM BLOOD Glucose-203* UreaN-30* Creat-0.8 Na-138
K-4.9 Cl-103 HCO3-24 AnGap-16
___ 09:00AM BLOOD CK-MB-5 cTropnT-0.04*
___ 08:10PM BLOOD CK-MB-5 cTropnT-0.05*
___ 07:00AM BLOOD CK-MB-3 cTropnT-0.06*
CXR ___
No significant changes from the previous CXR with bibasilar
atelectasis. No e/o volume overload.
Arterial US ___
1. Significant bilateral SFA/popliteal disease. There is also
significant
bilateral tibial disease.
CT torso ___
1. No pathologically enlarged lymph nodes in the mediastinum,
hilum, or axilla according to CT size criteria.
2. Stable herniation of the lung in the right anterior lateral
chest wall with adjacent focal soft tissue opacity likely
scarring.
3. Diverticulosis.
4. Similar moderate atherosclerotic disease of the aorta and
coronary
arteries. Similar moderate aortic and mitral valve
calcifications.
Brief Hospital Course:
___ with past medical history notable for DMII, CAD s/p stent,
venous insufficiency with venous stasis ulcers, PAD, dCHF, COPD,
lung cancer s/p R upper lobectomy p/w two week history of
worsening BLE edema and erythema.
# BLE ERYTHEMA
It was thought that erythema was mostly due to worsening chronic
lesions of venous stasis and possible cellulitis on the right
leg and foot. There were no open ulcer or drainage. Patient was
treated IV vancomycin (renally dosed) for 7days. Erythema and
pain improved rapidly. Patient remained afebrile and
hemodynamically stable throughout. She complained of bone pain
but there was low suspicion for osteomyelitis given her stable
clinical picture, bilateral distribution, and absence of
leukocytosis. See below for further discussion. Blood culture
was negative. Bilateral x-rays of the tibia/fibula were done
prior to discharge and were preliminarily negative. The final
results will need to be followed up.
.
# BLE EDEMA
It was thought that venous insufficieny and dCHF were
contributing to her baseline leg edema. Diuretics however were
initially held given her hypovolemic state and prerenal ___.
There was no evidence of pulmonary edema throughout her hostpial
stay. ACE wrap and leg elevation led to marked improvement in
edema. Torsemide and metalizone were restarted on the day of
discharge but torsemide at half the home dose. Torsemide should
be uptitrated to twice a day dosing while at the ___.
.
# INTERMITTENT CHEST TIGHTNESS/HISTORY OF CAD
She complained intermittent chest pressures at rest. Multiple
ECG were all unremarkable for ischemic process. Cardiac enzymes
x 3 were not elevated (mildly raise in the setting of ___. PPI
was added. She found it helpful. Patient was continued on
outpatient ASA, simvastatin, metaprolol.
.
# PURPURIC TOE LESIONS
On HD #2, she was noted to have small coalescing purpuric
lesions at the tips of her bilateral ___ toes. given her
history of recent brachial a thrombus, there was a concern for
possible thromboembolic events. TTE from ___ had shown no
cardiac sources. The lesions spontaneously resolved within days,
and there were no additional signs or symptoms suggestive of
thromboembolic process. See below for anticoagulation.
Anti-cardiolipin antibodies were pending at discharge and will
need to be followed-up.
# ANTICOAGULATION
Patient was initially found to be subtherapeutic on coumadin
(for history of arterial thrombus). Given her history of
arterial thrombosis without prior hypercoagulability work-up,
heme onc was consulted. Recommened CT torso was negative for any
recurrent malignancy. Anti-cardiolipin was pending. She was
started on heparin gtt for bridging. Her discharge INR was 1.8.
She was advised to continue on heparin gtt until therapeutic INR
of ___ for at least 48h.
.
# COPD/HISTORY OF LUNG CANCER S/P R LOBECTOMY
Patient was maintained on standing ipratropium/albuterol
nebulizers + PRN albuterol. She was satting in low ___ on RA -
4L. She developed worsening dyspnea on ___, which promoted
initiation of 3d course of prednisone 60mg pulsing. There were
no clincial and radiographic evidence of pulmonary edema. Her
respiratory status improved with prednisone treatment. She
should be given prednisone 40mg daily for a total of 7 days
after discharge.
.
# ___
Patient developed ___ with peak Cr 2.4 from baseline 1.0-1.2
with prerenal picture. This resovled with fluid administration.
She maintained good UOP. Diuretics and ARBs were held and
restarted at partial dose day prior to discharge.
.
# DM
Per OMR, patient had refused insulin in the past. Her glucose
remained high in 200-300s and required daily increase in insulin
regimen. This unfortunately worsened in the setting of
prednisone treatment. Glipizide was held. Patient was amenable
to getting started with insulin upon discharge. Insulin Lantus
will have to be titrated down after completion of steroids. It
may be reasonable to have discussion with primary care doctor,
___, and patient's family regaring suitability of insulin at
home.
.
# ANEMIA
Normocytic. It remained stbale from her baseline. Patient was
advised to folow up with PCP.
'
# PAD
Mild-mod peripheral PAD. ABIs were 0.5's. She had palpable DP's
and showed no evidence of critical limb ischemia.
.
# Carotid stenosis
80-99% stenosis of her left carotid artery per OMR. Patient
remained aymptomatic.
.
# Depression/anxiety
Patient was continued on outpatient zoloft.
.
# Chronic back pain
It remained stable with fentanyl patch.
.
# HTN
Losartan, torsemide, and metolazone were initially held given
her hypovolemic state and ___. They were restarted close to
discharge. BP was stable.
# TRANSITIONAL ISSUES
- completion of heparin bridge: need to have therapeutic INR ___
for at least 48h before discontinuing heparin. Needs PTT and INR
monitoring.
- follow up on anti-cardiolipin ab
- follow up on anemia
- diabetic teaching and insulin dose adjustment after steroid
ends
- continue prednisone 40mg for 7 more days from ___
- titrate up torsemide to previous home dose
- Please arrange INR check at the ___ clinic upon discharge
from rehab
- Please wrap both legs/feet with ACE wrap and have them
elevated at all time
- Please weigh her daily and restart home torsemide at twice a
day dosing, 40mg BID
Medications on Admission:
Medications: (per OMR, reviewed by PCP ___
- allopurinol ___ mg Tablet daily
- cephalexin 500 mg Capsule - QID (started ___, by pcp
___
- fentanyl 25 mcg/hour Patch 72 hr
- fluticasone-salmeterol [Advair Diskus] 500 mcg-50 mcg/Dose
Disk with Device - 1 inhalation BID
- glipizide 10 mg Tablet po BID
- hydromorphone 2 mg Tablet TID prn
- ipratropium-albuterol 0.5 mg-3 mg (2.5 mg base)/3 mL Solution
for Nebulization inhaled QID PRN shortness of breath
- ipratropium-albuterol [Combivent] 18 mcg-103 mcg (90
mcg)/Actuation Aerosol - 2 puff(s) IH QID
- lactulose 10 gram/15 mL Solution PRN
- lidocaine [Lidoderm] 5 % (700 mg/patch) Adhesive Patch,
Medicated
- losartan 25 mg Tablet daily
- metolazone 2.5 mg Tablet daily
- metoprolol succinate 25 mg Tablet Extended Release 24 hr daily
- omeprazole 20 mg Capsule, Delayed Release(E.C.) daily
- prednisone 2.5 mg Tablet daily
- sertraline 50 mg Tablet daily
- simvastatin 80 mg Tablet QHS daily
- sitagliptin [Januvia] 25 mg Tablet daily
- torsemide 20 mg x2 Tablets (total 40mg) BID
- warfarin 3 mg Tablet daily OR AS DIRECTED
- warfarin 4mg tablet daily OR AS DIRECTED
- aspirin 325 mg Tablet daily
- calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable BID
- cholecalciferol (vitamin D3) 400 unit Tablet - 2 tabs daily
- cyanocobalamin (vitamin B-12) - 1,000 mcg Tablet
- ferrous sulfate
- sennosides [senna] PRN
Discharge Medications:
1. prednisone 20 mg Tablet Sig: Two (2) Tablet PO once a day for
7 days.
2. allopurinol ___ mg Tablet Sig: One (1) Tablet PO once a day.
3. fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
4. Advair Diskus 500-50 mcg/dose Disk with Device Sig: One (1)
Inhalation twice a day.
5. hydromorphone 2 mg Tablet Sig: Two (2) Tablet PO three times
a day as needed for pain.
6. ipratropium-albuterol 0.5 mg-3 mg(2.5 mg base)/3 mL Solution
for Nebulization Sig: One (1) Inhalation four times a day as
needed for shortness of breath or wheezing.
7. Combivent ___ mcg/actuation Aerosol Sig: Two (2)
Inhalation four times a day.
8. lactulose 10 gram/15 mL (15 mL) Solution Sig: One (1) PO
once a day as needed for constipation.
9. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical once a day.
10. losartan 25 mg Tablet Sig: One (1) Tablet PO once a day.
11. metolazone 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. metoprolol succinate 25 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
13. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
14. prednisone 2.5 mg Tablet Sig: One (1) Tablet PO once a day:
Please DO NOT take this until ___. Then take 1 tablet daily.
15. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. simvastatin 40 mg Tablet Sig: Two (2) Tablet PO at bedtime.
17. torsemide 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
18. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
___.
19. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
20. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO BID (2 times a day).
21. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
22. cyanocobalamin (vitamin B-12) 1,000 mcg Tablet Sig: One (1)
Tablet PO once a day.
23. ferrous sulfate 27 mg iron Tablet Sig: One (1) Tablet PO
once a day.
24. Senna Laxative 8.6 mg Tablet Sig: One (1) Tablet PO once a
day as needed for constipation.
25. Lantus 100 unit/mL Solution Sig: 0.25 Subcutaneous at
bedtime.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: cellulitis
COPD exacerbation
___
Secondary:
DMII
CHF
PAD
Venous insufficiency
Depression
anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to ___ for
leg redness and swelling. You were treated with intravenous
antibiotics for 7 days and your cellulitis improved. Your leg
swelling improved further with leg elevation and ACE wrap. We
held your torsemide and metalizone because you were dehydrated.
You had transient decrease in kidney function related to
dehydration. This resolved with intravenous fluids. You
complained of some chest pain. This was not related to your
heart. We think this was related to reflux, and you stopped
having symptoms after we gave you ranitidine.
You were started on intravenous heparin because your INR was
initially low on coumadin. Coumadin dose was increased as well.
You will continue with heparin treatment until your INR is ___
for at least 48h. Clinicians at rehab will help you with this.
You had increased difficulty breathing related to your COPD.
This improved with nebulizers and steroids which should be
continued in the ___.
Your blood sugar ranged 200-400. We adjusted your insulin dosing
daily. This was especially high when you were on high dose
steroids. You agreed to take insulin upon discharge.
You had some bone pain. X-ray was preliminary negative. Weigh
yourself every morning, call MD if weight goes up more than 3
lbs.
We made the following changes to your medications.
- Added prednisone 40mg for the next 7days (last dose ___
- Added insulin lantus 25 U bedtime, this will need to be
titreated
- discontinued prednisone 2.5mg until ___ please resume on
___
- discontinued cephalexin
- discontinued glipizide, this should be restarted if you are
not on insulin at discharge from the ___.
- discontinued itagliptin, this should be restarted if you are
not on insulin at discharge from the ___.
Followup Instructions:
___
|
19589238-DS-14
| 19,589,238 | 23,086,534 |
DS
| 14 |
2177-09-01 00:00:00
|
2177-09-01 16:14:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Constipation
Major Surgical or Invasive Procedure:
___ placement
History of Present Illness:
___ is a ___ with history of gastric bypass and
alcohol dependence who presents complaining of constipation x2w.
Per ED note, Patient states that she moved her bowels very
minimally on ___. Subsequent to that has not moved her
bowels. The patient has gotten subsequently more distended and
has been having diffuse abdominal pain. Otherwise no vomiting
however does have some nausea. The patient denies having any
fevers or chills. The patient went to see her hepatologist who
referred her here for admission for consideration for feeding
tube as well as further work-up for constipation abdominal pain.
Per referral from hepatology, she has a history of painless
jaundice that did not improve with ERCP, likely secondary to
delayed presentation from alcoholic hepatitis. They recommended
admission for feeding tube placement and consideration for liver
transplant evaluation.
Recent admission ___ when she presented with painless
jaundice and obstructive transaminitis. MRCP showed
choledocholithiasis and possible stricture. She underwent ERCP
on
___ with placement of axios stent and sphincterotomy with
sludge
and stone fragment removal but no gallstones and no stricture
seen. She had persistent hyperbilirubinemia despite the
intervention, so hepatology was consulted for consideration of
other etiologies. Liver biopsy ___ showed toxic-metabolic injury
and severe steatosis consistent with injury likely from alcohol
use. This raised concern for alcoholic hepatitis, MDF <32,
discharged with outpatient liver f/u.
In the ED initial vitals:
Pain ___, T 96.2, HR 100, BP 119/78, RR 18, O2 98% RA
- Exam notable for: not noted
- Labs notable for:
CBC: WBC 13, Hb 9.4, Plt 328
Chem7: Na 132, Cr 0.5, K 4.0
LFTs: AST 241, ALT 36, Alk phos 271, T bili 13.8
Coags: INR 1.6
- Imaging notable for:
CT A/P with contrast
1. Enlarged, markedly heterogeneous liver which could be due to
underlying liver disease, hepatic congestion, underlying hepatic
steatosis. Patent main portal vein and right and left portal
vein
branches. Hepatic veins appear patent.
2. Likely sequela of portal hypertension including splenomegaly
and ascites.
3. No evidence of bowel obstruction.
4. Status post cholecystectomy. Status post gastric bypass
surgery.
- Consults: none
- Patient was given:
___ 19:32IVFNS 1000 mL
___ 20:07IVHYDROmorphone (Dilaudid) 1 mg
On arrival to the floor, patient reports she has had abdominal
discomfort every since her procedures last admission, but that
it
has been mild and tolerable. She has not had a BM since ___
(just
some intermittent "liquid" or "small bits"). She thought she was
constipated and took miralax, and then Mg citrate this past
weekend, which caused abdominal cramping but no bowel movements.
She also gained 10 pounds in the past two weeks and she now
thinks this is accumulation of fluid in her belly as she feels
very bloated and has had difficulty eating. She has been
drinking
a lot, ___ "gallons" of water per day because she wanted to
"flush her system of liver toxins."
She denies fevers, chills, cough, diarrhea, dysuria.
She reports her liver doctor advised she get a feeding tube,
which she is prepared to get and keep for several months. She
says she very much wants to get better.
Past Medical History:
- Hyperglycemia in the setting of steroids
- Panic Disorder
- Prior lumbar fusion surgery with repeat surgery
- Sinus surgeries
- Asthma
- CCY
- recurrent EtOH pancreatitis
- ___ gastric bypass ___
Social History:
___
Family History:
Mother passed away from complications with
emphysema/COPD/tobacco
Father passed away from complications with CHF. CAD/CABG at ___
Sister needed a cholecystectomy for gallstones
No known family history of GI malignancies or
hypertriglyceridemia
Physical Exam:
ADMISSION EXAM
===================
Gen: appears jaundiced, comfortable, sitting up in bed
CV: RRR, normal s1/s2, no murmurs
Pulm: clear to auscultation bilaterally
GI: large and distended, soft, mildly tender to palpation in
RUQ,
palpable liver
Ext: warm, well perfused, no edema, red/green tattoo on LLE
Neuro: A&Ox3, no asterixis
DISCHARGE EXAM
===================
24 HR Data (last updated ___ @ 1156)
Temp: 97.8 (Tm 98.4), BP: 109/75 (108-112/71-80), HR: 97
(80-97), RR: 18, O2 sat: 97% (97-99), O2 delivery: Ra, Wt: 195.7
lb/88.77 kg
Gen: icteric, comfortable, sitting up in bed, with headphones
CV: RRR, normal s1/s2, no murmurs
Pulm: clear to auscultation bilaterally
GI: large and distended, soft, non tender abdomen
Ext: warm, well perfused, some diffuse edema b/l lower
extremities to knees, red/green tattoo on LLE
Neuro: A&Ox3, no asterixis
Pertinent Results:
ADMISSION LABS
==================
___ 04:25PM BLOOD WBC-13.0* RBC-3.16* Hgb-9.4* Hct-30.8*
MCV-98 MCH-29.7 MCHC-30.5* RDW-16.0* RDWSD-57.7* Plt ___
___ 04:25PM BLOOD ___ PTT-33.4 ___
___ 04:25PM BLOOD Glucose-81 UreaN-7 Creat-0.5 Na-132*
K-4.0 Cl-96 HCO3-22 AnGap-14
___ 04:25PM BLOOD ALT-36 AST-241* AlkPhos-271*
TotBili-13.8*
___ 05:49AM BLOOD HAV Ab-NEG IgM HAV-NEG
DISCHARGE LABS
===================
___ 05:22AM BLOOD WBC-10.2* RBC-2.55* Hgb-7.3* Hct-24.1*
MCV-95 MCH-28.6 MCHC-30.3* RDW-15.5 RDWSD-53.7* Plt ___
___ 04:25PM BLOOD Neuts-81.0* Lymphs-11.0* Monos-6.4
Eos-0.4* Baso-0.4 Im ___ AbsNeut-10.56* AbsLymp-1.43
AbsMono-0.83* AbsEos-0.05 AbsBaso-0.05
___ 05:22AM BLOOD Plt ___
___ 05:22AM BLOOD Glucose-136* UreaN-10 Creat-0.4 Na-134*
K-3.7 Cl-99 HCO3-23 AnGap-12
___ 05:22AM BLOOD ALT-44* AST-273* AlkPhos-341*
TotBili-5.3*
___ 05:22AM BLOOD Calcium-8.2* Phos-3.9 Mg-1.6
___ 05:49AM BLOOD HAV Ab-NEG IgM HAV-NEG
___ 06:20AM BLOOD %HbA1c-4.4 eAG-80
RELEVANT STUDIES
==================
___ CT ABD/PELVIS W/ CONTRAST:
1. Enlarged, markedly heterogeneous liver which could be due to
underlying
liver disease, hepatic congestion, underlying hepatic steatosis.
Patent main portal vein and right and left portal vein
branches. Hepatic veins appear patent.
2. Likely sequela of portal hypertension including splenomegaly
and ascites.
3. No evidence of bowel obstruction.
4. Status post cholecystectomy. Status post gastric bypass
surgery.
MICROBIOLOGY
===================
__________________________________________________________
___ 12:48 pm PERITONEAL FLUID PERITONEAL FLUID.
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
__________________________________________________________
___ 11:26 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 11:15 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
Brief Hospital Course:
___ woman with ___ RNY gastric bypass, alcohol use
disorder who was admitted for severe alcoholic hepatitis.
Infectious work-up was negative and tube feeds were started.
Bilirubin rapidly improved suggesting ongoing alcohol use
predating admission. Steroids were deferred given improvement
using tube feeds.
TRANSITIONAL ISSUES
===================
[] Patient will need stent removal with EGD (with Dr. ___
one month post-ERCP (end of ___.
[] Patient will need the second dose of her HAV vaccine in 6
months (___).
[] She could work with her nutrition specialists to increase her
tube feed rate to the following cycling options: Osmolite 1.5 at
90cc/hr for 20 hours or Osmolite 1.5 at 110cc/hr for 16 hours.
Currently, she is tolerating Osmolite 80cc/hr for 22 hours.
[] Started on Lasix 20 mg PO daily, Spironolactone 100 mg PO
daily this admission.
ACTIVE ISSUES
=============
# Alcoholic Hepatitis
She was recently admitted with painless jaundice and
transaminitis concerning for obstruction. She had MRCP and ERCP
during that admission with sphincterotomy and axios stent
placed. Liver biopsy showed severe steatosis. She was admitted
from Liver Clinic given concern for bowel obstruction as she
endorsed no bowel movements in ___/P ruled
this out. She had severe alcoholic hepatitis and was started on
tube feeds. Bilirubin rapidly improved suggesting ongoing
alcohol use predating admission. Steroids were deferred given
improvement. She will be discharged with tube feeds and
Hepatology follow-up. Counseled patient to avoid alcohol moving
forward given the risk for ongoing liver injury. Patient voiced
understanding.
# Constipation
Patient presented with unclear history of 2 weeks of
intermittent
constipation with mild relief from Miralax and Mg Citrate. CT
A/P
showed no evidence of obstruction. Abdominal distention improved
post 1L tap ___ and numerous bowel movements with an
aggressive bowel regimen with senna, Colace, and miralax. In
addition, abdominal distension was well controlled with
simethicone for gas relief.
# Anemia
Iron studies during last admission consistent with borderline
iron deficiency anemia, no evidence of chronic inflammation
given
normal ferritin.
CHRONIC ISSUES
==============
# Panic disorder and Anxiety - Continued on home QHS Ativan PRN
and continued home buspirone 5mg TID
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Multivitamins W/minerals Chewable 1 TAB PO DAILY
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN dyspnea
3. BusPIRone 5 mg PO TID
4. Cetirizine 10 mg PO DAILY
5. FoLIC Acid 1 mg PO DAILY
6. LORazepam 1 mg PO QHS:PRN insomnia
7. LORazepam 1 mg PO DAILY:PRN anxiety or insomnia
8. Montelukast 10 mg PO DAILY
9. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
10. Thiamine 100 mg PO DAILY
Discharge Medications:
1. Chloraseptic Throat Spray 1 SPRY PO Q4H:PRN Throat
irritation
RX *phenol [Throat Spray] 1.4 % Spray in mouth every four (4)
hours Disp #*1 Spray Refills:*0
2. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 spr by mouth once a day Disp #*30 Tablet
Refills:*0
3. Multivitamins 2 TAB PO DAILY
RX *multivitamin 1 capsule(s) by mouth once a day Disp #*30
Capsule Refills:*0
4. Simethicone 40-80 mg PO QID:PRN bloating, gas
RX *simethicone 80 mg 80 mg by mouth four times a day Disp #*120
Tablet Refills:*0
5. Spironolactone 100 mg PO DAILY
RX *spironolactone 100 mg 1 tablet(s) by mouth once a day Disp
#*30 Tablet Refills:*0
6. Albuterol Inhaler 2 PUFF IH Q4H:PRN dyspnea
7. BusPIRone 5 mg PO TID
8. Cetirizine 10 mg PO DAILY
9. FoLIC Acid 1 mg PO DAILY
10. LORazepam 1 mg PO QHS:PRN insomnia
11. LORazepam 1 mg PO DAILY:PRN anxiety or insomnia
12. Montelukast 10 mg PO DAILY
13. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
14. Thiamine 100 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES
====================
Severe alcoholic hepatitis
Alcohol use disorder
Malnutrition
SECONDARY DIAGNOSES
======================
Gastric Bypass
Panic Disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___.
Why was I admitted?
- You were admitted for alcoholic hepatitis.
What was done for me while I was admitted?
- Your liver function tests were monitored closely.
- You had a feeding tube placed and you were given tube feeds to
improve your nutrition.
What should I do when I go home?
- You should stop drinking alcohol. If you drink, this will
further damage your liver and you could die from liver failure.
- You should take all of your medications as prescribed.
- You should attend all of your follow-up appointments.
We wish you the best in the future.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19589523-DS-10
| 19,589,523 | 25,257,175 |
DS
| 10 |
2112-08-16 00:00:00
|
2112-08-16 12:07:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
BLE edema and ascites
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ EtOH abuse (15 drinks/week), psoriatic arthritis, Hx
lumpectomy (no clinical documentation available for further
details), presented with 1.5 weeks progressively worsening
peripheral edema and new onset ascites.
Pt reports normal state of health until recently. 1.5 weeks ago
noted new abdominal swelling, continuing and worsening until
present with some abdominal tightness discomfort but no n/v,
change in BM. Tolerating diet though generally has limited
appetite. Also some pedal swelling she attributed to long
standing at work; went down with elevating legs. No jaundice,
easy bleeding/bruising. No known Hx cirrhosis or liver disease.
Had a past history of heavy etoh though she now drinks
occasionally, about once weekly. Current long term smoker, ___
years.
Some recent social stressors, went through a divorce and
subsequently had to move several times. Some depression and
'PTSD' Sx per pt though not seeing any MD formally and not on
meds. Feels mood has improved with starting work again (works
___ in a bar)
In general not following up actively with PCP, doesn't have one
established at present
Labs at ___ notable for H/H of 10.4/30.8, WBC 10.9, INR 1.67, Na
127, TBili 5.9, DBili 3, AST 169 (ALT 28), ALP 189, albumin 2.3.
Neg serum tox, neg hep panel. UA pos for UTI. CT scan performed
showed liver masses concerning for metastatic disease; distended
GB and CBD with no stones; pancreatic calcifications indicative
of chronic pancreatitis (lipase WNL), ascites, splenomegaly. GI
at OS___ consulted and rec'd MRCP, liver Bx w/ transfer to ___.
In ED:
VS: afeb, HR 87, 104/62, 97% on RA
ED Exam: NAD, scleral icterus noted, distended abdomen, 1+ edema
to mid-shin
Labs: wbc 11, hb 10.4 (no prior), plt 171, Na 127, other BMP
unremarkable, AST 169, ALT 28, AP 189, Tbili 5.9, Dbili 3.0, Alb
2.3, lipase 33, Stox neg, hepatitis panel neg
- UA: 3+ bact, ___ wbc, ___ rbc, 1+ leuk, nitr+; EPI 2+
Imaging: see above; no new imaging
Received: CTX/flagyl
Consult: ERCP felt position of lesiosn not amenable to ERCP/EUS,
rec MRI and ___ consult eventually
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
- H/o EtOH abuse (15 drinks/week),
- psoriatic arthritis,
- Hx lumpectomy (no clinical documentation available for further
details)
Social History:
___
Family History:
Alcohol use disorder
Physical Exam:
Admission physical exam
========================
VITALS: Afebrile and vital signs significant for normotensive,
oxygenating well
GENERAL: Alert and in no apparent distress
EYES: +scleral icteris, 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. Trace pedal
edema
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen moderate-severely distended, not tympanic; mildly
TTP
diffusely. 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; no diffuse 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
Discharge physical exam
==========================
Patient examined on day of discharge. Abdomen is soft and
non-tender, no drainage for paracentesis site. +spider angiomas,
and +palmar erythema. No asterixis on exam.
Pertinent Results:
Admission labs
=====================
___ 06:01AM BLOOD WBC-7.6 RBC-2.79* Hgb-9.5* Hct-27.8*
MCV-100* MCH-34.1* MCHC-34.2 RDW-15.5 RDWSD-57.5* Plt ___
___ 06:01AM BLOOD Glucose-82 UreaN-11 Creat-0.7 Na-135
K-3.7 Cl-100 HCO3-24 AnGap-11
___ 06:01AM BLOOD ALT-23 AST-145* LD(LDH)-167 AlkPhos-188*
TotBili-4.1* DirBili-2.9* IndBili-1.2
___ 06:01AM BLOOD Calcium-8.1* Phos-3.1 Mg-1.8
Discharge labs
=====================
___ 05:36AM BLOOD WBC-8.9 RBC-2.55* Hgb-8.6* Hct-25.6*
MCV-100* MCH-33.7* MCHC-33.6 RDW-15.1 RDWSD-55.1* Plt ___
___ 05:36AM BLOOD Glucose-173* UreaN-6 Creat-0.6 Na-134*
K-3.3* Cl-97 HCO3-23 AnGap-14
___ 05:36AM BLOOD ALT-26 AST-97* AlkPhos-163* TotBili-3.2*
___ 06:05AM BLOOD ___ AFP-7.1
___ 06:05AM BLOOD AMA-NEGATIVE Smooth-PND
___ 06:05AM BLOOD I___-___
Imaging
=====================
TTE:
IMPRESSION: Normal study. Normal biventricular cavity sizes and
regional/global biventricular
systolic function. No valvular pathology or pathologic flow
identified. Normal estimated pulmonary
artery systolic pressure.
CXR:
Mild bibasilar atelectasis. No focal consolidation.
MRI liver:
Evidence of cirrhosis associated to expected splenomegaly and
ascites. No
focal liver lesions are identified.
Heterogeneous pancreas with mild dilation of the pancreatic
duct. As per
clinical note, calcifications are described on CT evaluation,
making these
findings consistent with chronic pancreatitis.
Brief Hospital Course:
___ yo F with h/o EtOH abuse (15 drinks/week), psoriatic
arthritis, h/o lumpectomy (no clinical documentation for further
details) who presented with 1.5 weeks of progressively worsening
peripheral edema and new onset ascites. At BID-P, a CT scan
showed heterogeneity concerning for liver lesions; she was
therefore transferred to ___. An MRI of the abdomen was
obtained, which showed no lesions, but was consistent with
cirrhosis. She had an LVP with 3.5 liters removed; no SBP with
good symptom relief. She was evaluated by hepatology; her
cirrhosis was most consistent with alcoholic, though given her
history of psoriatic arthritis, autoimmune certainly possible as
well. ___ negative; remainder of serologies are pending at
discharge. Hepatitis serologies were negative at BID-P. She was
starting on furosemide and spironalactone. Renal function was
normal. The patient strongly desired discharge so she would not
lose her job; therefore, she was discharged on these
medications. Because of low potassium (3.3) she was also sent on
a potassium supplement. She will follow up next week with
hepatology for an electrolyte check. She will also need an EGD
as an outpatient to screen for varices.
1. New cirrhosis.
2. Ascites
- follow up anti SMA and remainder of autoimmune serologies
- spironalactone 50 mg, furosemide 20 mg
- BMP to be checked within a week
3. Asymptomatic bacteuria. She recieved two doses of
ceftriaxone; because of absence of symptoms this was stopped.
> 35 minutes spent on discharge activities.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
Discharge Medications:
1. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. Potassium Chloride 40 mEq PO DAILY
RX *potassium chloride 20 mEq 2 tablets by mouth Daily in the
morning Disp #*60 Tablet Refills:*0
3. Spironolactone 50 mg PO DAILY
RX *spironolactone 50 mg 1 tablet(s) by mouth once a day Disp
#*30 Tablet Refills:*0
4. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
Discharge Disposition:
Home
Discharge Diagnosis:
cirrhosis with ascites
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
You were admitted with abdominal swelling. Initially we had
concerns that you might have masses in your liver; however, we
performed an MRI which showed no masses but new cirrhosis with
ascites (fluid). You had this fluid drained, and you were
started on diuretics (furosemide and spironalactone) to keep the
fluid off. You will have to have close follow up with a
hepatologist (liver doctor), and likely need these medications
increased.
You will also need an endoscopy to evaluate for varices (blood
vessels in your throat that can bleed). This will be scheduled
my your hepatologist.
It has been a pleasure taking care of you. Good luck!
Followup Instructions:
___
|
19589947-DS-24
| 19,589,947 | 20,073,654 |
DS
| 24 |
2179-02-01 00:00:00
|
2179-02-01 12:23:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Iodine-Iodine Containing
Attending: ___
Chief Complaint:
decreased urine output
Major Surgical or Invasive Procedure:
- ___ b/l PCN exchanged
- ___ pt tore apart his R PCN
- ___ R PCN replaced
History of Present Illness:
PRIMARY ONCOLOGIST: ___, MD
PRIMARY CARE PHYSICIAN: ___
PRIMARY DIAGNOSIS: Metastatic urothelial carcinoma
TREATMENT REGIMEN: Atezolizumab C10D1 ___
CHIEF COMPLAINT: decreased urine output
HISTORY OF PRESENT ILLNESS:
Mr. ___ is a ___ y/o man with a PMH of metastatic urothelial
carcinoma (on atezolizumab) with recent admission for
obstructive
renal failure with bilateral pyelonephritis s/p bilateral PCN
tube placement, who presented for decreased output from his
nephrostomy tubes. He was seen in clinic at ___ today,
where he was found to have a creatinine of 8.0, for which he was
___ transferred to ___. Per the call-in note, he was
also noted to have pain in the left lower back at the site of
disease progression into the psoas and T3/T4 spine, which is
potentially amenable to radiation. He was noted to be failing at
home with ___ care unable to care for him.
On arrival to the ___ ED, his initial labs were notable for T
98.2F P 65 BP 131/70 mmHg RR 16 O2 100% RA. He reported
decreased
PCN output as above as well as intermittent abdominal
discomfort.
He denied fevers, chills, pain with urination, chest pain, or
shortness of breath. On examination, the left sided nephrostomy
tube was noted to have clear yellow drainage. The right side had
decreased tea colored, malodorous urine. Labs were notable for a
UA with few bacteria 14 WBCs, moderate leukocytes, negative
nitrites. Lactate 0.9. BUN/Cr 88/8.1 (from baseline Cr of 1.3).
Na 133, HCO3 19. WBC 6.0k, H/H 9.6/28.8, PLT 235,000. INR 1.2.
TSH 1.4. LFTs within normal limits. He received 1g IV
ceftriaxone
and 4 mg IV ondansetron. ___ was consulted. The PCN tubes were
noted to be significantly pulled back. The right tube had bloody
drainage and only the tip in the calyx. Both bilateral PCN tubes
were changed. He was admitted to the OMED service.
On arrival to the floor, he reported that he has been
experiencing severe back pain, to the point where he has not
been
able to eat. He endorsed nausea. He denied fevers, chills, chest
pain, shortness of breath, abdominal pain. He denied dysuria or
hematuria, although he did have bloody PCN output on admission.
Past Medical History:
PAST ONCOLOGIC HISTORY (Per OMR, reviewed):
-___: Initial diagnosis of muscle-invasive high-grade
urothelial carcinoma of the bladder by TURBT after workup for
gross hematuria. Imaging showed no evidence of metastatic
disease.
-___: Initiated neoadjuvant ddMVAC and completed 4 cycles.
-___: Partial cystectomy. Pathology showed high-grade
urothelial carcioma with micropapillary features, T3aN0 disease
(0 of 1 lymph nodes involved), indeterminate lymphovascular
invasion. Margins were negative (distance of invasive carcinoma
from closest margin <1mm from the peripheral margin, 1.5 mm from
the deep margin).
-___ to ___: Intravesical BCG/IFN x6. Continued routine
cystoscopies.
-___: Maintenance BCG/IFN x3.
-___: MRI Abdomen/Pelvis showed 2 sub-centimeter mucosal
nodules within the bladder concerning for recurrent disease as
well as new pelvic sidewall lymphadenopathy up to 1.2 x 1.6 cm
concerning for nodal metastasis.
-___: Cystoscopy showed 1 cm left anterolateral wall solid
appearing tumor and other 2-3 mm nodular areas concerning for
tumors. Urine cytology showed atypical urothelial cells.
-___: CT Torso without contrast showed pelvic
lymphadenopathy
mildly increased compared to the MRI from ___, with the
largest lymph nodes measuring 1.6 x 1.4 cm.
-___: Biopsies of 5 areas within the bladder showed
urothelial mucosa with chronic inflammation and minimal
urothelial atypicality, likely reactive; no malignancy
identified.
-___: Biopsy of left pelvic lymph node showed high grade
urothelial carcinoma.
-___: Completion of concurrent chemoradiotherapy with weekly
Taxol and XRT 5400 cGy to bladder and pelvic lymph nodes.
-___: CT showed enlargement of metastatic left pelvic and
retroperitoneal lymph nodes.
-___: C1 Atezolizumab.
-___: CT A/P showed mild L hydroureteronephrosis and stable
wall bladder thickening. Slight enlargement of 8 mm aortocaval
node and new prominent R common iliac nodes.
-___: Stable response with 8C atezolizumab
-___: C10D1
PAST MEDICAL HISTORY (Per OMR, reviewed):
-Atrial fibrillation s/p cardioversion ___ without recurrence.
-Hypertension.
-___ prostatic hypertrophy.
-Obstructive sleep apnea - does not use CPAP.
-s/p Bilateral total hip replacements.
-s/p Appendectomy.
-s/p Sinus surgery.
Social History:
___
Family History:
Father - liver cancer, CAD died ___
Mother - skin cancer, died after broke her hip
Sister - healthy
Physical ___:
Admission PHYSICAL EXAM:
VS: T 98.2F BP 157/85 mmHg P 66 RR 18 O2 99% RA
General: Elderly man, comfortable, in NAD.
HEENT: Anicteric sclerae; EOMs intact. MMM, OP clear.
Neck: Supple.
CV: RRR, no MRGs; normal S1/S2.
Pulm: CTA b/l; no wheezes, rhonchi, or rales.
Abd: Soft, non-tender, non-distended, NABS.
GU: Bilateral PCN tubes in place, c/d/I. L PCN tube draining
clear yellow urine. R PCN tube draining bloody output. No CVA
tenderness.
Ext: Warm and well-perfused. No edema.
Neuro: A&Ox3.
Discharge Physical Exam
___ ___ Temp: 98.1 Axillary RR: 20
General: Elderly man in NAD asleep, appears comfortable,
arousable and conversant
Pertinent Results:
___ 06:50AM BLOOD WBC-5.3 RBC-3.02* Hgb-8.5* Hct-26.5*
MCV-88 MCH-28.1 MCHC-32.1 RDW-14.1 RDWSD-44.6 Plt ___
___ 06:50AM BLOOD Glucose-113* UreaN-40* Creat-3.4* Na-133*
K-4.5 Cl-96 HCO3-26 AnGap-11
___ 06:50AM BLOOD Albumin-2.7* Calcium-8.6 Phos-3.7 Mg-2.0
___ 12:03PM BLOOD TSH-1.4
___ 12:03PM BLOOD Free T4-1.0
___ 9:50 am BLOOD CULTURE 1 OF 2.
Blood Culture, Routine (Preliminary):
YEAST. BUDDING YEAST WITH PSEUDOHYPHAE.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus, yeast or other
fungi.
___ Perc Nephrostomy Exchange
FINDINGS: 1. Left antegrade nephrostogram shows the tube is
pulled back into a calyx. 2. Appropriate final position of Left
nephrostomy tube. 3. Right antegrade nephrostogram could not be
performed due to the tube being entirely clogged. The tube was
straightened with only the tip within a calyx. 4. Appropriate
final position of right nephrostomy tube with filling defects in
the collecting system, likely representing clots. IMPRESSION:
Technically successful Bilateral 8 ___ nephrostomy exchange.
Brief Hospital Course:
___ w/ Afib, HTN, BPH OSA and metastatic urothelial carcinoma on
atezolizumab (C10D1 ___ c/b oliguric obstructive renal
failure s/p b/l PCN, who is referred from clinic after found to
have acute renal failure, malfunctioning L PCN, and inadequate
pain control and failure to thrive at home. Unfortunately has
very aggressive cancer and now septic with fungemia. He has
incurable aggressive metastatic cancer and in light of his poor
prognosis, persistent delirium, and his goals of care which are
to go home, palliative care was consulted and they as well as
with Dr ___ myself had many family meetings with him and
his wife and it was clear his wishes are to focus on a quality
of life at home. He physically declined and it was unsafe to
fulfill his wishes to go home and he agreed to go to hospice.
His pain has been adequately controlled with oxycontin and prn
hydromorphone.
- cont pain control has been adequate w/ narcotics and apap
- no radiation therapy indicated at this time
# OBSTRUCTIVE RENAL FAILURE ___ CLOGGED/DISLODGED PERCUTANEOUS
NEPHROSTOMY
B/L PCN replaced. He has intermittent hematuria that is known
and he does not urinate from his penis.
- cont PCN care
# Delirium/Toxic Metabolic Encephalophy
Multifactorial- uremia, older age, multiple lines/tubes,
multiple deliriogenic meds, progressive advanced cancer, and now
fungemia.
- frequent reorientation
- delirium precautions
# PYELONEPHRITIS.
- received CTX and urine cultures NGTD
- no further antibiotics indicated
# Severe protein calorie malnutrition:
- nutrition consulted but now focus on eating for comfort
# Hypomagnesemia: repleted, no further checks
# Fungemia: discovered on ___ from ___ blood cultures growing
yeast. Due to CMO status, will not pursue treatment
CHRONIC ISSUES
# HYPERTENSION. stopped meds, no longer indicated
# ATRIAL FIBRILLATION. stopped meds, no longer indicated
# DEPRESSION. Stopped escitalopram, no longer indicated
# GERD. Continue home omeprazole 20 mg PO daily.
FEN: Regular diet as tolerated
DVT Proph: not indicated
ACCESS: PIV discontinued, no longer needed
CODE: DNR/DNI
DISPO: ___
BILLING: >30 min spent coordinating care for discharge
____________________
___, D.O.
Heme/___ Hospitalist
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY
2. Carvedilol 12.5 mg PO BID
3. Doxazosin 4 mg PO HS
4. Escitalopram Oxalate 10 mg PO DAILY
5. Gabapentin 400 mg PO BID
6. Omeprazole 20 mg PO DAILY
7. Docusate Sodium 100 mg PO BID
8. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN Pain - Moderate
9. OxyCODONE SR (OxyconTIN) 30 mg PO Q12H
10. Senna 8.6 mg PO BID:PRN constipation
11. benazepril 40 mg oral DAILY
12. Aspirin 325 mg PO DAILY
13. Flecainide Acetate 50 mg PO Q12H
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever
2. Nicotine Patch 21 mg TD DAILY
3. Polyethylene Glycol 17 g PO DAILY
4. Gabapentin 100 mg PO DAILY
5. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN Pain - Moderate
RX *hydromorphone 4 mg ___ tablet(s) by mouth q3h prn pain Disp
#*32 Tablet Refills:*0
6. Omeprazole 20 mg PO DAILY
7. OxyCODONE SR (OxyconTIN) 30 mg PO Q12H
RX *oxycodone 30 mg 1 tablet(s) by mouth q12 Disp #*4 Tablet
Refills:*0
8. Senna 8.6 mg PO BID:PRN constipation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
metastatic urothelial carcinoma
fungemia
comfort measures only
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Mr ___,
Happy birthday and wish you wellness at your new home.
Followup Instructions:
___
|
19590046-DS-2
| 19,590,046 | 26,207,472 |
DS
| 2 |
2172-05-19 00:00:00
|
2172-05-19 10:12:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
"chest opening up", "hips feeling loose", "weird feeling in my
face and body"
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ yo left-handed woman with history of lupus
complicated by aseptic meningitis and seizure as well as a C7
fracture who presented to ED for evaluation of multiple
complaints: progressive face and torso numbness with bowel and
bladder incontinence, and a constellation of other symptoms
including headaches and spasms in the back of her head, symptoms
of pain up and down her back, unsteadiness, and a feeling of
swelling in her head, opening of her chest, and collapsing of
her hips. She was accompanied by her husband who provided some
of the history.
She was last in her normal state of health several months ago.
She has had numbness in her face, progressing to her torso, more
on the left than on the right. She has not noticed the time
course over which the numbness has progressed. Over the past
several weeks, she has also started to have feelings of pain and
pressure which start at the back of her head and radiate down
her back. These are sometimes associated with muscle spasms,
and last week she had incontinence of liquid stool during one of
these episodes. She has otherwise been continent of stool,
although she has intermittent involuntary urinary incontinence.
She denies saddle anesthesia and is typically able to control
her bowel and bladder.
The symptoms are new for her. Since her diagnosis with lupus in
___, she has had flares which largely consist of neurocognitive
symptoms: "brain fog", difficulty concentrating, and seizures.
Either seizures or brain fog can be the presenting symptom.
During at least two of these episodes she has had aseptic
meningitis with sterile lymphocytic pleocytosis on LP. She has
had MRI of her brain on at least two occasions, both of which
were normal. She reportedly had an MRI of her cervical spine
several weeks ago after her most recent seizure, which she
believes was also normal. Her symptoms typically respond to
steroid burst and plaquenil.
For the past 6 months, she has had several physical complaints
which she feels have not been taken seriously by clinicians.
The started off with severe pain in her right face and jaw.
This was initially attributed to dental pain, but it did not
improve with dental intervention. She has also had headaches
and spasms in the back of her head. These are dull, bitemporal
pains which can be relieved by massaging her head. She has had
hip pain, with a feeling that her hips are "collapsing." She
was very frustrated that these symptoms were ascribed to body
dysmorphic disorder, when she believes something much more
serious is going on. In the setting of this frustration, she
took an overdose of alprazolam earlier this year; it is unclear
whether this was an intentional suicide attempt, but she was
taken to ___ where she was admitted. While she was
there, she was placed in four-point restraints for unclear
reasons and she received more doses of benzodiazepines than
usual. Since this hospitalization an episode of restraint, all
of her symptoms have become much worse. Her headaches are now
constant, her hip pain is worse, she feels like her chest is
"opening up," and her face isfalling into her throat when she is
lying down; she has feelings of unsteadiness (a mix of vertigo,
lightheadedness and unsteadiness) when standing, as well as the
symptoms described above. She does see a therapist and has an
appointment to see a psychiatrist but is still on the waiting
list.
Of note, during her most recent admission at ___
___, she was discovered to have a C7 fracture, which was
reportedly thought to have occurred at the time of her restraint
at ___ earlier this year. This did not require
any surgical intervention. She has since been to ___
Regarding her seizure history, she has had four lifetime
seizures. The semiology is odd behavior, followed a scream,
followed by loss of consciousness and tonic-clonic activity
which is often accompanied by tongue bite and urinary
incontinence, followed by a prolonged postictal phase. It is
consistent during all four seizures. She typically has no
recollection of the tonic-clonic portion of her seizure, and she
is not reactive during this time. She had her first seizure in
___ and at that time she was started on Trileptal. She
continued seizure-free on Trileptal from ___ to ___ and it was
then weaned off due to her plans to conceive. She subsequently
had 2 children. In ___ she was hospitalized for
symptoms of brain fog and difficulty concentrating at work and
found to have an abnormal LP. She was started on a steroid
taper and discharged home. She subsequently had another seizure
in ___. No antiseizure medications were started at
that time. In ___, several weeks ago she had her latest
seizure. This occurred in the context of a decrease in
benzodiazepine use and was thought to perhaps represent a
withdrawal seizure. However at that time she was started on
levetiracetam 500 mg twice a day. These medications have been
managed by her PCP, but she has an intake appointment at ___
___ neurologists later this month.
Regarding her lupus, in addition to the neuropsychiatric
symptoms above, she endorses joint pain and swelling, rash on
her chest and upper lip, and fatigue. She has chronic
leukopenia. She has not had any lupus nephritis. She has been
on Plaquenil since her diagnosis, with the exception of the
times when she was pregnant, and she receives intermittent
steroid bursts.
Neuro ROS is notable as above, otherwise, the pt denies loss of
vision, blurred vision, diplopia, dysarthria, dysphagia, or
hearing difficulty. Denies difficulties producing or
comprehending speech. Denies tremor or incoordination.
On ___ review of systems, she endorses "pimple-like"
vesicles on her neck. She endorses fatigue and lightheadedness.
She has intermittent fecal urgency at baseline. She 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 dysuria.
Past Medical History:
Neuropsychiatric lupus -- on Plaquenil
Seizure disorder -- on Keppra, medical marijuana. Last seizure
was 2 weeks ago
Cerebritis/meningitis in the past
Depression
___
Social History:
___
Family History:
No seizures
Physical Exam:
Physical Exam on admission:
___: Thin woman, lying in bed clutching her head.
HEENT: NC/AT, no occipital Tinels. No scleral icterus noted,
MMM, no lesions noted in oropharynx
Neck: supple, no nuchal rigidity. L'Hermitte's negative
Pulmonary: Normal work of breathing on room air, no wheezes or
crackles.
Cardiac: S1/S2 appreciated, RRR, no murmurs, rubs or gallops
Abdomen: Thin, soft, nondistended, mildly tender to palpation
diffusely
Extremities: warm, well perfused. No joint swelling or redness
noted.
Skin: There is a fine papular rash over the anterior chest wall.
There individual red bumps on the neck, without purulence or
vesicles.
Neurologic:
-Mental Status: Awake, alert, oriented x 3. Able to relate
history without difficulty. Mildly inattentive, able to name ___
backward slowly. Language is fluent and intact to naming of high
and low-frequency objects, repetition and comprehension of cross
body and grammatically complex commands. Speech was not
dysarthric. There was no evidence of apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 5 to 4mm without RAPD. EOMI without
nystagmus. Normal saccades. VFF to confrontation with finger
counting, although responses are delayed.
V: Facial sensation decreased in R V2, R V3 and L V3 (60% to
light touch, 50% to pin), does not split the midline.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No tremor or asterixis. Of note, movements are
often very slowed and effortful but are of normal strength and
trajectory.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: Decreased sensation to pin and temperature from ~T6 to
L4 bilaterally. Position sense is normal in great toes
bilaterally. Sensation to light touch further decreases in a
stocking distribution in the lower extremities. Decreased
sensation to light touch in the right arm compared to the left.
Decreased sensation neck circumferentially to about C4. No
extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 3 3 3 3 2
R 3 3 3 3 2
Pectoralis jerks and crossed adductors present bilaterally.
Plantar response was mute bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Able to rise to standing without pushing off with hands.
Gait is slow and cautious with good initiation, narrow-based,
normal stride and arm swing. Able to walk in tandem without
difficulty. Romberg absent.
_
_
_
_
_
_
_
_
_
_
_
________________________________________________________________
Physical exam at discharge
-___: sitting in chair comfortable
-Mental Status: Awake, alert, oriented x 3. Labile mood.
Language
is fluent. Speech was not dysarthric. There was no evidence of
apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 4 to 3mm without RAPD. EOMI without
nystagmus. Normal saccades. VFF
V: Facial sensation decreased in R V2, R V3 (70% to light touch
and pinprick), does not split the midline.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No tremor or asterixis. Patient has give-away
weakness, full strength at maximum.
-Sensory: Reported decreased sensation to light touch over right
face, b/l feet, ~T9 and below to L5 bilaterally (changes with
exam). Position sense is normal in great toes bilaterally.
Decreased sensation to light touch in the right arm compared to
the left (70% compared to left).
-DTRs:
Bi Tri ___ Pat Ach
L 3 3 3 2 2
R 3 3 3 2 2
Pectoralis jerks and crossed adductors present bilaterally.
Plantar response was mute bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: functional gait
Pertinent Results:
___ 02:32PM BLOOD WBC-3.0* RBC-3.94 Hgb-12.1 Hct-35.0
MCV-89 MCH-30.7 MCHC-34.6 RDW-12.6 RDWSD-41.3 Plt ___
___ 08:45AM BLOOD WBC-1.6* RBC-3.62* Hgb-11.0* Hct-32.7*
MCV-90 MCH-30.4 MCHC-33.6 RDW-12.9 RDWSD-42.1 Plt ___
___ 02:32PM BLOOD Glucose-106* UreaN-13 Creat-0.7 Na-141
K-4.0 Cl-104 HCO3-20* AnGap-21*
___ 08:45AM BLOOD Glucose-76 UreaN-11 Creat-0.6 Na-138
K-3.6 Cl-104 HCO3-27 AnGap-11
___ 05:00AM BLOOD calTIBC-291 Ferritn-57 TRF-224
___ 08:45AM BLOOD calTIBC-319 Ferritn-64 TRF-245
___ 04:50AM BLOOD C3-80* C4-13
___ 02:32PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Labs:
MRI brain w/wo contrast was normal.
MRI cervical and thoracic spine did not show evidence of
fracture
CXR was neg
Hip xray neg
C3 80
c4 14
anti cardiolipin neg
sjogrens ab neg
lupus anticoagulant neg
___ 05:00AM BLOOD ___ Titer-1:1280 CRP-0.4
Pending: Beta 2 glycoprotein
CD4
NMDA receptor Ab
Brief Hospital Course:
___ is a ___ yo left-handed woman with history of lupus
complicated by aseptic meningitis and seizure d/o who presented
with
multiple neurological complaints which began 2weeks ago and seem
to have been triggered around recent suicide attempts (2 within
past 6 weeks). Patient reports decreased sensation in the right
side of the body, "chest opening up", "hips feeling loose" and
reports one episode where she had incontinence however she was
having a seizure at that time.
On examination, she reported decreased sensation from the
thoracic to lumbar levels however the sensory level varies with
each exam (t12, 10). She also reports decreased sensation in V2,
V3 on the R that does not spilt midline. Her sensory complaints
also vary sometimes involving b/l feet and skipping to b/l hips.
They do not follow any particular dermatomal pattern. There is
accompanied by symmetric hyperreflexia in b/l UE without upgoing
toes.
CT head from several weeks ago is unrevealing. MRI brain w/wo
contrast was normal. MRI cervical and thoracic spine did not
show evidence of fracture. CXR was neg. Hip xray results pend.
Differential diagnosis includes functional/hypochondriac
disorder or somatization triggered by psychosocial stressors and
underlying chronic illness (SLE).
She was evaluated by psychiatry and determined to require
inpatient psychiatric admission. Patient was ___ and 1:1
sitter with safety tray ordered.
# NEURO:
- Continued home levetiracetam 500 mg BID
- Seizure precautions
- NMDA red Ab pending
# ID: cxr neg
- UA bland
- Ucx strep viridans
- macrobid x 7 days
# Heme
- chronic leukopenia reportedly baseline (trended, chronic)
- cd4 count pending
-In addition, she was given Bactrim for a UTI which can cause
neutropenia
# Lupus:
- continue plaquenil
# Tox/Metabolic: Tox screens negative for non-prescribed meds
- LFTs WNL
# FEN- ___ diet safety tray
#DVT ppx: Pneumoboots/SQH
# Psych: no active SI
- Psych and SW consulted. Admit to inpatient psychiatry
- ___
- 1:1 sitter
# CODE STATUS: full
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. LevETIRAcetam 500 mg PO BID
2. Hydroxychloroquine Sulfate 400 mg PO DAILY
3. ALPRAZolam 0.5 mg PO TID:PRN anxiety
4. Amphetamine-Dextroamphetamine 20 mg PO BID
5. Multivitamins 1 TAB PO DAILY
6. Ferrous Sulfate 325 mg PO DAILY
7. Ibuprofen 800 mg PO Q8H:PRN Pain - Mild
8. Lidocaine 5% Ointment 1 Appl TP ONCE
9. meloxicam 15 mg oral DAILY
10. Tizanidine 4 mg PO BID
11. Levothyroxine Sodium 25 mcg PO DAILY
Discharge Medications:
1. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H Duration: 7
Days
RX *nitrofurantoin monohyd/m-cryst 100 mg 1 capsule(s) by mouth
every twelve (12) hours Disp #*14 Capsule Refills:*0
2. Amphetamine-Dextroamphetamine 20 mg PO BID
3. Ferrous Sulfate 325 mg PO DAILY
4. Hydroxychloroquine Sulfate 400 mg PO DAILY
5. Ibuprofen 800 mg PO Q8H:PRN Pain - Mild
6. LevETIRAcetam 500 mg PO BID
7. Levothyroxine Sodium 25 mcg PO DAILY
8. Lidocaine 5% Ointment 1 Appl TP ONCE
9. meloxicam 15 mg oral DAILY
10. Multivitamins 1 TAB PO DAILY
11. HELD- ALPRAZolam 0.5 mg PO TID:PRN anxiety This medication
was held. Do not restart ALPRAZolam until determined by
psychiatry
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Psychiatric d/o
SLE (hx of cns involvement in the past)
Seizure d/o
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
You were admitted to ___ for evaluation of the
following reported complaints ...
- right sided sensory numbness
- incontinence during seizure episodes
- "chest opening"
- "hips floating"
You were diagnosed with functional overlay on top of your
chronic Lupus.
Your MRI brain w/wo contrast was normal
Your MRI cervical and thoracic spine did not show evidence of
fracture
Your CXR did not show any infection or masses
You did not have any seizures while admitted to the Neurology
service
It was discovered that you have had 2 suicidal attempts over the
past 6 weeks by overdosing on Xanax. You were evaluated by our
Psychiatrist who determined you needed mandatory inpatient
psychiatric admission. Your husband was made aware and kept
informed throughout the process.
Followup Instructions:
___
|
19590098-DS-27
| 19,590,098 | 29,324,428 |
DS
| 27 |
2163-07-08 00:00:00
|
2163-07-10 13:10:00
|
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Nifedipine / amlodipine
Attending: ___.
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ year old woman with a history of COPD on 2L
NC, CAD (EF >55% ___ s/p AAA repair ___ complicated by
ischemic bowel, with subsequent colostomy complicated by
ischemia s/p multiple abdominal surgeries, most recently
colectomy and end ileostomy ___ who presents with several
days of dyspnea on exertion and 2 episodes of acute shortness of
breath. Reports recent dry cough but denies sputum production,
fevers/chills, sick contacts; Reports more frequent use of
albuterol nebulizer at home over the last several days and has
required constant O2 via nasal cannula which she had previously
used only at night. Has not yet been able to obtain her
prescribed fluticasone and symbicort. Denies chest pain,
nausea/vomiting, abdominal pain, increased ostomy output.
Reports improving lower extremity edema since discharge last
week and stable 3 pillow orthopnea for many years. Has spent
most of the time since recent discharge in bed.
She initially presented to ___ hospital, found to have a
negative troponin, BNP 379; given nitrates and Lasix without
much relief. In the ED, initial VS were: 97 92 141/75 22 96% 2L.
CXR demonstrated hyperinflation, EKG with NSR. Exam with Faint
bibasilar crackles on examination, prominent end expiratory
wheezing bilaterally. Surgery saw her in the ED and recommended
admission to medicine for possible COPD flare and agreed with
steroids if medically indicated. She recieved 500mg
Azithromycin, 60mg prednisone, as well as albuterol/ipratropium
nebs for a presumed COPD exacerbation.
Past Medical History:
- CAD (TTE ___ w EF 60%)
- DM2
- HTN
- COPD on home O2
- Recurrent PNA
- h/o interstitial lung disease of hypersensitivity pneumonitis
s/p prednisone ~ ___ s/p wedge resection of RML ___
- GERD
- Hx thyroid dz
- previous smoker
- L thalamic ICH w residual mild RLE weakness (___)
- Concern for cryptogenic cirrhosis
- lactose intolerance
- s/p TAH/BSO unknown
- s/p Appy unknown
- Tonsillectomy unknown
- L lumpectomy ___
- s/p Lung biopsy ___
- s/p open infrarenal AAA repair w/ dacron (___)
- s/p Sigmoid colectomy end colostomy (___)
- s/p ___ reversal, SBR, bladder repair, liver bx
(___)
- s/p take down of the ileostomy in ___
Social History:
___
Family History:
Father died age ___ w/complications of Alzheimer's. Mother is
aged ___ w/mild memory issues and is retired ___.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS 98.1 HR 95 BP 186/92 R 22 O2 97% 2L NC
GEN Cachectic female, Alert, oriented, no acute distress
HEENT NCAT dry mucous membranes EOMI sclera anicteric, OP clear
NECK supple, JVP @ 10cm, no LAD
PULM distant lung sounds, + rales to mid lung fields
posteriorly, no wheezes
CV RRR normal S1/S2, no mrg
ABD ostomy in place with surrounding erythema c/d/i, midline
surgical incision dressing c/d/i, soft NT ND normoactive bowel
sounds, no r/g
EXT WWP 2+ pulses palpable bilaterally, mild pitting edema
bilateral lower extremities to mid shin
NEURO CNs2-12 intact, motor function grossly normal
SKIN no ulcers or lesions
Pertinent Results:
___ 07:42PM WBC-5.1 RBC-3.41* HGB-9.1* HCT-28.6* MCV-84
MCH-26.5* MCHC-31.7 RDW-17.2*
___ 07:42PM PLT COUNT-337
___ 07:42PM ___ PTT-35.2 ___
___ 10:30AM GLUCOSE-118* UREA N-8 CREAT-0.6 SODIUM-139
POTASSIUM-3.9 CHLORIDE-98 TOTAL CO2-37* ANION GAP-8
___ 10:30AM estGFR-Using this
___ 10:30AM ALT(SGPT)-11 AST(SGOT)-17 LD(LDH)-182 ALK
PHOS-137* TOT BILI-0.3
___ 10:30AM CK-MB-2 cTropnT-<0.01 proBNP-4293*
___ 10:30AM ALBUMIN-2.5* CALCIUM-8.2* PHOSPHATE-3.7
MAGNESIUM-1.5*
___ 10:30AM WBC-5.4 RBC-3.18* HGB-8.6* HCT-26.6* MCV-84
MCH-27.0 MCHC-32.3 RDW-17.2*
___ 10:30AM NEUTS-92.3* LYMPHS-4.8* MONOS-2.8 EOS-0.1
BASOS-0.1
___ 10:30AM PLT COUNT-325#
___ 04:05AM BLOOD WBC-6.7 RBC-3.44* Hgb-8.9* Hct-28.9*
MCV-84 MCH-26.0* MCHC-30.8* RDW-17.2* Plt ___
___ 03:20AM BLOOD WBC-6.2 RBC-3.27* Hgb-8.9* Hct-27.4*
MCV-84 MCH-27.1 MCHC-32.4 RDW-17.2* Plt ___
___ 09:00AM BLOOD WBC-8.5# RBC-3.17* Hgb-8.3* Hct-26.4*
MCV-83 MCH-26.3* MCHC-31.5 RDW-17.2* Plt ___
___ 04:05AM BLOOD Plt ___
___ 03:20AM BLOOD Plt ___
___ 03:20AM BLOOD ___ PTT-35.3 ___
___ 09:00AM BLOOD Plt ___
___ 04:05AM BLOOD Glucose-93 UreaN-10 Creat-0.7 Na-136
K-3.9 Cl-96 HCO3-36* AnGap-8
___ 09:00AM BLOOD Glucose-96 UreaN-11 Creat-0.6 Na-137
K-3.6 Cl-96 HCO3-36* AnGap-9
___ 09:00AM BLOOD ALT-12 AST-20 AlkPhos-151* TotBili-0.2
___ 04:05AM BLOOD Calcium-8.6 Phos-3.3 Mg-2.1
___ 09:00AM BLOOD Calcium-8.0* Phos-3.5 Mg-2.4
___ 05:12AM BLOOD Type-ART Temp-36.8 pO2-87 pCO2-48*
pH-7.48* calTCO2-37* Base XS-10
___ 05:12AM BLOOD Glucose-106* Lactate-0.8
___ 05:12AM BLOOD O2 Sat-96
Brief Hospital Course:
Ms. ___ is a ___ year old woman with COPD, AAA repair c/b
ischemic bowel s/p multiple abdominal surgeries including recent
colectomy and end ileostomy ___ who presents with several
day h/o progressive DOE and 2 episodes of acute SOB and evidence
of small subsegmental PE on CTA who experienced a hemorrhagic
stroke of the pons and transferred to the neurology service.
.
#Pontine stoke- on ___ the patient had SBP- from 150-180,
asymptomatic, no neurologic deficits, denied headache, chest
pain, dyspnea or vision changes with normal mental status and
orientation. Standing Labetalol was increased to 300mg TID and
she was given 100mg extra dose twice for asymptomatic SBP of 180
the night of ___. Early AM on ___ the patient experienced
acute mental status change and right sided weakness. She was
transferred to the neuro ICU after a code stroke was called.
Once in the ICU she developed left sided weakness as well with a
dilated right pupil and began having extensor posturing. CT scan
showed a pontine hemorrhage. It was thought that her hemorrhage
was most likely attributed to coagulopathy attributed to the use
of LMWH for her pulmonary embolism. She was intubated and given
mannitol. The following morning the patient's exam was very
poor, indicating compression of the midbrain. The poor prognosis
was communicated to the family. They decided to make the patient
CMO in accordance with her clearly stated wishes and the patient
was extubated on ___. She passed during the night.
.
# Shortness of breath: high suspicion for PE on admission given
recent surgery and subsequent immobilization as well as acute
nature of SOB episodes. CTA chest this showed small subsegmental
PE LUL and worsening bilateral effusions. Deconditioning and
bibasilar atelectasis related to recent surgery and
immobilization also likely contributing factors.Was treated with
heparin drip and was transition ed to Lovenox and Coumadin
bridge with normal renal function.
.
# Bilateral Pleural effusions: Likely exacerbating current SOB.
CHF possible given pro-BNP elevation to the 1000s although TTE
earlier this month showed no abnormality. Diuresed with good
symptomatic effect with 2 bolus's of 20mg IV lasix until the
stroke per above.
.
# COPD: On 2L home O2.
- continued home tiotropium, Flovent, albuterol nebs; symbiot
non formulary
.
# Recent Colectomy/ileostomy:
- pain control with oxycodone
# CAD:
- continued ASA and simvastatin
# Depression:
- continued home Celexa
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Citalopram 10 mg PO DAILY
3. Simvastatin 20 mg PO DAILY
4. Tiotropium Bromide 1 CAP IH DAILY
5. Acetaminophen (Liquid) 650 mg PO Q6H
6. Fluticasone Propionate 110mcg 2 PUFF IH BID
7. Labetalol 250 mg PO TID
8. OxycoDONE Liquid 2.5-5 mg PO Q4H:PRN pain
9. Omeprazole 20 mg PO DAILY
10. Symbicort *NF* (budesonide-formoterol) 160-4.5 mcg/actuation
Inhalation TID
11. Vitamin D 1000 UNIT PO DAILY
12. Ferrous Sulfate 160 mg PO DAILY
13. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
Pontine Hemorrhage
Discharge Condition:
deceased
Discharge Instructions:
The patient was initially admitted for a pulmonary embolism. She
was started on blood thinners for this. In the middle of the
night on ___ she suddenly had right sided weakness. She was
found to have a bleed in her brainstem. She was intubated and
brought to the ICU but unfortunately there were signs that the
blood was significantly compressing the brain stem. The
patient's family made her wishes clear that she did not wish to
be rescusitated or have a prolonged intubation. In accordance
with her wishes she was made CMO.
Followup Instructions:
___
|
19590142-DS-11
| 19,590,142 | 24,897,671 |
DS
| 11 |
2189-10-10 00:00:00
|
2189-10-16 11:57:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
___ Complaint:
vaginal bleeding
Major Surgical or Invasive Procedure:
None
Physical Exam:
Admission exam:
Gen: NAD
Lungs: no resp distress
Abd: soft, nontender, nondistended
SSE: normal external genitalia, normal vaginal mucosa -> 2
scopettes of dark red blood cleared from vault, no active
bleeding visualized, cervix visually closed
SVE: cervix closed, no uterine or adnexal tenderness
Discharge exam:
BP recheck 104/64
Gen NAD
CV regular rate
Pulm nl respiratory effort
Abd soft, NT/ND
Ext warm, well perfused. no calf tenderness
Pelvis pad with single streak of dark red blood
Pertinent Results:
___ 10:30PM BLOOD WBC-10.9* RBC-3.10* Hgb-10.3* Hct-31.4*
MCV-101* MCH-33.2* MCHC-32.8 RDW-12.8 RDWSD-47.7* Plt ___
___ 10:30PM BLOOD Neuts-76.4* Lymphs-17.6* Monos-4.8*
Eos-0.5* Baso-0.3 Im ___ AbsNeut-8.35* AbsLymp-1.92
AbsMono-0.52 AbsEos-0.05 AbsBaso-0.03
___ 10:30PM BLOOD Glucose-83 UreaN-6 Creat-0.5 Na-138 K-4.2
Cl-110* HCO3-17* AnGap-11
___ 10:30PM BLOOD Calcium-7.9* Phos-2.5* Mg-1.6
___ 10:30PM BLOOD ___
Brief Hospital Course:
___ was admitted to the antepartum service with
vaginal bleeding in the setting of a cesarean scar ectopic
pregnancy, known from prior. Upon admission, her bleeding had
significantly improved and her hematocrit remained stable. She
received Rhogam for a negative Rh status and her KB returned
negative.
She underwent a formal ultrasound at the ___ Maternal and
Fetal medicine, which showed consistent biometry, normal FI, a
retroplacenta hematoma and a cervix measuring 1.5cm. In
addition, the ultrasound noted continued features of PAS. She
again received counseling on the risks of PAS. Given a stable
clinical exam with improved bleeding and stable hematocrit, she
was discharged on hospital day 1 with appropriate outpatient
follow up.
Discharge Medications:
1. Prenatal Vitamins 1 TAB PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
cesarean scar ectopic pregnancy, ___ trimester bleeding
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital with vaginal bleeding in the
setting of a cesarean scar ectopic pregnancy. You underwent an
ultrasound which revealed a hematoma (blood clot) in the uterus,
near the placenta.
We think it is now safe for you to go home. Please follow the
instructions below:
- Attend all appointments with your obstetrician and all fetal
scans
- Monitor for the following danger signs:
- headache that is not responsive to medication
- abdominal pain
- increased swelling in your legs
- vision changes
- Worsening, painful or regular contractions
- Vaginal bleeding
- Leakage of water or concern that your water broke
- Nausea/vomiting
- Fever, chills
- Decreased fetal movement
- Other concerns
Followup Instructions:
___
|
19590214-DS-15
| 19,590,214 | 20,374,882 |
DS
| 15 |
2152-07-31 00:00:00
|
2152-08-01 10:36:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
clindamycin / Bactrim
Attending: ___.
Chief Complaint:
Central venous access device (Powerport) infection
Major Surgical or Invasive Procedure:
Removal of CVL port by interventional radiology ___
PICC placement ___
History of Present Illness:
Ms. ___ is a ___ y/o woman with metastatic breast cancer
(diagnosed in ___, currently on Taxol 75mg/m2 day 1 and 8 of a
21-day-cycle and Herceptin 2mg/kg weekly), RUE lymphedema and
recurrent RUE cellulitis, with recent L port infection (coag
negative staph) and admission on ___, s/p 14-day-course of
Vancomycin IV and vancomycin locks (from ___, who is now
admitted with recurrent fever. Pt states last week she started
to
redness around port site again, no drainage, no tenderness or
fevers like the prior episode so she didnt want to get
evaluated.
In clinic today, nurse and physician were concerned for
recurrent
infection. She received chemotherapy per port, but when she
went
home after treatment she spiked a fever to 100.7. She was
encouraged to come to the ED for further evaluation. Of note,
Ms. ___ is on chronic amoxicillin and doxycycline for prevention
of recurrent cellulitis. She denies any cough, SOB, sore throat,
rhinorrhea, congestion, dysuria, ab pain, diarrhea or sick
contacts. No other skin lesions.
In the ED, initial vitals were: 99.8 68 186/83 16 100% RA.
Patient then spiked to 101.3. Cultures were drawn through port
and peripherally, and Ms. ___ was given one dose of vancomycin
1000mg IV and admitted to oncology.
ROS: no HA, vision problems, numbness/weakness, bleeding. BM are
regular. Eating fine. Remainder 10pt ROS negative other than HPI
above.
Past Medical History:
PAST ONCOLOGIC HISTORY
___ Diagnosed with inflammatory breast cancer metastatic to
bone. Taxol/herceptin and zometa.
___. CT chest/abd/pelvis/Bone scan: New mixed lytic and
sclerotic lesion within the sternum compatible with a new
metastatic deposit. Minimal arthritic uptake in the right foot.
Patient is status post trauma minor to her sternum in ___. The appearance by both CT and bone scan could be that of a
healing sternal fracture.
PAST MEDICAL HISTORY:
___ Osteonecrosis of the jaw, zometa stopped.
RUE cellulitis
Contact dermatitis
hypertension
lymphedema
Social History:
___
Family History:
no history of cancers patient is aware of
Physical Exam:
ADMISSION PHYSICAL EXAM:
General: NAD
VITAL SIGNS: 99.2 116/60 62 18 97%RA
HEENT: MMM, no OP lesions,
Neck: supple, no JVD
CV: RR, NL S1S2 no S3S4 or MRG
PULM: CTAB
ABD: BS+, soft, NTND, no masses or hepatosplenomegaly
EXT: warm well perfused, no edema
SKIN: No rashes, L port site w/ 1-2 cm surrounding erythema
only
sl ttp no drainage appreciated
NEURO: alert and oriented x 4, ___, EOMI, no nystagmus, face
symmetric, no tongue deviation, full hand grip, shoulder shrug
and bicep flexion, full toe dorsiflexion and hip flexion against
resistance bilateral, sensation intact to light touch, no clonus
DISCHARGE PHYSICAL EXAM:
VITALS: 98.5 110/66 52 16 99% RA
General: thin elderly female in NAD, standing/sitting
comfortably, conversant
HEENT: MMM, no OP lesions
Neck: supple, no JVD at 45 degrees
CV: RR, NL S1S2 no S3S4 or MRG
PULM: CTAB
ABD: BS+, soft, NTND, no masses or hepatosplenomegaly
EXT: warm well perfused, no edema
SKIN: No rashes, L port site dressing c/d/i, no surroudning
erythema visualized, no drainage on gauze, slightly ttp
NEURO: alert and oriented x 3, ___, EOMI, no facial asymmetry,
gait normal
Pertinent Results:
ADMISSION LABS:
___ 07:22PM BLOOD WBC-4.4# RBC-3.67* Hgb-11.3* Hct-32.2*
MCV-88 MCH-30.8 MCHC-35.0 RDW-17.1* Plt ___
___ 07:22PM BLOOD Neuts-80.5* Lymphs-6.5* Monos-11.6*
Eos-0.9 Baso-0.6
___ 07:22PM BLOOD Plt ___
___ 07:22PM BLOOD Glucose-102* UreaN-13 Creat-0.8 Na-132*
K-3.8 Cl-95* HCO3-26 AnGap-15
___ 07:22PM BLOOD Calcium-9.2 Phos-3.5 Mg-1.7
DISCHARGE LABS:
___ 06:35AM BLOOD WBC-3.0* RBC-3.59* Hgb-11.0* Hct-31.5*
MCV-88 MCH-30.6 MCHC-34.9 RDW-16.4* Plt ___
___ 06:35AM BLOOD Glucose-83 UreaN-22* Creat-0.9 Na-136
K-4.4 Cl-98 HCO3-28 AnGap-14
___ 06:35AM BLOOD Calcium-9.6 Phos-4.3 Mg-1.9
___ 05:00PM BLOOD Vanco-14.9
___ 06:35AM BLOOD Vanco-14.6
STUDIES:
CXR ___:
Left-sided Port-A-Cath is unchanged position. Heart size is
within normal
limits. Lungs are grossly clear. Retrosternal calcification at
the sternomanubrial junction is again seen there is generalized
demineralization.
Echocardiogram ___:
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF = 60%). Tissue Doppler imaging suggests a normal left
ventricular filling pressure (PCWP<12mmHg). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Trace aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
The estimated pulmonary artery systolic pressure is normal.
There is no pericardial effusion.
IMPRESSION: no vegetations seen
MICRO:
- Blood cx ___ and ___ S. epidermidis (sensitivities below)
- Blood cx ___ to ___ NGTD
- Wound cx ___ pending
_________________________________________________________
STAPHYLOCOCCUS EPIDERMIDIS
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
VANCOMYCIN------------ 2 S
Brief Hospital Course:
___ y/o woman with a pmhx. significant for Her2+ inflammatory
breast cancer with bony disease Taxol and Herceptin, recent L
port infection treated with 14 days of IV vanc and vancomycin
locks in ___ (discontinued on ___, who presented
with fever and erythema around port site due to recurrent port
infection.
# Port infection: The patient initially presented from clinic
due to fever along with erythema and tenderness around her left
side Powerport while receiving chemotherapy. She was initiated
on IV vancomycin through her port along with vancomycin locks in
the port. Her vancomycin levels were checked and titrated
accordingly thorughout admission. Her blood cultures grew out S.
epidermidis which was the same organism as the prior port
infection. Infectious disease was consulted and recommended
removal of the port since both infections were caused by the
same bacterial organism. In addition, ID recommended a TTE which
did not show any vegetations. She was taken to the
interventional radiology suite on ___ and had her Powerport
removed. Following port removal, she had a PICC line placed by
___ on ___ in order for her to continue her IV chemotherapy
regimen and her IV vancomycin. She was discharged with follow up
in ___ (infectious disease) clinic for managing her IV
antibiotics. Her course of vancomycin ___ end on ___. She was
discharged home with ___ services to help with wound dressing
changes of the former port site as well as nursing services for
her IV antibiotics. She ___ receive weekly labs for CBC and
vancomycin levels and results ___ be faxed to the ___ clinic.
# Stage IV breast cancer: on Taxol and herceptin, normally
follows with Dr. ___ as an outpatient. She was discharged with
instructions to follow up in Dr. ___ for continued
management of her breast cancer and administration of her
chemotherapy.
# Hypertension: Continued Hctz, lisinopril, atenolol
# Transitional issues:
- Stop antibiotics on ___
- Keep PICC following completion of antibiotics for chemotherapy
- Can place new port upon completion of antibiotics
- Infectious disease appointment on ___
- Wound care nurse ___
- ___ need weekly CBC with differential, BUN, Cr, Vancomycin
trough. Fax results to ___ CLINIC - FAX: ___
- All questions regarding outpatient parenteral antibiotics
after discharge should be directed to the ___
R.N.s at ___ or to the on-call ID fellow when the
clinic is closed
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 25 mg PO DAILY
2. Hydrochlorothiazide 25 mg PO DAILY
3. Lisinopril 20 mg PO BID
4. Lorazepam 0.5 mg PO QHS:PRN insomnia
5. Ranitidine 150 mg PO QHS
6. Zolpidem Tartrate 7.5 mg PO QHS:PRN insomnia
Discharge Medications:
1. Hydrochlorothiazide 25 mg PO DAILY
2. Lisinopril 20 mg PO BID
3. Ranitidine 150 mg PO QHS
4. Zolpidem Tartrate 7.5 mg PO QHS:PRN insomnia
5. Lorazepam 0.5 mg PO QHS:PRN insomnia
6. Vancomycin 750 mg IV Q 12H
Please take through ___
RX *vancomycin 750 mg 1 bag IV TWICE DAILY Disp #*26 Vial
Refills:*0
7. Atenolol 25 mg PO DAILY
8. Outpatient Lab Work
Please check CBC with differential, BUN, Cr, and Vancomycin
trough on ___ and ___.
ICD-9 code ___.7 bacteremia.
PLEASE FAX TO: ___ CLINIC - FAX: ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
S. epidermidis bacteremia from port 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 during your stay. You were
admitted for a port infection. You were treated with IV
vancomycin and your port was removed. An echocardiogram did not
show any infection on the heart valves. A PICC line was placed
for IV therapy at home. You ___ need to be on antibiotics until
___ and have an appointment with the infectious disease team
on ___. We wish you the best!
Your ___ care team
Followup Instructions:
___
|
19590214-DS-16
| 19,590,214 | 20,319,192 |
DS
| 16 |
2156-04-07 00:00:00
|
2156-04-07 12:18:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
clindamycin / Bactrim
Attending: ___
Chief Complaint:
Low-grade fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ yo woman with metastatic breast cancer (to
bone) on ado-trastuzumab(Kadcyla) who presented with fever and
chills.
Ms ___ was in her USOH until the day before admission when she
began to notice intermittent nausea. Later in the afternoon, she
developed shaking chills. Her temperature at that time was 98.
She rechecked her temperature a few hours later, found it
elevated to 100.3 F. She presented to the ED for evaluation.
On ROS, she denied headache, cold symptoms including congestion,
sore throat, rhinorrhea, chest pain, cough, shortness of breath,
palpitations, abdominal pain, diarrhea, dysuria. No sick
contacts. No suspicious food intake.
In the ED, initial vitals @ 10 pm on ___ were T 99.9, BP 170/57,
HR 76, sat 99% RA. Per the ED attending note, on his evaluation,
her temperature spiked to 102.1 F (not documented in the ED
dash).
Initial workup showed pancytopenia with leukopenia to 3.9 (ANC
3040), unchanged from prior (WBC 2.6 on ___, bland UA,
negative rapid Flu, stable mild transaminitis, normal CXR and
negative ___ dopplers. She was given vanc/cefepime initially and
then further abx were held in light of the negative workup
above.
She remained in the ED for 24 hours awaiting an inpatient bed.
Prior to transfer at 8 pm, she spiked another low grade temp to
100.6F.
All other review of systems are negative unless stated otherwise
=== PAST MEDICAL HISTORY ===
- Breast Cancer with bony mets
- Renal Infarct
- Chemotherapy induced neuropathy
- HTN
- Osteonecrosis of the Jaw
- Lymphedema c/b cellulitis
- Question of port infection ___ - redness at port site. cx
grew
coag negative staph. treated with vanc x 14 days with port
locks.
Few months later again fever and port erythema w/ cx grew coag
negative staph. Port removed.
ONCOLOGIC HISTORY: Metastatic breast cancer. Please refer to
___ for detailed history
- ___ dx with right inflammatory breast cancer associated
with
bony metastatic disease. She was treated with taxol and
herceptin. She had also been on bisphosphonate therapy, but this
was discontinued when she developed clinical signs of
osteonecrosis and osteomyelitis of the jaw.
- ___: new focus of uptake in left fifth rib c/w new met
- ___ started TDM-1
- Last repeat imaging studies done ___ no changes suggestive
of metastatic disease. Unchanged 6 mm groundglass nodule in
right
lung apex.
- Last received Ado-trastuzumab on ___
Past Medical History:
PAST ONCOLOGIC HISTORY
___ Diagnosed with inflammatory breast cancer metastatic to
bone. Taxol/herceptin and zometa.
___. CT chest/abd/pelvis/Bone scan: New mixed lytic and
sclerotic lesion within the sternum compatible with a new
metastatic deposit. Minimal arthritic uptake in the right foot.
Patient is status post trauma minor to her sternum in ___. The appearance by both CT and bone scan could be that of a
healing sternal fracture.
PAST MEDICAL HISTORY:
___ Osteonecrosis of the jaw, zometa stopped.
RUE cellulitis
Contact dermatitis
hypertension
lymphedema
Social History:
___
Family History:
no history of cancers patient is aware of
Physical Exam:
Admission physical exam:
General: Frail elderly Caucasian woman, resting in bed, tired
appearing
Neuro: PERRL, EOMI, Acuity- able to read large letters "Today is
9 (of ___ on the back wall. Oriented, able to provide
clear
history. Awake and alert, but very tired appearing with latency
of several seconds with answering questions
HEENT: Subconjunctival hemorrhage on the temporal aspect of the
left eye. Right eye is clear. Oropharynx clear, MMM, no palpable
cervical or supraclavicular adenopathy
Cardiovascular: RRR no murmurs
Chest/Pulmonary: Crackles at the right base that cleared with
deep breathing
Abdomen: Soft, nontender, nondistended, bowel sounds present
Extr/MSK: Right arm wrapped in ace bandage for chronic
lymphedema. No significant swelling noted over the upper or
lower
extremities, warm and well perfused
Skin: No significant rashes
Access: R POC is c/d/I, nontender, no surrounding erythema
Discharge physical exam:
General: Elderly female in no acute distress
Neuro: PERRL, EOMI, cranial nerves intact, no focal deficits
HEENT: Subconjunctival hemorrhage on the temporal aspect of the
left eye. Right eye is clear. Oropharynx clear, MMM, no palpable
cervical or supraclavicular adenopathy
Cardiovascular: RRR no murmurs
Chest/Pulmonary: CTA bilaterally
Abdomen: Soft, nontender, nondistended, bowel sounds present
Extr/MSK: Right arm wrapped in ace bandage for chronic
lymphedema. No significant swelling noted over the upper or
lower
extremities, warm and well perfused
Skin: No significant rashes
Access: R POC is c/d/I, nontender, no surrounding erythema
Pertinent Results:
___ 08:44AM LACTATE-0.6
___ 08:40AM GLUCOSE-97 UREA N-18 CREAT-0.8 SODIUM-139
POTASSIUM-3.2* CHLORIDE-106 TOTAL CO2-24 ANION GAP-9*
___ 08:40AM ALT(SGPT)-37 AST(SGOT)-65* ALK PHOS-164* TOT
BILI-1.2
___ 08:40AM WBC-2.4* RBC-2.98* HGB-9.9* HCT-28.3* MCV-95
MCH-33.2* MCHC-35.0 RDW-14.8 RDWSD-51.6*
___ 08:40AM PLT COUNT-61*
___ 02:50AM URINE COLOR-Yellow APPEAR-Hazy* SP ___
___ 01:52AM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
Microbiology
UCx ___: No growth
BCx x ___ AM: No growth
BCx x ___ ___: No gross
Radiology
___: No evidence of deep venous thrombosis in the right
or
left lower extremity veins.
Mild bilateral subcutaneous edema.
___: No acute intrathoracic process.
Brief Hospital Course:
___ with metastatic breast cancer (to bone) on
ado-trastuzumab(Kadcyla) who presented with fever and chills,
without clear infectious source. She was given one dose of IV
broad-spectrum antibiotics in the ED. However based on her
overall clinical presentation and initial laboratory workup,
broad-spectrum antibiotics were discontinued. She was monitored
in the hospital for 48 hours without evidence of fevers or
hemodynamic instability. She underwent an extensive infectious
workup which was unrevealing. After discussing her overall
clinical presentation with patient, family members and
outpatient hematologist/oncologist, patient was agreeable to
discharge home with close outpatient PCP and hematology and
oncology follow-up.
Chronic medical issues:
# Metastatic breast cancer on TDM-1
Started TDM-1 ___. Repeat staging studies on ___
without evidence of metastatic disease.
- heme/onc team notified of admission. Plan to follow-up as an
outpatient.
# HTN:
- continue atenolol
- continue lisinopril
- continue Triamterene-HCTZ
# Pancytopenia, stable, chronic.
Likely secondary to chemotherapy
# Mild transaminitis, stable and chronic.
Likely secondary to chemotherapy
#Renal infarct
- continue on ASA 325 mg daily
# Lymphedema w/ hx of cellulitis on ppx
- continue amoxicillin, doxycycline
# GERD
- continue ranitidine at bedtime
# Insomnia
- continue ambien PRN
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 20 mg PO BID
2. Ranitidine 150 mg PO QHS
3. Zolpidem Tartrate 7.5 mg PO QHS:PRN insomnia
4. Atenolol 25 mg PO DAILY
5. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY
6. Amoxicillin 500 mg PO Q12H
7. Doxycycline Hyclate 100 mg PO DAILY
8. Aspirin 325 mg PO DAILY
Discharge Medications:
1. Amoxicillin 500 mg PO Q12H
2. Aspirin 325 mg PO DAILY
3. Atenolol 25 mg PO DAILY
4. Doxycycline Hyclate 100 mg PO DAILY
5. Lisinopril 20 mg PO BID
6. Ranitidine 150 mg PO QHS
7. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY
8. Zolpidem Tartrate 7.5 mg PO QHS:PRN insomnia
Discharge Disposition:
Home
Discharge Diagnosis:
Low-grade fever
Metastatic breast cancer on active chemotherapy
Pancytopenia
Discharge Condition:
Discharge conditionstable
Mental statusalert and oriented x3
Ambulatory
Discharge Instructions:
You were admitted to the hospital for low-grade fever. Given
your low blood counts and active chemotherapy, you were admitted
to the hospital for close observation. You were monitored for
48 hours off antibiotics without any evidence of fevers or
laboratory/microbiology abnormalities. Your clinical
presentation was discussed with your outpatient
hematologist/oncologist who agrees with discharge home with
close PCP and hematology/oncology follow-up.
Followup Instructions:
___
|
19590413-DS-21
| 19,590,413 | 26,823,381 |
DS
| 21 |
2113-09-07 00:00:00
|
2113-09-07 11:23:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
R elbow pain
Major Surgical or Invasive Procedure:
ORIF R humerus
History of Present Illness:
___ with hx of HTN/HLD presetns as transfer from osh s/p
fall with open right distal humerus fracture. Patient fell off
ladder while at work, landed on R elbow and immediate pain since
that time. Denies any numbness/tingling/weakness distally.
Denies
head strike, loc, current HA, neck pain, back pain, ___ pain,
abd pain, cp, sob, flank pain.
Past Medical History:
HTN
HLD
Social History:
___
Family History:
nc
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
In general, the patient is in pain but NAD AOx4
Vitals:
Right upper extremity:
2cm x 2cm open laceration to right elbow and there is bone
exposure. Unable to move R elbow secondary to pain
Full, painless AROM/PROM of shoulder, wrist, and digits
+EPL/FPL/DIO (index) fire
+SILT axillary/radial/median/ulnar nerve distributions
+Radial pulse, cap refill <2 secs
DISCHARGE PE:
AO3
AVSS
Dressing c/d/i
NVID
Pertinent Results:
___ 07:06AM BLOOD WBC-13.0* RBC-3.68* Hgb-11.1* Hct-30.9*
MCV-84 MCH-30.2 MCHC-36.0* RDW-13.4 Plt ___
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have R distal humerus fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for ORIF R humerus, which the
patient tolerated well (for full details please see the
separately dictated operative report). The patient was taken
from the OR to the PACU in stable condition and after recovery
from anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient was given perioperative antibiotics and anticoagulation
per routine. The patients home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to home was appropriate. The ___
hospital course was otherwise unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is NWB in the RU extremity, and will
be discharged on asa for DVT prophylaxis. The patient will
follow up in two weeks per routine. A thorough discussion was
had with the patient regarding the diagnosis and expected
post-discharge course, and all questions were answered prior to
discharge.
Medications on Admission:
See OMR.
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
Decrease dosage as soon as possible.
2. Atorvastatin 20 mg PO QPM
3. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
4. Docusate Sodium 100 mg PO BID
5. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain
RX *hydromorphone 2 mg ___ tablet(s) by mouth q4h prn Disp #*60
Tablet Refills:*0
6. Aspirin 325 mg PO DAILY
7. Lisinopril 20 mg PO DAILY
8. Senna 8.6 mg PO BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
R distal humerus fracture
Discharge Condition:
Improved. AO3. NWB RUE. WBAT BLE.
Discharge Instructions:
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox 40mg daily for 2 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
ACTIVITY AND WEIGHT BEARING:
- NWB RUE. PROM elbow as tolerated.
Followup Instructions:
___
|
19590732-DS-4
| 19,590,732 | 23,659,100 |
DS
| 4 |
2126-01-08 00:00:00
|
2126-01-08 12:41:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right distal humerus fracture
Major Surgical or Invasive Procedure:
ORIF Right distal humerus fracture ___, Dr. ___
History of Present Illness:
HPI: ___ male presents with the above fracture s/p mechanical
fall. He was walking down a flight of stairs when he had a
mechanical fall down 6 stairs, no LOC. He immediately noted
pain
in his L elbow. At OSH imaging revealed comminuted
intraarticular fracture of both humeral condyles, as well as R
flank hematoma.
Past Medical History:
PMH/PSH:
___ Disease
HTN
HLD
Arthritis
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have right distal humerus fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for ORIF of the above fracture, which
the patient tolerated well. For full details of the procedure
please see the separately dictated operative report. The patient
was taken from the OR to the PACU in stable condition and after
satisfactory recovery from anesthesia was transferred to the
floor. The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given ___
antibiotics and anticoagulation per routine. The patient's home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to rehab
was appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
NVI distally in the right upper extremity, and will be
discharged on aspirin for DVT prophylaxis. The patient will
follow up with Dr. ___ routine. A thorough discussion was
had with the patient regarding the diagnosis and expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient was also given written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient expressed readiness for discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 300 mg PO TID
2. Naproxen 375 mg PO Q12H
3. Pramipexole 0.5 mg PO TID
4. Atorvastatin 20 mg PO QPM
5. Hydrochlorothiazide 25 mg PO DAILY
6. Carbidopa-Levodopa (___) 2 TAB PO TID
Discharge Medications:
1. Atorvastatin 20 mg PO QPM
2. Carbidopa-Levodopa (___) 2 TAB PO TID
3. Gabapentin 300 mg PO TID
4. Hydrochlorothiazide 25 mg PO DAILY
5. Pramipexole 0.5 mg PO TID
6. Acetaminophen 1000 mg PO Q8H
7. Calcium Carbonate 500 mg PO TID
8. Docusate Sodium 100 mg PO BID
9. Aspirin EC 325 mg PO DAILY Duration: 4 Weeks
10. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth QPM Disp #*60 Tablet
Refills:*0
11. Senna 8.6 mg PO BID
12. Vitamin D 400 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right distal humerus fx, now s/p ORIF Right distal humerus
fracture ___, Dr. ___
Discharge Condition:
Overall: Stable
Mental status: AOX3
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- NWB RUE, no splint, passive/active ROM as tolerated
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take ASA 325 mg daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
Followup Instructions:
___
|
19590769-DS-15
| 19,590,769 | 22,137,370 |
DS
| 15 |
2169-09-16 00:00:00
|
2169-09-16 15:37:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
oxycodone
Attending: ___.
Chief Complaint:
Left Femur Fracture s/p assault
Major Surgical or Invasive Procedure:
___: PROCEDURE: Intramedullary rod fixation of left femur
fracture.
History of Present Illness:
___ who was at his fiancés house when he was attacked by his
fiancés. The patient reports that he and his fiancé were in the
process of a breakup, and he was getting his stuff out of their
apartment when his fiancé attacked. He currently endorses left
femur pain. No chest pain, sob, n/v.
Past Medical History:
Anxiety, depression, seasonal allergies
Social History:
___
Family History:
n/a
Physical Exam:
NAD, A&OX3
Left lower extremity:
- Incisions clean/dry/intact
- ___ fire
- SILT SPN/DPN/TN/saphenous/sural distributions
- 1+ ___ pulses, foot warm and well-perfused
Pertinent Results:
___ 09:45AM BLOOD WBC-6.0 RBC-2.34* Hgb-7.3* Hct-21.8*
MCV-93 MCH-31.2 MCHC-33.5 RDW-14.6 RDWSD-49.1* Plt ___
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have left femur fracture and was admitted to the orthopedic
surgery service. The patient was taken to the operating room on
___ for left femur nailing, which the patient tolerated
well. For full details of the procedure please see the
separately dictated operative report. The patient was taken from
the OR to the PACU in stable condition and after satisfactory
recovery from anesthesia was transferred to the floor. The
patient was initially given IV fluids and IV pain medications,
and progressed to a regular diet and oral medications by POD#1.
The patient was given ___ antibiotics and
anticoagulation per routine. The patient's home medications were
continued throughout this hospitalization. The patient worked
with ___ who determined that discharge to home was appropriate.
The ___ hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
weight bearing as tolerated in the left lower extremity, and
will be discharged on Lovenox for DVT prophylaxis. The patient
will follow up with Dr. ___ routine. A thorough
discussion was had with the patient regarding the diagnosis and
expected post-discharge course including reasons to call the
office or return to the hospital, and all questions were
answered. The patient was also given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient expressed readiness for discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. QUEtiapine Fumarate 25 mg PO QHS
2. Propranolol 10 mg PO BID
3. OXcarbazepine 150 mg PO BID
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8)
hours Disp #*90 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
3. Enoxaparin Sodium 40 mg SC DAILY Duration: 2 Weeks
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 30 mg/0.3 mL 1 once a day Disp #*14 Syringe
Refills:*0
4. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every
four (4) hours Disp #*80 Tablet Refills:*0
5. LORazepam 0.5 mg PO Q8H:PRN Anxiety
RX *lorazepam [Ativan] 0.5 mg 1 by mouth every eight (8) hours
Disp #*60 Tablet Refills:*0
6. OXcarbazepine 150 mg PO BID
7. Propranolol 10 mg PO BID
8. QUEtiapine Fumarate 25 mg PO QHS
9. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
Discharge Disposition:
Home
Discharge Diagnosis:
Left femur fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Weight bearing as tolerated
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take Lovenox 40 mg SC daily for 2 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
Followup Instructions:
___
|
19591207-DS-11
| 19,591,207 | 24,652,930 |
DS
| 11 |
2126-11-05 00:00:00
|
2126-11-05 15:57:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dysphagia, neck pain
Major Surgical or Invasive Procedure:
___
EGD, bronchoscopy and right VATS mediastinal drainage.
History of Present Illness:
___ year old female with history of
prior neck infections who presented to an OSH with difficulty
swallowing, sensation of something stuck ___ throat and throat
pain for 4 days. She underwent CT neck which showed a right
paraesophageal inflammatory process and
small abscess at level of lung apices with minimal
fluid/infection tracking into RP space. She is now transferred
to
___ ED for further evaluation. She was given vancomycin/zosyn
and decadron at 10am. ORL was consulted and did a scope at the
bedside which was unremarkable. She
endorses chest pain and sensation of something stuck ___ her
throat. She denies any difficulty with secretions, fevers, neck
stiffness, difficutly breathing, noisy breathing, history of
Zenker's diverticulum, regurgitation of food or symptoms of
aspiration. She is currently not tolerating PO well due to pain.
Past Medical History:
PAST MEDICAL HISTORY:
Asthma
PAST SURGICAL HISTORY:
Tonisllectomy
Prior I&D of neck infections x2 with tonsillectomy(done
transorally); approximately 2 and ___ years ago
Social History:
___
Family History:
Paternal aunt with breast cancer, unknown age.
Maternl uncle with colon cancer ___ his ___.
Physical Exam:
Vitals: 97.7 72 124/74 20 99% RA
GENERAL
[x] WN/WD [x] NAD [x] AAO [ ] abnormal findings:
HEENT
[x] NC/AT [x] EOMI [x] PERRL/A [x] Anicteric
[x] OP/NP mucosa normal [x] Tongue midline
[x] Palate symmetric [x] Neck supple/NT/without mass
[x] Trachea midline [x] Thyroid nl size/contour
[ ] Abnormal findings:
RESPIRATORY
[x] CTA/P [ ] Abnormal findings:
CARDIOVASCULAR
[x] RRR [x] No m/r/g [x] Abnormal findings:
GI
[x] Soft [x] NT [x] ND [x] No mass/HSM [x] No hernia
[ ] Abnormal findings:
GU [x] Deferred
[ ] Nl genitalia [ ] Nl pelvic/testicular exam [ ] Nl DRE
[ ] Abnormal findings:
NEURO
[x] Strength intact/symmetric [x] Sensation intact/ symmetric
[x] Reflexes nl [x] No facial asymmetry [x] Cognition intact
[x] Cranial nerves intact [ ] Abnormal findings:
MS
[x] No clubbing [x] No cyanosis [x] No edema [x] Gait nl
[x] No tenderness [x] Tone/align/ROM nl [x] Palpation nl
[x] Nails nl [ ] Abnormal findings:
LYMPH NODES
[x] Cervical nl [x] Supraclavicular nl [x] Axillary nl
[x] Inguinal nl [ ] Abnormal findings:
SKIN
[x] No rashes/lesions/ulcers
[x] No induration/nodules/tightening [ ] Abnormal findings:
PSYCHIATRIC
[x] Nl judgment/insight [x] Nl memory [x] Nl mood/affect
[ ] Abnormal findings:
Pertinent Results:
WBC RBC Hgb Hct MCV MCH MCHC RDW
RDWSD Plt Ct
___ 04:01 9.8 3.38* 10.1* 31.3* 93 29.9 32.3 13.2
44.4 235
___ 09:55 10.1* 3.59* 10.7* 32.8* 91 29.8 32.6 13.2
44.1 252
___ 05:54 9.2 3.72* 10.7* 34.1 92 28.8 31.4* 13.0
43.1 262
___ 07:41 8.9 3.75* 11.0* 34.3 92 29.3 32.1 12.8
42.3 253
___ 06:40 10.5* 3.72* 10.8* 34.9 94 29.0 30.9* 13.1
44.7 232
___ 01:39 10.8* 3.68* 10.9* 33.6* 91 29.6 32.4 13.1
43.5 247
___ 01:49 17.5* 4.37 12.8 40.3 92 29.3 31.8* 13.2
44.1 280
___ 03:53 12.5* 3.89* 11.4 35.4 91 29.3 32.2 13.2
43.5 250
___ 04:20 14.7* 4.22 12.4 38.1 90 29.4 32.5 12.8
42.2 313
___ 16:05 15.0* 4.63 13.5 41.1 89 29.2 32.8 12.9
41.6 309
Glucose UreaN Creat Na K Cl HCO3 AnGap
___ 04:01 ___ 141 3.83 ___
___ 05:54 ___ 145 3.53 ___
___ 07:41 ___ 145 3.63 ___
___ 06:40 ___ 144 3.73 ___
___ 01:39 ___ 144 4.03 ___
___ 01:49 ___ 138 ___ 172
___ 03:53 ___ 4.43 ___
___ 04:20 ___ 144 4.73 ___
___ 16:05 ___ 141 4.53 103 20* 182
___ 12:30 am ABSCESS Site: MEDIASTINUM
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS.
FLUID CULTURE (Final ___:
STAPH AUREUS COAG +. MODERATE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
RIFAMPIN should not be used alone for therapy.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=0.5 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
___ 12:34 pm SWAB Source: Retropharyngeal Fluid.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
SMEAR REVIEWED; RESULTS CONFIRMED.
WOUND CULTURE (Final ___:
MIXED BACTERIAL FLORA.
MIXED BACTERIAL FLORA ( >=3 COLONY TYPES) CONSISTENT
WITH
OROPHARYNGEAL FLORA. SPARSE GROWTH.
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.
ANAEROBIC CULTURE (Final ___:
MIXED BACTERIAL FLORA.
Mixed bacteria are present, which may include anaerobes
and/or
facultative anaerobes. Bacterial growth was screened
for the
presence of B.fragilis, C.perfringens, and C.septicum.
None of
these species was found.
___ Ba swallow :
No evidence of esophageal perforation or leak.
___ Chest CT :
1. Slight interval decrease ___ paraesophageal phlegmon, residual
from prior developing abscess with background esophagitis.
2. Retropharyngeal fluid collection does not demonstrate
definitive signs of abscess and may represent reactive edema.
However, there is mild mass effect on the oropharynx and close
airway surveillance advised.
3. Likely large splenic artery aneurysm. Please note, however,
current study does not substitute dedicated abdominopelvic
imaging.
4. Trace right pleural effusion with bibasilar atelectasis.
___ Chest CT :
1. Ill-defined soft tissue at the site of prior right
paraesophageal abscess, decreased ___ size from prior.
2. Post-surgical changes at the right lung apex.
3. Tiny right apical pneumothorax.
4. Unchanged trace right pleural effusion.
Brief Hospital Course:
Ms. ___ was evaluated by the Thoracic Surgery service
___ the Emergency Room and admitted to the hospital for further
management of her dysphagia and neck pain. She remained NPO and
was hydrated with IV fluids and placed on Vancomycin, Zosyn and
Fluconozole after being pan cultured. Her WBC was 15K. She
subsequently underwent a barium swallow on ___ which showed
no evidence of a leak.
The Infectious Disease service also evaluated her and
recommended tapering her antibiotics to Unasyn for this
paraesophageal abscess. After 48 hours her odynophagia got worse
along with her neck pain. ENT did a fiberoptic exam which was
normal appearing and aspirated the retropharyngeal mass. A chest
CT was done which showed a new retropharyngeal fluid collection
and she was subsequently taken to the Operating Room where she
underwent an EGD, bronchoscopy and right VATS with mediastinal
drainage. She tolerated the procedure well and returned to the
TSICU intubated and ___ stable condition. She maintained stable
hemodynamics and her pain was controlled with IV Dilaudid. Her
___ drain put out a modest amount of serosanguinous fluid and
had no air leak. Her antibiotics continued with Unasyn and
Vancomycin was added pending intraop cultures. She was weaned
and extubated later on post op day 1 and progressed well.
Following transfer to the Surgical floor she progressed well.
She remained afebrile and her WBC trended down to 9K. She began
a liquid diet and was able to swallow without difficulty and was
gradually increased to soft solids. Her intraop cultures were
notable for MRSA and mixed bacterial flora. A right PICC line
was placed for home antibiotic therapy. The ID service
recommended 2 weeks of IV Vancomycin which will end on ___
___s 1 week of IV Unasyn which ended ___ followed by
a week of Augmentin orally which will also end on ___. The
ID service will not need to see her as an outpatient but the ___
will obtain a Vanco trough on ___ as her dose was changed
to 1250 mg Q 12 hrs from 1000 mg Q 12 hrs on ___ as her
Vancomycin trough was 11 on ___.
She was discharged to home on ___ and will have ___
services to help with home IV administration. She will follow up
with Dr. ___ ___ 2 weeks.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN
wheezing
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
RX *acetaminophen 500 mg 2 tablet(s) by mouth every six (6)
hours Disp #*100 Tablet Refills:*0
2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
Use through ___
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tab by mouth
twice a day Disp #*16 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*2
4. GuaiFENesin ER 1200 mg PO Q12H
RX *guaifenesin 1,200 mg 1 tablet(s) by mouth twice a day Disp
#*28 Tablet Refills:*0
5. Ipratropium-Albuterol Neb 1 NEB NEB Q6H wheeze/SOB
RX *ipratropium-albuterol 0.5 mg-3 mg (2.5 mg base)/3 mL 1 NEB
INH every six (6) hours Disp #*60 Ampule Refills:*1
6. Miconazole Nitrate Vag Cream 2% 1 Appl VG QHS Duration: 3
Days
RX *miconazole nitrate 4 % (200 mg)-2 % (9 gram) 1 application
at bedtime Disp #*1 Package Refills:*0
7. Nystatin Oral Suspension 5 mL PO QID *AST Approval Required*
stop on ___
RX *nystatin 100,000 unit/mL 5 mls by mouth four times a day
Refills:*0
8. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*40 Tablet Refills:*0
9. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
10. Vancomycin 1250 mg IV Q 12H
Use through ___
RX *vancomycin 500 mg 1250 mg IV every twelve (12) hours Disp
#*42 Vial Refills:*0
11. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN
wheezing
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Descending mediastinitis.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
* You were admitted to the hospital with neck pain, difficulty
swallowing and paraesophageal inflammation on your CT scan. You
underwent surgery to clean out the infection and you've
recovered well. You are now ready for discharge but will need to
continue on antibiotics for another week. You had a PICC line
placed for that purpose and that will be removed by the ___
following completion of therapy.
.
* Continue to use your incentive spirometer 10 times an hour
while awake along with your nebulizers.
* Check your incisions daily and report any increased redness or
drainage. Cover the area with a gauze pad if it is draining.
* You may need pain medication once you are home but you can
wean it over the next week as the discomfort resolves. Make
sure that you have regular bowel movements while on narcotic
pain medications as they are constipating which can cause more
problems. Use a stool softener or gentle laxative to stay
regular.
* No driving while taking narcotic pain medication.
* Take Tylenol ___ mg every 6 hours .
* Continue to stay well hydrated and eat well to heal your
incisions
* Shower daily. Wash incision with mild soap & water, rinse, pat
dry
* No tub bathing, swimming or hot tubs until incision healed
* No lotions or creams to incision site
* Walk ___ times a day and gradually increase your activity as
you can tolerate.
Call Dr. ___ ___ if you experience:
-Fevers > 101 or chills
-Increased shortness of breath, chest pain or any other
symptoms that concern you.
Followup Instructions:
___
|
19591506-DS-18
| 19,591,506 | 26,422,534 |
DS
| 18 |
2159-05-06 00:00:00
|
2159-05-06 13:49:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
Hypotension/Altered Mental Status
Major Surgical or Invasive Procedure:
___ Right internal jugular central venous line
History of Present Illness:
___ year old man with lymphocyte-rich Hodgkin Lymphoma who
presented for his first cycle of chemotherapy and was
increasingly lethargic during infusion, was transferred to the
ED and found to be hypotensive despite 2L IVF, started on
levophed and admitted to MICU for hypotension.
He has a recent diagnosis of Hodgkin Lymphoma and was feeling
lethargic prior to his first cycle of AVDB today. He received
0.5 mg Ativan prior to the infusion and then was increasingly
lethargic, pale and was not following basic commands. He was
also found to be borderline hypotensive to 93/57 and was started
on 1L IVF and transferred to the ED. Patient notes that he ate
800mg of edible marijuana from ___ at 1130AM prior to his
infusion. He denies any other drug use at that time. He
complains of poor po intake and nausea, but no abdominal pain,
dysuria, diarrhea, dyspnea, chest pain.
In the ED, initial vitals: 98.7 92 113/62 12 100% RA
Exam notable for: Pallorous, globally weak, but soft nontender
nondistended, lungs clear to auscultation bilaterally and no
petechiae
Labs notable for: WC 5.1, hgb 7.5, PLT 123, lactate 2.1, Chem 10
WNL, negative UA, negative flu, T bili 1.6 D bili 0.3 o/w LFTs
WNL
Imaging:
CXR: Subtle lower lung opacities concerning for multifocal
pneumonia.
Liver/gallbladder US:
4 mm gallbladder polyp. No cholelithiasis or evidence of acute
cholecystitis.
No evidence of biliary obstruction. Massively enlarged and
heterogeneous spleen measuring up to 25 cm, similar to recent
CT.
CT Head: No acute intracranial abnormalities.
Patient received: 2 L IVF, 1xRBC, cefepime, azithromycin, RIJ
placed and started on levophed (for BP 86/43 after 2L IVF)
Vitals on transfer: 97.7 62 108/53 18 98% RA
Upon arrival to ___, patient notes that he feels well.
Complains of chronic fever which has been ongoing for a number
of months and was his presenting symptom. He notes poor
appetite. States that dizziness started in the bathroom at the
___. Notes that he eat an edible marijuana product
the morning before the infusion, while he normally smokes
marijuana. Denies any other drug use. Complains of cough for the
last few days along with nasal congestion. He denies diarrhea or
constipation.
Past Medical History:
1. EBV positive
2. Lymphocyte-rich Hodgkin's lymphoma, cycle 1 ABV-Brentuximab
3. Marijuana use
Social History:
___
Family History:
Maternal grandmother with breast cancer diagnosed in ___ and
also diabetes. He has a younger brother who is reportedly in
good health. He has no known family history of thalassemia,
blood disorders, Mediterranean fevers or
tuberculosis to his knowledge.
Physical Exam:
===============================
ADMISSION PHYSICAL EXAMINATION:
===============================
GENERAL: Lying comfortably in bed with parents at bedside.
A+Ox3.
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Bradycardia. Irregular. Normal S1, S2. No murmurs, rubs,
gallops
ABD: Soft, non-tender, non-distended. No rebound tenderness or
guarding, no organomegaly.
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: Multiple tattoos all over body. No rashes or lesions.
NEURO: CNII-XII intact. Strength ___ in upper and lower
extremities. Slow affect.
ACCESS: R IJ
===============================
DISCHARGE PHYSICAL EXAMINATION:
===============================
VS: Temp: 97.6 (Tm 98.3), BP: 104/71 (100-109/60-71), HR: 86
(85-90), RR: 18 (___), O2 sat: 100% (99-100), O2 delivery: RA
GENERAL: thin man, lying comfortably in bed, no acute distress
HEENT: no conjunctival pallor, anicteric sclera, MMM, oropharynx
without lesions
NECK: supple, non-tender, no JVD
CV: RRR, S1 and S2 normal, no murmurs/rubs/gallops
RESP: CTAB, no wheezes/crackles, breathing comfortably without
use of accessory muscles of respiration
___: soft, non-tender, non-distended, + splenomegaly, BS
normoactive
EXTREMITIES: warm/well perfused, no lower extremity edema
NEURO: A/O x3, grossly intact
SKIN: no skin rashes
Pertinent Results:
===============
ADMISSION LABS:
===============
___ 02:20PM BLOOD WBC-4.7# RBC-2.69* Hgb-7.5* Hct-24.6*
MCV-91 MCH-27.9 MCHC-30.5* RDW-17.0* RDWSD-54.9* Plt ___
___ 02:20PM BLOOD Neuts-81.2* Lymphs-9.0* Monos-7.7
Eos-0.2* Baso-0.2 Im ___ AbsNeut-3.80# AbsLymp-0.42*
AbsMono-0.36 AbsEos-0.01* AbsBaso-0.01
___ 07:30PM BLOOD Glucose-140* UreaN-29* Creat-1.1 Na-136
K-4.9 Cl-99 HCO3-25 AnGap-12
___ 02:20PM BLOOD ALT-7 AST-11 LD(LDH)-130 AlkPhos-76
TotBili-1.4
___ 07:30PM BLOOD CK-MB-<1 cTropnT-<0.01 proBNP-199*
___ 02:15AM BLOOD CK-MB-<1 cTropnT-<0.01
___ 07:30PM BLOOD Albumin-3.6 Calcium-9.9 Phos-4.4 Mg-1.7
___ 07:27PM BLOOD Lactate-2.1*
___ 09:41PM URINE Color-Straw Appear-Clear Sp ___
___ 09:41PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 09:41PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
========================
PERTINENT INTERVAL LABS:
========================
___ 07:27PM BLOOD Lactate-2.1*
___ 02:15AM BLOOD CK-MB-<1 cTropnT-<0.01
___ 02:40AM BLOOD Lactate-1.5
___ 08:08AM BLOOD Cortsol-0.3*
___ 08:08AM BLOOD TSH-2.9
___ 06:10AM BLOOD ___ 02:20PM BLOOD WBC-4.7 Lymph-9* Abs ___ CD3%-60 Abs
CD3-254* CD4%-24 Abs CD4-100* CD8%-35 Abs CD8-147* CD4/CD8-0.68*
___ 06:10AM BLOOD Cortsol-0.2*
======
MICRO:
======
___ Urine Culture -
___ Blood Culture x2 -
================
IMAGING/REPORTS:
================
___ CXR
Lung volumes are low. There are subtle ill-defined opacities in
the mid and lower lungs bilaterally concerning for multifocal
pneumonia. There is no large effusion or pneumothorax.
Cardiomediastinal silhouette appears normal. Imaged bony
structures are intact.
___ CT HEAD WITHOUT CONTRAST
No acute intracranial abnormalities\
___ LIVER/GALLBLADDER US
4 mm gallbladder polyp. No cholelithiasis or evidence of acute
cholecystitis. No evidence of biliary obstruction. Massively
enlarged and heterogeneous spleen measuring up to 25 cm, similar
to recent CT.
___ CXR
Compared with chest radiograph performed earlier on same day,
patient has
undergone interval placement of a right IJ central venous
catheter, which
terminates in the SVC. Lung volumes are improved from prior,
with improvement in previously seen bibasilar opacities, likely
representing improved atelectasis. No focal consolidation. No
pleural effusion or pneumothorax. Cardiomediastinal silhouette
is stable.
===============
DISCHARGE LABS:
===============
___ 06:10AM BLOOD WBC-3.2*# RBC-2.81* Hgb-7.9* Hct-25.5*
MCV-91 MCH-28.1 MCHC-31.0* RDW-17.2* RDWSD-55.5* Plt Ct-98*
___ 06:10AM BLOOD Neuts-86.9* Lymphs-7.2* Monos-4.7*
Eos-0.3* Baso-0.0 Im ___ AbsNeut-2.79# AbsLymp-0.23*
AbsMono-0.15* AbsEos-0.01* AbsBaso-0.00*
___ 06:10AM BLOOD ___ PTT-32.6 ___
___ 06:10AM BLOOD Glucose-93 UreaN-27* Creat-0.9 Na-140
K-4.3 Cl-104 HCO3-26 AnGap-10
___ 06:10AM BLOOD ALT-10 AST-16 LD(LDH)-145 AlkPhos-58
TotBili-2.1*
___ 06:10AM BLOOD Calcium-8.5 Phos-2.8 Mg-2.2 UricAcd-8.8*
Brief Hospital Course:
___ with new diagnosis of lymphocyte-rich Hodgkin's lymphoma,
cycle 1 AVD-Brentuximab Q2 weeks, who was transferred to ED with
increasing lethargy during first infusion of chemotherapy, found
to be hypotensive despite adequate fluid resuscitation in ED,
and transferred to ___ for pressure management with pressors.
====================
ACUTE/ACTIVE ISSUES:
====================
# Hypotension
# Lethargy
Patient presented to ED with increasing lethargy and altered
mental status during first infusion of chemotherapy. Found to be
hypotensive, not-responsive to 2L of IVF, requiring admission to
___ for pressure support with norepinephrine. Required pressors
overnight, but was quickly weaned of norepinephrine ___, with
pressures remaining stable. Etiology somewhat unclear; the most
likely etiology was marijuana overdose, given patient reported
ingestion of 1g of edible marijuana prior to chemotherapy
infusion, and ___ previous similar episodes following marijuana
ingestion at home. However, it was strange symptoms persisted
overnight, with continued requirement for pressure support.
Infectious work-up was negative, but patient was prescribed a
course of azithromycin for possible CAP, which he will complete
on discharge. Other possible etiologies included cardiac
toxicity from Adriamycin with associated bradycardia, although
unlikely given onset of lethargy prior to initiation of
chemotherapy, and adrenal insufficiency, in the setting of
recent dexamethasone use and AM cortisol of 0.3, although repeat
AM cortisol of 0.2 on ___. Patient remained stable on the
floor, and was discharged with oncology follow-up and to
complete course of azithromycin.
# Bradycardia
On admission to the ___, patient was found to be bradycardic to
___, but in sinus rhythm. Required increasing doses of
norepinephrine initially, before weaning off same. EKG
demonstrated 1mm STE in the inferior leads without reciprocal
changes most
consistent with benign early repolarization. Troponins negative
x2. Although etiology unclear, it was most likely secondary to
increased vagal tone in the setting of marijuana overdose. Heart
rates remained stable on the floor.
# Toxic-metabolic encephalopathy
Patient presented with altered mental status in the setting of
hypotension. There was concern initially for hypoperfusion, as
mental status improved with IVF and norepinephrine, however
symptoms likely correlated with marijuana overdose. CT head was
negative for bleed. Symptoms resolved, and patient back to
baseline prior to discharge.
# Anemia
# Thrombocytopenia
Hemoglobin decreased to 7.5 from ___ in ___, likely in the
setting of Hodgkin's lymphoma. Remained stable throughout
admission, but may drop in the setting of chemotherapy.
# EBV positive
# Lymphocyte rich Hodgkin's lymphoma
Diagnosed from biopsy on ___ with EBV positive classic
Hodgkin's lymphoma. Biospy consistent with lymphocyte-rich
variant rather than mixed cellularity subtype. Underwent first
infusion of AVD-Brentuximab on ___ and developed
hypotension and altered mental status shortly thereafter, as
detailed above. Started on allopurinol for prophylaxis. Will be
discharged with close follow-up with oncologist.
====================
TRANSITIONAL ISSUES:
====================
- discharge WBC 3.2
- discharge Hgb 7.9
- discharge Plt 9.8
- discharge creatinine 0.9
MEDCIATION CHANGES:
[] allopurinol ___ daily
[] azithromycin 250mg daily for two days
[] stopped dexamethasone and prochlorperazine
[] Follow-up with oncology for next dose of AVD-Brentuximab
[] Encourage reduction/discontinuation of marijuana use given
presentation
[] Re-check AM cortisol
=========================================
# CODE STATUS: Full
# CONTACT: ___, HCP/mother, ___
Medications on Admission:
1. Ondansetron 8 mg PO Q8H:PRN nausea
2. Dexamethasone 4 mg PO DAILY
3. Prochlorperazine 5 mg PO Q6H:PRN nausea
4. Docusate Sodium 100 mg PO BID
5. Senna 8.6 mg PO BID:PRN constipation
6. Multivitamins 1 TAB PO DAILY
7. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
RX *allopurinol ___ mg 1 tablet(s) by mouth Daily Disp #*30
Tablet Refills:*0
2. Azithromycin 250 mg PO DAILY Duration: 2 Doses
RX *azithromycin 250 mg 1 tablet(s) by mouth Daily Disp #*2
Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
4. Multivitamins 1 TAB PO DAILY
5. Ondansetron 8 mg PO Q8H:PRN nausea
6. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
7. Senna 8.6 mg PO BID:PRN constipation
Discharge Disposition:
Home
Discharge Diagnosis:
- Hypotension/Bradycardia/Altered mental status, likely
secondary to marijuana ingestion
- Marijuana use disorder
- Hodgkin's lymphoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
WHY YOU CAME TO THE HOSPITAL
You were admitted to the hospital because you became confused
and had a low blood pressure during your chemotherapy infusion
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL
- You were transferred to the ICU for a medication to raise your
blood pressure
- This medication was also used to increase your heart rate
- Your symptoms improved and we were able to stop the
medication, without recurrence of symptoms
- You had a number of scans and tests which did not show any
evidence of infection prior to discharge
- We started you on a number of medications which are important
to take while you are having chemotherapy
- We also started you on an antibiotic to treat possible
underlying pneumonia, which you will need to complete at home
WHAT YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL
- It is important to follow-up with all your oncology
appointments
- Please take all your medications as prescribed
It was a pleasure taking care of you!
Your ___ Healthcare Team
MEDICATION CHANGES:
[] allopurinol ___ daily
[] azithromycin 250mg daily for two days
[] stopped dexamethasone and prochlorperazine
Followup Instructions:
___
|
19591855-DS-5
| 19,591,855 | 24,495,526 |
DS
| 5 |
2155-03-09 00:00:00
|
2155-03-10 21:26:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
RUQ abdominal pain
Major Surgical or Invasive Procedure:
s/p laparoscopic cholecystectomy
History of Present Illness:
Mrs. ___ is an ___ year old female with HTN who presents
with abdominal pain for 1 day. The pain is located primary in
her right upper quadrant and mid-epigastrium, started after
dinner, constant, with radiation to the back and mid-abdomen,
associated with 1 episode of nonbloody "projectile" vomiting.
She had never had pain like this before. She last had a soft
non-bloody BM at home prior to arrival in ED. She has no fever,
chills, chest pain, shortness of breath, diarrhea, or recent
malaise.
Past Medical History:
HTN, arthritis, psoriasis
Social History:
___
Family History:
Non-contributory
Physical Exam:
Physical exam on admission ___
VS: T 97.6, HR 89, BP 185/73, RR 20, SaO2 97% RA
GEN: Uncomfortable appearing, alert and cooperative
HEENT: NCAT, EOMI, dry mucous membranes
CV: hypertensive SBP 180s, regular rate and rhythm
PULM: Easy work of breathing, clear to auscultation
ABD: Soft, diffusely tender to palpation, RUQ worst, + ___,
no
guarding or rebound tenderness
MSK: Moving all extremities spontaneously, palpable bilateral
radial and DP pulses
NEURO: CII-XII grossly intact
PSYCH: Appropriate mood and affect
Pertinent Results:
___ 01:54AM BLOOD WBC-9.0# RBC-4.58 Hgb-13.0 Hct-40.2
MCV-88 MCH-28.4 MCHC-32.3 RDW-15.1 RDWSD-48.0* Plt ___
___ 01:54AM BLOOD Neuts-66.7 ___ Monos-5.7 Eos-0.3*
Baso-0.2 Im ___ AbsNeut-5.97 AbsLymp-2.40 AbsMono-0.51
AbsEos-0.03* AbsBaso-0.02
___ 02:57AM BLOOD ___ PTT-27.7 ___
___ 01:54AM BLOOD Plt ___
___ 01:54AM BLOOD Glucose-142* UreaN-17 Creat-0.8 Na-138
K-3.7 Cl-100 HCO3-25 AnGap-17
___ 01:54AM BLOOD ALT-13 AST-15 AlkPhos-110* TotBili-0.2
___ 01:54AM BLOOD Lipase-46
___ 01:54AM BLOOD cTropnT-<0.01
___ 01:54AM BLOOD Albumin-4.0 Calcium-9.4 Phos-1.5* Mg-2.1
___ 02:21AM BLOOD ___ pO2-57* pCO2-37 pH-7.42
calTCO2-25 Base XS-0 Comment-GREEN TOP
___ 05:33AM BLOOD Lactate-3.6*
___ 02:21AM BLOOD Lactate-4.7*
Liver, gallbladder ultrasound ___:
IMPRESSION:
Thickened gallbladder wall with irregular mucosal surface is
suspicious for a cholecystitis with mucosal sloughing. Multiple
gallstones are identified in the gallbladder neck.
CTA abdomen pelvis ___
IMPRESSION:
1. Gallbladder wall is thickened and edematous, consistent with
cholecystitis. Gallbladder contains multiple gallstones.
CXR ___
Bibasilar atelectasis and/ or small pleural effusions. No
evidence of large pneumoperitoneum is identified. If there is
clinical concern for
pneumoperitoneum, consider repeat radiograph with upright
patient position or CT.
ECG ___
Clinical indication for EKG: R10. 84 - Generalized abdominal
pain
Sinus rhythm. Compared to the previous tracing of ___ no
change.
Brief Hospital Course:
Mrs. ___ is an ___ year old female with HTN who presented to
the ED with
abdominal pain for 1 day. The pain was located primary in her
right upper quadrant and mid-epigastrium, started after dinner,
constant, with radiation to the back and mid-abdomen, associated
with 1 episode of nonbloody "projectile" vomiting. She
has never had pain like this before. She last had a soft
nonbloody BM at home prior to arrival in ED. She has no fever,
chills, chest pain, shortness of breath, diarrhea, or recent
malaise.
She had an abdominal CT and ultrasound on ___ which showed
acute cholecystitis with gallstones present. She underwent a
laparoscopic cholecystectomy on ___. The patient had minimal
blood loss without surgical complications. No post-operative
antibiotics were needed.
She was started on a clear diet on POD1, then transitioned to a
regular diet POD2. Her pain has been well controlled on oral
analgesia. She has been ambulating independently. She has not
been passing gas or had a bowel movement. Her vital signs have
been stable. She has been started on her home medications. She
is medically stable for discharge.
Medications on Admission:
HCTZ 25 QD
Lisinopril 20 mg QD
Hydrocortisone 2.5% topical cream prn
Tylenol 3 TID prn pain
Discharge Medications:
1. Senna 17.2 mg PO HS
2. Hydrochlorothiazide 25 mg PO DAILY
3. Lisinopril 20 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*20 Capsule Refills:*0
5. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
this may cause drowsiness, do not drive with this medication
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*25 Tablet Refills:*0
6. Acetaminophen 650 mg PO TID
Discharge Disposition:
Home
Discharge Diagnosis:
acute cholecystitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with abdominal pain and were
found to have an inflamed gallbladder and underwent a
laparoscopic cholecystectomy. You have been able to tolerate a
regular diet. Your pain is been well controlled with oral pain
meds. You are being discharged 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:
___
|
19591974-DS-6
| 19,591,974 | 24,071,410 |
DS
| 6 |
2131-05-30 00:00:00
|
2131-05-30 13:14:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Neck pain/stiffness/falls s/p programming of DBS
Major Surgical or Invasive Procedure:
___ L DBS extension, lead replacement
History of Present Illness:
___ yo male patient known to us. He underwent implantation
of Left DBS on ___. Since presenting to ___ to programming
he has had a flexed cervical posture and piltaeral frontal scalp
pain. Per his wife he has been more agitated and not sleeping.
He want back last week to get the programming adjusted and since
then his symptoms have worsened.
Past Medical History:
___ disease, gastritis, DM2, bilateral DBS placement
Social History:
___
Family History:
Non-contributory
Physical Exam:
On admission:
O: T:98.9 BP: 126/61 HR:104 R:22 O2Sats: 98 RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: ERRLA ___ EOMs intact
Neck: nontender.
Chest/Head: Surgical DBS incisions CDI without and redness or
erythema
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: nonverbal. follows commands
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, except slight RLE
weakness with ___ ___ (baseline) Unable to test drift. RUE
tremor > LUE and BLE.
Sensation: Intact to light touch.
On discharge:
Surgical DBS incisions CDI without and redness or
erythema Nonverbal. EO spontaneously. Follows simple commands,
Right tremor, PERRL, R side ___, L side ___
Pertinent Results:
___ Chest:
Left lung base opacity most likely represents atelectasis, but
infection or aspiration should be considered in the appropriate
clinical setting. No large pleural effusions.
___ CT c-spine without contrast:
No acute fracture or traumatic malalignment.
___ CT head without contrast:
1. No acute intracranial process.
2. Unchanged position of bilateral deep brain stimulators.
Brief Hospital Course:
Mr. ___ was admitted to the inpatient ward for further
work-up of his neck pain and extreme neck flexion. CT head and
c-spine were negative for any acute changes. The patient's DBS
lead was in good placement and stable when compared to prior
imaging. Mr. ___ had a lactate level of 2.4, so he was
given IV fluids for hydration. He was pan-cultured to rule out
an infectious source leading to his recent falls.
On ___, Neurology was consulted due to concerns of worsening
___ disease. Based on their evaluation, his Rytara was
increased to 2 tablet four times daily. Mr. ___ was kept
inpatient for continued neurologic monitoring.
On ___, Physical Therapy was asked to see the patient to
disposition planning. As expected, the patient would benefit
from discharged to a SNF as his needs are quite difficult to
manage at home. Case Management began the search for a
facility. According to Mr. ___ wife, the patient continued
to have intermittent left-sided headaches/pain and quite
possibly shocks. To rule out the latter scenario, Mr. ___
DBS was turned off and the frequency of further episodes would
be assessed.
On ___ Patient reported improvement in pain since DBS was
turned off. He was more awake and interactive but tremor was
worse. DBS was turned on for a second trial and one hour after
DBS had be on patient was having obvious increased pain.
Stimulator was turned off. Plan was made for revision of DBS
tomorrow in the OR.
On ___ Patient was taken to the OR for extension of L DBS lead.
The procedure was uncomplicated. He was transferred to the PACU
post operatively for recovery.
On ___, the patient's pain improved. He was screened for a
rehabilitation bed and authorized for one on ___.
On ___, the patient remained comfortable and stable.
On ___, the patient was pain-free and his neurological exam
remained stable.
On ___, the patient remained comfortable. His neurologic
examination was stable. He was deemed ready for discharge to a
skilled nursing facility.
Medications on Admission:
atorvastatin, carbidopa/levadopa, glycoprrolate, opratropium
bromide nasal spray, repaglinide, aspirin, colace, lactose
reduced food with fibr, miralax
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain, fever
2. Atorvastatin 20 mg PO QPM
3. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
4. Docusate Sodium 100 mg PO BID
5. Heparin 5000 UNIT SC TID
6. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using REG Insulin
7. Nystatin Oral Suspension 5 mL PO QID:PRN thrush
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
9. Repaglinide 1 mg PO BID
10. Rytary (carbidopa-levodopa) 23.75-95 mg oral QID
11. Senna 8.6 mg PO BID:PRN constipation
12. TraMADOL (Ultram) ___ mg PO Q4H:PRN pain
RX *tramadol 50 mg ___ tablet(s) by mouth q4H PRN Disp #*45
Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
___ Disease
Neck Pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid.
Nonverbal. EO spontaneously. Follows simple commands, Right
tremor, PERRL, R side ___, L side ___
Discharge Instructions:
You were admitted to ___ Neurosurgery service for further
work-up of your neck pain and neck mobility issues. Your head
CT and cervical spine CT showed no new findings attributable to
your symptoms. Neurology was consulted for their assistance in
evaluating your condition.
Your Rytary has been increased to two tablets four times daily.
Your are now being discharged with the following instructions:
Activity
You may gradually return to your normal activities, but we
recommend you take it easy for the next ___ hours.
Strenuous activity should be avoided for ten (10) days.
You may take leisurely walks and slowly increase your activity
at your own pace. ___ try to do too much too soon.
Do not go swimming or submerge yourself in water until your
staples have been removed and for fourteen (14) days after your
procedure.
Do not get your head wet in the shower until your staples are
removed.
Resume your normal ___ medications. The neurologist
programming your device may adjust your medications once
programming begins.
Take any new medications (i.e. pain medications) as directed.
If you were on a medication such as Coumadin (Warfarin), or
Plavix (Clopidogrel), or Aspirin, do not take this until cleared
by your Neurosurgeon.
Do not take any anti-inflammatory medicines such as Motrin,
Aspirin, Advil, or Ibuprofen etc. until follow up.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
Mild tenderness along the incisions.
Soreness in your arms from the intravenous lines.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
Severe Constipation
Blood in your stool or urine
Nausea and/or vomiting
Extreme sleepiness
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Followup Instructions:
___
|
19592648-DS-16
| 19,592,648 | 20,871,209 |
DS
| 16 |
2179-10-30 00:00:00
|
2179-10-30 13:04:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left ankle fracture
Major Surgical or Invasive Procedure:
Left ankle ORIF ___, K rod)
History of Present Illness:
___ male presents with the above fracture s/p direct crush
incident. Patient reports that he was at work, and closed to
Demster door on his ankle. He noted immediate pain. He states
that the pain is primarily over his ankle and the dorsum of his
foot. He feels he is unable to walk. He denies any numbness or
tingling of the foot. Denies any injuries to additional joints
including knee, hip. No history of previous orthopedic
surgeries
or injuries to this foot. Otherwise healthy, no past medical
history, medications.
Past Medical History:
none
Social History:
___
Family History:
nc
Physical Exam:
Left lower extremity:
In short leg splint
Sensation intact over exposed toes
Firing ___, FHL
Toes WWP
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left ankle fracture and was admitted to the orthopedic
surgery service. The patient was taken to the operating room on
___ for left ankle ORIF which the patient tolerated well. For
full details of the procedure please see the separately dictated
operative report. The patient was taken from the OR to the PACU
in stable condition and after satisfactory recovery from
anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient was given ___ antibiotics and anticoagulation
per routine. The patient's home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to home was appropriate. The ___
hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
touchdown weightbearing in the left lower extremity, and will be
discharged on aspirin 325 mg daily for DVT prophylaxis. The
patient will follow up with Dr. ___ routine. A
thorough discussion was had with the patient regarding the
diagnosis and expected post-discharge course including reasons
to call the office or return to the hospital, and all questions
were answered. The patient was also given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient expressed readiness for discharge.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild
Reason for PRN duplicate override: Alternating agents for
similar severity
2. OxyCODONE (Immediate Release) ___ mg PO Q3H:PRN Pain -
Moderate
3. Senna 8.6 mg PO BID:PRN Constipation - First Line
Discharge Disposition:
Home
Discharge Diagnosis:
Left ankle fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
-Touchdown weightbearing right lower extremity in splint
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is
an over the counter medication.
2) Add oxycodone as needed for increased pain. Aim to wean
off this medication in 1 week or sooner. This is an example on
how to wean down:
Take 1 tablet every 3 hours as needed x 1 day,
then 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per state regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you
should drink eight 8oz glasses of water daily and continue
following the bowel regimen as stated on your medication
prescription list. These meds (senna, colace, miralax) are over
the counter and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your
physicians at discharge.
8) Continue all home medications unless specifically
instructed to stop by your surgeon.
ANTICOAGULATION:
- Please take aspirin 325 mg daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
- If you have a splint in place, splint must be left on until
follow up appointment unless otherwise instructed. Do NOT get
splint wet.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever ___ 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
FOLLOW UP:
Please follow up with your Orthopaedic Surgeon, Dr. ___.
You will have follow up with ___, NP in the
Orthopaedic Trauma Clinic 14 days post-operation for evaluation.
Call ___ to schedule appointment upon discharge.
Please follow up with your primary care doctor regarding this
admission within ___ weeks and for any new medications/refills.
Followup Instructions:
___
|
19592787-DS-6
| 19,592,787 | 23,888,277 |
DS
| 6 |
2189-08-21 00:00:00
|
2189-11-12 11:09:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
cefazolin
Attending: ___.
Chief Complaint:
Abdominal pain
Postoperative ileus
Major Surgical or Invasive Procedure:
___ Laparotomy and resection of ileocolic anastomosis
___ Drainage of intra-abdominal collection
History of Present Illness:
___ with recent history of laparoscopic colectomy for colon CA
discharged from ___ under colorectal surgery service ___
now presents with abdominal pain. Since discharge he has had
moderate difficulty with PO intake, reporting frequent burping
and emesis after taking liquids. He called with concerns on
___ and was suggested to come in but elected to try to manage
with liquids at home. Now he presents with about 24 hours of
decreased bowel function as measured by no stool output and
decreased flatus.
Past Medical History:
hypothyroid
depression
htn
prostate CA- s/p RRP
Social History:
___
Family History:
Non-contributory
Physical Exam:
Exam on presentation:
98.5 98 114/70 18 97% RA
AOx3 NAD, pleasant
RRR S1S2
Normal WOB
Abd softly distended, incisions healing well, mild ttp, nonfocal
examination
Ext well perfused
Exam at discharge:
General: cooperative, abulating with assistance
VSS
GEN: NAD, AOx3
ABD: midline incision open and packed with gauze dressing, ___
drain in place
Pertinent Results:
___ 04:15AM BLOOD WBC-10.6 RBC-3.59* Hgb-9.7* Hct-30.1*
MCV-84 MCH-27.1 MCHC-32.3 RDW-14.6 Plt ___
___ 06:40AM BLOOD WBC-12.1* RBC-3.32* Hgb-9.0* Hct-28.1*
MCV-85 MCH-27.0 MCHC-31.9 RDW-14.3 Plt ___
___ 06:20AM BLOOD WBC-14.7* RBC-3.65* Hgb-9.7* Hct-30.9*
MCV-85 MCH-26.7* MCHC-31.6 RDW-14.5 Plt ___
___ 04:40AM BLOOD WBC-15.6* RBC-4.30* Hgb-11.7* Hct-35.9*
MCV-83 MCH-27.2 MCHC-32.6 RDW-14.7 Plt ___
___ 08:10AM BLOOD WBC-11.2* RBC-4.09* Hgb-11.2* Hct-34.4*
MCV-84 MCH-27.4 MCHC-32.5 RDW-14.8 Plt ___
___ 07:10AM BLOOD WBC-12.2* RBC-3.95* Hgb-10.9* Hct-33.3*
MCV-84 MCH-27.6 MCHC-32.7 RDW-14.6 Plt ___
___ 06:50AM BLOOD WBC-12.5* RBC-3.81* Hgb-10.3* Hct-31.9*
MCV-84 MCH-27.1 MCHC-32.4 RDW-14.1 Plt ___ 04:15AM
BLOOD Glucose-149* UreaN-20 Creat-0.7 Na-137 K-3.7 Cl-103
HCO3-27 ___ 05:09AM BLOOD Glucose-127* UreaN-20
Creat-0.7 Na-139 K-4.0 Cl-104 HCO3-30 ___ 10:13AM
BLOOD Glucose-493* UreaN-17 Creat-0.7 Na-134 K-4.0 Cl-102
HCO3-30 AnGap-6
___ 06:20AM BLOOD Glucose-129* UreaN-13 Creat-1.0 Na-137
K-4.8 Cl-102 HCO3-28 AnGap-12
___ 04:40AM BLOOD Glucose-135* UreaN-12 Creat-0.9 Na-138
K-4.8 Cl-103 HCO3-29 AnGap-11
___ 08:10AM BLOOD Glucose-118* UreaN-7 Creat-0.9 Na-138
K-4.5 Cl-103 HCO3-30 AnGap-10
___ 07:10AM BLOOD Glucose-135* UreaN-7 Creat-0.9 Na-139
K-4.5 Cl-101 HCO3-31 AnGap-12
___ 06:50AM BLOOD Glucose-133* UreaN-8 Creat-1.0 Na-142
K-3.9 Cl-103 HCO3-33* AnGap-10
___ 10:13AM BLOOD Albumin-2.6* Calcium-8.7 Phos-3.1 Mg-2.1
Iron-17*
___ 06:40AM BLOOD Calcium-8.8 Phos-3.7 Mg-2.1
___ 06:20AM BLOOD Calcium-9.0 Phos-3.1 Mg-2.0
___ 04:40AM BLOOD Calcium-8.7 Phos-3.7 Mg-1.9
___ 08:10AM BLOOD Albumin-3.1*
___ 10:13AM BLOOD calTIBC-198* Ferritn-209 TRF-152*
___ 10:13AM BLOOD Triglyc-117
___ 05:00AM BLOOD HoldBLu-HOLD
___ 05:00AM BLOOD LtGrnHD-HOLD
CHEST PORT. LINE PLACEMENT Study Date of ___ 9:26 AM
IMPRESSION:
Right PICC terminates in the mid SVC. No pneumothorax.
CT ABD & PELVIS WITH CONTRAST Study Date of ___ 10:31 AM
IMPRESSION:
1. Multiple new organized fluid collections within the abdomen
as described above, raising concern for abscess/infection.
2. Two foci of air are seen adjacent to the duodenum, could
reflect a
potential leak versus residual post-operative air.
3. Right and left colonic anastomoses appear grossly intact.
4. Multiple fluid-filled dilated loops of small bowel with no
definite
transition point identified and fluid seen in distal colon.
Findings could
relate to postsurgical ileus.
5. Moderate intra-abdominal ascites.
6. 6.8 cm fat attenuating lesion in the right upper quadrant,
for which
differential diagnoses include lipoma versus low grade
liposarcoma.
7. Moderate amount of air seen within the urinary bladder,
likely relates to
recent instrumentation. Correlation with history recommended.
PERC IMAGE GUID FLUID COLLECT DRAIN W
CATH(ABSC,HEMA/SEROMA;LYMPHOCELE,CYST);PERIT/RETROPERITONEAL
Study Date of ___ 3:36 ___
IMPRESSION:
Successful US-guided placement of ___ pigtail catheter into
the right mid abdominal collection. Sample sent for
microbiology evaluation.
CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of ___
11:42 AM
IMPRESSION:
1. No acute aortic pathology or pulmonary embolism. No
pneumonia.
2. Small foci of extraluminal air at the right colonic
anastomotic site, deep to the umbilical port site, are new from
___. If there has been interval manipulation of the
port site, the air may be related to manipulation. If there is
not been manipulation, this raises the possibility of an
anastomotic leak and close clinical followup is suggested.
3. Ileus. No drainable fluid collection in the abdomen or
pelvis.
Brief Hospital Course:
Mr. ___ presented to the ED at ___ on ___ for
abdominal pain and symptoms of postoperative ileus as well as
rash, which was non-operatively managed without the need for NGT
placement. After a brief and uneventful stay in the ED, the
patient was transferred to the floor for further management.
Neuro: His pain was well-controlled on IV transitioned to PO
pain meds.
CV: He remained stable throughout the hospitalization from a
cardiac standpoint.
Pulm: He remained stable throughout his hospitalization from a
pulmonary standpoint. Incentive Spirometry and frequent
ambulation were encoraged.
GI: CT scan at the time of admission showed no specific focal
findings, other than a small amount of air under the midline
incision near the ileocolic anastomosis. On ___ the midline
incision began to drain moderate amounts of bilious fluid
through the wound and this was likely a fistula. Given that the
patient was not to far from his initial procedure he was taken
to the operating room for Laparotomy and resection of ileocolic
anastomosis ___. THe remainer of the admission was
complicated by awaiting return of bowel function, intraabdominal
fluid collection, and wound infection. An NGT was left in place
post-opreatively and was draining bilious fluid. On ___ the
foley catheter was removed and the patient was due to void. We
awaited retun of bowel function. On ___ The NGT was
removed. On ___ The pervena vac was removed and the
incision looked intact. On ___ antibiotics were
discontinued however the wound appeared red and this was opened
at the bedside. On ___ The patient had signs of ileus and a
CT scan of the abdomen was preformed to rule out leak and a
fluid collections were seen within the abdomen above, raising
concern for infection. The collection was drained. On ___
the patient was started on PPN and he remained NPO with
intravenous fluids. On ___ a PICC line was placed and TPN
initiated. ___ the patient had episodes of desat's to mid
80's however this improved with oxygen. Over the next few days
he continued to improve. The drain was drianing. The abscess
appeared to be connected to the bowel and the ___ placed drain
was draining green bile. The patient remained on bowel rest with
the hopes that this connection would close on it's own. He was
started on PO antibiotics for discharge home to cover the
multiple bacteria which grew from the abscess culture. He would
remain on TPN for discharge home with close followup with Dr.
___ to decide if the diet would be advanced or if any further
intervention whould be needed to repair this area. The Midine
wound was left open with a gauze packing to be cared for at home
by the ___. It was not redened or drianing puss.
GU: After the foley catheter was removed, the patient voided
without issue.
SKIN: On admission, patient had a raised rash whith what
appeared to be wheels over the skin of his anterior abdomen
extending to his groin, chest, and back. He was not taking any
new medications that would signify the rash to be allergic.
However, after drainage of the intraabdominal fluid collection
and improvement in his overall clinical picutre, the rash
resolved. The exact cause of this rash was not determined
however, it seemed to be likely related to a reaction to his
overall clinical situation at the time of his admission.
Discharge Planning: There was a large effort from case managment
and the nursing staff to organize a safe discharge plan for this
patient. The patient was taught to care for the drain site and
basic PICC line care. There were multiple levels of discharge
planning coordinating with the family and IV services for the
TPN. The family decided to pay for the TPN on their own given
lack of insurance coverage. The IV team met with the family
prior to discharge.
Post-Surgical Complications During Inpatient Admission:
[ ] Post-Operative Ileus resolving w/o NGT
[ ] Post-Operative Ileus requiring management with NGT
[ ] UTI
[ ] Wound Infection
[x] Anastomotic Leak/fistula to midline incision
[ ] Staple Line Bleed
[ ] Congestive Heart failure
[ ] ARF
[ ] Acute Urinary retention, failure to void after Foley D/C'd
[ ] Acute Urinary Retention requiring discharge with Foley
Catheter
[ ] DVT
[ ] Pneumonia
[x] Abscess s/p drainage in radiology
[ ] None
Social Issues Causing a Delay in Discharge:
[ ] Delay in organization of ___ services
[ ] Difficulty finding appropriate rehabilitation hospital
disposition.
[ ] Lack of insurance coverage for ___ services
[ ] Lack of insurance coverage for prescribed medications.
[ ] Family not agreeable to discharge plan.
[ ] Patient knowledge deficit related to ileostomy delaying
discharge.
[x] No social factors contributing in delay of discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 12.5 mcg IV DAILY
2. Amlodipine 10 mg PO DAILY
3. Epinephrine 1:1000 0.3 mg IM ASDIR
4. Hydrochlorothiazide 25 mg PO DAILY
5. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
6. Sertraline 50 mg PO DAILY
7. Acetaminophen 650 mg PO Q6H:PRN pain
8. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Metoprolol Tartrate 25 mg PO BID
RX *metoprolol tartrate 25 mg 1 tablet(s) by mouth twice day
Disp #*14 Tablet Refills:*0
2. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*14
Tablet Refills:*0
3. Epinephrine 1:1000 0.3 mg IM ASDIR
uses only for bee stings
4. Hydrochlorothiazide 25 mg PO DAILY
RX *hydrochlorothiazide 25 mg 1 tablet(s) by mouth once a day
Disp #*14 Tablet Refills:*0
5. Sertraline 50 mg PO DAILY
RX *sertraline [Zoloft] 50 mg 1 tablet(s) by mouth once a day
Disp #*14 Tablet Refills:*0
6. Levothyroxine Sodium 25 mcg PO DAILY
RX *levothyroxine 25 mcg 1 tablet(s) by mouth once a day Disp
#*14 Tablet Refills:*0
7. Amlodipine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth once a day Disp #*14
Tablet Refills:*0
8. MetRONIDAZOLE (FLagyl) 500 mg PO TID Duration: 2 Weeks
Continue until ___
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth three
times a day Disp #*42 Tablet Refills:*0
9. Ciprofloxacin HCl 500 mg PO Q12H Duration: 2 Weeks
Coninue until ___
RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth Twice a
day Disp #*28 Tablet Refills:*0
10. Acetaminophen 650 mg PO Q6H:PRN pain
RX *acetaminophen 325 mg ___ tablet(s) by mouth every six (6)
hours Disp #*40 Tablet Refills:*0
11. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every ___ hours Disp
#*40 Tablet Refills:*0
12. sodium chloride 0.9 % 5 cc ___ drain site Daily
Please flush ___ placed drain with 5cc of sterile normal saline
once saily to maintain patency of drain
RX *sodium chloride 0.9 % 0.9 % 5 cc ___ Drain Daily Disp #*14
Syringe Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Postoperative ileus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for symptoms of postoperative
ileus (or functional bowel obstruction). You were given bowel
rest and intravenous fluids. You also had a very significant
rash for which you were seen by dermatology. This was related to
a connection or fistula which formed from the staple line of an
area in the colon where the two ends were stapled together. This
required surgical repair. Unfortunately, after the surgical
repair, you developed symptoms of infection and this was related
to a fluid collection that also seems to be connected to the
bowel. An ___ drain was placed in this collection and has been
draining green bile however, with bowel rest, the drainage has
been decreasing in amount and is controlled. You will need to
take the antibiotics Cipro and Flagyl. It is very important you
continue to take this medication to prevent infection. Dr. ___
will see you at our ___ next ___ at 10am.
It is very important that you continue to care for the ___ placed
drain. You may shower with the drain in place. The visiting
nurses ___ help care for the drain however, it should be
cleansed as ordered daily and a clean dry sterile gauze dressing
applied with paper tape. Monitor the incertion site for signs of
infection including: swelling of the site, drainage of
yellow/green/foul smelling drainage around the catheter or
increased pain at the site. If the site is bleeding please call
our office. Please record the amount of drainage from the drai
each time it is emptyied. Please be sure that the bulb drain is
emptied when it is ___ full to prevent leaking. The drain should
be flushed with 5cc of sterile normal saline daily. Please call
with issues related to the drain.
You cannot eat or drink until your follow-up with Dr. ___. You
should use ice mouth swabs for comfort. Dr. ___ loosen the
diet restrictions next week at your follow-up. While we are
allowing the fistula/collection to drain and heal, we will be
giving you TPN at home. This will be delivered by the infusion
company. IT is important that the PICC line is cared for, please
monitor the incertion site for infection: pain at the site,
drianage of puss or infected appearing drainage, redness of the
site, or if you develop a fever. The nurses ___ care for your
___ line dressing, however it is important that the dressing
stays clean and intact. You should cover the line with plastic
wrap and tape prior to showers.
You have an open midline would which is a dry sterile gauze
dressing and secured with paper tape. This should be changed
twice daily by the visiting nursing team. Monitor the wound for
signs of infection: increased pain in the wound, infected
(yellow, green, foul smelling, thick) drainage, please call if
the skin around the wound has increasing redness.
Please monitor your bowel function closely. If you notice that
you are passing bright red blood with bowel movements or having
loose stool without improvement please call the office or go to
the emergency room if the symptoms are severe. If you are taking
narcotic pain medications there is a risk that you will have
some constipation. Please take an over the counter stool
softener such as Colace, and if the symptoms do not improve call
the office. If you have any of the following symptoms please
call the office for advice or go to the emergency room if
severe: increasing abdominal distension, increasing abdominal
pain, nausea, vomiting, inability to tolerate food or liquids,
prolonged loose stool, or extended constipation.
You will continue to take antibiotics until your follow up
appointment with colorecetal surgery.
Thank you for allowing us to participate in your care! Our hope
is that you will have a quick return to your life and usual
activities. Good luck!
Followup Instructions:
___
|
19592790-DS-5
| 19,592,790 | 29,523,030 |
DS
| 5 |
2185-08-05 00:00:00
|
2185-08-05 19:11:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
ciprofloxacin / Codeine / Latex, Natural Rubber / naproxen /
Tylenol
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with extensive abdominal pain, N/V/D history and work-up,
now being treated for suspected Crohn's (on Mesalamine and
Prednisone) admitted for acute on chronic abdominal pain. Pt has
had extensive workup and multiple OSH admissions for abdominal
pain. She has had GI symptoms since age ___, initially followed at
___. For the last ___ years, she has had
episodes of recurrent abdominal pain with imaging showing small
bowel inflammation. She has had several endoscopies and
colonoscopies that did not show inflammation. Exploratory
laparotomy in ___ was normal. She was treated in ___ with
triple therapy for possible tuberculosis enteritis after a
positive PPD. Double balloon enteroscopy in ___ was also
normal.
More recently, she has presented to ___ with acute
on chronic abdominal pain. Imaging again intermittently showed
inflammation in TI and decision was made to start empiric
prednisone which resulted in improvement of symptoms.
She was recently admitted ___ after her
gastroenterologist at ___ referred her to ___
for second opinion. During this admission, GI consultation, MR
enterography, and small bowel biopsy were performed. MR
enterography showed distal terminal/cecal wall thickening.
Colonoscopy was performed and was unremarkable. Small bowel
biopsy showed focal active enteritis with ulceration,
differential including Crohn's, infection, drug-related injury.
Since discharged on ___, she ran out of pain medications on
___ and developed acute exacerbation of her chronic pain and
N/V. She had abdominal pain when having a BM today. Reports
feeling constipated, no blood in stools. Denies fevers/chills,
diarrhea.
In the ED, initial VS were: 99.1 ___ 18 96% RA. Labs
were grossly unremarkable with the exception of a dirty U/A.
Surgery was consulted who did not feel cross sectional imaging
was warranted and recommended medicine admission for GI workup.
She was given 1mg iv dilaudid x2, 2mg iv ativan, and 4mg iv
zofran. She received 1L NS
Past Medical History:
- Bulemia (as per records)
- Status post cholecystectomy
- Chronic abdominal pain
* Suspected tuberculosis enteropathy due to positive PPD,
treated for antibiotics for 7 months
* Meckel's scan ___ negative
* Colonoscopy ___ with granuloma but no inflammation
* Colonscopy ___ normal to terminal ileum
* Colonscopy ___: Normal.
* Small bowel follow-through ___: Ileal inflammatory
changes consistent with Crohn's
* Exploratory laparotomy ___ WNL. Appendectomy at the time
with ? granuloma at the tip.
* Laparoscopic small bowel biopsy (___): "Focal active
enteritis with ulceration. No granulomas seen. No significant
inflammation of the muscularis propria or serosa seen. No
pyloric metaplasia seen. No evidence of vasculitis (trichrome
stain and elastic stain evaluated). Special stain for AFB is
negative with appropriate positive control. Additional levels
examined. The differential diagnosis includes Crohn's disease,
infection, drug related injury, etc."
* EGD (___): Normal
* EGD (___): Normal
* EGD with biopsies (___): Duodenum without inflammation,
gastric mucous with chronic inactive gastritis.
* CT scan ___ ileal thickening
* CT scan (___): "A 40-50cm segment of ileum just proximal
to the terminal ileum shows diffuse wall thickening, adjacent
fat
stranding and luminal narrowing consistent with regional
ileitis".
* Capsule endoscopy ___ WNL
* Prometheus panel ___: Not consistent with IBD.
* DBE ___: Normal to 250 cm
* Abdominal ultrasound (___): Normal
- IBS
- Depression
- ADHD
- Anxiety
- GERD
- Cyclic Vomiting Syndrome
- PID
Social History:
___
Family History:
- Cousin with IBS
- No history of IBD
- Grandmother with colon ca in ___.
- Great aut with colon cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: T 98.3 BP 153/113 HR 103 RR 19 SaO2 95% on RA
General: Alert, crying, uncomfortable.
HEENT: Sclera anicteric, MMM
Neck: JVP flat
Lungs: CTAB
CV: Tachycardic. Regular rhythm. No m/r/g.
Abdomen: Obese, soft, no massess appreciated. Bowel sounds
normoactive. No rebound, rigidity, or guarding. Healing
laparoscopic incision scars are nonerythematous. No
organomegaly appreciated. No costovertebral angle tenderness.
Ext: WWP, nonedematous
Skin: There is a patchy, confluent, pink rash over the right
buttocks crossing the midline to the left. It is minimally
tender to palpation. There is no crusting, vesicles, or
excoriation.
Neuro: A&Ox3. Moving all four extremities spontaneously.
Follows commands.
Pelvic: No tenderness or masses appreciated on bimanual
examination. Speculum exam reveals vaginal vault with milky
fluid. No cervical discharge. No cervical motion tenderness,
erythema, or ulceration.
Pertinent Results:
___ 05:30AM BLOOD WBC-5.2 RBC-4.29 Hgb-12.8 Hct-40.2 MCV-94
MCH-29.9 MCHC-31.9 RDW-13.5 Plt ___
___ 05:30AM BLOOD Glucose-116* UreaN-6 Creat-0.7 Na-136
K-4.6 Cl-102 HCO3-26 AnGap-13
___ 05:30AM BLOOD ALT-12 AST-15 LD(LDH)-160 AlkPhos-46
TotBili-0.3
___ 05:30AM BLOOD Albumin-3.9 Calcium-9.0 Phos-3.4 Mg-2.1
___ 05:45AM BLOOD CRP-6.0*
___ 09:00AM BLOOD C3-120 C4-30
___ 09:00AM BLOOD RheuFac-6
___ 09:00AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
___ 09:00AM BLOOD Cryoglb-NEGATIVE
___ 09:00AM BLOOD HCV Ab-NEGATIVE
___ 09:30PM URINE UCG-NEGATIVE
___ 9:30 pm URINE
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
| STAPHYLOCOCCUS,
COAGULASE NEGATIVE
| |
AMPICILLIN------------ <=2 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- <=0.12 S
NITROFURANTOIN-------- <=16 S <=16 S
OXACILLIN------------- =>4 R
TETRACYCLINE---------- <=1 S =>16 R
VANCOMYCIN------------ 1 S 1 S
___ 11:48 am SWAB Source: Cervical.
**FINAL REPORT ___
Chlamydia trachomatis, Nucleic Acid Probe, with Amplification
(Final
___: Negative for Chlamydia trachomatis by PCR.
NEISSERIA GONORRHOEAE (GC), NUCLEIC ACID PROBE, WITH
AMPLIFICATION
(Final ___: Negative for Neisseria Gonorrhoeae by
PCR.
CT OF THE ABDOMEN WITH IV CONTRAST:
Included views of the lung bases are clear. There is no
pericardial or
pleural effusion. The heart size is normal.
The liver, pancreas, spleen, adrenal glands, kidneys, stomach,
and
intra-abdominal loops of small and large bowel are normal.
There is no
mesenteric or retroperitoneal lymphadenopathy, and no free air
or free fluid. The patient is post-cholecystectomy (3:23).
There is mild periumbillical stranding and soft tissue
thickening (3:47). Neighboring mild subcutaneous emphysema
overlies the left paramedial anterior abdominal wall (3:40). No
drainable fluid collections are seen.
CT OF THE PELVIS WITH IV CONTRAST:
The bladder, uterus, adnexa, rectum, and intrapelvic loops of
small and large bowel appear normal. There is no intrapelvic
lymphadenopathy or free fluid.
OSSEOUS STRUCTURES: There is no acute fracture. There are no
bony lesions concerning for malignancy or infection.
IMPRESSION:
1. No acute intra-abdominal or intrapelvic process.
2. Mild periumbilical stranding and adjacent subcutaneous
emphysema may
represent recent surgery or instrumentation.
Brief Hospital Course:
Regarding her acute abdominal pain and ENTERITIS, NOS:
Ms. ___ presented with acute abdominal pain which was similar
in character to prior exacerbations of her known chronic
cryptogenic abdominal pain. She initially was unable to
tolerate PO due to nausea and severe pain and required PO
hydromorphone with several doses of IV hydromorphone for
breakthrough.
She was evaluated with imaging (CT abdomen), inflammatory
markers, serological testing for vasculitis (hepatitis
serologies, CRP, ESR, cryoglobulin, RF) all of which were
unrevealing. She was afebrile and with no leukocytosis. She
had a recent full-thickness small bowel biopsy (unrevealing) and
extensive serological testing which has been negative to date.
Her pelvic exam and chlamydia/gonorrhea PCR did not suggest
gynecological pathology.
Regarding her bacterial UTI:
Her urine grew enterococcus and staphylococcus epidermidis,
sensitive to amoxicillin. She improved dramatically on
amoxicillin and increased prednisone from her home 20mg QD dose
to 40mg QD and her abdominal pain improved to her baseline. It
is unclear which of these interventions, if either, resulted in
an improvement in her pain. She was discharged on a 7 day total
course of amoxicillin for UTI and a prednisone taper down to her
baseline 20mg QD dose. She was scheduled for follow-up with her
PCP and set to be scheduled for a ___ GI follow-up appointment.
Regarding her depression/anxiety:
Of note, while here she met with SW and described a previous
history of abuse as a child in addition to being kidnapped by
her father. This may play into a functional component of her
abdominal pain. She is already seeing a therapist, but SW had
astutely suggested investigating if this therapist is trained in
trauma and if not, switching to a therapist that is.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ascorbic Acid ___ mg PO DAILY
2. BuPROPion (Sustained Release) 200 mg PO QAM
3. Calcium Carbonate 1000 mg PO DAILY
4. Cyanocobalamin 250 mcg PO DAILY
5. DiCYCLOmine 20 mg PO TID
6. Docusate Sodium 100 mg PO BID:PRN constipation
7. Fluticasone Propionate NASAL 1 SPRY NU DAILY
8. FoLIC Acid 1 mg PO DAILY
9. Lansoprazole Oral Disintegrating Tab 30 mg PO BID
10. Multivitamins 1 TAB PO DAILY
11. Ranitidine 150 mg PO HS
12. Vitamin D 1000 UNIT PO DAILY
13. Gildess *NF* (norethindrone ac-eth estradiol) 1.5-30 mg-mcg
Oral daily
14. lactobacillus acidophilus *NF* 1 billion cell Oral BID
15. Ondansetron 4 mg PO Q8H:PRN nausea
16. Lubiprostone 24 mcg PO DAILY
17. Mesalamine 1250 mg PO QAM
18. Mesalamine 1500 mg PO LUNCH
19. Mesalamine 1250 mg PO QPM
20. PredniSONE 20 mg PO DAILY
21. HYDROmorphone (Dilaudid) ___ mg PO Q6H:PRN pain
Discharge Medications:
1. Ascorbic Acid ___ mg PO DAILY
2. BuPROPion (Sustained Release) 200 mg PO QAM
3. Calcium Carbonate 1000 mg PO DAILY
4. Cyanocobalamin 250 mcg PO DAILY
5. DiCYCLOmine 20 mg PO TID
6. Docusate Sodium 100 mg PO BID:PRN constipation
7. Fluticasone Propionate NASAL 1 SPRY NU DAILY
8. FoLIC Acid 1 mg PO DAILY
9. HYDROmorphone (Dilaudid) ___ mg PO Q6H:PRN pain
RX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth Every 6
hours Disp #*12 Tablet Refills:*0
10. Lubiprostone 24 mcg PO DAILY
11. Mesalamine 1250 mg PO QAM
12. Mesalamine 1500 mg PO LUNCH
13. Mesalamine 1250 mg PO QPM
14. Multivitamins 1 TAB PO DAILY
15. PredniSONE 40 mg PO DAILY
RX *prednisone 10 mg 4 tablet(s) by mouth Daily Disp #*40 Tablet
Refills:*0
16. Ranitidine 150 mg PO HS
17. Vitamin D 1000 UNIT PO DAILY
18. Amoxicillin 500 mg PO Q8H Duration: 7 Days
RX *amoxicillin 500 mg 1 tablet(s) by mouth Three times per day
Disp #*10 Tablet Refills:*0
19. Clotrimazole Cream 1 Appl TP BID Mycosis
RX *clotrimazole 1 % Apply to the affected area Twice daily Disp
#*1 Bottle Refills:*0
20. Gildess *NF* (norethindrone ac-eth estradiol) 1.5-30 mg-mcg
Oral daily
21. lactobacillus acidophilus *NF* 1 billion cell Oral BID
22. Ondansetron 4 mg PO Q8H:PRN nausea
23. Lansoprazole Oral Disintegrating Tab 30 mg PO BID
24. Docusate Sodium (Liquid) 100 mg PO BID
RX *docusate sodium 50 mg/5 mL 10 ml by mouth Twice daily Disp
#*1 Bottle Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Cryptogenic abdominal pain
Urinary tract infection
Anxiety
Irritable bowel syndrome
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___
___. You were admitted for abdominal pain. After
extensive work-up, we were again unable to reveal a definitive
cause. You were incidentally discovered to have a urinary tract
infection which we treated with antibiotics. We also increased
your prednisone to 40mg. It is likely either the prednisone,
the antibiotics, or both helped improve your abdominal pain.
Followup Instructions:
___
|
19592790-DS-6
| 19,592,790 | 23,710,613 |
DS
| 6 |
2185-08-13 00:00:00
|
2185-08-13 20:13:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
ciprofloxacin / Codeine / Latex, Natural Rubber / naproxen /
Tylenol
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old female well known to our service
(discharged by me 5 days ago) with a history of cryptogenic
abdominal pain who presents with abdominal pain after exhausting
her supply of PO hydromorphone.
Ms. ___ reports doing well after her discharge on ___ and
was abdominal pain free. After exhausting her PO hydromorphone,
her pain began to come back. It is described as intermittent,
severe pain primarily in the RLQ and suprapubic areas. She
thinks it is similar to prior flares. There is associated
bilateral back pain. It is made better with defecation. It is
not positional. She is unclear of the relationship to eating
since she has not eaten much secondary to concurrent nausea and
emesis x 2. She has been stooling regularly with normal soft,
cardboard colored, formed stools. Yesterday, she reported that
her stool burned her anus "like I ate a bunch of hot peppers."
She denies dysuria, frequency, urgency, hesitancy, but does
endorse suprapubic pain. She also denies fevers, chills. She
denies vaginal discharge, vaginal discomfort. She denies any
recent sexual activity.
She becomes tearful when I state that I will not give her
narcotics. "Will you just leave me in pain?" The patient later
attempts to elope from the hospital. I intercepted her at the
elevator and coaxed her to return to her room. We then
discussed her life stressors, which she describes many. She is
upset because she is unable to work secondary to her pain and
used to enjoy her job as an EMT emensely. She also is in the
process of her landlord threatening eviction, and she struggles
to take care of her brother who lives with her because he is
handicapped. She is also under significant stress because her
mother is dating a man who she thinks is "playing her" "but she
won't listen to me." Finally, she thinks that yesterday's
events involving the bombing at the ___ also have
her on edge emotionally. She thinks her emotional stressors
worsen or trigger her abdominal pain.
She then states that "I wish I could just got to sleep and never
wake up." She denies wanting to harm herself or others.
Events following discharge from ___ on ___ - PCP appointment, no show.
___ - Completed course of amoxicillin for UTI
___ to ___ - Observed in ___ ED complaining of severe
abdominal pain, N/V. She had 3BMs which were soft and formed,
associated with suprapubic pain and rectal burning. No blood,
fever. Received 2mg + 4mg IV morphine with moderate
improvement. She feels that her pain is different than her
usual abdominal pain. She was discharged with planned
outpatient GI follow-up at ___ at 2:00pm ___. Of note, she
feels that the bombing in ___ today and the anxiety/stress
associated with that may contribute to her symptoms.
___ Telephone call to ___. Stated abdominal pain recurred at
4:00PM. Took her meds wihtout relief. Feels that it is a flare
of her ongoing abdominal pain. She is curled over in pain. She
will call ___ and go to ___.
In the ED, initial vs were: Pain 5 T 97.8 HR 74 BP 114/72 RR 16
SaO2 99% RA. Labs were not performed in the ED prior to
admission since they had been apparently performed at ___
___ the day PTA.
Prior to transfer, vitals were T 98.0 HR 65 BP 126/80 RR 16 SaO2
97%
On the floor, vs were: T 98.4 BP 130/88 HR 70 RR 18 SaO2 98% on
RA
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. Denies diarrhea, constipation. No
dysuria, frequency, urgency. Denies arthralgias or myalgias.
Ten point review of systems is otherwise negative.
Past Medical History:
- Chronic abdominal pain
* Suspected tuberculosis enteropathy due to positive PPD,
treated for antibiotics for 7 months
* Meckel's scan ___ negative
* Colonoscopy ___ with granuloma but no inflammation
* Colonscopy ___ normal to terminal ileum
* Colonscopy ___: Normal.
* Colonoscopy ___: Normal mucosa was noted in the whole
colon
and the terminal ileum up to 15cm. Biopsy performed for
histology
at the terminal ileum.
* Small bowel follow-through ___: Ileal inflammatory
changes consistent with Crohn's
* Exploratory laparotomy ___ WNL. Appendectomy at the time
with ? granuloma at the tip.
* Laparoscopic small bowel biopsy (___): "Focal active
enteritis with ulceration. No granulomas seen. No significant
inflammation of the muscularis propria or serosa seen. No
pyloric metaplasia seen. No evidence of vasculitis (trichrome
stain and elastic stain evaluated). Special stain for AFB is
negative with appropriate positive control. Additional levels
examined. The differential diagnosis includes Crohn's disease,
infection, drug related injury, etc."
* EGD (___): Normal
* EGD (___): Normal
* EGD with biopsies (___): Duodenum without inflammation,
gastric mucous with chronic inactive gastritis.
* CT scan ___ ileal thickening
* CT scan (___): "A 40-50cm segment of ileum just proximal
to the terminal ileum shows diffuse wall thickening, adjacent
fat stranding and luminal narrowing consistent with regional
ileitis".
* CT scan (___): "No acute intra-abdominal or intrapelvic
process.
2. Mild periumbilical stranding and adjacent subcutaneous
emphysema may represent recent surgery or instrumentation."
* CT scan (___): No signs of IBD. Duodenoduodenal
intussusception, likely transient.
* Capsule endoscopy ___ WNL
* Prometheus panel ___: Not consistent with IBD.
* DBE ___: Normal to 250 cm
* Abdominal ultrasound (___): Normal
* Serological vasculitis work-up: Hepatitis A, B, C negative,
normal C3+C4, C1 inhibitor negative, ___ negative, ANCA
negative, RF negative, cryoglobulin negative
- Bulemia (as per records)
- Status post cholecystectomy
- Irritable bowel syndrome
- Depression
- ADHD
- Anxiety
- GERD
- Cyclic Vomiting Syndrome
- PID
Social History:
- Living situation: Lives in ___ with brother who is
disabled.
- Occupation: ___
- Tobacco: Recently quit tobacco.
- EtOH: Denies.
- Illicits: Occasional MJ (helps with nauasea), but none
recently.
- Emotional stressors
* Previous history of abuse as a child in addition to being
kidnapped by her father. She is already seeing a therapist, but
he is not a trauma specialist.
* History of being raped "both ways" at age ___.
* Conflict with her mother regarding her mother's boyfriend
who she believes is mistreating her mother.
* Being evicted from her apartment.
* Caring for her disabled brother.
* The events of the ___ bombing.
* Frustration of not having a diagnosis of her abdominal pain.
Family History:
- Cousin with IBS
- No history of IBD
- Grandmother with colon ca in ___.
- Great aunt with colon cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T 98.4 BP 130/88 HR 70 RR 18 SaO2 98% on RA Pain ___
General: Tearful, upset
HEENT: EOMI, MMM
Neck: No JVD. No LAD of cervical chains. No thyromegaly.
Lungs: CTAB anterior and posteriorly.
CV: RRR, no m/r/g. Normal S1, S2.
Abdomen: Obese. There is a healing laparoscopy scar in the
suprapubic region. There is no tenderness to deep palpation in
all four quadrants nor the suprapubic area. No focal
tenderness. No rebound, rigidity, masses, guarding. No CVA
tenderness.
Ext: WWP, nonedmatous
Skin: Buttocks rash is significantly faded since being
discharged ___. No other rashes.
Neuro: A&Ox3. Moving all four extremities. Follows commands.
DISCHARGE PHYSICAL EXAM:
Vitals: T 98.6 BP 109/72 HR 81 RR 18 SaO2 98% on RA Pain ___
General: No apparent distress
HEENT: EOMI, MMM
Lungs: CTAB
CV: RRR, no m/r/g.
Abdomen: Obese. Mildly tender to deep palpation in RLQ. No
tenderness in other areas. No CVA tenderness.
Ext: WWP, nonedmatous.
Skin: Rash on buttocks nearly resolved. No other rashes.
Neuro: A&Ox3. Moving all four extremities. Follows commands.
Pertinent Results:
___ 10:30AM BLOOD CRP-0.6
___ 10:30AM BLOOD Lipase-19
___ 10:30AM BLOOD ALT-31 AST-34 AlkPhos-44 TotBili-0.7
___ 07:55AM BLOOD Glucose-142* UreaN-10 Creat-0.9 Na-139
K-4.6 Cl-101 HCO3-27 AnGap-16
___ 07:45AM BLOOD Albumin-3.9 Calcium-9.1 Phos-3.5 Mg-2.2
___ 10:30AM BLOOD Neuts-57.8 ___ Monos-6.4 Eos-0.6
Baso-0.7
___ 10:30AM BLOOD WBC-10.4# RBC-4.58 Hgb-13.9 Hct-43.7
MCV-96 MCH-30.2 MCHC-31.7 RDW-13.4 Plt ___
___ 01:25PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.0 Leuks-NEG
___ 01:25PM URINE Color-Yellow Appear-Clear Sp ___
___ 06:58PM URINE bnzodzp-NEG barbitr-NEG opiates-POS
cocaine-NEG amphetm-NEG mthdone-NEG
___ 1:25 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH FECAL
CONTAMINATION.
ABDOMINAL CT WITH CONTRAST (___)
Abdomen CT: The visualized portions of the lung bases are
clear. The liver parenchyma enhances homogeneously. No focal
liver lesions are identified. There is no intrahepatic or
extrahepatic biliary duct dilatation. The portal vein is
patent. The gallbladder is surgically absent. The spleen,
pancreas, adrenal glands, and left kidneys are normal. Note is
made of a duplex right kidney with 2 ureters that appear to join
just above the level of the ureterovesical junction. The
stomach is unremarkable. There is a duodenoduodenal
intussusception involving the ___ portion of the duodenum,
likely transient in nature. There is no upstream bowel
dilatation. The remainder of the small bowel and colon are
unremarkable. A small caliber tubular structure filled with
oral contrast material that measures approximately 11 mm in
length extends from the base of the cecum (601 3:30), possibly
an appendiceal stump related to prior appendectomy. There is no
free fluid or free air in the abdomen. No pathologically
enlarged abdominal lymph nodes are seen. The abdominal aorta is
normal in caliber.
Pelvis CT: The bladder, uterus, and adnexae are unremarkable.
There is no
free fluid in the pelvis. No pathologically enlarged pelvic
lymph nodes are seen.
Soft tissues and bones: No suspicious lytic or blastic lesions
are
identified. Foci of subcutaneous air along the anterior
abdominal wall could relate to prior injections.
IMPRESSION:
1. No CT findings suggestive of inflammatory bowel disease.
2. Duplex right kidney with two ureters that appear to join just
above the
level of the ureterovesical junction.
3. Duodenoduoneal intussusception, likely tranient on nature.
No upstream
bowel dilatation.
Brief Hospital Course:
The exhaustion of her nacrotics and worsening of her
psychosocial stressors seems most likely to have prompted her
admission. Her pain seems typical for her flares of chronic
cryptogenic abdominal pain, but other processes were also
considered. She recently had a UTI and discharged on
amoxacillin which would cover one of the two pathogens which
grew from her urine; thus, she could have had an incompletely
treated UTI. However, her urinalysis suggests no such
infection, and she has no LUTS. A nephrolith is also possible
given colicky nature of her pain but none was seen on CT scan.
Another possibility is post-surgical changes including an
entrapped cutaneous nerve, but the lack of positional nature to
her pain argues against. At the suggestion of gastroenterology,
a rheumatology consult was obtained to rule out any obscure
vasculitic process which we had not considered, but rheumatology
felt that there was almost certainly no vasculitis at play.
They considered the GI-associated vasculitides PAN, HSP, but
given both the history and serological work-up, this was very
unlikely the cause.
Of note, her CT scan did not show a process to explain her
abdominal pain. It did show a duodenoduodenal intussusception,
but after discussion with radiology and gastroenterology, this
was felt to be an incidental finding since she did not show
signs of proximal obstruction.
Over the years she has had extensive work-up, including numerous
CT scans, endoscopies, colonoscopies, MRI/Es, and most recently
a full-thickness bowel biopsy. Interestingly, her biopsy did
indeed show some objective findings of ulceration and
inflammation; the significance of this is unclear, but could
suggest she may have an undiagnosed organic process in addition
to her more-than-likely functionally worsened abdominal pain.
She is currently on numerous medications for presumed Crohn's
disease, but does not meet criteria for Crohn's or IBD. She was
intermittently refusing all medications while here, except for
minocycline, steroids, and eventually hydromorphone, so it is
unclear how much these medications are doing at least in the
context of a flare up.
Of note, the patient eloped from the hospital twice, and was
either intercepted by me or called by me via phone and coaxed to
return. She was initially upset that we were not controlling
her pain with narcotics, and felt that she was being punished.
After evaluation by psychiatry, she was thought to NOT be a
suicide risk, and did indeed have capacity to leave AMA if she
wished. After extensive discussion with social work, she was
felt to be a low-risk for narcotics abuse, and was thus started
on low dose hydromorphone with good effect.
On this admission, she ultimately improved with PO hydromorphone
and IV methylprednisolone. She was discharged on a PO
prednisone taper, and continued on PO hydromorphone with enough
to reach her outpatient appointments. Given her now long term
steroids, she was started on TMP-SMX for PCP ___.
TRANSITIONAL ISSUES
===================
- Would consider paring down medication list where possible.
- Would consider switching buproprion to citalopram since this
medication is more likely to help with IBS/cryptogenic abdominal
pain. We acknowledge, however, that she has reached a balance
with regard to her depression/ADHD on buproprion.
- Attempt frequent, short primary care visits as outpatient team
has been doing.
- Encourage close follow-up with mental health.
- Would attempt to wean steroids as possible
- Would attempt to wean narcotics where possible
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ascorbic Acid ___ mg PO DAILY
2. BuPROPion (Sustained Release) 200 mg PO QAM
3. Calcium Carbonate 1000 mg PO DAILY
4. Cyanocobalamin 250 mcg PO DAILY
5. DiCYCLOmine 20 mg PO TID
6. Docusate Sodium 100 mg PO BID:PRN constipation
7. Fluticasone Propionate NASAL 1 SPRY NU DAILY
8. FoLIC Acid 1 mg PO DAILY
9. Lubiprostone 24 mcg PO DAILY
10. Mesalamine 1250 mg PO QAM
11. Mesalamine 1500 mg PO LUNCH
12. Mesalamine 1250 mg PO QPM
13. Multivitamins 1 TAB PO DAILY
14. PredniSONE 40 mg PO DAILY
15. Ranitidine 150 mg PO HS
16. Vitamin D 1000 UNIT PO DAILY
17. Amoxicillin 500 mg PO Q8H
18. Clotrimazole Cream 1 Appl TP BID Mycosis
19. Gildess *NF* (norethindrone ac-eth estradiol) 1.5-30 mg-mcg
Oral daily
20. lactobacillus acidophilus *NF* 1 billion cell Oral BID
21. Ondansetron 4 mg PO Q8H:PRN nausea
22. Lansoprazole Oral Disintegrating Tab 30 mg PO BID
23. Docusate Sodium (Liquid) 100 mg PO BID
Discharge Medications:
1. Ascorbic Acid ___ mg PO DAILY
2. BuPROPion (Sustained Release) 200 mg PO QAM
3. Calcium Carbonate 1000 mg PO DAILY
4. Clotrimazole Cream 1 Appl TP BID Mycosis
5. Cyanocobalamin 250 mcg PO DAILY
6. DiCYCLOmine 40 mg PO TID
RX *dicyclomine 20 mg 2 tablet(s) by mouth Three times per day
Disp #*30 Tablet Refills:*0
7. Docusate Sodium 100 mg PO BID:PRN constipation
8. Fluticasone Propionate NASAL 1 SPRY NU DAILY
9. FoLIC Acid 1 mg PO DAILY
10. Lansoprazole Oral Disintegrating Tab 30 mg PO BID
11. Lubiprostone 24 mcg PO DAILY
12. Multivitamins 1 TAB PO DAILY
13. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth every eight hours Disp
#*20 Tablet Refills:*0
14. Ranitidine 150 mg PO HS
15. Vitamin D 1000 UNIT PO DAILY
16. Docusate Sodium (Liquid) 100 mg PO BID
17. Gildess *NF* (norethindrone ac-eth estradiol) 1.5-30 mg-mcg
Oral daily
18. lactobacillus acidophilus *NF* 1 billion cell Oral BID
19. Mesalamine 1250 mg PO QAM
20. Mesalamine 1500 mg PO LUNCH
21. Mesalamine 1250 mg PO QPM
22. PredniSONE 60 mg PO QD Duration: 2 Days
RX *prednisone 20 mg 3 tablet(s) by mouth Daily Disp #*6 Tablet
Refills:*0
23. PredniSONE 40 mg PO QD Duration: 4 Days Start: After 60 mg
tapered dose.
RX *prednisone 10 mg four tablet(s) by mouth Daily Disp #*16
Tablet Refills:*0
24. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN Pain
RX *hydromorphone 2 mg 1 tablet(s) by mouth Every four hours
Disp #*30 Tablet Refills:*0
25. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
RX *sulfamethoxazole-trimethoprim 400 mg-80 mg 1 tablet(s) by
mouth Daily Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Cryptogenic abdominal pain
Irritable bowel syndrome
Anxiety
Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
It was a pleasure taking care of you at ___
___. You were admitted for severe abdominal pain.
After extensive evaluation with gastroenterology, rheumatology,
and CT imaging, we were unable to find a clear source of your
pain. You improved on steroids and pain medications. You
should follow-up closely with your outpatient
gastroenterologist.
Followup Instructions:
___
|
19592790-DS-7
| 19,592,790 | 29,488,518 |
DS
| 7 |
2185-11-22 00:00:00
|
2185-11-24 07:10:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
ciprofloxacin / Codeine / Latex, Natural Rubber / naproxen /
Tylenol
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ female with a history of chronic abdominal pain of
unclear etiology, constipation, dyspepsia, GERD, and IBS
presents with "abdominal pain flare." Of note, the patient has
had multiple workup for abdominal pain involving multiple ED
visits and hospitalizations. She has had multiple upper
endoscopies and colonoscopies with ileal intubation which have
been unrevealing. She has had an upper endoscopy and
colonoscopy in ___, and ___. She has also had a
negative capsule endoscopy as well as a Meckel scan. In ___,
she underwent an exploratory laparotomy which apparently was
grossly normal. On pathology, there was a single granuloma seen
on the appendix. In ___, she was found to have a positive PPD
and in light of her symptoms she was treated for latent TB with
triple therapy. She also had a double balloon enteroscopy in
___. She has had a negative Prometheus IBD panel as well as a
negative vasculitis workup.
The patient's most recent hospitalization for abdominal pain was
on ___ at ___ in the setting of a UTI, was treated with
bowel rest, IV fluids, IV dilaudid and IV Zofran. Of note, she
endorses another hospitalization at ___ for
abdominal and treated conservatively to good effect.
In the ED, initial vitals: 98.8 94 123/74 16 100%. Initial labs
including a metabolic panel, CBC, LFTs, and lipase, and UA and
bHCG were overall negative. She was managed with bowel rest,
given maalox, and initially treated with Morphine 5 mg IV and
given Zofran 4 mg IV. She was admitted to ED observation for
improvement of her symptoms under this regimen. A PO challenge
was attempted, but the patient's symptoms worsened and thus was
tranferred to the medical ward for further management.
Currently, the patient endorses nausea, ___ lower
abdominal/suprapubic pain, and low back pain. She denies any
dysuria but overall reports poor appetite. She endorses
dyspepsia comparable to her baseline. Her last bowel movement
was yesterday notable for loose stool without any blood or
mucous.
Past Medical History:
- Chronic abdominal pain
- Bulemia (as per records)
- Status post cholecystectomy
- Irritable bowel syndrome
- Depression
- ADHD
- Anxiety
- GERD
- Cyclic Vomiting Syndrome
- PID
Social History:
Living situation: Lives in ___ with brother who is
disabled.
- Occupation: ___
- Tobacco: Recently quit tobacco.
- EtOH: Denies.
- Illicits: Occasional MJ (helps with nauasea), but none
recently.
- Emotional stressors
* Previous history of abuse as a child in addition to being
kidnapped by her father. She is already seeing a therapist, but
he is not a trauma specialist.
* History of being raped "both ways" at age ___.
* Conflict with her mother regarding her mother's boyfriend who
she believes is mistreating her mother.
* Being evicted from her apartment.
* Caring for her disabled brother.
* The events of the ___ bombing.
* Frustration of not having a diagnosis of her abdominal pain.
Family History:
- Cousin with IBS
- No history of IBD
- Grandmother with colon ca in ___.
- Great aunt with colon cancer.
- Cousin with IBS
- No history of IBD
- Grandmother with colon ca in ___.
- Great aunt with colon cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS 98 73 107/69 16 100% RA
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- Supple, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- RRR, normal S1 + S2, no murmurs, rubs, gallops
Abdomen- Obese appearing, no apparent scars or rashes,
moderately distended, +normactive bowel sounds, mild tenderness
on RLQ and LLQ on deep palpation with gaurding. No hepatomegaly
or splenomegaly. Suprapubic tenderness.
GU- Exam deferred.
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
DISCHARGE PHYSICAL EXAM:
Pertinent Results:
Admission Labs:
---------------
___ 12:10AM BLOOD WBC-6.6 RBC-5.27 Hgb-16.4* Hct-47.8
MCV-91 MCH-31.1 MCHC-34.2 RDW-12.2 Plt ___
___ 12:10AM BLOOD Neuts-59.6 ___ Monos-6.4 Eos-1.2
Baso-1.5
___ 12:10AM BLOOD Plt ___
___ 12:10AM BLOOD Glucose-92 UreaN-6 Creat-0.8 Na-144 K-3.8
Cl-101 HCO3-27 AnGap-20
___ 12:10AM BLOOD ALT-16 AST-20 AlkPhos-76 TotBili-0.3
___ 08:20AM BLOOD Calcium-8.5 Phos-2.8 Mg-1.9
___ 02:35AM URINE Color-Yellow Appear-Clear Sp ___
___ 02:35AM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-2* pH-5.5 Leuks-NEG
___ 02:35AM URINE RBC-12* WBC-4 Bacteri-NONE Yeast-NONE
Epi-2
___ 02:35AM URINE UCG-NEGATIVE
Discharge Labs:
---------------
Imaging:
---------------
NONE
Microbiology:
---------------
NONE
Brief Hospital Course:
___ female with a history of chronic abdominal pain of
unclear etiology, constipation, dyspepsia, GERD, and IBS
presents with "abdominal pain flare" consistent with previous
abdominal pain.
#Abdominal pain: The patient presented with abdominal pain
similar in quality as previous presentations. The pain was
nonradiating and was not associated with any rigidity or rebound
guarding. On exam, there was moderate tenderness localized to
the left and right lower quadrant and suprapubic region. Initial
labs were notable for normal electrolytes, negative bHCG, and
unremarkable urinalysis. Given the patient's history of
extensive workup for abdominal pain, no further diagnostic
procedures were performed. The patient was admitted for pain
control. The patient was managed with bowel rest, IV fluids, IV
Zofran, IV Ativan, and IV Morphine. The patient's diet was
advanced as tolerated and her medications were transitioned to
PO. With this regimen, the patient's symptoms improved. At the
time of discharge, the patient's abdominal pain and nausea were
completely resolved and and the patient was tolerating a clear
liquid diet. The patient was discharged with 6 tablets 5mg
oxycodone, home Zofran and new Phenergan.
#Nausea: The patient was admitted with intense nausea limiting
PO intake. Although she initially did not have any episodes of
emesis, the patient vomitted several times during her
hospitalization. Each time, the emesis was nonbloody,
nonbilious. There was no major relief in her abdominal pain
following these episodes of emesis. The patient was initially
managed on standing IV Zofran. The patient was weened of IV
Zofran to PO PRN Zofran and initiating of Phenergan.
#Rash: During her hospitalization, the patient developed
erythematous macules on the inferior border of her nasal bridge.
The patient complained of pruritis on this area. The patient was
managed with diphenhydramine to good effect.
#Chronic Conditions:
#GERD: Stable throughout hospitalization. The patient was
continued on her home medications: Lansoprazole 30 mg PO BID and
Ranitidine 150 mg PO QHS
#Irritable Bowel Syndrome: Stable throughout hospitalization.
The patient was continued on her home medications: Dicyclomine
20 mg PO QID, Lubiprostone 24 mcg PO QD, and bowel regimen with
Colace.
#Anxiety/Depression: Stable throughout hospitalization. The
patient was continued on her home Buproprion 100 mg PO BID.
Transitional Issues:
--------------------
- Initiated Phenergan for nausea control in addition to Zofran
- Will benefit from continued psychosocial services
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ascorbic Acid ___ mg PO DAILY
2. BuPROPion (Sustained Release) 200 mg PO QAM
3. Calcium Carbonate 1000 mg PO DAILY
4. Clotrimazole Cream 1 Appl TP BID Mycosis
5. Cyanocobalamin 250 mcg PO DAILY
6. DiCYCLOmine 40 mg PO TID
7. Docusate Sodium 100 mg PO BID:PRN constipation
8. Fluticasone Propionate NASAL 1 SPRY NU DAILY
9. FoLIC Acid 1 mg PO DAILY
10. Lansoprazole Oral Disintegrating Tab 30 mg PO BID
11. Lubiprostone 24 mcg PO DAILY
12. Multivitamins 1 TAB PO DAILY
13. Ondansetron 4 mg PO Q8H:PRN nausea
14. Ranitidine 150 mg PO HS
15. Vitamin D 1000 UNIT PO DAILY
16. Docusate Sodium (Liquid) 100 mg PO BID
17. Gildess *NF* (norethindrone ac-eth estradiol) 1.5-30 mg-mcg
Oral daily
18. lactobacillus acidophilus *NF* 1 billion cell Oral BID
Discharge Medications:
1. Ascorbic Acid ___ mg PO DAILY
2. BuPROPion (Sustained Release) 200 mg PO QAM
3. Calcium Carbonate 1000 mg PO DAILY
4. Cyanocobalamin 250 mcg PO DAILY
5. DiCYCLOmine 40 mg PO TID
6. Fluticasone Propionate NASAL 1 SPRY NU DAILY
7. FoLIC Acid 1 mg PO DAILY
8. Lansoprazole Oral Disintegrating Tab 30 mg PO BID
9. Lubiprostone 24 mcg PO DAILY
10. Multivitamins 1 TAB PO DAILY
11. Ranitidine 150 mg PO HS
12. Vitamin D 1000 UNIT PO DAILY
13. lactobacillus acidophilus *NF* 1 billion cell Oral BID
14. Ondansetron 4 mg PO Q8H:PRN nausea
15. Docusate Sodium 100 mg PO BID:PRN constipation
16. Docusate Sodium (Liquid) 100 mg PO BID
17. Clotrimazole Cream 1 Appl TP BID Mycosis
18. Gildess *NF* (norethindrone ac-eth estradiol) 1.5-30 mg-mcg
Oral daily
19. Promethazine 25 mg PO Q6H:PRN Nausea
RX *promethazine 25 mg 1 tablets by mouth every 8 hours as
needed for nausea Disp #*90 Tablet Refills:*0
20. OxycoDONE (Immediate Release) 5 mg PO Q8H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every 8 hours as needed
for pain Disp #*9 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal pain
Nausea
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 ___ with abdominal pain and nausea.
On admission your blood and urine lab tests were normal. Your
physical exam was not suggestive of an acute abdomen and given
your history of multiple imaging and tests, we did not pursue
futher workup. You were managed with bowel rest, IV Zofran and
IV ativan for your pain and nausea. Your diet was advanced as
tolerated. On this regimen, your abdominal pain and nausea
improved. You were discharged with oral oxycodone to help manage
your symptoms.
Please take your medications as instructed. Please followup with
your primary care physician.
It was a pleasure taking care of you.
Followup Instructions:
___
|
19592830-DS-26
| 19,592,830 | 22,571,303 |
DS
| 26 |
2153-04-20 00:00:00
|
2153-04-21 11:36:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
right ankle pain and swelling
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old gentleman with h/o Ewings Sarcoma of L tibia ___
s/p chemo ___, no current therapy, who complains of right
ankle pain. Patient first noted pain 2 days along the lateral
aspect of his right ankle along with worsening redness.
Yesterday he was evaluated at ___ and started on Keflex. Since
that time the redness has continud to spread and his pain has
increased along now with swelling along the lateral, posterior
and medial ankle. He has pain particularly with walking after
resting, although the pain will decrease after continued
exercise. He denies any fevers or chills at home. No recent
injury to the ankle although he does have a small skin break
near the initial infection site. No IV drug use. Has a
monogamous relationship with his gilfriend of the past year.
Denies any dysuria.
In the ED, initial vital signs were 100.9 80 127/75 18 98% RA.
Patient was given vancomycin 1g IV and Percocet. Ankle films did
not show any evidence of fracture or changes consistent with
osteomyelitis.
On the floor, T 98.1 BP 119/68 HR 62 RR 18 O2 Sat 98% RA.
Patient is comfortable and has no complaints. His ankle is not
currently in any pain.
Past Medical History:
ONCOLOGIC HISTORY:
___ diagnosed with Ewing sarcoma of the left tibia
measuring 4.5 x 1.4 x 1.4 cm. Bone biopsy performed on
___ showed preliminary results consistent with Ewing
sarcoma. Staging workup has included a CT chest on ___
and a bone scan on ___, both of which revealed no
evidence of metastatic disease. He underwent bone marrow biopsy
for staging, which showed ___. His baseline echocardiogram shows
an EF of 50%.
He started C1 of dose-dense chemotherapy based on protocol AEWS
0031 on ___, with CAV alternating with IE every other week.
Dosing is: Cyclophosphamide 1200 mg/m2 on D1 /Doxorubicin 75
mg/m2 CIV D1-2/ Vincristine 2 mg D1; alternating with Etoposide
100 mg/m2 D1-D5/Ifosfamide 1800 mg/m2 CIV D1-D5 every other
week. He had a one week treatment delay for cycle 3 due to an
elevated ANC.
OTHER PMH: None
Social History:
___
Family History:
Both parents are alive and healthy. Has 1 brother who is also
healthy. Grandmother with breast cancer. Grandfather with early
cardiac death.
Physical Exam:
Admission Exam:
Vitals- T 98.1 BP 119/68 HR 62 RR 18 O2 Sat 98% RA
General: Alert and oriented x3, no acute distress, lying
comfortably in bed
HEENT: PERRLA, EOMI, MMM, oropharynx clear without lesions
Neck: supple, no supraclavicular or cervical lymphadenopathy
CV: r/r/r, no m/r/g
Lungs: CTA bilaterally
Abdomen: soft, nontender, nondistended, normoactive bowel sounds
GU: no foley
Ext: marked area of erythema around R ankle, both lateral and
medial malleolus with small effusions palpated both on lateral
and medial aspects of the ankle. Erythema most dense around
malleoli with extension of the erythema to the posterior ankle,
limited range of motion of R ankle when compared to L with
tenderness on plantar and dorsiflexion of the ankle to its
maximum. No tenderness on lateral range of motion.
Neuro: CN II-XII intact, ___ strength upper and lower
extremities
Discharge Exam:
Vitals: 98 97/51 55 18 99% RA
General: Alert and oriented x3, no acute distress, lying
comfortably in bed
HEENT: PERRLA, EOMI, MMM, oropharynx clear without lesions
Neck: supple, no supraclavicular or cervical lymphadenopathy
CV: r/r/r, no m/r/g
Lungs: CTA bilaterally
Abdomen: soft, nontender, nondistended, normoactive bowel sounds
GU: no foley
Ext: marked area of erythema around R ankle, both lateral and
medial malleolus with decreased effusions palpated both on
lateral and medial aspects of the ankle. Erythema most dense
around malleoli with extension of the erythema to the posterior
ankle, limited range of motion of R ankle when compared to L
with tenderness on plantar and dorsiflexion of the ankle to its
maximum. No tenderness on lateral range of motion.
Neuro: CN II-XII intact, ___ strength upper and lower
extremities
Pertinent Results:
Admission labs:
___ 02:50PM BLOOD WBC-9.7# RBC-4.10* Hgb-13.4* Hct-38.8*
MCV-95 MCH-32.6* MCHC-34.5 RDW-12.4 Plt ___
___ 02:50PM BLOOD Neuts-79.9* Lymphs-10.4* Monos-8.5
Eos-0.9 Baso-0.3
___ 02:50PM BLOOD Glucose-105* UreaN-15 Creat-0.8 Na-138
K-4.1 Cl-103 HCO3-28 AnGap-11
Discharge labs:
___ 05:55AM BLOOD WBC-8.3 RBC-4.25* Hgb-13.6* Hct-40.0
MCV-94 MCH-32.1* MCHC-34.1 RDW-12.3 Plt ___
___ 05:55AM BLOOD Glucose-97 UreaN-12 Creat-0.8 Na-140
K-4.3 Cl-101 HCO3-30 AnGap-13
Imaging:
___ ankle:
FINDINGS: There is no fracture or dislocation. The ankle
mortise and
syndesmosis are intact. There are no focal osseous lesions.
There is
moderate soft tissue swelling over the lateral malleolus.
IMPRESSION: No fracture or dislocation.
Brief Hospital Course:
Impression: ___ year old gentleman with h/o Ewings Sarcoma of L
tibia ___ s/p chemoXRT ___, no current therapy, who
complains of right ankle pain and erythema.
# Cellulitis: Patient p/w progressing erythema of his lateral
and medial aspects of R ankle and a low-grade temperature of
100.8 in the ED. Xray of his ankle did not show any fractures.
Given his cellulitis progressed on Keflex, he was treated with
vancomycin for 2 days. Due its unusual location around both the
medial and lateral malleoli and palpable effusions, involvement
of the joint was considered. However, patient did not have
extensive pain on range of motion exams, either passive or
active. Pain was well controlled with tramadol and on HD3 when
cellulitis appeared to improve, patient discharged home with a 7
day course of keflex and bactrim.
# h/o depression/anxiety: Continued home citalopram
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Citalopram 40 mg PO DAILY
Discharge Medications:
1. Cephalexin 500 mg PO Q6H
RX *cephalexin 500 mg 1 capsule(s) by mouth every six (6) hours
Disp #*28 Capsule Refills:*0
2. Sulfameth/Trimethoprim DS 1 TAB PO BID
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1
tablet(s) by mouth twice a day Disp #*14 Tablet Refills:*0
3. Citalopram 40 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: cellulitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you during your stay at ___
___. You were admitted for an
infection of your skin. You were treated with IV antibiotics for
2 days with improvement of your infection. Please take your new
antibiotics, Keflex and Bactrim for 7 days total, THROUGH
___.
Thank you for allowing us to participate in your care.
Followup Instructions:
___
|
19593416-DS-14
| 19,593,416 | 25,208,155 |
DS
| 14 |
2166-05-22 00:00:00
|
2166-05-22 22:24:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
E-Mycin
Attending: ___
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female with asthma, PCOS and morbid obesity with
chief complaint of shortness of breath starting yesterday at
3pm. Noted onset of cough and shortness of breath yesterday
while driving. Endorses sputum production and runny nose which
she notes are both yellow and at times blood tinged. Her
coughing became so severe that she developed severe pleuritic
chest pain. She started using her albuterol inhaler Q1-2 hours
since 3pm yesterday without much relief.
She initially presented to ___, where it was noted that she was
SOB w talking, O2sat 96%, tachycardic, has Q3T3 on EKG, as well
as a complaint of swollen leg, was sent to the ED for further
evaluation. Notably Peak flow was 250.
ED COURSE: Patient tachycardic to the 130s refractory to fluids.
91% on RA, requiring NC. rales and wheezing L>R. ABG normal, ABG
7.44 / 40 / 127/28. D-dimer was 590 and chest CTA was without PE
or any other pulmonary processes. . Elevated lactate. She
received IVF, and ordered xopenex from pharamacy (but not up
from pharamacy yet), steroids, IV mag. CTA chest was negative.
Vitals prior to transfer: 99.8-132-128/78 RR 35 91%RA (96%)
On arrival to the MICU, patient's VS. HR 123 BP 101/33 RR 20
92%on RA. No complaints other than shortness of breath. Has had
asthma attacks before and notes that she gets "pneumonia or
bronchitis" typically in the ___ and ___ and that her
allergies are very bad around cats, cotton, and pollen, but
unlike this time, her attacks are usually relieved with
albuterol. Patient does not take any controller medications.
Has never required intubation. No unusual travel, has had
contact with sick children as nanny. Denies fever or chills.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies shortness of breath, cough, dyspnea or
wheezing. Denies chest pain, chest pressure, palpitations.
Denies constipation, abdominal pain, diarrhea, dark or bloody
stools. Denies dysuria, frequency, or urgency. Denies
arthralgias or myalgias. Denies rashes or skin changes.
Past Medical History:
APPENDECTOMY
DEPRESSION
ENDOMETRIAL POLYP
IRREGULAR MENSES
OBESITY
POLYCYSTIC OVARIES
TONSILLECTOMY
Social History:
___
Family History:
There is a history of ovarian, thyroid, and
breast cancer in her family.
Physical Exam:
ADMISSION EXAM
General: Alert, obese, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD, throat clear without
exudate.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Scattered wheezing but reasonable air movement
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding
GU: no foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
Pertinent Results:
ADMISSION LABS
___ 01:05PM BLOOD WBC-14.6*# RBC-5.37 Hgb-15.5 Hct-46.5
MCV-87 MCH-28.9 MCHC-33.3 RDW-13.1 Plt ___
___ 01:05PM BLOOD Neuts-85.9* Lymphs-7.3* Monos-4.4 Eos-2.1
Baso-0.3
___ 05:56AM BLOOD ___ PTT-32.0 ___
___ 01:05PM BLOOD Glucose-53* UreaN-5* Creat-0.2* Na-145
K-2.0* Cl-123* HCO3-16* AnGap-8
___ 08:20PM BLOOD Mg-1.9
___ 05:56AM BLOOD Calcium-8.6 Phos-2.3* Mg-9.2*
___ 01:05PM BLOOD D-Dimer-590*
___ 01:05PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 08:30PM BLOOD Type-ART pO2-127* pCO2-40 pH-7.44
calTCO2-28 Base XS-3 Comment-GREEN-TOP
___ 08:30PM BLOOD Lactate-2.4*
___ 06:23AM BLOOD Lactate-1.8
.
URINE
___ 12:10PM URINE Color-Yellow Appear-Clear Sp ___
___ 12:10PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
___ 12:10PM URINE UCG-NEGATIVE
.
MICROBIOLOGY
___ URINE URINE CULTURE-PENDING EMERGENCY WARD
.
STUDIES
CTA chest
IMPRESSION:
1. Slightly limited views of the distal pulmonary arterial
branches. No
evidence of central pulmonary embolus.
2. Fatty liver.
The study and the report were reviewed by the staff radiologist.
.
Lower extremity dopplers
XXXXX
Brief Hospital Course:
This is a ___ year old woman with PMH of obesity, asthma (never
intubated), coming in with a complaint of shortness of breath.
#Asthma exacerbation from URI: Patient with increased cough and
productive yellow sputum likely causing exacerbation of her
underlying asthma. She was admitted to the ICU given concern
over tachycardia and respiratory status. In the ICU saturations
were intially good on 3L NC O2. It was also felt that he body
habitus might also result in some degree of obesity
hypoventilation syndrome. As above CTA was negative of both
infectious process and PE. She was given IV mag x 1 and started
on nebulizer treatments. She was also started on oral prednisone
60 mg daily for a planned 5 day course. Flovent was started
given the patient has not been on any controller medications at
home. Her oxygen saturations improved and she was weaned to
room air. She was able to ambulate without difficulty and was
discharged home. Prior to discharge an asthma action plan was
reviewed.
.
#Tachycardia - Likely ___ to albuterol. This resolved prior to
discharge.
.
# Increased magnesium- Magnesium was noted to increase from 1.9
to 9 in the setting of 2g IV magnesium. Reflexes remained
normal on exam and therefore this was no indication for
intervention.
.
# Leg edema- Pateint was noted to have unilateral ___ edema.
Presentation concerning for DVT given history of association
with long travel. Intermittent course is not completely
consistent with thrombosis however LENIs were done to rule out
DVT which were negative.
.
#Leukocytosis - likely related to underlying viral etiology of
what set off her current exacerbation versus stress response.
No indication for abx as there was no evidence of bacterial
infection.
.
#Elevated Lactate - Likely ___ to dehydration as this improved
with hydration.
.
#PCOS - metformin was held as the patient has not been taking
this medication. She was restarted on this medication at
discharge. She should discuss with her PCP if she no longer
wishes to take this medication.
.
TRANSITIONAL ISSUES
- Patient was full code throughout this admission
- Urine culture was pending at the time of discharge
Medications on Admission:
albuterol sulfate - 90 mcg HFA Aerosol Inhaler
fluticasone 50 mcg Spray, Suspension ___ sprays(s) daily
metformin -1,000 mg Tablet - BID: Not taking
norethindrone (contraceptive) -0.35 mg Tablet one tablet by
mouth: Not taking
cetirizine - 10 mg Tablet: Says it makes her very sleepy and so
not taking
Discharge Medications:
1. Flovent Diskus 50 mcg/actuation Disk with Device Sig: One (1)
puff Inhalation twice a day.
Disp:*1 inhaler* Refills:*2*
2. fluticasone 50 mcg/actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
3. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
4. prednisone 20 mg Tablet Sig: Three (3) Tablet PO once a day
for 3 days.
Disp:*9 Tablet(s)* Refills:*0*
5. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
One (1) Inhalation PRN as needed for shortness of breath or
wheezing.
Discharge Disposition:
Home
Discharge Diagnosis:
Acute Asthma Exacerbation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted for an asthma exacerbation most likely caused
by a viral infection. You improved with nebulizers and steroid
treatment.
The following changes were made to your medications:
START Flovent one puff twice a day
START Prednisone for 4 more days
USE your peak flow meter when you feel well, to establish a
baseline and when you feel sick, if your peak flow is less than
50% of your normal, then call your doctor immediately.
Followup Instructions:
___
|
19593443-DS-30
| 19,593,443 | 20,919,046 |
DS
| 30 |
2144-08-08 00:00:00
|
2144-08-09 16:21:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Penicillins / Ativan
Attending: ___
Chief Complaint:
R eyelid droop and pain
Major Surgical or Invasive Procedure:
Lumbar puncture with fluoroscopic guidance ___
History of Present Illness:
Mr. ___ is a ___ year old man with a complicated past
medical history which includes liver transplant in ___
secondary
to alcohol and hepatitis C cirrhosis, end-stage renal disease on
HD ___ to immunosuppressive agents s/p liver transplant
(currently being worked up for kidney transplant), hypertension,
diabetes mellitus type 2 (not on home insulin), tonsillar cancer
status post resection ___ years ago and radiation therapy to the
left side of his neck. He presents today for evaluation of new
onset right eye ptosis. History obtained by patient as well as
patient's wife and daughter who are at bedside.
The patient reports that he was in his usual state of health up
until a few weeks ago when, during an elective hospital
admission
at ___ as part of his kidney transplant
workup, he developed left supraorbital eye pain associated with
left eye ptosis with progression to left CN3 palsy with limited
adduction, upgaze, and downgaze. Workup at the time included
CT/CTA Head and Neck with and without contrast and MRI/MRA
without contrast, which demonstrated by report only (imaging not
yet obtained) no intracranial abnormality. The remainder of his
neurological exam at the time was notable for
He was diagnosed with a diabetic CN3 palsy at the time. After
his
kidney transplant workup was complete, he was discharged home
with a plan for routine follow-up with Neuro-opthalmology.
When he arrived back to the ___ area, he reported being
tired.
His left eye remained largely closed without significant
improvement in symptoms. Three days ago, he noticed that the
initial supraorbital pain that was on his left eye seemed to
have
traversed to his right orbit with similar supraorbital pressure.
Yesterday his right eye became droopy so he presented for urgent
eval out of concern that his right eye will also suffer from a
nerve paralysis.
Past Medical History:
#EtOH/HCV cirrhosis complicated by ___ s/p liver transplant in
___.
1) Complications:
-S/p tx w/Harvoni in ___ with sustained virologic response
-De ___ ascites without cirrhosis or clear lymphatic or venous
obstruction
-ESRD on HD MWF, transplant workup underway
#HTN
#Tonsillar CA s/p XRT ___
#IDDM (___)
#OSA (home CPAP)
Social History:
___
Family History:
No known neurologic diseases.
No known history of cancer or auto-immune conditions.
Physical Exam:
ADMISSION EXAM:
Vitals: 36.7, HR50, RR18, BP140/65, SaO2 98%.
General: Awake, cooperative, NAD.
HEENT: NC/AT, scant scleral icterus, periorbital edema, MMM, no
lesions noted in oropharynx
Neck: Supple, audible bruit on left from known AV fistula. No
nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted. LUE AV fistula with
palpable thrill.
Abdomen: soft, NT, ND normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No ___ edema.
Skin: no rashes or lesions noted. Neck/t-shirt line is slightly
erythematous.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive to conversation, although
intermittently falls asleep. 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. Speech was not dysarthric. Able to follow
both midline and appendicular commands. There was no evidence of
apraxia or neglect.
-Cranial Nerves: Right eye 1.5>1, Left eye 1.25>1. Visual fields
are full to finger counting. Left CN3 palsy, with limited
adduction, upgaze, and downgaze. Right eye EOMI. Left eyelid is
closed at baseline and with effort can only open to uncover just
below the lower level of the ___. Right eyelid is with mild
ptosis to just above the pupil. Notably, his right eyeptosis
fluctuates throughout exam, with less ptosis after resting
closed. He could not tolerate the ice-pack challenge for more
than 20 seconds but there was no demonstrable change in ptosis
within the confines of this time period. Eyelid closure was
fullstrength. Tongue protrudes slightly to right but strength is
full to tongue-in-cheek bilaterally. Remaining CN exam was
intact.
-Motor: Normal bulk, tone throughout. Notable upward drift
bilaterally with ___ beats of rebound, slightly more pronounced
in right upper extremity. Subtle head titibation at rest. No
other adventitious movements or asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 4 ___ ___ 4+ 5 5 5 5 5 5
R 5 ___ ___ 4 5 5 5 5 5 5
***After repetitive deltoid stimulation with wing flapping,
patient had some subtle weakness (4- L, 4 R) in deltoid
muscles.***
-Sensory: No deficits to light touch, pinprick, cold sensation.
Proprioceptive deficits to fine movements in both toes
bilaterally. No extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2+ 2+ 2+ 2+ 0
R 2+ 2+ 2+ 0 0
Plantar response was mute.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF.
-Gait: Good initiation. Wide-based, circumductive stride with
slightly exaggerated arm swing. Cannot walk in tandem. Sway with
Romberg but does not fall.
DISCHARGE EXAM:
VS: Temp: 98.1 PO BP: 144/52 HR: 49 RR: 18 O2 sat: 97%
Physical Exam:
General: Awake, cooperative, NAD
HEENT: NC/AT, no scleral icterus, no periorbital edema, MMM
Pulmonary: Breathing comfortably in room air
Cardiac: RRR. LUE AV fistula with palpable thrill.
Abdomen: soft, NT, ND
Extremities: No ___ edema.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive to conversation. Language is
fluent with normal prosody. There were no paraphasic errors.
Speech was not dysarthric. Able to follow both midline and
appendicular commands. There was no evidence of apraxia or
neglect.
-Cranial Nerves: Right eye 3->2, Left eye 3->2. Left EOM with
adduction past midline, relatively preserved intorsion in the
adducted state, relatively preserved upgaze. Right eye with
impaired adduction unable to cross midline, impaired downgaze in
all directions. RIGHT eyelid is closed at baseline, unable to
hold open with effort. Right eyelid ptosis to just above pupil.
Sensation intact to light touch and cold V1-V3 bilaterally.
Tongue protrudes slightly to right but strength is full to
tongue-in-cheek bilaterally. Smile symmetric with activation.
SCM ___.
-Motor: Normal bulk, tone throughout. No pronator drift.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 4 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation.
Proprioceptive deficits to fine movements in great toes
bilaterally.
-DTRs:
Bi Tri ___ Pat Ach
L 2 0 0 0 0
R 2+ 0 0 0 0
Plantar response flexor bilaterally.
-Coordination: No intention tremor. No dysmetria on FNF.
-Gait: Deferred
Pertinent Results:
___:
CBC: WBC: 3.5* RBC: 2.95* Hgb: 9.4* Hct: 26.2* MCV: 89 MCH: 31.9
MCHC: 35.9 RDW: 13.1 RDWSD: 42.___*
Chem10: Glucose: 119* UreaN: 17 Creat: 4.0* Na: 137 K: 3.8 Cl:
96
HCO3: 30 AnGap: 11 Calcium: 8.3* Phos: 2.2* Mg: 1.8
FK level: pending
___:
TacroFK: 5.6
ACE: pending
___: pending
CRP: pending
ESR: pending
CSF:
Protein: 44
Glucose: 63
WBC: 1
RBC: 2
gram stain:
culture:
LDH: 23
flow cytometry: pending
cytology: pending
M. tb culture: pending
M. tb PCR: pending
ACE: pending
Lyme Ab: pending
___
WBC: 3.5* RBC: 3.14* Hgb: 9.9* Hct: 27.7* MCV: 88 MCH: 31.5
MCHC:
35.7 RDW: 13.1 RDWSD: 42.___*
Glucose: 104* UreaN: 37* Creat: 6.5* Na: 139 K: 4.0 Cl: 96 HCO3:
29 AnGap: 14
TSH: 2.3
Free T4: 1.8*
tacroFK: 5.6
Prior OSH labs:
- HTLV1/2 reactive
- syphilis IgG negative
- Varicella IgG positive, IgM negative
- HIV negative
- Quant gold negative
- A1C 5.1,
- ESR<1
- CRP<3
IMAGING:
========
CT Abdomen & Pelvis ___:
IMPRESSION:
Within limits of an unenhanced CT, no evidence of a mass lesion
or
lymphadenopathy in the abdomen or pelvis.
CT Chest w/o contrast ___:
IMPRESSION:
No evidence of primary malignancy within the thorax.
CT Neck w/o contrast ___:
IMPRESSION:
1. Asymmetric appearance of palatine tonsils, likely related to
prior right tonsillectomy, correlate with surgical history or
direct visualization.
2. No adenopathy.
MRI brain and orbits w/ and w/o contrast ___:
IMPRESSION:
1. Asymmetric enhancing soft tissue right cavernous sinus, in
the
region of the expected course of the third cranial nerve,
consider lymphoma, meningioma, inflammatory process including
sarcoid, inflammatory pseudotumor, metastasis.
2. Moderate chronic small vessel ischemic changes.
3. Probably moderate central canal narrowing C3-C4 level,
suggestion of central disc protrusion.
Prior OSH imaging (from ___ Report read):
MRI brain/MRA head and neck ___: Read as "No acute infarct
of or hemorrhage. There is mild nonspecific prominence of
ventricles with surrounding mild somewhat confluent
periventricular white matter hyperintensity. Bilaterally, the
carotid and vertebral arteries are grossly normal without
evidence for dissection or significant narrowing.
CTA head and Neck w and wo contrast: Correlation with MRA head
and neck and CT head: Stable mild diffuse cortial atrophy and
hypodensities in the periventricular white matter consistent
with
microvascular ischemic angiopathy.No CT evidence of large vessel
cortical based infarct. No intracranial hemorrhage. No
abnormal
intracranial enhancement. Fetal configuration bilateral
posterior cerebral arteries without aneurysm formation. No
intracranial aneurysm or evidence of intracranial dissection.
No
significant stenosis with bilateral carotid siphon
calcifications. Focal calcified plaque right intracranial
vertebral artery with mild stenosis based on coronal reformatted
images with origin of the right posterior inferior cerebellar
artery proximal to this calcified atheromatous plaque. Patent
major dural sinuses. Normal aortic arch branching pattern with
ostial calcified atheromatous plaque but no significant
stenosis.
Dominant left vertebral artery with calcified atheromatous
plaque
at its origin appears to result in moderate grade stenosis,
50-69% diameter narrowing but it is difficult to assess given
degree of calcification. No CT evidence of cervical vessel
dissection. Calcified atheromatous plaque bilateral carotid
bifurcations with mild stenosis, slightly greater on the left
but
less than 50% diameter narrowing. Asymmetric enlargement right
thyroid lobe without distinct mass. Advanced cervical
degenerative disc disease and hypertrophic facet arthropathy
with
anterior listhesis of C3 and C4 and marked endplate sclerosis as
well as marked remodeling of the left C2-3 and C3-4 facet
joints.
Associated disc protrusion at C3-4 appears to result in moderate
central canal stenosis with mild compression of the cervical
cord.
Brief Hospital Course:
___ year old man with a complicated medical history as above with
recent presentation of left CN3 neuropathy with pupil sparing
who
now presents with right ptosis and eye movement impairment.
#CN 3 Palsy: While etiology of his isolated L-sided neuropathy
was felt to be diabetic, the relatively mild headache which is
positional-i.e. worse when supine, raised the question for
alternative etiologies e.g. inflammation or mass lesion
affecting the brain stem or nIII, or cavernous sinus. MRI brain
showed a soft tissue enhancing lesion in the R cavernous sinus
in the region of the course of CN 3, compatible with his R eye
symptoms. There is no apparent lesion on the left side, and the
etiology of the L-sided symptoms remains unclear. Differential
includes infection (e.g. fungal in the setting of
immunocompromise), malignancy (e.g. lymphoma, meningioma,
metastasis), or other inflammatory process e.g. sarcoid. CSF
studies were negative for gross markers of inflammation (1 WBC,
normal protein and glucose), while Tb, Lyme, cytology and flow
cytometry are pending. CT torso and neck were done prior to
discharge to screen for lymphoma or recurrence of tonsilloma and
did not reveal evidence of additional malignancy within the
limits of a non-contrast enhanced study (performed to preserve
remaining renal function).
Pain was managed with renally dosed gabapentin.
Chronic issues:
#ESRD on HD
Nephrology transplant team was consulted and followed throughout
his admission. He received an additional session (2 consecutive
days) for a total of 2 sessions immediately following IV
contrast load for MRI.
#EtOH/HCV cirrhosis s/p transplant - maintained on home
immunosuppressive regimen. Tacrolimus level followed daily and
in therapeutic range, with hepatology transplant team following.
Transitional issues:
- Multiple lab tests are pending at time of discharge and will
be followed up by the time of outpatient follow-up in clinic.
-Evaluation in ___ clinic; clinic has been
contacted.
- FDG-PET if there remains high concern for lymphoma.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY
2. Calcium Acetate 1334 mg PO BID
3. Carvedilol 25 mg PO BID
4. Doxazosin 4 mg PO HS
5. Pantoprazole 40 mg PO Q24H
6. PredniSONE 2.5 mg PO DAILY
7. Prograf (tacrolimus) 0.5 mg oral BID
8. Torsemide 80 mg PO DAILY
9. Levothyroxine Sodium 50 mcg PO DAILY
10. Atorvastatin 20 mg PO QPM
11. CloNIDine 0.1 mg PO TID
Discharge Medications:
1. Gabapentin 100 mg PO DAILY
You may take an additional 100mg by mouth after dialysis on
dialysis days.
RX *gabapentin 100 mg 1 capsule(s) by mouth daily Disp #*45
Capsule Refills:*0
2. Polyethylene Glycol 17 g PO DAILY:PRN constipation
RX *polyethylene glycol 3350 [Miralax] 17 gram/dose 1 powder(s)
by mouth daily Refills:*2
3. amLODIPine 10 mg PO DAILY
4. Atorvastatin 20 mg PO QPM
5. Carvedilol 25 mg PO BID
6. CloNIDine 0.1 mg PO TID
7. Doxazosin 4 mg PO HS
8. Levothyroxine Sodium 50 mcg PO DAILY
9. Pantoprazole 40 mg PO Q24H
10. PredniSONE 2.5 mg PO DAILY
11. Prograf (tacrolimus) 0.5 mg oral BID
12. Torsemide 80 mg PO DAILY
13. HELD- Calcium Acetate 1334 mg PO BID This medication was
held. Do not restart Calcium Acetate until instructed to do so
by the nephrology team
14.Outpatient Physical Therapy
walker or cane for ambulation assistance
Discharge Disposition:
Home
Discharge Diagnosis:
Bilateral cranial nerve 3 palsy
Right cavernous sinus imaging abnormality
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ due to
symptoms of right eyelid drooping and pain, which we believe is
due to a mass compressing the nerve that controls the movements
of your right eye. This mass could be related to infection,
inflammation or malignancy. It is difficult to determine for
certain, but it is likely this same process was involved in your
left eye symptoms, which are fortunately now improving. You had
an MRI of your brain, and also a lumbar puncture for lab studies
to gather information related to the mass, many of which are
still pending.
Because of the MRI contrast you received, you received an
additional hemodialysis session while you were admitted, but on
discharge you should resume your usual home schedule.
After discharge, you should keep your previously scheduled
appointment with neuro-opththalmology.
Followup Instructions:
___
|
19593675-DS-15
| 19,593,675 | 29,853,928 |
DS
| 15 |
2195-02-15 00:00:00
|
2195-02-15 17:46:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
simvastatin
Attending: ___.
Chief Complaint:
___ infection
Major Surgical or Invasive Procedure:
Upper endoscopy (EGD)
Incision and drainage with debridement of right lower extremity
ulcer
History of Present Illness:
___ with h/o poorly controlled IDDM2, HTN, ___ presenting with
R ___ infection. Pt stated that he first noticed a wound on his
R sole one week ago, initially just a scratch that he did not
know when that happened. He was seen by his PCP and started on
Keflex. However, the redness continued to spread. In the past
two days, pt had fever (up to 100.1 at home), chill and some
sweating. His sugar has been running much higher than his
baseline. Pt noticed some diarrhea that started 2 days ago,
watery and up to q1 two nights ago. He denies chest pain, SOB,
cough, headache, abdominal pain, nausea, vomiting, dysuria.
There were no changes in his urinary pattern. Of note, pt was
recently found to have hyperkalemia and started on kayexalate
daily. He also started to take iron supplements daily. He denies
melena or hematochezia. Pt also reported a 10 lbs weight gain
through the winter. In the ED, initial VS were: 99.5 73 163/55
17 98% ra. Exam was unremarkable except for his inflammed right
___. Rectal exam was negative. Lab was notable for WBC of 11.7
with mild left shift, K 2.8, Mg 1.7, Cr 2.9 (at recent baseline)
and glucose 417 without anion gap. Pt was given vancomycin 1
gram, K 40 mEq and regular insulin 10 u. There were no
documentation of IV fluids given. On the floor, the patient had
an O2 requirement and evidence of volume overload on exam, but
was not given diuresis due to his low K+. He was given another
20mEq of PO K on the floor and 8R insulin with home glargine for
sugar in 400s. He feels like his breathing is better this
morning than it was last night. He has pain in his right ___,
but otherwise no complaints.
Past Medical History:
CKD Stage ___
DM Type II
Hypertension
Coronary Artery Disease - probable anterior septal MI by stress
ECHO with EF 33%, followed by Dr. ___
___ Hepatitis C
Depression
Social History:
___
Family History:
Mother and Father with coronary artery disease. Brother with
coronary artery disease s/p CABG.
Physical Exam:
Admission:
VS: 98.0, 92, 164/63, 22, 88% on RA (inc to 93% on 3L)
GENERAL: well appearing, no acute distress
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM
NECK: supple, no LAD, JVD 14 cm (@ jaw)
LUNGS: bibasilar crackles, resp unlabored, no accessory muscle
use
HEART: RRR, no MRG, nl ___
ABDOMEN: normal bowel sounds, soft, ___,
no rebound or guarding, no masses
EXTREMITIES: R: pitting edema to knee, tender to palpaltion in
calf, L: no edema.
R ___, Intense erythema over ___ digits, diffusely spread to
midfoot, with white induration over plantar aspects of MTT,
nontender to touch or movement,
Pulse: 1+ pulses ___ on the left, dopplerable on the R
NEURO: awake, A&Ox3,
.
Discharge:
VS: 98.3, 149/78, ___, 16, 100% RA
FSBG: ___
GENERAL: well appearing, no acute distress
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM
LUNGS: CTAB
HEART: RRR, ___ ___ systolic murmur best heard at RUSB, and ___
blowing holosystolic murmur best heard at apex, nl ___
ABDOMEN: normal bowel sounds, soft, ___,
no rebound or guarding, no masses
EXTREMITIES: R: mild pitting edema to knee, L: no edema.
R ___: erythema decreased on ___, still has edema and erythema
plantar and dorsal surfaces adjacent to digits ___
NEURO: awake, A&Ox3
Pertinent Results:
LABS:
___ 10:30PM BLOOD ___
___ Plt ___
___ 10:30PM BLOOD ___
___
___ 07:50AM BLOOD ___
___ Plt ___
___ 10:45AM BLOOD ___
___ Plt ___
___ 06:30AM BLOOD ___
___ Plt ___
___ 08:55AM BLOOD ___
___ 06:05AM BLOOD ___
___ Plt ___
___ 11:24AM BLOOD ___
___ 10:30PM BLOOD ___ ___
___:58AM BLOOD ___ ___
___ 06:50AM BLOOD ___
___ 10:30PM BLOOD Ret ___
___ 10:30PM BLOOD ___
___
___ 07:50AM BLOOD ___
___
___ 05:45AM BLOOD ___
___
___ 05:58AM BLOOD ___
___
___ 06:05AM BLOOD ___
___
___ 10:30PM BLOOD ___ LD(LDH)-190 ___
___
___ 10:30PM BLOOD ___
___ 06:05AM BLOOD ___
___ 10:30PM BLOOD ___
___ 10:30PM BLOOD ___
___ 06:50AM BLOOD ___
___ 11:44PM BLOOD ___
___ Base ___
___ 11:44PM BLOOD ___
.
MICRO:
___ HELICOBACTER PYLORI ANTIBODY ___ negative
___ 9:18 am SWAB Source: R ___ interspace.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final ___:
STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
___ 5:27 pm SWAB Source: R ___.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final ___:
This culture contains mixed bacterial types (>=3) so an
abbreviated
workup is performed. Any growth of P.aeruginosa, S.aureus
and beta
hemolytic streptococci will be reported. IF THESE BACTERIA
ARE NOT
REPORTED BELOW, THEY ARE NOT PRESENT in this culture..
ENTEROCOCCUS SP.. SPARSE GROWTH.
STAPH AUREUS COAG +. RARE GROWTH. OF TWO COLONIAL
MORPHOLOGIES.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted. VANCOMYCIN Sensitivity testing per ___. ___
___.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
| STAPH AUREUS COAG +
| |
AMPICILLIN------------ <=2 S
CLINDAMYCIN----------- <=0.25 S
ERYTHROMYCIN---------- <=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- 0.5 S
PENICILLIN G---------- 2 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 2 S 1 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
___ Blood Culture, ___ no growth EMERGENCY WARD
___ Blood Culture, ___ no growth EMERGENCY WARD
.
Renal U/S Doppler ___:
1. No hydronephrosis. Unremarkable appearance of the kidneys.
2. No evidence of renal artery stenosis. Bilateral resistive
indices are elevated consistent with chronic renal disease.
.
EGD ___:
Impression:
Irregular Z line was noted. Biopsies were not taken on account
of the indication (GI bleeding).
Erythema and friability consistent with gastritis was seen in
the fundus and antrum. Erosions were seen in the antrum.
Erythema, friability, and congestions consistent with duodenitis
was seen in the duodenal bulb.
Otherwise normal EGD to third part of the duodenum
Recommendations:
-High dose PPI
-Test for H pylori
-Colonoscopy was recommended to the patient, but he currently
declines. If he agrees to this procedure as an outpatient, would
consider repeat EGD with biopsies of the GE junction.
.
EKG ___:
Sinus rhythm. Within normal limits. No change compared to
previous tracing of ___ other than less marked lateral T
wave inversion.
Rate PR QRS QT/QTc P QRS T
79 166 96 426/459 68 12 86
.
___ ___:
No evidence of DVT in the right lower extremity. Only one of
the two right peroneal veins was imaged.
.
___ AP,LAT & OBL RIGHT ___ ___:
1. No radiographic evidence of osteomyelitis.
2. Mild calcaneal enthesopathy.
3. Atherosclerosis.
.
CXR ___:
REASON FOR EXAMINATION: Fever and oxygen requirement in a
patient with history of congestive heart failure.
PA and lateral upright chest radiographs were reviewed in
comparison to ___ and chest CT from ___.
Heart size is top normal. Mediastinum is stable. Currently,
there is minimal interstitial engorgement that might be
concerning for mild interstitial pulmonary edema. There is on
the lateral demonstration of small bilateral effusions,
symmetric and adjacent opacity not very well seen on the PA
view.
Those findings are most likely representing interstitial edema
but basal consolidation in particular in the right lower lung
cannot be entirely excluded. Followup of the patient after
diuresis and antibiotic treatment in four weeks is recommended
for documentation of resolution.
.
ART EXT (REST ONLY) ___:
Findings consistent with moderate left tibial disease, and mild
right tibial disease.
.
MR ___ No Contrast ___:
No evidence of right ___ osteomyelitis. Extensive subcutaneous
soft tissue edema with more focal fluid collections surrounding
the second interspace and second toe compatible with cellulitis.
Assessment for focal abscess is limited, given lack of
intravenous contrast.
.
CXR ___:
As compared to the previous radiograph, the patient has received
a left PICC line. The course of the line is unremarkable, the
tip of the line projects over the mid to lower SVC. There is no
evidence of complications, notably no pneumothorax.
The ___ signs indicative of interstitial lung edema
have decreased, but mild fluid overload is still present.
Unchanged moderate cardiomegaly.
Brief Hospital Course:
Mr. ___ is a ___ with h/o poorly controlled IDDM2, HTN,
sCHF presenting with R ___ infection.
# Cellulitis/Abscess: Expanding cellulitis after failing oral
keflex. This was likely exacerbated by diabetic nephropathy and
peripheral vascular disease. Staph was thought to be most likely
given ___ abscess. Given the extent of disease and
elevated ESR and CRP, osteo was considered as well. Podiatry
was consulted and did I&D w/ daily debridement for several days.
It did not probe to bone. ___ was negative for osteo, but is
only about 50% sensitive. MRI also without evidence of osteo.
Micro swab cultures showed MSSA and enterococcus sensitive to
penicillins. Patient was initially on vancomycin, but when Cx
sensitivity returned, he was transitioned to nafcillin. Though
enterococcus is generally not covered by nafcillin, patient
improved clinically on nafcillin, and staph was thought to be
main pathogen responsible for purulent abscess and cellulitis.
Therefore, pt will be continued on a >2 week course of
antibiotics with nafcillin. Podiatry did definitive closure of
the ___ wound on ___ at the bedside. Patient will follow
up with podiatry on ___, and it can be decided at that time if
any further antibiotics are necessary. PICC was placed in
dominant (left) arm, as ___ arm needs to be spared for
possible HD access in the future. Blood cultures are negative.
Daily dressing changes: NS wash, betadyne, pat dry, apply 4x4s,
wrap in curlex.
# GI Bleed: Upper GI bleed with melena, rising BUN, dropping HCT
on ___. GI was consulted. Patient remained hemodynamically
stable. Patient received 2u pRBCs on ___ and HCT appropriately
increased from 18 to 25. HCT has remained stable at 25 since.
EGD showed gastritis and duodenitis with erosions, but without
active bleed. Patient was initally started on IV pantoprazole
BID. He was transitioned to PO pantoprazole BID. Colonoscopy
was recommended by GI, but patient refused. He agreed to follow
up with PCP for outpatient colonoscopy.
# HTN: Pt with poorly controlled HTN. Labetolol was uptitrated
for better control. Increased eventually to 800mg TID from
200mg BID. He continued to have hypertension up to 170s, but
was always asymptomatic. He is on max doses of labetolol,
amlodipine, and losartan. U/S doppler showed no renal artery
stenosis. Etiology is likely his CKD. An additional agent may
need to be initiated in the future. Patient is obejctively
orthostatic, but has no symptoms of orthostasis (likely from
autonomic dysfunction and antihypertensives). Blood pressure
and signs/sxs of orthostasis should be monitored closely at
rehab and upon discharge from rehab.
# Acute on Chronic Systolic CHF: Pt has known history of
systolic CHF likely secondary ischemic cardiomyopathy, last
documented EF in ___ was 40%. Upon admission, he presented with
new hypoxia and O2 requirement. Initial exam was consistent with
volume overload. CXR with some interstitial edema. Exam and sxs
and O2 requirement improved with IV Lasix. His home Lasix was
increased to 60mg from 40mg. Carvedilol or metoprolol could be
considered in future given benefits in patients with heart
failure. Losartan was continued. Patient was placed on a salt
restricted, 1.5L fluid restricted diet. Adherence to dietary
recommendations was an issue during hospitalizatin (family
brought in fast food for pt) and may be an issue in outpt
setting as well. Discharge weight was 76.8 kg, and pt appeared
euvolemix.
# IDDM2: poorly controlled IDDM2, recent A1c 8.5. Worsening
hyperglycemia in the setting of acute infection. Glargine and
insulin sliding scale were uptitrated for better control.
# Hypokalemia: Patient came in with a K+ of 2.8. This was
likely in the setting of diuretics and kayexalate use. EKG
showed no U wave. He was repleted, and Kayexalate was stopped.
# Anemia: In addition to acute bleed, he most likely has chronic
anemia secondary to to CKD and iron deficiency with low iron
level and iron saturation of 6%. No evidence of hemolysis. TSH
and B12 NML. PO iron supplement, but will need IV iron and EPO
as outpt.
# CKD: Current Cr at recent baseline, which makes him stage ___
CKD. Pt had worsening GFR likely secondary to diabetic
nephropathy. He has been followed by Dr. ___. No blood
draws or IVs in ___ (right) arm. We attempted to get
midline instead of PICC, but nafcillin is not compatible with
midline, so PICC was put in.
# CAD: Pt not on statin due to hx of rhabdo. We continued
aspirin 325 mg.
# Depression: Continued citalopram.
Transitional Issues:
- Full code
- Patient is on antibiotics (nafcillin) through ___
- Patient should have outpatient colonoscopy, which he agreed to
set up through PCP
- ___ can likely be switched from twice daily to once
daily after ___
- Patient should have endocrinology (diabetes) follow up after
leaving rehab
- Carvedilol or metoprolol could be considered in the future for
mortality benefit given heart failure
- Outpatient ECHO is recommended to reassess pump function and
valvular disease
- Initiation of statin should be considered in this patient (he
did develop rhabdo on simvastatin in the past)
- No IVs or blood draws in the right (___) arm, given
potential need for dialysis in the future
- Pt will likely need IV iron and EPO in the future for anemia
- Discharge weight is 76.8 kg (169 lbs), and pt appeared
euvolemic
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
2. Furosemide 40 mg PO DAILY
in AM
3. Losartan Potassium 100 mg PO DAILY
in AM
4. Labetalol 200 mg PO BID
5. Citalopram 40 mg PO DAILY
in ___
6. Vitamin D 50,000 UNIT PO 1X/WEEK (TH)
7. Sodium Polystyrene Sulfonate 15 gm PO DAILY
8. Cephalexin 500 mg PO Q6H
9. Glargine 25 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
10. Ferrous Sulfate 325 mg PO DAILY
11. Aspirin EC 325 mg PO DAILY
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Aspirin EC 325 mg PO DAILY
3. Citalopram 40 mg PO DAILY
4. Ferrous Sulfate 325 mg PO BID
5. Furosemide 60 mg PO DAILY
6. Glargine 33 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
7. Labetalol 800 mg PO Q8H
8. Losartan Potassium 100 mg PO DAILY
9. Vitamin D 50,000 UNIT PO 1X/WEEK (TH)
10. Acetaminophen 650 mg PO Q6H:PRN pain
11. Docusate Sodium 100 mg PO BID
12. Heparin 5000 UNIT SC TID
13. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
14. Nafcillin 1 g IV Q6H cellulitis
15. Pantoprazole 40 mg PO Q12H
Take twice daily through ___. After that, talk to your PCP
about decreasing it to once daily.
16. Senna 1 TAB PO BID:PRN constipation
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Staph (MSSA) ___ abscess and cellulitis
Hypokalemia
Poorly controlled diabetes
Hypertension
Acute on chronic systolic heart failure
Upper gastrointestinal blood
Gastritis and duodenitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane); partial weight bearing on right lower extremity
(weight on heal only with surgical boot in place
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital with an infection of your
right ___. This infection was treated with IV antibiotics
(first vancomycin, then nafcillin). You were seen by podiatry,
who did several I&D procedures (incision and drainage). They
also closed the wound on ___. You had a PICC line placed
for administration of IV antibiotics. You should continue
taking the antibiotic until you are seen by your podiatrist Dr.
___ on ___. He will determine whether the antibiotics can
be stopped.
While you were here, you also had heart failure,
gastrointestinal bleed, hypertension (high blood pressure), and
low potassium level. The heart failure was treated with IV
diuretics and then by increasing your oral diuretic pill
furosemide (Lasix). For the gastrointestinatl bleed, you
required a blood transfusion with 2 units of red blood cells.
You had an upper endoscopy (EGD), which showed inflammation and
erosion or your stomach. We started you on a medication called
pantoprazole to protect your stomach from further bleeding. You
will need to get a colonoscopy in the future, which your PCP can
help you set up. The high blood pressure was treated by
increasing the dose of your labetolol. You were given
potassium, and the medication Kayexalate was stopped.
Your diabetes was not ___, and we suggest you go to
an endocrinologist (diabetes specialist) after you leave rehab
for further management of your diabetes.
Please make sure to avoid putting weight on your right ___
until at least until you are seen by the podiatrist. Partial
weight on the heal while wearing a surgical boot is okay. You
will work with physical therapy at rehab on improving your
strength and mobility.
You should adhere to a ___ diet,
___ diet and weigh yourself every morning.
If your weight changes by more than 3 lbs, call your doctor
immediately. You current weight is 169 lbs.
It was a pleasure caring for you here at ___.
Followup Instructions:
___
|
19593675-DS-17
| 19,593,675 | 21,387,022 |
DS
| 17 |
2196-10-29 00:00:00
|
2196-10-30 22:29:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
simvastatin
Attending: ___.
Chief Complaint:
Foot ulcer
Major Surgical or Invasive Procedure:
Left third toe partial amputation
History of Present Illness:
Mr. ___ is a ___ man with h/o DM c/b diabetic foot
ulcer/wounds s/p toe amputation, CKD stage IV-V with AVF in
place for expectant HD, PVD, sCHF who presents with purulent
foot ulcer.
Patient reports 3 days of discoloration and pain from the base
of his left third toe. He reports that he wears shoes at home
regularly. His daughter first noted the pus draining today. He
denies fevers/chills/pain except that it is sore to touch.
In the ED initial vitals were: 98.2 83 142/51 16 100% RA
- Labs were significant for WBC 5.8, CRP 12.3. K 5.2, BUN 91. Cr
4.1. Lactate 0.7.
- Podiatry consultation recommended IV antibiotics and admission
to medicine given ___ medical complexity
- Patient was given Vancomycin/Zosyn, 25mg hydralazine, 100mg
labetalol and admitted to medicine
Vitals prior to transfer were: 98.4 72 176/73 18 98% RA
On the floor, initial VS were 98 179/81 80 18 96% RA. Patient
feeling well without any complaints. Foot is not especially
painful.
Review of Systems:
(+) per HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
- CKD stage IV-V - creatinine ___
- s/p right brachiocephalic fistula ___
- CAD s/p probably anterior MI by prior stress
- DM type II on insulin c/p diabetic foot ulcer, CKD
- HTN
- PVD
- s/p right ___ tow amputation
- sCHF
- Hyperlipidemia
- Reactive airway disease
- HCV
- Anxiety
- Cellulitis
- UGIB ___ to gastrtitis and duodenitis
- Rhabdomyolysis attributed to statin
- Depression
Social History:
___
Family History:
Mother and Father with coronary artery disease. Brother with
coronary artery disease s/p CABG.
Physical Exam:
Admission physical exam
Vitals - 98 179/81 80 18 96% RA.
GENERAL: Elderly gentelman in NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: soft, bibasilar crackles, otherwise clear to auscultation
bilaterally
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: trace edema left leg to shin. right foot s/p ___
toe amputation. left foot ___ toe with black eschar on plantar
surface, minimal purulent drainage by nail bed, unable to
express further drainage. minimal overlying erythema.
PULSES: 1+ DP pulses bilaterally
NEURO: AAOx3, CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Discharge physical exam
Vitals - Tm 97.8 150s-160s/___ ___ 16 98% RA. , 3BM
___: 190-> 120->93->203
GENERAL: Very friendly elderly gentelman in NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, I/VI systolic murmur loudest in RUSB, no
gallops, or rubs
LUNG: clear to auscultation bilaterally, no wheezes or crackles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: No lower extremity edema. right foot s/p ___ toe
amputation. Left foot with dressing removed ___ toe with dry
ulcer with bone exposure on plantar surface.
PULSES: 2+ DP pulses not appreciated
NEURO: No focal deficits
SKIN: warm and well perfused, no excoriations or lesions, no
rashes except third toe
Pertinent Results:
Admission labs
___ 10:00PM BLOOD WBC-5.9 RBC-3.37* Hgb-9.3* Hct-28.7*
MCV-85 MCH-27.7 MCHC-32.5 RDW-14.7 Plt ___
___ 10:00PM BLOOD Neuts-75.2* Lymphs-12.7* Monos-6.3
Eos-5.0* Baso-0.8
___ 10:00PM BLOOD Glucose-353* UreaN-91* Creat-4.1* Na-136
K-5.2* Cl-101 HCO3-23 AnGap-17
___ 06:10AM BLOOD ALT-37 AST-30 AlkPhos-129 TotBili-0.4
___ 06:10AM BLOOD Calcium-8.0* Phos-4.1 Mg-1.8
___ 10:00PM BLOOD CRP-12.3*
___ 09:58PM BLOOD Lactate-0.7
Discharge labs
___ 04:55AM BLOOD WBC-6.3 RBC-3.49* Hgb-9.8* Hct-29.2*
MCV-84 MCH-28.0 MCHC-33.5 RDW-14.4 Plt ___
___ 04:55AM BLOOD Glucose-98 UreaN-73* Creat-4.4* Na-142
K-4.4 Cl-104 HCO3-25 AnGap-17
___ 04:55AM BLOOD Calcium-8.5 Phos-5.1* Mg-2.1
Imaging
FINDINGS:
There is no evidence for fracture, dislocation or bone
destruction. The joint spaces appear preserved.
IMPRESSION:
No bony lysis identified
Micro
___ 4:00 pm TISSUE Site: TOE LEFT THIRD TOE BONE.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Preliminary):
STAPH AUREUS COAG +. RARE GROWTH.
SENSITIVITIES PERFORMED ON CULTURE # ___
___.
GRAM NEGATIVE ROD(S). RARE GROWTH.
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
Brief Hospital Course:
___ with history of DM c/b diabetic foot ulcer/wounds s/p toe
amputation, CKD stage IV-V with AVF in place for expectant HD,
PVD, sCHF who presents with foot infection.
# Foot infection: Likely complication of diabetes +/- PVD. No
evidence of osteolysis on toe x-ray. Podiatry evaluated patient
and recommended amputation after assessment of blood flow in the
lower extremities. Noninvasive arterial exam showed patency of
the SFA stent on the right.
Was initially placed on vanc/zosyn (renally dosed) and then was
transitioned to PO Augmentin for 7 days.
# CKD Stage IV-V: Baseline Cr 4.2-4.4. Was stable. Initially
there was no acute indication to initiate dialysis. However
fistula was placed in ___ and is ready to be used.
# HTN: Initially hypertensive but became normotensive once
placed on home regimen.
# Chronic anemia: Stable. Attributed to CKD. On Aranesp as
outpatient. Continued iron supplements
# Chronic Systolic CHF: likely ischemic cardiomyopathy.
Continued home furosemide, losartan
# Type 2 DM on insulin: With complications of infections, foot
ulcer, CKD. Last A1c 7.2 on ___. Continue home glargine
and sliding scale.
# CAD: Stable. Pt not on statin due to history of rhabdomyolysis
in ___ leading to hospitalizations at ___ and ___. Plan then
was to start atorvastatin but patient could not afford it. Given
it is now generic. Patient tried on 20mg of Atorvastatin while
inpatient and monitored closely. Continued aspirin, labetalol.
# Depression: Stable. Continued on citalopram. EKG showed QTc
was 454.
## TRANSITIONAL ISSUES
- Hep C positive from ___ and ___ lab work. Will need f/u with
outpatient hepatologist on discharge.
-The patient will need to follow up with podiatry 1 week after
discharge
-The patient will need to take Augmentin BID THROUGH ___
-The patient was restarted on low dose statin while inpatient
and and tolerated it well. Given history of rhabdomyolysis, he
should be monitored closely for symptoms.
-During admission, the patient had low morning glucose and thus
lantus was decreased from 33u at bedtime to 22u. ___ need
insulin adjustments if sugars become elevated.
-Tissue cultures, Anaerobic cultures, and blood cultures pending
at discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
2. Citalopram 40 mg PO QPM
3. Calcitriol 0.25 mcg PO EVERY OTHER DAY
4. darbepoetin alfa in polysorbat 60 mcg/0.3 mL injection every
other week
5. Furosemide 80 mg PO QAM
6. Furosemide 40 mg PO QPM
7. HydrALAzine 25 mg PO QPM
8. Glargine 33 Units Bedtime
9. Labetalol 300 mg PO Q8H
10. sevelamer CARBONATE 2400 mg PO TID W/MEALS
11. Sodium Polystyrene Sulfonate 15 gm PO EVERY OTHER DAY
12. Aspirin 325 mg PO DAILY
13. Ferrous Sulfate 325 mg PO BID
14. HydrALAzine 50 mg PO BID
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Aspirin 325 mg PO DAILY
3. Calcitriol 0.25 mcg PO EVERY OTHER DAY
4. Citalopram 40 mg PO QPM
5. Ferrous Sulfate 325 mg PO BID
6. Furosemide 80 mg PO QAM
7. Furosemide 40 mg PO QPM
8. HydrALAzine 25 mg PO QPM
9. HydrALAzine 50 mg PO BID
10. Glargine 22 Units Bedtime
11. Labetalol 300 mg PO Q8H
12. sevelamer CARBONATE 2400 mg PO TID W/MEALS
13. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
Please take this medication THROUGH ___
RX *amoxicillin-pot clavulanate 500 mg-125 mg 1 tablet(s) by
mouth twice a day Disp #*13 Tablet Refills:*0
14. Atorvastatin 20 mg PO DAILY
RX *atorvastatin 20 mg 1 tablet(s) by mouth Daily Disp #*30
Tablet Refills:*0
15. darbepoetin alfa in polysorbat 60 mcg/0.3 mL injection every
other week
16. Sodium Polystyrene Sulfonate 15 gm PO EVERY OTHER DAY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis
Toe ulcer
Hypertension
Diabetes
Chronic kidney disease-stage IV-V
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr ___,
You were admitted due to a toe infection. You were seen by the
podiatry who recommended an amputation. We assessed blood flow
through your feet and saw that the stent on your right leg was
open and that you have adequate blood flow to you left foot to
allow for healing of the amputated toe. You are being discharged
on an antibiotic called Augmentin that you will need to take
THROUGH ___.
Please continue to take your other medications as prescribed but
note that we DECREASED your lantus from 33 units at bedtime to
22 units. Please follow up with your providers as listed below.
It was a pleasure being part of your care. We wish you the ___!
Your ___ Care Team
Followup Instructions:
___
|
19593690-DS-17
| 19,593,690 | 26,244,397 |
DS
| 17 |
2174-02-09 00:00:00
|
2174-02-13 19:45:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
lisinopril / Rituxan / Cipro
Attending: ___.
Chief Complaint:
Symptomatic right carotid artery stenosis.
Major Surgical or Invasive Procedure:
Right carotid endarterectomy
History of Present Illness:
___ yo male with ascending aortic aneurysm, AAA, HTN, HLD, PVD,
NHL (in remission), p/w worsening L facial droop and L
hemiplegia.
Patient was originally seen at ___ on ___ for L facial
droop and hemiplegia. Was found to have a R parietofrontal acute
ischemia. Further CVA w/u showed R ICA critical stenosis >90%
per
MRA Neck and US Duplex. He was also found to have new onset Afib
for which he was placed on Apixiban. He was discharged with ASA
and Apixiban. Never followed up with a vascular surgeon.
He was again found to have recurrent L facial droop and
hemiplegia yesterday and was brought in by daughter. His
symptoms
have since improved, now only with a mild L facial droop. CT/CTA
Head during this admission showed no acute ischemia but there
was
again critical stenosis of R ICA (80%). He is awaiting an MRI
Head.
Past Medical History:
CARDIAC HISTORY:
-Hypertension
-hyperlipidemia
-abdominal aortic aneurysm
-peripheral vascular disease
-AF on apixaban
-CVA (___)
OTHER PAST MEDICAL/SURGICAL HISTORY:
-non-Hodgkin lymphoma s/p 2 cycles of Rituxan c/b seizure
-herniated disk and chronic back pain
-appendectomy
-eye surgery
Social History:
___
Family History:
Mother with "enlarged heart."
Father with cancer.
Sister with cancer, DM.
Physical Exam:
VS 97.5, 98.6, 134/86, 78, 15, 95%RA
GEN: A&Ox3, NAD, resting comfortably
HEENT: no scleral icterus, mucus membranes moist
NECK: trachea midline, no JVD
CV: Irregularly irregular rhythm
CHEST: normal symmetric expansion with inspiration, no
respiratory distress; faint inspiratory crackles at the bases
ABD: mildly distended, non-tender, no rigidity/guarding
BACK: no CVA tenderness
EXT: trace edema ___
NEURO: AAx3, CN ___ grossly intact; L sided upper and lower
strength ___, normal cerebellar function, patient able to
ambulate
Pertinent Results:
___ 07:35AM BLOOD WBC-6.0 RBC-4.72 Hgb-10.0* Hct-35.5*
MCV-75* MCH-21.2* MCHC-28.2* RDW-22.7* RDWSD-59.1* Plt ___
___ 07:50AM BLOOD WBC-6.6 RBC-4.66 Hgb-9.9* Hct-35.0*
MCV-75* MCH-21.2* MCHC-28.3* RDW-22.5* RDWSD-57.2* Plt ___
___ 05:19PM BLOOD WBC-9.0 RBC-4.72 Hgb-10.1* Hct-35.4*
MCV-75* MCH-21.4* MCHC-28.5* RDW-22.4* RDWSD-56.2* Plt ___
___ 05:15AM BLOOD WBC-6.6 RBC-3.96* Hgb-8.4* Hct-29.5*
MCV-75* MCH-21.2* MCHC-28.5* RDW-21.6* RDWSD-53.1* Plt ___
___ 04:45AM BLOOD WBC-6.4 RBC-4.80 Hgb-10.3* Hct-35.4*
MCV-74* MCH-21.5* MCHC-29.1* RDW-21.6* RDWSD-50.6* Plt ___
___ 05:55AM BLOOD WBC-7.0 RBC-4.83 Hgb-10.3* Hct-35.6*
MCV-74* MCH-21.3* MCHC-28.9* RDW-21.6* RDWSD-50.7* Plt ___
___ 07:05AM BLOOD WBC-7.8 RBC-4.84 Hgb-10.1* Hct-35.3*
MCV-73* MCH-20.9* MCHC-28.6* RDW-20.8* RDWSD-50.1* Plt ___ CTA Head and Neck:
1. Small chronic right posterior frontal infarct.
2. Otherwise no evidence of acute large territorial infarct or
hemorrhage.
3. Patent intracranial vasculature without significant stenosis,
occlusion, or aneurysm formation.
4. Moderate left and severe right calcified and mainly
noncalcified
atherosclerotic plaques of the carotid bifurcations with near
complete occlusion of the right internal carotid artery with
greater than 90% stenosis.
5. Otherwise patent cervical vasculature without occlusion, or
dissection.
6. Severe centrilobular emphysema.
___ MR Head:
1. Acute to subacute right frontal infarct in a right MCA/ACA
watershed distribution.
2. Numerous scattered punctate areas of slow diffusion in the
right frontal and right parietal lobes as well as the right
caudate head compatible with acute to subacute infarct, in a
thromboembolic distribution.
3. No hemorrhage or suggestion of mass.
4. Mild global atrophy and areas of white matter signal
abnormality in a distribution suggestive of chronic small vessel
ischemic disease.
Note that reported prior imaging from ___ dated
___ is not available for review.
Brief Hospital Course:
___ with Hx of AAA, HTN, HLD, PVD, NHL (in remission), R
frontoparietal stroke on ___/ left arm and leg weakness,
found to be in new-onset Afib with >90% stenosis of R internal
carotid artery, who presented with new L facial weakness and
worsened L sided weakness on ___. The patient was originally
seen at ___ on ___ for 5 days of L facial droop and
hemiplegia. Further CVA w/u showed R ICA critical stenosis >90%
per MRA Neck and US Duplex. A carotid ultrasound showed showed
over 90% stenosis of the right internal carotid artery. The
patient was kept on permissive hypertension during his
hospitalization and both of his hypertension medications,
atenolol and amlodipine, were discontinued. He was discharged
with plan to follow up with vascular surgery.
While in the hospital, he was also noted to be in rapid atrial
fibrillation with a heart rate in the 140s. The patient denied
any symptoms of palpitations, shortness of breath,
lightheadedness or chest discomfort. Cardiology was consulted,
and the patient was started on diltiazem, digoxin, and apixaban.
A TTE showed an EF of 60% with no wall motion abnormalities.
Also of note, the patient had an abdominal ultrasound to
evaluate known AAA, found to be 4.1 x 4.5 cm. On ___, He was
again found to have recurrent L facial droop and hemiplegia and
was brought in by his daughter. A CT/CTA Head during this
admission showed no acute ischemia but there was again critical
stenosis of R ICA (80%). A repeat MRI showed a subacute right
frontal infarct in a right MCA/ACA with no hemorrhage. Medicine
was initially consulted due to the patient's cardiac history and
hypoxia. He was felt to be in heart failure. Since ___ the
patient has been undergoing diuresis with Lasix 20mg IV x4. His
aspirin was held initially and restarted on ___. He was
started on a heparin gtt and his apixaban was held.
CTA on ___ was consistent with a critical stenosis of
greater than 90% of the right internal carotid artery. The
patient was evaluated by neurology and cardiology and deemed
high risk for endarterectomy from a cardiac standpoint. However,
he was not a good candidate for stent placement due to severe
tortuosity of the access vessels, inadequae length from the
clavicle to the bifurcation, and the severity of stenosis in a
symptomatic octogenarian. Therefore, the decision was made to
proceed with carotid endarterectomy under local anesthetic with
some sedation. Please refer to the operative report dated
___ for details of the procedure.
The patient tolerated the operation well and there were no major
complications. The patient was transferred to the PACU for
observation and neurologic exams showed no new deficit.
After surgery the patient was kept NPO for 6hrs and the allowed
to have liquids which he tolerated. His neurologic status was
frequently assessed. On ___ the patient was found to have
low O2 Sats and basilar crackles, requiring diuresis. Diltiazem
was discontinued. He experienced several episodes of tachycardia
during ___ sessions. His cardiac medications were adjusted per
cardiology recommendations. On ___ the patient was started
on apixaban and prophylactic heparin discontinued. After several
sessions, physical therapy cleared the patient to be discharged
home with home with ongoing home OT. Patient will follow up with
outpatient ___ neurology, cardiology and vascular surgery
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Digoxin 0.25 mg PO DAILY
2. Diltiazem 120 mg PO DAILY
3. Atorvastatin 10 mg PO QPM
4. Atenolol 25 mg PO DAILY
5. amLODIPine 2.5 mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Vitamin E 400 UNIT PO DAILY
8. Fish Oil (Omega 3) Dose is Unknown PO Frequency is Unknown
9. multivitamin with iron oral Unknown
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet(s) by
mouth every eight (8) hours Disp #*21 Tablet Refills:*0
2. Apixaban 5 mg PO BID Afib
RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day
Disp #*70 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*20 Capsule Refills:*0
4. Metoprolol Succinate XL 100 mg PO DAILY
Do not take if HR<60 SBP<100.
5. Atorvastatin 80 mg PO DAILY
6. Fish Oil (Omega 3) 1000 mg PO DAILY
7. amLODIPine 2.5 mg PO DAILY
8. Aspirin 81 mg PO DAILY
9. Digoxin 0.25 mg PO DAILY
10. multivitamin with iron oral Frequency is Unknown
11. Vitamin E 400 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
-Symptomatic right carotid artery stenosis with acute cerebral
ischemia
-Stroke
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 ___ and
underwent a right carotid endarterectomy (removal of plaque from
your right carotid artery). You have now recovered from surgery
and are ready to be discharged. Please follow the instructions
below to continue your recovery:
WHAT TO EXPECT:
1. Surgical Incision:
It is normal to have some swelling and feel a firm ridge along
the incision
Your incision may be slightly red and raised, it may feel
irritated from the staples
2. You may have a sore throat and/or mild hoarseness
Try warm tea, throat lozenges or cool/cold beverages
3. You may have a mild headache, especially on the side of your
surgery
Try ibuprofen, acetaminophen, or your discharge pain medication
If headache worsens, is associated with visual changes or lasts
longer than 2 hours- ___ vascular surgeons office
4. It is normal to feel tired, this will last for ___ weeks
You should get up out of bed every day and gradually increase
your activity each day
You may walk and you may go up and down stairs
Increase your activities as you can tolerate- do not do too much
right away!
5. It is normal to have a decreased appetite, your appetite will
return with time
You will probably lose your taste for food and lose some weight
Eat small frequent meals
It is important to eat nutritious food options (high fiber, lean
meats, vegetables/fruits, low fat, low cholesterol) to maintain
your strength and assist in wound healing
To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
MEDICATION:
Take all of your medications as prescribed in your discharge
ACTIVITIES:
No driving until post-op visit and you are no longer taking pain
medications
No excessive head turning, lifting, pushing or pulling (greater
than 5 lbs) until your post op visit
You may shower (no direct spray on incision, let the soapy water
run over incision, rinse and pat dry)
Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area
___ THE OFFICE FOR: ___
Changes in vision (loss of vision, blurring, double vision, half
vision)
Slurring of speech or difficulty finding correct words to use
Severe headache or worsening headache not controlled by pain
medication
A sudden change in the ability to move or use your arm or leg or
the ability to feel your arm or leg
Trouble swallowing, breathing, or talking
Temperature greater than 101.5F for 24 hours
Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions
During your hospitalization, you were also evaluated and treated
for a stroke. A stroke happens when blood flow to part of the
brain stops.
First, you received treatment to prevent further damage to the
brain, and to help the heart, lungs, and other important organs
heal.
After you were stable, doctors did testing and started treatment
to help you recover from the stroke and prevent a future stroke.
You may have stayed in a special unit that helps people recover
after a stroke.
What to Expect at Home
Because of possible injury to the brain from the stroke, you may
notice problems with:
Changes in behavior
Doing easy tasks
Memory
Moving one side of the body
Muscle spasms
Paying attention
Sensation or awareness of one part of the body
Swallowing
Talking or understanding others
Thinking
Seeing to one side (hemianopia)
You may need help with daily activities you used to do alone
before the stroke.
Depression after a stroke is fairly common as you learn to live
with the changes. It may develop soon after the stroke or up to
___ years after the stroke.
DO NOT drive your car without your doctor's permission.
Moving Around
Moving around and doing normal tasks may be hard after a stroke.
Make sure your home is safe. Ask your doctor, ___, or
nurse about making changes in your home to make it easier to do
everyday activities.
Find out about what you can do to prevent falls and keep your
bathroom safe to use.
Family and caregivers may need to help with:
Exercises to keep your elbows, shoulders, and other joints loose
Watching for joint tightening (contractures)
Making sure splints are used in the correct way
Making sure arms and legs are in a good position when sitting or
lying
If you or your loved one is using a wheelchair, follow-up visits
to make sure it fits well are important to prevent skin ulcers.
Check every day for pressure sores at the heels, ankles, knees,
hips, tailbone, and elbows.
Change positions in the wheelchair several times per hour during
the day to prevent pressure ulcers.
If you have problems with spasticity, learn what makes it worse.
You or your caregiver can learn exercises to keep your muscles
lose.
Learn how to prevent pressure ulcers.
Thinking and Speaking
Tips for making clothing easier to put on and take off are:
Velcro is much easier than buttons and zippers. All buttons and
zippers should be on the front of a piece of the clothing.
Use pullover clothes and slip-on shoes.
People who have had a stroke may have speech or language
problems. Tips for family and caregivers to improve
communication include:
Keep distractions and noise down. Keep your voice lower. Move to
a quieter room. DO NOT shout.
Allow plenty of time for the person to answer questions and
understand instructions. After a stroke, it takes longer to
process what has been said.
Use simple words and sentences, speak slowly. Ask questions in a
way that can be answered with a yes or no. When possible, give
clear choices. DO NOT give too many options.
Break down instructions into small and simple steps.
Repeat if needed. Use familiar names and places. Announce when
you are going to change the subject.
Make eye contact before touching or speaking if possible.
Use props or visual prompts when possible. DO NOT give too many
options. You may be able to use pointing or hand gestures or
drawings. Use an electronic device, such as a tablet computer or
cell phone, to show pictures to help with communication.
Bowel Care
Nerves that help the bowels work smoothly can be damaged after a
stroke. Have a routine. Once you find a bowel routine that
works, stick to it:
Pick a regular time, such as after a meal or a warm bath, to try
to have a bowel movement.
Be patient. It may take 15 to 45 minutes to have bowel
movements.
Try gently rubbing your stomach to help stool move through your
colon.
Avoid constipation:
Drink more fluids.
Stay active or become more active as much as possible.
Eat foods with lots of fiber.
Ask your health care provider about medicines you are taking
that may cause constipation (such as medicines for depression,
pain, bladder control, and muscle spasms).
Tips for Taking Medicines
Have all of your prescriptions filled before you go home. It is
very important that you take your medicines the way your
provider told you to. DO NOT take any other drugs, supplements,
vitamins, or herbs without asking your provider about them
first.
You may be given one or more of the following medicines. These
are meant to control your blood pressure or cholesterol, and to
keep your blood from clotting. They may help prevent another
stroke:
Antiplatelet medicines (aspirin or clopidogrel) help keep your
blood from clotting.
Beta blockers, diuretics (water pills), and ACE inhibitor
medicines control your blood pressure and protect your heart.
Statins lower your cholesterol.
If you have diabetes, control your blood sugar at the level your
provider ___.
DO NOT stop taking any of these medicines.
If you are taking a blood thinner, such as warfarin (Coumadin),
you may need to have extra blood tests done.
Staying Healthy
If you have problems with swallowing, you must learn to follow a
special diet that makes eating safer. The signs of swallowing
problems are choking or coughing when eating. Learn tips to make
feeding and swallowing easier and safer.
Avoid salty and fatty foods and stay away from fast food
restaurants to make your heart and blood vessels healthier.
Limit how much alcohol you drink to a maximum of 1 drink a day
if you are a woman and 2 drinks a day if you are a man. Ask your
provider if it is OK for you to drink alcohol.
Keep up to date with your vaccinations. Get a flu shot every
year. Ask your doctor if you need a pneumonia shot.
DO NOT smoke. Ask your provider for help quitting if you need
to. DO NOT let anybody smoke in your home.
Try to stay away from stressful situations. If you feel stressed
all the time or feel very sad, talk with your provider.
If you feel sad or depressed at times, talk to family or friends
about this. Ask your provider about seeking professional help.
When to ___ the Doctor
___ your provider if you have:
Problems taking drugs for muscle spasms
Problems moving your joints (joint contracture)
Problems moving around or getting out of your bed or chair
Skin sores or redness
Pain that is becoming worse
Recent falls
Choking or coughing when eating
Signs of a bladder infection (fever, burning when you urinate,
or frequent urination)
___ ___ if the following symptoms develop suddenly or are new:
Numbness or weakness of the face, arm, or leg
Blurry or decreased vision
Not able to speak or understand
Dizziness, loss of balance, or falling
Severe headache
Followup Instructions:
___
|
19593791-DS-25
| 19,593,791 | 22,255,690 |
DS
| 25 |
2147-09-17 00:00:00
|
2147-09-18 15:02:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Aloe / Levaquin / Tape ___ / Penicillins / Betaseron
Attending: ___.
Chief Complaint:
Urinary Tract Infection
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old male with history of multiple
sclerosis, baseline cognitive defects, chronic indwelling
suprapubic catheter and recurrent resistant urinary tract
infections who was sent to ___ by outpatient Urologist for
evaluation of UTI. Patient was recently seen in the ___ in
___ with a recurrent UTI. He was started on Tobramycin
through PICC placed in ___. He received an 11 day course with
improvement in symptoms and with clearing of urine odor, color
and sediment. He was taken off Tobramycin prematurely due to
some reaction which patient's wife is unaware of. He was seen
this past ___ for blood and urine evaluation in order to
remove PICC> Patient's wife was called this week that patient
still had an infection and needed to be seen in ___. Labs and
notes are at ___ and patient's wife does not know
the results of lab work.
Over past 4 days patient's wife reports that he become more
somnolent, lethargic, falling asleep during meals, requiring
arousal to take in POs. Urine has been increasing in malodor
worsening since off Tobramycin. Urine sediment has increased
somewhat though not frankly purulent like prior UTIs. He has not
had fevers, chills, dysuria, or changes in the color of urine.
Urologist note mentions that his urine has changed from cloudy
to clear since last UTI though patients clinical status has
deteriorated most acutely. Wife reports that with each UTI his
mental status progresses in this manner, lethargy/somnolence,
increased confusion then eventually to inability to arouse.
He also developed diarrhea which is new for him. Has been on
many antibiotics and has a history of Cdiff, home ___ sent a
sample.
Of note, wife reports they use Gentamicin urinary flushes twice
daily and have been for past ___ years
In the ___, initial vitals 99 80 122/84 16 100% RA. Patient was
alert but not oriented and in no acute distress accompanied with
his wife, primary caretaker. UA showed dirty urine consistent
with UTI. Patientt reated with Vancomycin and Zosyn given recent
treatment for Staph UTI with Tobramucin. Urine culture sent and
C.Diff toxin sent prior to arrival to floor. Vitals prior to
transfer to floor: 91, RR: 16, BP: 147/80, O2Sat: 96, O2Flow:
RA, Pain: 0.
On arrival to floor, patient accompanied with wife at bedside.
He is oriented to person and place but not to time. He is in no
acute distress.
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, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria.
Past Medical History:
- Multiple sclerosis diagnosed in ___. Wheel chair bound.
- Neurogenic bladder s/p suprapubic catheter ___
- Multiple urinary tract infections (Providencia, Pseudomonas,
MRSA)
- Multiple episodes Bacteremia and urosepsis
- Nephrolithiasis s/p R ureteral stent placement ___, multiple
lithotripsy procedure, s/p L ureteral stent exchange ___.
s/p removal of L stent on ___.
Social History:
___
Family History:
Family history not pertinent to this hospitalization
Physical Exam:
Admission Exam:
VS - Temp97.1 ___ 99%RA
GENERAL - Chronically ill appearing ___ yo M laying in bed,
pleasant, child-like, in NAD, comfortable, appropriate.
HEENT - NC/AT, PERRL, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no ___, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilaterally, reduced air movement but symmetrically
HEART - S1 S2 clear and of good quality, RRR, no MRG
ABDOMEN - NABS, distended but soft, non-tender, palpable stool
over lower abdomen, no HSM, no rebound/guarding. Suprapubic
catheter in place, surrounding skin pink, small amount of
drainage around site, clear-yellow color, no frank exudate or
blood. Poor rectal tone with incontinent stool in bed and hard
stool in rectal vault. Guiac negative.
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
NEURO - Awake, Alert and oriented to person and place but not to
time. Knows the president and ___ team of ___. Wife
reports his baseline is oriented to person and place. He has
poor short term recall but good long term. CNs II-XII grossly
intact, saccading eye movement and overshooting. ___ hand grip
bilaterally with shaking of arms with grip. ___ strength in UE
at major joints. RLE ___ strength, able to lift knee but not
heel off bed, LLE ___ strength. Unable to moves toes on either
foot. Poor rectal tone. Patient is wheelchair bound and roles in
bed with assistance
Discharge Exam:
GENERAL - Chronically ill appearing ___ yo M laying in bed,
pleasant, interactive, appropriate, in NAD and in good humor
HEENT - NC/AT, PERRL, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no ___, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilaterally, reduced air movement but symmetrically
HEART - S1 S2 clear and of good quality, RRR, no MRG
ABDOMEN - NABS, distended but soft, non-tender, palpable stool
in LLQ, no HSM, no rebound/guarding. Suprapubic catheter in
place, no frank exudate or blood. EXTREMITIES - WWP, no c/c/e,
2+ peripheral pulses (radials, DPs)
NEURO - Alert and oriented to person and place but not to time.
CNs II-XII grossly intact, saccading eye movement and
overshooting. ___ hand grip bilaterally with shaking of arms
with grip. Hypertonic and hyper-reflexive UE bilaterally. ___
strength in UE at major joints. RLE ___ strength, able to lift
knee but not heel off bed, LLE ___ strength.
Pertinent Results:
Admission Labs:
___ 11:45AM BLOOD WBC-6.0 RBC-5.01 Hgb-15.0 Hct-42.3 MCV-85
MCH-30.0 MCHC-35.5* RDW-15.2 Plt ___
___ 11:45AM BLOOD Neuts-71.0* ___ Monos-5.3 Eos-1.1
Baso-0.4
___ 11:45AM BLOOD Glucose-92 UreaN-15 Creat-0.7 Na-141
K-4.2 Cl-104 HCO3-30 AnGap-11
___ 11:58AM BLOOD Lactate-0.9
Discharge Labs:
___ 06:29AM BLOOD WBC-6.7 RBC-4.67 Hgb-13.6* Hct-40.5
MCV-87 MCH-29.1 MCHC-33.6 RDW-15.4 Plt ___
___ 06:29AM BLOOD Plt ___
___ 06:29AM BLOOD Glucose-84 UreaN-21* Creat-1.0 Na-141
K-3.9 Cl-106 HCO3-29 AnGap-10
___ 06:29AM BLOOD ALT-31 AST-26 AlkPhos-86 TotBili-0.4
Microbiology:
- UCx from ___ ___: MRSA sensitive to
Vancomycin, Bactrim and Tetracycline.
- UCx from ___ at ___
___ 11:45 am URINE
URINE CULTURE (Preliminary):
STAPH AUREUS COAG +. >100,000 ORGANISMS/ML.
- BCx NGTD x2
- C.Diff Negative
.
Urine culture during prior admission to ___
___ PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 16 I
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN--------- 2 I
GENTAMICIN------------ 8 I
MEROPENEM------------- 2 S
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ 4 S
.
Reports:
- CXR ___ Low lung volumes with left lung base
consolidation, most likely atelectasis or
infection in the appropirate clinical setting
- KUB ___: Multiple prominent air-filled loops of bowel. No
definite evidence of obstruction.
Brief Hospital Course:
Patient is a ___ yo M with PMH of progressive multiple sclerosis
with indwelling suprapubic catheter and recurrent urinary tract
infections who presented to ___ with altered mental status, UTI
and diarrhea admitted for encephalopathy management
#UTI: Acute complicated cystitis without evidence of
Pyelonephritis. Patient with indwelling catheter and history of
recurrent urinary tract infections with resistant pseudomonas
and MRSA. Recently treated with Tobramycin for UTI found at
___ ___ visit the end of ___. Tobramycin course stopped
prematurely at 11 days because of allergic reaction. Patient's
clinical status of somnolence and requiring arousal is
consistent with prior UTIs per patient's wife. ___ in ___
dirty and consistent with a urinary tract infection. Given hx of
resistant psudomonas UTIs and one MRSA UTI, he was started on
Vancomycin and Zosyn in ___. On medicine service Zosyn was
discontinued because of ?penicillin allergy and changed to
Meropenem 500mg IV Q6hours. In addition prior ID notes read
"discontinue Ceftazadime and start Meropenem" during prior
admission for Pseudomonas UTI. Vancomycin was discontinued
because of unlikely infection given no MRSA UTI since ___.
Morning of discharge urine culture from ___
obtained which grew MRSA sensitive to Tetracycline, Bactrim and
Vancomycin. Prelim urine culture prior to discharge growing GPCs
Coag+ but no GNR. Vancomycin initially restarted but
discontinued half-way through dose because of ?allergy. Patient
was switched to PO Bactrim and discharged to complete 14 day
course of DS 2 tabs BID. Meropenem was discontinued since no
pseudomonas (or GNRs) growing on either sample. Of note,
however, patient was discharged with PICC line and with
instruction for PCP to follow up final urine culture result. If
final urine culture without Pseudomonas or GNRs then PICC could
be discontinued.
# Encephalopathy: Increased lethargy and somnolence per
patient's wife account. ___ be related to urinary tract
infection causing delirium or mental status may be related to
progression of multiple sclerosis. Regardless, decision made to
treat urinary tract infection given positive culture data and is
a reversible cause of mental status changes. Patient's mental
status did improve slightly during admission. If patient's
mental status does not improve with UTI treatment as an
outpatient then would pursue diagnosis of multiple sclerosis
progession
# Diarrhea: History and physical consistent with Encoparesis.
C.Diff negative, low suspicion for enteric pathogens. KUB with
stool and without obstruction. Diarrhea also related to poor
rectal tone. Patient was given bowel regimen including senna,
colace and miralax which would help control constipation and
thus leaking.
#Hypertension: Chronic, Stable without evidence of urgency or
emergency during admission. Continue Amlodipine 5mg Daily
#Multiple Sclerosis: Chronic, progressive, wheelchair bound with
chronic suprapubic catheter in place. At home, he has help from
4 PCAs. Per outpatient Neurologist, Dr. ___: "Advanced
secondary progressive multiple sclerosis with, however, marked
inflammatory findings, again Gadolinium enhancement on recent
MRI, which is of a degree that there may be some contribution to
his cognitive decline." Encephalopathy, as above, may be related
to progression of MS in addition to UTI. He was continued on
Baclofen 20mg PO 5 times per day, Oxybutynin 10mg XR QHS. Plan
to ___ 20mg SC daily as an outpatient though was not
started while inpatient.
TRANSITIONAL ISSUES:
- CODE STATUS: DNR/DNI
- Wife is health care proxy
- ___ has "Vancomycin" listed as an allergy. I spoke
personally to ___ who labeled allergy. The allergy is to
Tobramycin and course was discontinued after 11 days. Patient
developed red, raised, rash around PICC and along chest area
which resolved after Tobramycin discontinued
- Penicillin allergy is still unconfirmed and unknown reaction
- ___ may be started as an outpatient
- BCx NGTD
- Urine culture should be followed up, prior to discontinuing
___ line
- Patient to continue Bactrim for full ___s an
outpatient
- Would reconsider Gentamicin urinary flushes since he has been
growing Gentamicin resistant Pseudomonas, but will refer to
outpatient Urologist.
Medications on Admission:
- Amlodipine 5mg Daily
- Baclofen 20mg PO 5 times per day
- Planning to start ___ 20mg SC daily
- Oxybutynin 10mg XR QHS
- Famotidine 20mg BID
- MVI Daily
- Gentamicin urinary flushes
Discharge Medications:
1. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. oxybutynin chloride 5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. baclofen 10 mg Tablet Sig: Two (2) Tablet PO 5X/DAY (5 Times
a Day).
4. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
5. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily).
7. PICC placed previously, ok to use per Radiology
PICC placed previously, ok to use per Radiology
8. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: Two (2)
Tablet PO BID (2 times a day) for 14 days.
Disp:*56 Tablet(s)* Refills:*0*
Discharge Disposition:
Home with Service
Facility:
___
Discharge Diagnosis:
Acute Complicated Cystitis
Encephalopathy
Multiple Sclerosis
Hypertension
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Mr. ___,
It was a pleasure treating you during this hospitalization. You
were admitted to ___ with a
urinary tract infection and encephalopathy. You were treated
with IV antibiotics which you will continue after discharge. You
are being discharged in improved condition with some improvement
in mental status. Your diarrhea is related to constipation and
poor rectal tone. You can take laxatives to improve constipation
which will resolve diarrhea after constipation improves.
The following changes to your medications were made:
- START Bactrim 2 double stregnth tablets every 12 hours and
continue for 2 weeks
- You can take Miralax daily as needed for constipation
- No other changes were made, please continue taking home
medications as previously prescribed
Other instructions:
- Your primary care physician should follow up the final urine
culture results from ___
- ___ the final urine culture at ___ is not growing
Pseudomonas then the PICC line can be removed
- The PICC line should remain in place until final urine culture
can be confirmed
Followup Instructions:
___
|
19593791-DS-34
| 19,593,791 | 24,289,204 |
DS
| 34 |
2150-12-28 00:00:00
|
2150-12-28 20:37:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Aloe / Levaquin / Tape ___ / Penicillins / Betaseron /
vancomycin / Methenamine
Attending: ___.
Chief Complaint:
dark, foul smelling urine
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ w/ hx of advanced MS ___ neurogenic bladder with suprapubic
catheter (___), recurrent resistant organism UTI ___ bacteremia
and urosepsis, seizures, who presents with dark, foul smelling
urine.
Patient's wife reports that he has been feeling more fatigued
during the past week, and napping during the day. Over the
weekend, the patient's wife noticed dark red, foul smelling
urine coming out of his catheter. The wife sent in a urine test
to the patient's PCP on ___, and was told to come in
to the hospital yesterday (___) for pseudomonas UTI. The
patient has a history of recurrent, resistant organism UTI
(pseudomonas, MRSA) i/s/o indwelling catheter, and the wife
reports that he has had around 12 UTIs during the past 12
months. She states that he is usually treated with ceftaz, and
discharged with a PICC line. She states that he had one febrile
episode to 102 a week ago but has been completely asymptomatic
otherwise. He denies any suprapubic tenderness or associated
nausea, vomiting, constipation, diarrhea, night sweats, chills,
night sweats, weight loss, dyspnea, chest pain, cough. Of note,
the patient's catheter is usually changed once every 3 weeks
(last changed ___.
In the ED, initial vitals were: T 97.9, HR 72, BP 129/63, RR 20,
O2 100% RA. Labs were remarkable for WBC 7.3, Cr 1.1, bicarb 32,
stable H and H. UA demonstrated > 182 WBC, >182 RBC, many
bacteria, positive nitritie and >600 protein. The patient, per
the wife, was mentally intact in the ED, was given 500mg IV
ceftazadime, and subsequently transferred to the floor with T
97.7, HR 68, BP 132/94, RR 17, O2 98% RA.
On the floor the patient reports feeling well though is unsure
of why he is in the hospital. He thinks it is because he was
confused and screaming at home. He is unable to recount any of
the details of his history. We called his wife, and she states
that he was not confused at all at home, and that when she left
last night he was intact mentally. Currently A+O x 1, only
oriented to name. He believes it is winter.
Past Medical History:
- Advanced Multiple sclerosis diagnosed in ___. Wheel chair
bound.
- Neurogenic bladder s/p suprapubic catheter ___
- Multiple urinary tract infections (Providencia, Pseudomonas,
MRSA)
- Multiple episodes Bacteremia and urosepsis
- Nephrolithiasis s/p R ureteral stent placement ___, multiple
-lithotripsy procedure, s/p L ureteral stent exchange ___.
s/p removal of L stent on ___
-seizure d/o
-thrush
Social History:
___
Family History:
no history of seizures or neurologic disease
Physical Exam:
ADMISSION EXAM
Vitals: 97.9, 131/80, 78, 18, 97% on RA
General: Alert, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no rebound or guarding
GU: suprapubic catheter in place draining dark yellow urine,
surrounding area is without erythema or discharge
Ext: Warm, well perfused, 2+ pulses, trace edema bilaterally
DISCHARGE EXAM
Tm 99.5, Tc 97.3, P ___ (78-102), BP 110/66 (102-131/61-75), RR
18, O2 96-98% RA
General: Alert, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
NEURO: A+O x 1, wife states this is baseline; delayed responses;
bilateral weakness in lower extremities; significant bilateral
hand tremor with movement, slight tremor at rest;
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no rebound or guarding
GU: suprapubic catheter in place draining dark yellow urine,
surrounding area is without erythema or discharge
Ext: Warm, well perfused, 2+ pulses, trace edema bilaterally
Pertinent Results:
ADMISSION LABS
___ 09:00PM BLOOD WBC-7.3 RBC-5.05 Hgb-13.7 Hct-43.0 MCV-85
MCH-27.1 MCHC-31.9* RDW-15.1 RDWSD-46.5* Plt ___
___ 09:00PM BLOOD Neuts-57.7 ___ Monos-8.9 Eos-2.3
Baso-0.7 Im ___ AbsNeut-4.24 AbsLymp-2.20 AbsMono-0.65
AbsEos-0.17 AbsBaso-0.05
___ 09:00PM BLOOD Glucose-110* UreaN-14 Creat-1.1 Na-135
K-4.5 Cl-96 HCO3-32 AnGap-12
___ 09:00PM BLOOD Calcium-10.0 Phos-2.9 Mg-2.1
___ 09:00PM BLOOD Lactate-2.0
DISCHARGE LABS
___ 05:41AM BLOOD WBC-5.9 RBC-4.74 Hgb-13.0* Hct-40.0
MCV-84 MCH-27.4 MCHC-32.5 RDW-15.0 RDWSD-45.6 Plt ___
___ 05:41AM BLOOD Glucose-95 UreaN-13 Creat-1.1 Na-136
K-4.3 Cl-100 HCO3-26 AnGap-14
___ 05:41AM BLOOD Calcium-9.4 Phos-2.4* Mg-2.0
IMAGING
___: CXR AP
In comparison with the study of ___, there again
are low lung volumes with atelectatic streaks in the lower left
lung. Colonic interposition is seen on the right. The right
PICC line has been removed. No evidence of vascular congestion,
cardiomegaly, or acute focal pneumonia.
___: CT Abdomen and Pelvis
1. Multiple bilateral renal calculi, with the largest measuring
up to 1.9 cm
at the midpole of the right kidney. No right-sided
hydronephrosis.
2. Chronic left-sided hydronephrosis, unchanged since ___.
3. Left ureteral double-J stent with superior pigtail within
the proximal
ureter, and inferior pigtail within the bladder.
MICRO
BCX x 2 (___): NGTD
UCx (___): NGTD
Brief Hospital Course:
Mr. ___ is a ___ y/o male with a h/o advanced multiple
sclerosis wheel chair bound, neurogenic bladder s/p suprapubic
catheter placement ___, recurent resistant organism UTI with
h/o bacteremia and urosepsis, seizure disorder, and HTN who was
managed for ? UTI.
#? UTI: Patient was completely asymptomatic upon presentation to
the hospital with UCx from PCP growing pseudomonas. Since the
patient has a suprapubic catheter, his cultures will always grow
out bugs. UTI treatment was discontinued. Urology knows the
patient very well and recommended that he contact them first in
the future with any UTI-related questions. Set up follow up with
urology.
CHRONIC ISSUES
#AMS: A+O x1, frequent factual errors in speech, confusion. Wife
reports this is patient's baseline.
# MS: Severe, wheelchair bound.
-continued home glatiramer
-continued home baclofen for muscle spasms
# HTN: continued home amlodipine
# Seizure disorder: continued home levetiracetam
# Depression: continued home fluoxetine
# GERD: continued home famotidine
# Constipation: continued home colace/senna
Transitinal Issues
-Urology follow up
-Urology advised patient contact them first re: any UTI-related
questions.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 5 mg PO DAILY
2. Ascorbic Acid ___ mg PO DAILY
3. Baclofen 20 mg PO TID
4. Baclofen 40 mg PO QHS
5. Famotidine 20 mg PO BID
6. Fluoxetine 20 mg PO DAILY
7. LeVETiracetam 750 mg PO BID
8. Multivitamins 1 TAB PO DAILY
9. Copaxone (glatiramer) 20 mg/mL subcutaneous DAILY
10. Docusate Sodium 100 mg PO DAILY
11. Senna 8.6 mg PO DAILY
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. Ascorbic Acid ___ mg PO DAILY
3. Baclofen 20 mg PO TID
4. Baclofen 40 mg PO QHS
5. Copaxone (glatiramer) 20 mg/mL subcutaneous DAILY
6. Docusate Sodium 100 mg PO DAILY
7. Famotidine 20 mg PO BID
8. Fluoxetine 20 mg PO DAILY
9. LeVETiracetam 750 mg PO BID
10. Multivitamins 1 TAB PO DAILY
11. Senna 8.6 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
-urinary colonization
Secondary
-advanced MS
-___ bladder s/p suprapubic catheter
-recurrent UTI
-bilateral nephrolithiasis
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Wheelchair bound (from MS)
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you during your most recent
stay at the ___! You presented with dark colored, foul
smelling urine, and were found to likely be dehydrated. Since
you have a catheter in place, your urine will continue to grow
out different pathogens. There is no need for antibiotic
treatment, however, unless you have symptoms of a urinary tract
infection (urgency, frequency, suprapubic
tenderness/pain/fevers). In the future, please contact your
Urologist (instead of your PCP) with any UTI concerns. He will
better be able to advise you on treatment options. We have made
you an appointment with your Urologist for follow up of your
stent and kidney stones (information below).
We wish you the best!
Your ___ Team
Followup Instructions:
___
|
19594197-DS-20
| 19,594,197 | 25,257,283 |
DS
| 20 |
2131-04-06 00:00:00
|
2131-04-06 14:25:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
left hip fracture
Major Surgical or Invasive Procedure:
left hip hemiarthroplasty
History of Present Illness:
___ hx partial colectomy with ostomy who is s/p mechanical trip
and fall while walking to the bathroom suffering immediate left
hip pain and inability to bear weight. No HS or LOC. Patient
uses walker at baseline. No preceding hip pain. Patient denies
pain in other extremities. No numbness or paresthesias.
Past Medical History:
DEPRESSION - On Lexapro since ___
DIVERTICULITIS - ___ perforated sigmoid diverticulitis and
fecal peritonitis
HEARING LOSS
GASTROESOPHAGEAL REFLUX
HUSBAND DIED -___
HYPERTENSION
MACULAR DEGENERATION
SPINAL STENOSIS
VITAMIN D DEFICIENCY -Started Vit D 3 1000 IU daily ___
Social History:
___
Family History:
Non-contributory
Physical Exam:
Gen: NAD, hard of hearing but AAOX4
LLE: incision c/d/I with staples to skin. No erythema, edema or
ecchymoses around the incision. Minimal serous drainage, no pus.
Thigh mildly edematous, but soft and compressible. Appropriately
tender to palpation. SILT s/s/spn/dpn/tn, fires ___,
1+ dorsalis pedis pulse; toes wwp.
Pertinent Results:
___ 04:40AM BLOOD WBC-12.7* RBC-3.13* Hgb-9.4* Hct-29.2*
MCV-93 MCH-30.0 MCHC-32.2 RDW-13.6 RDWSD-46.5* Plt ___
___ 04:25AM BLOOD WBC-15.2* RBC-3.74* Hgb-11.1* Hct-34.4
MCV-92 MCH-29.7 MCHC-32.3 RDW-13.2 RDWSD-45.1 Plt ___
___ 04:55PM BLOOD WBC-22.3*# RBC-4.52 Hgb-13.5 Hct-42.4
MCV-94 MCH-29.9 MCHC-31.8* RDW-13.2 RDWSD-45.2 Plt ___
___ 08:23PM BLOOD WBC-12.2* RBC-4.54 Hgb-13.6 Hct-42.0
MCV-93 MCH-30.0 MCHC-32.4 RDW-12.9 RDWSD-43.9 Plt ___
___ 08:23PM BLOOD Neuts-80.5* Lymphs-13.2* Monos-4.9*
Eos-0.5* Baso-0.2 Im ___ AbsNeut-9.79* AbsLymp-1.61
AbsMono-0.60 AbsEos-0.06 AbsBaso-0.03
___ 04:40AM BLOOD Plt ___
___ 04:25AM BLOOD Plt ___
___ 04:55PM BLOOD Plt ___
___ 08:23PM BLOOD Plt ___
___ 08:23PM BLOOD ___ PTT-21.7* ___
___ 04:40AM BLOOD Glucose-107* UreaN-28* Creat-1.0 Na-136
K-3.5 Cl-107 HCO3-22 AnGap-11
___ 04:25AM BLOOD Glucose-139* UreaN-17 Creat-0.6 Na-137
K-3.3 Cl-104 HCO3-23 AnGap-13
___ 08:23PM BLOOD Glucose-98 UreaN-20 Creat-0.7 Na-138
K-4.0 Cl-104 HCO___ AnGap-15
___ 04:40AM BLOOD Calcium-7.4* Phos-2.3* Mg-2.5
___ 04:25AM BLOOD Calcium-7.8* Mg-1.8
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have left femoral neck fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for left hip hemi-arthroplasty, which
the patient tolerated well. For full details of the procedure
please see the separately dictated operative report. The patient
was taken from the OR to the PACU in stable condition and after
satisfactory recovery from anesthesia was transferred to the
floor. The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given ___
antibiotics and anticoagulation per routine. The patient's home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to rehab
was appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, including naproxen and Tylenol with
codeine. She did not tolerate narcotics well, so these were
discontinued after one dose. Incision was noted to be
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is weight-bearing as tolerated in the
left lower extremity, and will be discharged on lovenox for DVT
prophylaxis. There was some concern for a LLE DVT as pt was
complaining of calf pain. A noninvasive vascular study was
performed and was negative for DVT. The patient will follow up
with Dr. ___ routine. A thorough discussion was had with
the patient regarding the diagnosis and expected post-discharge
course including reasons to call the office or return to the
hospital, and all questions were answered. The patient was also
given written instructions concerning precautionary instructions
and the appropriate follow-up care. The patient expressed
readiness for discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lansoprazole Oral Disintegrating Tab 15 mg PO DAILY
2. Vitamin D 1000 UNIT PO DAILY
3. Amlodipine 5 mg PO HS
4. Escitalopram Oxalate 5 mg PO DAILY
Discharge Medications:
1. Amlodipine 5 mg PO HS
2. Escitalopram Oxalate 5 mg PO DAILY
3. Lansoprazole Oral Disintegrating Tab 15 mg PO DAILY
4. Vitamin D 1000 UNIT PO DAILY
5. Aluminum-Magnesium Hydrox.-Simethicone ___ ml PO Q6H:PRN
Dyspepsia
6. Docusate Sodium 100 mg PO BID
7. Enoxaparin Sodium 40 mg SC Q24H
Start: ___, First Dose: Next Routine Administration Time
8. Acetaminophen 1000 mg PO/NG Q8H:PRN pain
9. Milk of Magnesia 30 ml PO BID:PRN Constipation
10. Senna 8.6 mg PO BID
11. Ondansetron 4 mg PO Q8H:PRN nausesa
12. Naproxen 250 mg PO Q12H
13. Acetaminophen w/Codeine 1 TAB PO Q6H:PRN pain not controlled
with naproxen; in anticipation of ___ or movement oob
RX *acetaminophen-codeine 300 mg-30 mg 1 tablet(s) by mouth
every 6 hours Disp #*30 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
left femoral neck fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- weight bearing as tolerated in the left lower extremity
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take Lovenox 40mg daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
Physical Therapy:
weight bearing as tolerated in the left lower extremity
Treatments Frequency:
please monitor incisions for signs/symptoms of infection; may
shower after 48h, pat dry, but do not submerge wounds. Change
dry dressings prn.
Followup Instructions:
___
|
19594198-DS-10
| 19,594,198 | 25,696,734 |
DS
| 10 |
2142-10-01 00:00:00
|
2142-10-01 12:05:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
L knee osteomyelitis vs septic knee
Major Surgical or Invasive Procedure:
___ I&D L knee
History of Present Illness:
This is a ___ y/o male who presents to the ED from ___ who has recently been followed by an outside
orthopaedist Dr. ___ for left sided knee pain. He
underwent a left knee injection on ___ by Dr. ___.
He was referred for an MRI of his left knee ___ with concern
for osteomyelitis. He was advised to seek medical care at ___ and was later transferred to ___ for further
work up. He was admitted ___ with ID consultation, and
conservative management was agreed upon, with radiology-guided
aspiration planned as an outpatient on discharge.
Aspiration performed ___ with 14K WBC, 66%PMN, negative gram
stain. A culture grew GPCs in pairs and clusters by afternoon of
___, and patient was notified to present for admission, ID
consult, PICC placement, antibiotics, and knee washout.
In interim, patient has denies fevers, chills, weight loss,
additional constitutional symptoms, or other medical issue or
injury. He does note increasing pain and swelling at the left
knee with movement and weightbearing, without overlying erythema
or cellulitic changes.
Past Medical History:
Obstructive sleep apnea
Social History:
___
Family History:
Non-contributory
Physical Exam:
General: Well appearing gentlemen in no acute distress. Alert
and
oriented x 3. His mood and affect are appropriate.
LLE
- Skin dsg clean, dry, intact
- No deformity, erythema, induration or ecchymosis
- ___ fire
- SILT SPN/DPN/TN/saphenous/sural distributions
- 1+ ___ pulses, foot warm and well-perfused
Pertinent Results:
___ ___ M ___ ___ Microbiology Lab
Results
Close
___ 3:30 pm JOINT FLUID Source: Knee.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary):
Reported to and read back by ___ ___ ______) ___ AT
10:14AM.
STAPH AUREUS COAG +.
Isolated from broth media only, INDICATING VERY LOW
NUMBERS OF
ORGANISMS.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
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----------- R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN------------- 0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
Close
Brief Hospital Course:
The patient presented as a same day admission for surgery. The
patient was taken to the operating room on ___ for I&D L
knee, which the patient tolerated well. For full details of the
procedure please see the separately dictated operative report.
The patient was taken from the OR to the PACU in stable
condition and after satisfactory recovery from anesthesia was
transferred to the floor. The patient was initially given IV
fluids and IV pain medications, and progressed to a regular diet
and oral medications by POD#1. The patient was given
___ antibiotics and anticoagulation per routine. The
patient's home medications were continued throughout this
hospitalization. The patient worked with ___ who determined that
discharge to home with services was appropriate. The ___
hospital course included ID consult, PICC line placement.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
WBAT in the LL extremity, and will be discharged on asa for DVT
prophylaxis. The patient will follow up with Dr. ___
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course
including reasons to call the office or return to the hospital,
and all questions were answered. The patient was also given
written instructions concerning precautionary instructions and
the appropriate follow-up care. The patient expressed readiness
for discharge.
Medications on Admission:
Aleve
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
3. Docusate Sodium 100 mg PO BID
4. Aspirin 325 mg PO DAILY
RX *aspirin 325 mg 1 tablet(s) by mouth once a day Disp #*28
Tablet Refills:*0
5. Heparin Flush (10 units/ml) 2 mL IV ONCE MR1 For PICC
insertion Duration: 1 Dose
RX *heparin lock flush (porcine) 10 unit/mL 10 units IV ONCE MR1
Disp #*100 Vial Refills:*0
6. Nafcillin 2 g IV Q4H
RX *nafcillin in dextrose iso-osm 2 gram/100 mL 2 g IV every
four (4) hours Disp #*252 Intravenous Bag Refills:*0
7. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*40 Tablet Refills:*0
8. Senna 8.6 mg PO BID
9. Sodium Chloride 0.9% Flush 20 mL IV X1 PRN For PICC
insertion
RX *sodium chloride 0.9 % 0.9 % 20 ml IV x1 Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
L septic knee vs osteomyelitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- WBAT
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take aspirin daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
- If applicable, Splint must be left on until follow up
appointment unless otherwise instructed
- Do NOT get splint wet
Physical Therapy:
Activity: Activity: Activity as tolerated
Encourage turn, cough and deep breathe q2h when awake<br>LLE
WBAT, ROMAT knee gentle
Treatments Frequency:
Wound care:
Site: left knee
keep clean, dry with dry sterile dressing
Followup Instructions:
___
|
19594565-DS-13
| 19,594,565 | 20,859,244 |
DS
| 13 |
2161-11-02 00:00:00
|
2161-11-02 18:02:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fever, facial swelling/redness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mrs. ___ is an ___ year-old lady with refractory AML c/b myeloid
sarcoma having completed 10 cycles of decitabine who presents
with new low grade fever and facial edema/erythema.
She was in her usual state of health until a day prior to
admission when she developed edema and erythema in her right
cheek without associated pain. Denies dental pain, complaints or
recent procedures. On the day of admission she developed chills
and a low grade temperature to 100.1.
ED initial vitals were 98.5 92 165/67 18 99% RA
Prior to transfer vitals were 98.5 91 131/50 16 98% RA
Exam in the ED significant for : "HEENT: Swelling, erythema and
palpable, mobile lesion over right lower cheek without open
wound
or drainage. Oropharynx without erythema, exudates or ulcers. No
dental TTP or abscess appreciated, Neck: Supple, shotty
lymphadenopathy bilaterally."
ED work-up significant for:
-CBC: WBC: 1.4* HGB: 7.9*. Plt Count: 51*. ANC 80, Blasts 3%
-Chemistry: Na: 134* . K: 3.7. Cl: 95*. CO2: 27. BUN: 11. Creat:
0.5. Ca: 8.7. Mg: 1.9. PO4: 2.5*.
-Lactate: 2.1
-Coags: INR: 1.2*. PTT: 33.2.
-LFTs: ALT: 12. AST: 15. Alk Phos: 105. Total Bili: 0.8.
-CT neck/parotids (key findings): "1. Right facial inflammation
extending into the right anterior superior neck.The deep neck
space fat planes are preserved. No fluid collection. 2. No
definite periapical lucency to suggest an odontogenic source. No
sialadenitis. "
ED management significant for:
-Medications: Vancomycin, cefepime, metronidazole, NS 250mL/h
-Consult: ___, add metronidazole, obtain CT, admit to ___
On arrival to the floor, patient reports that the area of
swelling/redness only hurts when she touches it or sleeps on it
but not when she eats. She stopped having chills and feels
better
in general. Her daughter reports that she has not been eating or
drinking much in the past 2 days.
Patient denies night sweats, headache, vision changes,
dizziness/lightheadedness, weakness/numbnesss, shortness of
breath, cough, hemoptysis, chest pain, palpitations, abdominal
pain, nausea/vomiting, diarrhea, hematemesis,
hematochezia/melena, dysuria, hematuria.
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:
- ___: Presents with severe anemia, WBC 12.5, Hgb 7.2, Plt
184, 3% peripheral blasts.
- ___: Bone marrow biopsy reveals myelodysplastic syndrome
with excess blasts-2 with ringed sideroblasts. Blasts ___ in
marrow. Complex abnormal karyotype with trisomy 8 and 5q-. TP53
A276D point mutation present on Rapid Heme Panel. Very high risk
by R-IPSS score.
- ___: C1D1 decitabine 20 mg/m2 x 5 days.
- ___: C2D1 decitabine 20 mg/m2 x 5 days.
- ___: C3D1 decitabine 20 mg/m2 x 5 days.
- ___: C4D1 decitabine 20 mg/m2 x 5 days.
- ___: C5D1 decitabine 20 mg/m2 x 5 days.
- ___: C6D1 decitabine 20 mg/m2 x 5 days.
- ___: C7D1 decitabine 20 mg/m2 x 5 days.
- ___: C8D1 decitabine 20 mg/m2 x 5 days.
- ___: C9D1 decitabine 20 mg/m2 x 5 days. 10% peripheral
blasts noted.
- ___: Admitted in the context of new right leg pain. LENIs
show no evidence of DVT or focal fluid collection in the area of
pain. CT of the right thigh shows no correlate in the area of
reported pain. MRI of the right femur demonstrates an
aggressive-appearing marrow replacement process of the
mid-to-distal right femoral diaphysis with surrounding
periosteal
reaction and muscle edema and enhancement. She is seen by Dr.
___ Radiation ___ on ___, who recommends XRT to
the lesion because of risk of recurrent pain in this area and
even fracture. Orthopedic Surgery is consulted, and recommends a
plain film of the femur, which is negative for fracture. They
recommend no surgical intervention.
- ___: Discharged to home
- ___: Undergoes XRT simulation.
- ___: CBC with improving but persistent neutropenia (ANC
140), stable anemia (hemoglobin 8.0 g/dL), and improving
thrombocytopenia (platelet count 46,000/uL), with decreasing
peripheral blasts (2%).
PAST MEDICAL/SURGICAL HISTORY:
Very high risk MDS, as above
Latent Hepatitis B virus infection
Latent Tuberculosis infection
Osteoarthritis
Possible lacunar infarct
Social History:
___
Family History:
- One younger brother deceased, liver cancer
- Second younger brother deceased, either liver or kidney
cancer(unsure which)
- Mother deceased, stroke
- Father deceased, typhoid fever
Physical Exam:
ADMISSION PHYSICAL EXAM:
=========================
VS: ___ 2342 Temp: 99.3 PO BP: 135/67 HR: 90 RR: 19 O2 sat:
96% O2 delivery: Ra
GENERAL: Well- appearing lady, in no distress sitting in bed
comfortably.
HEENT: Anicteric, PERLL, Mucous membranes dry, oropharynx clear,
poor dentition. Erythema and edema in right cheek extending to
upper third of neck, area marked.
CARDIAC: Regular rate and rhythm, holosystolic murmur better
heard at apex, no rubs or gallops.
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi.
ABD: Non-distended, normal bowel sounds, soft, non-tender, no
guarding, no palpable masses.
EXT: Warm, well perfused. No lower extremity edema. No erythema
or tenderness.
NEURO: Alert and oriented, good attention, CN II-XII intact.
Strength full throughout. Sensation to light touch intact.
SKIN: Right chest port without erythema, secretion, tenderness.
DISCHARGE PHYSICAL EXAM:
=========================
VS: ___ 0720 Temp: 98.6 PO BP: 145/69 HR: 79 RR: 18 O2 sat:
95% O2 delivery: RA
TMax: 98.6
GENERAL: Well-appearing lady, in no distress sitting in chair
HEENT: Anicteric, PERLL, MMM, oropharynx clear, poor dentition.
Right cheek without edema or erythema.
CARDIAC: Regular rate and rhythm, holosystolic murmur better
heard at apex, no rubs or gallops.
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi.
ABD: Non-distended, normal bowel sounds, soft, non-tender, no
guarding, no palpable masses.
EXT: Warm, well perfused. No lower extremity edema. No erythema
or tenderness.
NEURO: Alert and oriented, good attention, No focal deficits.
SKIN: Right chest port without erythema, tenderness.
PYSCH: Very cheerful
Pertinent Results:
Admission Labs:
----------------
___ 01:10PM BLOOD WBC-1.0* RBC-2.58* Hgb-8.1* Hct-23.2*
MCV-90 MCH-31.4 MCHC-34.9 RDW-14.2 RDWSD-45.9 Plt Ct-21*
___ 01:10PM BLOOD Neuts-3* Bands-0 Lymphs-88* Monos-4*
Eos-0 Baso-1 ___ Myelos-0 Blasts-4* NRBC-1*
AbsNeut-0.03* AbsLymp-0.88* AbsMono-0.04* AbsEos-0.00*
AbsBaso-0.01
___ 06:16PM BLOOD ___ PTT-33.2 ___
___ 06:16PM BLOOD Glucose-141* UreaN-11 Creat-0.5 Na-134*
K-3.7 Cl-95* HCO3-27 AnGap-12
___ 01:10PM BLOOD ALT-11 AST-15 AlkPhos-108* TotBili-0.4
___ 06:16PM BLOOD Albumin-3.8 Calcium-8.7 Phos-2.5* Mg-1.9
UricAcd-3.5
___ 06:22PM BLOOD Lactate-2.1*
Imaging:
---------
___ CT Neck with contrast
IMPRESSION:
1. Right facial inflammation extending into the right anterior
superior neck. The deep neck space fat planes are preserved.
No fluid collection.
2. No definite periapical lucency to suggest an odontogenic
source. No
sialadenitis.
3. Unchanged bilateral calcified cervical lymph nodes which
presumably reflect prior granulomatous disease.
Discharge Labs:
-----------------
___ 12:23AM BLOOD WBC-2.4* RBC-2.48* Hgb-7.5* Hct-22.1*
MCV-89 MCH-30.2 MCHC-33.9 RDW-14.1 RDWSD-45.4 Plt Ct-29*
___ 05:00AM BLOOD Neuts-9* Bands-0 ___ Monos-21*
Eos-0 Baso-0 Atyps-1* Metas-4* Myelos-5* Blasts-12*
AbsNeut-0.20* AbsLymp-1.08* AbsMono-0.46 AbsEos-0.00*
AbsBaso-0.00*
___ 05:00AM BLOOD Plt Smr-VERY LOW* Plt Ct-31*
___ 12:23AM BLOOD Glucose-119* UreaN-10 Creat-0.4 Na-134*
K-3.6 Cl-97 HCO3-25 AnGap-12
___ 05:00AM BLOOD ALT-10 AST-13 LD(LDH)-159 AlkPhos-81
TotBili-0.7
___ 12:23AM BLOOD Calcium-7.9* Phos-2.6* Mg-1.9
Brief Hospital Course:
Mrs. ___ is an ___ year-old lady with refractory AML c/b myeloid
sarcoma having completed 10 cycles of decitabine who presents
with new low grade fever and facial edema/erythema consistent
with cellulitis.
ACUTE ISSUES:
--------------
#Facial Cellulitis | #Neutropenic infection
The patient presented with an absolute neutrophil count of 80 in
setting of dysplastic bone marrow, unlikely to be secondary to
chemotherapy as >14d of last
dose of decitabine. Her facial cellulitis and tooth pain were
concerning for
odontic source, therefore a CT was ordered, which could not rule
out an oral source. She was started on broad spectrum
antibiotics after blood cultures were drawn. ID was consulted
and felt that the facial cellulitis was likely an external
source as no acute dental infection was identified. She was
transitioned to oral antibiotics on ___ as she had significant
clinical improvement.
#Hyponatremia: Resolved after IV fluids. The most likely
etiology of hyponatremia was hypovolemic in setting of decreased
PO inake. Also potentially
worsened by hydrochlorothiazide, which was held ___.
CHRONIC ISSUES:
------------------
#AML, refractory | #Pancytopenia:
Transformed from MDS. ___ but with controlled blast count
at 3%. On review of notes by Dr. ___ will pursue
supportive treatment and may consider additional cycles of
decitabine if within goals. Transfused ___ with appropriate
increase in HGB.
#LTBI: Continued isoniazid and pyridoxine support
#Chronic HBV infection: Continued entecavir
Transitional Issues:
=========================
Discharge WBC 2.4
Discharge HGB 7.5
Discharge PLT 29
Discharge ANC 200
[] MEDICATION CHANGES:
# New medications:
Doxycycline 100mg PO twice daily until no longer neutropenic
Keflex ___ PO every 6 hours until no longer neutropenic
# Stopped medications:
Hydrochlorothiazide - hypotensive
#CODE: DNAR/DNI
#EMERGENCY CONTACT/HCP: ___ (daughter): ___# ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Entecavir 0.5 mg PO DAILY
2. Fluconazole 400 mg PO Q24H
3. Hydrochlorothiazide 12.5 mg PO DAILY
4. Isoniazid ___ mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Polyethylene Glycol 17 g PO DAILY
7. Pyridoxine 50 mg PO DAILY
Discharge Medications:
1. Cephalexin 500 mg PO Q6H
RX *cephalexin 500 mg 1 capsule(s) by mouth every six (6) hours
Disp #*80 Capsule Refills:*0
2. Doxycycline Hyclate 100 mg PO Q12H
RX *doxycycline hyclate 100 mg 1 capsule(s) by mouth every
twelve (12) hours Disp #*40 Capsule Refills:*0
3. Entecavir 0.5 mg PO DAILY
4. Fluconazole 400 mg PO Q24H
5. Isoniazid ___ mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Polyethylene Glycol 17 g PO DAILY
8. Pyridoxine 50 mg PO DAILY
9. HELD- Hydrochlorothiazide 12.5 mg PO DAILY This medication
was held. Do not restart Hydrochlorothiazide until you meet with
your doctor
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
===================
Facial Cellulitis
Hyponatremia
AML
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 ___!
WHY WAS I ADMITTED TO THE HOSPITAL?
You were admitted because you had a low grade fever, and and
infection on your face.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
You received antibiotics for the infection and it went away
WHAT SHOULD I DO WHEN I GO HOME?
Please continue to take all of your medications as prescribed,
and follow up with all of your doctors.
We wish you the best,
Your ___ care team
New medications:
Doxycycline 100mg PO twice daily
Keflex ___ PO every 6 hours
Stopped medications:
Hydrochlorothiazide - your blood pressure was low and you don't
need it.
Followup Instructions:
___
|
19594565-DS-14
| 19,594,565 | 28,323,458 |
DS
| 14 |
2161-12-01 00:00:00
|
2161-12-01 21:13:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is an ___ female with history of
refractory AML c/b myeloid sarcoma having completed 10 cycles of
decitabine who presents with neutropenic fever.
Patient recently admitted ___ to ___ for febrile
neutropenic likely from facial cellulitis. She was discharged on
Doxycycline and Keflex. She was seen on 7 ___ on ___ with
R
> L bilateral lower extremity edema. Exam during that visit
documented as "RLE with 2+ pitting edema with mild-moderate
erythema up ___ of calf and swelling involving foot as well with
hemosiderosis-type skin discoloration. LLE ___ edema (< right
side) with similar but less marked skin color changes. Both legs
warm to touch." She was broadened to Augmentin + doxycycline.
Bilateral lower extremity ___ was negative on ___ for DVT, but
notable for soft tissue edema in R calf.
Ms. ___ developed a fever on ___ and called her clinic to
report a temperature of 102. Her last ANC prior to presentation
was 200. She also reported chronic left hip pain and R leg
swelling as well as an expanding red and hot patch on the R
shin.
Given fever and symptoms with underlying neutropenia, she was
referred to the ED.
On arrival to the ED, initial vitals were Temperature:101.5,
heart rate 139, blood pressure 128/66, respiratory rate 15 O2:
98% RA. Exam was notable for tachycardia, RLE swelling and
pitting edema and non-blanching brawny erythema over left distal
calf, and non-infected appearing port site. Rectal exam was not
done. Labs were notable for:
- Hemoglobin 4.6, hematocrit 13.5
- Platelets 20
- WBC 6.8, ANC 410, Blasts 21%
- Na 129, Cl 89
- Lactate 1.2
- Flu negative
- INR 1.4
- blood and urine cultures drawn
She was given:
- 3u pRBC
- Acetaminophen 650mg
- Isoniazid ___
- Entecavir 0.5 mg
- Cefepime 2g x 3
- Vancomycin 1000mg x 1 and 1500 mg x 1
- Pyridoxine 50mg
- Hydroxyurea 500mg
- Diphenhydramine 50mg
- fluconazole 400 mg
- NS
Imaging revealed:
- CXR with R port-a-cath in place, no pneumonia or other acute
pathology
Labs prior to transfer were significantly improved with
hematocrit of 32.2. Prior to transfer vitals were 100.1 93
126/53
16 96% RA
On arrival to the floor, the patient and her daughter report
that
she has noticed progressive redness of the RLE for the past week
associated with swelling, though the swelling seems better over
the past day since she had been elevating her legs in the ED.
She
also endorses tolerable L hip pain, for which MRI was recently
done confirming likely leukemic infiltration of this area.
Past Medical History:
======================
PAST ONCOLOGIC HISTORY
======================
- ___: Presents with severe anemia, WBC 12.5, Hgb 7.2, Plt
184, 3% peripheral blasts.
- ___: Bone marrow biopsy reveals myelodysplastic syndrome
with excess blasts-2 with ringed sideroblasts. Blasts ___ in
marrow. Complex abnormal karyotype with trisomy 8 and 5q-. TP53
A276D point mutation present on Rapid Heme Panel. Very high risk
by R-IPSS score.
- ___: C1D1 decitabine 20 mg/m2 x 5 days.
- ___: C2D1 decitabine 20 mg/m2 x 5 days.
- ___: C3D1 decitabine 20 mg/m2 x 5 days.
- ___: C4D1 decitabine 20 mg/m2 x 5 days.
- ___: C5D1 decitabine 20 mg/m2 x 5 days.
- ___: C6D1 decitabine 20 mg/m2 x 5 days.
- ___: C7D1 decitabine 20 mg/m2 x 5 days.
- ___: C8D1 decitabine 20 mg/m2 x 5 days.
- ___: C9D1 decitabine 20 mg/m2 x 5 days. 10% peripheral
blasts noted.
- ___: Admitted in the context of new right leg pain. LENIs
show no evidence of DVT or focal fluid collection in the area of
pain. CT of the right thigh shows no correlate in the area of
reported pain. MRI of the right femur demonstrates an
aggressive-appearing marrow replacement process of the
mid-to-distal right femoral diaphysis with surrounding
periosteal reaction and muscle edema and enhancement. She is
seen
by Dr. ___ Radiation ___ on ___, who recommends
XRT to
the lesion because of risk of recurrent pain in this area and
even fracture. Orthopedic Surgery is consulted, and recommends a
plain film of the femur, which is negative for fracture. They
recommend no surgical intervention.
- ___: Discharged to home
- ___: Undergoes XRT simulation.
- ___: CBC with improving but persistent neutropenia (ANC
140), stable anemia (hemoglobin 8.0 g/dL), and improving
thrombocytopenia (platelet count 46,000/uL), with decreasing
peripheral blasts (2%).
- ___ - ___: Admitted for fever and facial edema and
treated
for facial cellulitis.
=============================
PAST MEDICAL/SURGICAL HISTORY
=============================
Very high risk MDS, as above
Latent Hepatitis B virus infection
Latent Tuberculosis infection
Osteoarthritis
Possible lacunar infarct
Social History:
___
Family History:
- One younger brother deceased, liver cancer
- Second younger brother deceased, either liver or kidney
cancer(unsure which)
- Mother deceased, stroke
- Father deceased, typhoid fever
Physical Exam:
==============================
ADMISSION PHYSICAL EXAMINATION
==============================
Vitals: 97.6 107/63 82 18 93% RA
Gen: pleasant woman in no acute distress, smiling
HEENT: oropharynx with petechiae but no wet purpura, no
mucositis, EOMI, anicteric sclerae
NECK: supple
LYMPH: no palpable adenopathy in neck
CV: RRR, no obvious m/r/g
LUNGS: CTAB posteriorly
ABD: NT/ND, +BS
EXT: warm. bilateral lower extremity pitting edema, R>L, with
dark red erythema extending about halfway up shins with
associated petechiae, warm to touch relative to left
SKIN: see above
NEURO: grossly intact, moving all four extremities
LINES: R Port without surrounding erythema, warmth or tenderness
==============================
DISCHARGE PHYSICAL EXAMINATION
==============================
T:97.4 BP:135/64 HR:78 RR:18 O2:98 ra
Gen: Exhausted woman lying in bed, continues to be very pleasant
HEENT: Blood blister noted on anterior lip, improving. New blood
blister on L interior cheek has drained. No new oropharyngeal
lesions.
LYMPH: One palpable lymph node on L anterior neck
CV: S1/S2 regular with no murmurs, rubs or S3/S4
LUNGS: Clear to auscultation bilaterally
ABD: Soft, non-tender, non-distended
EXT: Warm. Trace bilateral lower extremity edema. Significant
discoloration of the lower shin and foot bilaterally.
NEURO: Grossly intact, moving all four extremities
LINES: R Port without surrounding erythema, warmth or tenderness
Pertinent Results:
============================
ADMISSION LABORATORY STUDIES
============================
___ 08:54PM PLT SMR-RARE* PLT COUNT-20*
___ 08:54PM HYPOCHROM-2+* ANISOCYT-1+*
POIKILOCY-OCCASIONAL MACROCYT-NORMAL MICROCYT-2+*
POLYCHROM-NORMAL OVALOCYT-OCCASIONAL
___ 08:54PM NEUTS-4* BANDS-2 LYMPHS-60* MONOS-10 EOS-0
BASOS-0 ___ METAS-3* MYELOS-0 BLASTS-21* AbsNeut-0.41*
AbsLymp-4.08* AbsMono-0.68 AbsEos-0.00* AbsBaso-0.00*
___ 08:54PM WBC-6.8 RBC-1.51* HGB-4.6* HCT-13.5* MCV-89
MCH-30.5 MCHC-34.1 RDW-13.6 RDWSD-43.9
___ 08:54PM ALBUMIN-3.5 CALCIUM-8.4 PHOSPHATE-3.5
MAGNESIUM-1.6
___ 08:54PM cTropnT-<0.01
___ 08:54PM ALT(SGPT)-12 AST(SGOT)-21 ALK PHOS-79 TOT
BILI-0.7
___ 08:54PM GLUCOSE-154* UREA N-11 CREAT-0.6 SODIUM-129*
POTASSIUM-4.3 CHLORIDE-89* TOTAL CO2-22 ANION GAP-18
___ 09:02PM LACTATE-1.2
==========================================
DISCHARGE AND PERTINENT LABORATORY STUDIES
==========================================
___ 06:00AM BLOOD WBC-34.7* RBC-2.67* Hgb-7.9* Hct-23.9*
MCV-90 MCH-29.6 MCHC-33.1 RDW-14.3 RDWSD-46.5* Plt Ct-18*
___ 06:15AM BLOOD Neuts-7* Bands-2 ___ Monos-9 Eos-0
Baso-6* ___ Metas-1* Myelos-2* Blasts-51* AbsNeut-2.66
AbsLymp-6.49* AbsMono-2.66* AbsEos-0.00* AbsBaso-1.77*
___ 06:15AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
Schisto-OCCASIONAL
___ 06:00AM BLOOD Plt Ct-18*
___ 11:33AM BLOOD Plt Ct-50*
___ 06:00AM BLOOD ___ PTT-29.4 ___
___ 06:00AM BLOOD Glucose-178* UreaN-15 Creat-0.5 Na-134*
K-4.4 Cl-91* HCO3-29 AnGap-14
___ 06:00AM BLOOD ___
___ 06:00AM BLOOD ___
___ 06:00AM BLOOD ALT-80* AST-64* LD(LDH)-324* AlkPhos-102
TotBili-0.5
___:00AM BLOOD Albumin-2.9* Calcium-8.0* Phos-3.6 Mg-2.1
===========================
REPORTS AND IMAGING STUDIES
===========================
___ CT ABD/Pelvis: Unremarkable
___ CXR
IMPRESSION:
Compared the prior examination, there has been slight worsening
of borderline vascular congestion with perhaps trace
interstitial
edema. There is no consolidation to suggest pneumonia. There
is
no effusion pneumothorax. The cardiomediastinal silhouette and
hilar contours are unchanged. The right Port-A-Cath is
unchanged
___ CTA CHEST
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. No consolidations to suggest acute infection.
3. Unchanged chronic compression deformity of T12.
4. Diffuse idiopathic skeletal hyperostosis is noted.
___ Doppler Ultrasound L Leg
IMPRESSION:
No evidence of deep venous thrombosis in the left lower
extremity
veins.
___ CXR PA and LAT
FINDINGS:
AP upright and lateral views of the chest provided.
Port-A-Cath noted in the right chest wall with catheter tip in
the region of the low SVC. The lungs appear clear bilaterally
without evidence of pneumonia or edema. No large effusion or
pneumothorax. Cardiomediastinal silhouette is stable with aortic
knob calcifications again noted. Imaged bony structures are
intact. No free air below the right hemidiaphragm is seen. Dish
related changes of the T-spine noted.
============
MICROBIOLOGY
============
- ___ Blood Cultures: NGTD
- ___ Urine Cultures: No growth, final
- ___ UA: Few Bacteria; Trace Protein
- ___ Blood Culture #1 = No growth, final
- ___ Blood Culture #2 = No growth, final
- ___ Urine Culture = No growth
- ___ Blood Culture = No growth, final
Brief Hospital Course:
=================
SUMMARY STATEMENT
=================
Mr. ___ is an ___ female with history of
refractory AML c/b myeloid sarcoma having completed 10 cycles of
decitabine who presents with neutropenic fever. Right lower
extremity cellulitis was a presumed source, though blood
cultures were negative. She was treated with a prolonged course
of broad spectrum antibiotics due to recurrent fevers. She also
developed worsening nausea and bony pain though to be related to
progressing refractory AML, which was supported by a rising
white count and blast percentage. A family meeting was held and
the decision was made to transition the patient to oral
antibiotics and discharge home in order for her to have some
comfortable time out of the hospital. The family plans on
bringing her into the hospital for any new or concerning
symptoms and they do not wish to pursue home or inpatient
hospice.
====================
ACUTE MEDICAL ISSUES
====================
# Febrile Neutropenia
# Asymmetric lower extremity edema
# Lower extremity erythema
Presented with fever, presumed source could be right lower
extremity cellulitis. Completed 7d of vanc/cefepime. Cellulitic
appearance of R leg greatly improved. Transitioned back to
levaquin, then developed high 99 temperature and broadened to
vanc/cefepime again. A day later developed high T99 temperature
and broadened to
posaconazole. The following day (___) developed T of 101, still
no source on blood cultures or CXR. Patient started vomiting and
had hypotension to 90's. Broadened to meropenem. CT
abdomen/pelvis unremarkable. These fevers may represent
infection but more likely represent worsening disease process.
Given goals of care transitioned to oral levaquin on ___ and
she did not have further fevers or worsening in erythema of the
right leg, so she was discharged home.
#Refractory AML
#Transfusion dependence
#Nausea
S/p 10 cycles of decitabine. ANC 650 and blasts notably 37% on
presentation and significantly rising throughout
hospitalization. Had allergic reaction to platelets on ___,
resolved with 50mg IV hydrocortisone, 50mg IV Benadryl and 20mg
IV famotidine. No reaction to platelets on ___. Blasts >70% on
___. Worsening pain in her left hip thought to be related to
disease due to findings on ___ MRI of the pelvis. This was well
controlled with tramadol. She also developed nausea that was not
responsive to ondansetron. A CT abdomen/pelvis was negative. She
was given three days of 4mg IV dexamethasone with resolution of
her nausea. She also had one episode of chest pain and
tachycardia that resolved spontaneously, and a CTA was negative
for PE.
#Patient Values and Goals of Current Hospitalization
On ___ her primary oncologist, Dr. ___ a goals of
care conversation. Notably in this discussion: "She clearly
stated priorities for her goals of care from this point onward,
including:
1) Avoidance of pain.
2) The desire to pass away peacefully.
3) Not to have advanced interventions with "tubes and lines."
I asked her to clarify the latter point, and she stated that she
would not want a breathing tube or chest compressions.
Accordingly, her Code Status has been changed to DNR/DNI."
The patient's daughter confirmed DNR/DNI status. A second family
meeting was held after the patient's son flew in from ___ in
which a plan was devised to transition to only oral medication
and discharge home as long as the patient could remain
comfortable. If she could not do well at home, she will return
to the hospital and at that point we will re-address which
interventions are within the patient's goals of care. The family
clearly stated the patient is not interested in an ___
___ facility or in home hospice.
#Acute Anemia
Hemoglobin 7.2 to 4.6 in about 36 hours on presentation. Guaiac
negative in the ED. She received 3u pRBC. Of note, it is likely
the value of 4.6 was an erroneous lab value, because her
hemoglobin responded to the 10's. She did not require another
transfusion after being admitted to the hospital.
======================
CHRONIC MEDICAL ISSUES
======================
#Latent Tuberculosis
Continued isoniazid and pyridoxine.
# Chronic hepatitis B infection
Continued entecavir 0.5mg tablet daily.
===================
TRANSITIONAL ISSUES
===================
Discharge WBC: 34.7
Discharge PLT: 50
Discharge HGB/HCT: 7.9/23.9
[ ] Consider increasing strength of analgesic regimen, as bony
pain related to disease is expected to worsen
- New Meds: Tramadol 50mg PO Q4hr PRN; Lorazepam 0.5mg q8hrs PRN
nausesa; lidocaine 5% patch; levofrloxacin 500mg q24 hrs,
dexamethasone 2mg daily;
- Stopped/Held Meds: Augmentin, Furosemide, Keflex,
Multivitamins, Potassium Chloride,
Changed Med: Hydrea increased to 1g daily
- Code Status: DNR/DNI, do not transfer to an ICU, confirmed
- Contact Information: ___ (daughter) primary contact
person: cp# ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Entecavir 0.5 mg PO DAILY
2. Fluconazole 400 mg PO Q24H
3. Isoniazid ___ mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Polyethylene Glycol 17 g PO DAILY
6. Pyridoxine 50 mg PO DAILY
7. Cephalexin 500 mg PO Q6H
8. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
9. Furosemide 20 mg PO DAILY
10. Hydroxyurea 500 mg PO DAILY
11. Potassium Chloride 40 mEq PO BID
Discharge Medications:
1. Dexamethasone 2 mg PO DAILY
RX *dexamethasone 2 mg 1 tablet(s) by mouth Daily Disp #*30
Tablet Refills:*0
2. Levofloxacin 500 mg PO Q24H
RX *levofloxacin 500 mg 1 tablet(s) by mouth Daily Disp #*30
Tablet Refills:*0
3. Lidocaine 5% Patch 1 PTCH TD QPM
RX *lidocaine 5 % Every evening Disp #*30 Patch Refills:*0
4. lidocaine 4 % topical ONCE
RX *lidocaine [Lidocare] 4 % Apply to leg Every evening Disp #*6
Patch Refills:*0
5. LORazepam 0.5 mg PO Q8H:PRN nausea, anxiety, insomnia
RX *lorazepam 0.5 mg 1 tablet by mouth every 8 hours Disp #*30
Tablet Refills:*0
6. TraMADol 50 mg PO Q4H:PRN Pain - Moderate
Never take more then prescribed amount.
RX *tramadol 50 mg 1 tablet(s) by mouth Every 4 hours Disp #*60
Tablet Refills:*0
7. Hydroxyurea 1000 mg PO DAILY
RX *hydroxyurea 500 mg 2 capsule(s) by mouth daily Disp #*60
Capsule Refills:*0
8. Entecavir 0.5 mg PO DAILY
9. Fluconazole 400 mg PO Q24H
10. Isoniazid ___ mg PO DAILY
11. Polyethylene Glycol 17 g PO DAILY
12. Pyridoxine 50 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
=================
PRIMARY DIAGNOSIS
=================
Febrile Neutropenia
===================
SECONDARY DIAGNOSES
===================
Right lower extremity cellulitis
Refractory AML
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 caring for you while you were admitted to ___
___.
WHY WERE YOU ADMITTED TO THE HOSPITAL?
- You had a fever and we were worried you were having an
infection.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- We gave you antibiotics. You may have had an infection in your
leg.
- We gave your blood and platelets when your counts got too low.
- We treated you for pain and nausea.
WHAT SHOULD YOU DO WHEN YOU GO HOME?
- Carefully review the attached medication list as we may have
made changes to your medications.
- Call your doctor or go to the emergency department right away
if you have any concerning symptoms.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19594570-DS-18
| 19,594,570 | 24,368,205 |
DS
| 18 |
2134-12-16 00:00:00
|
2134-12-16 17:52:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
amoxicillin
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ is a ___ yo F with history significant for asthma
who presents with shortness of breath.
Per history obtained in the ED, patient was seen in primary care
clinic on day of admission with complaints of shortness of
breath
and wheezing for 3 days. She also reported associated chest
tightness, cough productive of yellow sputum, allergies, and
fever/ chills. Patient was diagnosed with an asthma
exacerbation,
likely triggered by an upper respiratory infection and/or
seasonal allergies. She was given duonebs in clinic, with
improvements in peak flow, and was sent home.
Patient subsequently returned to clinic after experiencing an
episode of dizziness, nausea, and vomiting after leaving her
appointment. She was referred to the ED for further management.
Past Medical History:
Asthma
Pseudotumor cerebri
Social History:
___
Family History:
- Diabetes mellitus
- HTN
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: T 98.1, 119 / 82, HR 87, RR 18, SpO2 96% on room air
GENERAL: Sitting upright in bed in no acute distress. Speaking
in
full sentences.
HEENT: Colored contacts in place, therefore no pupillary
reaction
to light or accommodation. EOMI. MMM. Clear oropharynx.
NECK: No cervical lymphadenopathy.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Breathing comfortably on room air. Wheezing in the lung
fields bilaterally. Moderate air flow.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
SKIN: Warm. No rashes or lesions noted.
NEUROLOGIC: AOx3. No gross abnormalities.
DISCHARGE PHYSICAL EXAM:
========================
24 HR Data (last updated ___ @ 632)
Temp: 97.9 (Tm 97.9), BP: 114/75 (114-137/75-88), HR: 85
(64-88), RR: 18 (___), O2 sat: 97% (95-98), O2 delivery: Ra,
Wt: 263.01 lb/119.3 kg
GEN: well-appearing, NAD, conversant
HEENT: atraumatic, normocephalic head
CV: RRR. no rubs, murmurs, gallops. normal S1 S2
PULM: No accessory muscle use, speaking in full sentences. Good
air movement. Only one inspiratory wheeze heard over left lung.
Not heard on repeat inspirations.
EXT: well perfused, warm to touch. no edema.
Pertinent Results:
ADMISSION LABS:
===============
___ 01:55PM BLOOD WBC-5.3 RBC-4.80 Hgb-12.0 Hct-37.5
MCV-78* MCH-25.0* MCHC-32.0 RDW-14.7 RDWSD-42.0 Plt ___
___ 01:55PM BLOOD Neuts-74.6* Lymphs-18.4* Monos-4.9*
Eos-1.3 Baso-0.6 Im ___ AbsNeut-3.93 AbsLymp-0.97*
AbsMono-0.26 AbsEos-0.07 AbsBaso-0.03
___ 01:55PM BLOOD Plt ___
___ 01:55PM BLOOD Glucose-105* UreaN-7 Creat-0.9 Na-142
K-3.4* Cl-104 HCO3-23 AnGap-15
___ 09:39PM BLOOD ___ pO2-45* pCO2-50* pH-7.31*
calTCO2-26 Base XS--1 Comment-GREEN TOP
DISCHARGE LABS:
===============
___ 06:48AM BLOOD WBC-4.5 RBC-4.92 Hgb-12.3 Hct-38.7
MCV-79* MCH-25.0* MCHC-31.8* RDW-15.2 RDWSD-43.3 Plt ___
___ 06:48AM BLOOD Neuts-62.3 ___ Monos-7.8 Eos-0.0*
Baso-0.2 Im ___ AbsNeut-2.81 AbsLymp-1.31 AbsMono-0.35
AbsEos-0.00* AbsBaso-0.01
___ 06:48AM BLOOD Plt ___
___ 06:48AM BLOOD ___ PTT-30.9 ___
___ 06:57AM BLOOD Glucose-96 UreaN-7 Creat-0.7 Na-143 K-3.8
Cl-106 HCO3-25 AnGap-12
MICRO:
======
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
IMAGING:
========
CXR: IMPRESSION: No acute cardiopulmonary process.
Brief Hospital Course:
___ is a ___ year old female with a PMH of asthma who
presented with shortness of breath, wheezing, productive cough,
and fever for 3 days. In the ED she had a temperature of 100.5,
HR of 115. No leukocytosis and CXR without focal consolidation.
She was treated as URI induced asthma exacerbation and started
on duonebs, advair and pred 60 with gradual improvement of her
symptoms. By day two patient had resolution of wheezing,
improved SOB. She was discharged on her home albuterol inhalers
and also instructed to start her flovent at home.
TRANSITIONAL ISSUES:
====================
[ ] NEW/CHANGED MEDICATIONS
- Started flovent 110mcg 2 PUFF IH daily
- Started prednisone 60mg daily x 5 days (end date ___
[ ] Continue to assess frequency of asthma exacerbations with
up-titration to ___ as indicated
ACTIVE ISSUES:
==============
#Asthma Exacerbation - Patient with known history of asthma
presented with several days worsening wheezing, SOB, chest
tightness, fever and productive cough. CXR on admission was
normal. She initially received albuterol and duoneb inhalers in
the ED and admitted for asthma exacerbation. This was felt to be
a URI induced asthma exacerbation, also likely worsened by her
seasonal allergies. Symptomatic improvement with duonebs, advair
and prednisone 60. Discussed home regimen with patient and she
states that she has not yet started flovent at home although she
was recently prescribed this (and has an Rx already at home).
She was therefore discharged with instructions to start taking
her home flovent in addition to albuterol inhalers:PRN. She will
continue prednisone 60mg burst through ___. Outpatient PCP
can continue to assess frequency of asthma exacerbations and if
indicated start ___.
CHRONIC/STABLE ISSUES:
======================
#Allergic rhinitis - Was continued on her home cetirizine and
Flonase nasal spray
#Psuedotumor cerebri: Patient without headache on admission. Her
home topiramate was resumed on discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Topiramate (Topamax) 50 mg PO BID:PRN headache
2. Fluticasone Propionate 110mcg 2 PUFF IH DAILY
3. Cetirizine 10 mg PO QD:PRN allergies
4. Albuterol Sulfate (Extended Release) 4 mg PO Q4H:PRN
wheezing, dyspnea
5. Fluticasone Propionate NASAL 1 SPRY NU DAILY
Discharge Medications:
1. PredniSONE 60 mg PO DAILY
RX *prednisone 20 mg 3 tablet(s) by mouth once a day Disp #*6
Tablet Refills:*0
2. Albuterol Sulfate (Extended Release) 4 mg PO Q4H:PRN
wheezing, dyspnea
3. Cetirizine 10 mg PO QD:PRN allergies
4. Fluticasone Propionate 110mcg 2 PUFF IH DAILY
5. Fluticasone Propionate NASAL 1 SPRY NU DAILY
6. Topiramate (Topamax) 50 mg PO BID:PRN headache
Discharge Disposition:
Home
Discharge Diagnosis:
Asthma Exacerbation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
You were in the hospital because of shortness of breath.
WHAT HAPPENED TO ME IN THE HOSPITAL?
In the hospital you were examined and determined to have an
asthma exacerbation. You were treated with medications
(prednisone, nebulizers) with improvement in your symptoms.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
-Please continue to take all of your medications and follow-up
with your appointments as listed below.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19594577-DS-18
| 19,594,577 | 20,893,565 |
DS
| 18 |
2166-05-31 00:00:00
|
2166-08-01 07:43:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with PMHx of Graves Disease and hyperparathyroidism s/p
total thyroidectomy and achalasia s/p balloon dilatation who
presents with epigastric pain. The pain awoke him from sleep at
1:30 am and was associated with nausea and chills. He drank a
small amount of ginger ale, but was unable to keep any liquids
down. He had a small bowel movement that was normal (not
diarrhea). He describes the pain as sharp, in the epigastric
area and radiating outwards. The pain is constant in nature. He
reports eating no unusual foods, however, he states he did drink
more alcohol then usual this weekend as he was celebrating. He
states he has never had a pain like this in the past. He denies
any chest pain or shortness of breath.
In the ED, initial VS were 98.8 64 167/100 15 100% RA. His labs
were notable for a lactate of 2.3, AST 46, ALT 23. His EKG
evidence J-point elevation without evidence of STEMI. He
underwent RUQ U/S, CT abdomen and pelvis, and KUB. He received
Pantoprazole 40 mg IV, Lidocaine Viscous 2% 10 mL PO , Donnatol
10 mL PO, Aluminum-Magnesium Hydrox, Simethicone 30 mL PO,
Ondansetron 4 mg IV, and Morphine Sulfate ___ mg IV.
Upon arrival to the floor he reports that his abdominal pain is
improved.
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria.
All other 10-system review negative in detail.
Past Medical History:
-Achalasia s/p ballon dilatation (___)
-Graves Disease and Hyperparathyroidism s/p total thyroidectomy
with subtotal parathyroidectomy (___), now hypothyroid
-Nephrolithiasis
-Borderline elevated cholesterol, diet controlled.
-Borderline hypertension, diet controlled.
-Adenomatous colonic polyp necessitating colonoscopy in ___
(___)
-Positive PPD, treated with 12 months of INH.
-Blind in R eye due to trauma
Past Surgical History:
1. Appendectomy.
2. Total thyroidectomy with subtotal parathyroidectomy.
3. Cataract surgery.
Social History:
___
Family History:
Father with a history of prostate cancer. Alive and well at age
___. Mother alive and well at age ___ with hypothyroidism. Has
two brothers and two sisters who are healthy. Denies a family
history of achalasia or GI cancers.
Physical Exam:
General: 100.8 141/89 80 16 98% on RA
Neck: no LAD, no JVD
CV: RRR, no m/r/g
Lungs: CTA bilaterally
Abdomen: soft, TTP in the epigastrum, liver at the angle on the
costal margin
Ext: no ___ edema, 2+ dp pulses, wwp
Pertinent Results:
___ 04:50AM PLT COUNT-313
___ 04:50AM NEUTS-55.6 ___ MONOS-6.3 EOS-2.7
BASOS-0.7
___ 04:50AM WBC-6.8# RBC-5.28 HGB-15.5 HCT-44.4 MCV-84
MCH-29.4 MCHC-35.0 RDW-13.4
___ 04:50AM HBsAg-NEGATIVE HBs Ab-NEGATIVE
___ 04:50AM PTH-76*
___ 04:50AM TSH-1.6
___ 04:50AM ALBUMIN-4.6 CALCIUM-9.3 PHOSPHATE-3.5
MAGNESIUM-2.0
___ 04:50AM LIPASE-34
___ 04:50AM ALT(SGPT)-27 AST(SGOT)-46* ALK PHOS-58 TOT
BILI-0.4
___ 04:50AM estGFR-Using this
___ 04:50AM GLUCOSE-118* UREA N-18 CREAT-1.2 SODIUM-142
POTASSIUM-3.8 CHLORIDE-106 TOTAL CO2-24 ANION GAP-16
___ 05:34AM LACTATE-2.3*
CT abdomen/pelvis:
1. No free air.
2. Nonspecific thickening of the gastric antrum, can be seen in
gastritis.
3. Cholelithiasis, but no evidence of cholecystitis.
4. Patulous esophagus consistent with known achalasia.
FINDINGS: AP view of the chest. There is no free air. The
lateral part of the right hemithorax and right upper abdomen is
not imaged. There is no focal consolidation, pleural effusion
or pneumothorax. The cardiomediastinal and hilar contours are
normal. The esophagus is dilated consistent with known
achalasia.
IMPRESSION: No acute cardiopulmonary process. No free air is
identified
ECG: Sinus rhythm with first degree atrio-ventricular
conduction delay, with J point elevation across precordium,
similar to ___.
RUQ ultrasound:
IMPRESSION: Cholelithiasis, but no evidence of cholecystitis.
Brief Hospital Course:
Alcoholic Gastritis- celebrated at recent party with friends
from home, admitted to drinking excess rum. CAGE negative,
usually only consumes less than one serving per week. Symptoms
improved quickly after PPI therapy, can likely be discontinued
in coming weeks. Patient understands likely etiology, will
refrain from binge drinking in the future. H. pylori stain
from EGD in ___ was negative.
Transaminitis due to acute alcohol ingestion
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 200 mcg PO DAILY
Discharge Medications:
1. Levothyroxine Sodium 200 mcg PO DAILY
2. Calcium Carbonate 500 mg PO TID W/MEALS
RX *calcium carbonate [Antacid] 200 mg calcium (500 mg) 1
tablet, chewable(s) by mouth TID with meals Disp #*100 Tablet
Refills:*0
3. Omeprazole 40 mg PO DAILY
Do not renew.
RX *omeprazole 40 mg 1 capsule,delayed ___ by
mouth DAILY Disp #*21 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Alcoholic Gastritis
Transaminitis due to acute alcohol ingestion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___. You were admitted
with abdominal pain. You underwent multiple imaging studies,
which did not show evidence of an infectious process or bleeding
in your GI tract. Given the history of alcohol intake over the
weekend along with your measure of liver function, you were
diagnosed with gastritis in the setting of acute alcohol
ingestion. You were given viscous lidocaine, which immediately
controlled your pain. You were started on omeprazole, a
medication to decreased your production of stomach acid. You
will continue this for 3 weeks.
Please followup with your PCP and your gastroenterologist, as
below.
Followup Instructions:
___
|
19594577-DS-19
| 19,594,577 | 25,357,648 |
DS
| 19 |
2172-03-15 00:00:00
|
2172-03-15 18:52:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
chlorthalidone
Attending: ___.
Chief Complaint:
Chest discomfort and light headedness
Major Surgical or Invasive Procedure:
Cardiac catheterization with drug eluting stent placement
___
History of Present Illness:
___ with a history of hypertension, hyperlipidemia, prediabetes,
achalasia status post repeated esophageal dilations, GERD, and
depression, who presents with chest discomfort and
light-headedness.
Patient was in his usual state of health until ~6:30AM this
morning, when he acutely developed left sided chest discomfort
and nausea, when ambulating from his car to work. Burning in
nature, non-radiating, worsened with exertion and improved with
rest. Associated shortness of breath, mild diaphoresis and
light-headedness. Given these symptoms, patient decided to drive
himself to the ED. Reported having to stop his car on multiple
occasions on route to the hospital as he felt he was going to
pass out. Nausea worsened, but he was unable to vomit.
In the ED, initial vital signs were notable for;
Temp 97.2 HR 56 BP 132/80 RR 22 SaO2 100% RA
Examination notable for;
Well appearing, RRR, no murmurs/rubs/gallops, CTAB, no
wheezes/crackles, no abdominal tenderness, no CVA tenderness, no
MSK deformities.
Labs were notable for;
WBC 8.6 Hgb 14.2 Plt 253
Na 143 K 4.0 Cl 105 HCO3 19 BUN 15 Cr 1.0 AnGap 19
Trop-T <0.01 x2 -> 0.04 CK-MB 24 (same time as elevated Trop-T)
VBG: 7.32/46/33
ECG (9AM) with sinus bradycardia, normal axis, first degree AV
block otherwise normal intervals, mild ST depression
V4-V6/I/aVL,
T wave flattening/inversion V4-V6/I/aVL.
ECG (4PM) with sinus bradycardia, normal axis, first degree AV
block otherwise normal intervals, 1mm ST elevation V1-V3, ST
depression and T wave inversion now resolved in V4-V6, more
consistent with previous repolarization changes seen on ECG in
___.
CXR demonstrated no acute intrathoracic process.
Cardiology were consulted; initial recommendation was for stress
imaging test given cardiac risk factors, however given
up-trending troponin and CK-MB, now concern for NSTEMI, would
start heparin drip, give full dose aspirin, and start high dose
statin, hold off metoprolol for now given bradycardia, NPO for
possible cath in AM.
Patient was given;
- Aspirin 325mg
- IV pantoprazole 40mg
- IV ondansetron 4mg
- Maalox 30ml
- Donnatal 10ml
- Acetaminophen 650mg
- Atorvastatin 80mg
- IV heparin 4000 units and drip at 1000 units/hr
Vital signs on transfer notable for;
Temp 98.0 HR 53 BP 120/83 RR 18 SaO2 96% RA
Upon arrival to the floor, patient repeats the above story. At
baseline he is very active, walks several miles each day at a
brisk pace. Previously ran, but unable to do so now given
chronic
knee pain. Denies exertional chest pain or shortness of breath
prior to this morning. Currently pain free and nausea has
resolved; all symptoms improved after he received Maalox and
Donnatal.
10-point review of systems otherwise negative.
Past Medical History:
- Hypertension
- Hyperlipidemia
- Prediabetes (HbA1c 6.3% ___
- Achalasia status post repeated esophageal dilations
- GERD/dyspepsia
- Depression
- Gout
- Grave's disease status post total thyroidectomy
- Parathyroid adenoma status post parathyroidectomy
- Nephrolithiasis
- Traumatic cataract status post extraction (___)
- History of positive PPD status post 12 months isoniazid
Social History:
___
Family History:
Father with history of prostate cancer. Mother with history of
hypothyroidism. No family history of premature coronary artery
disease, arrhythmias, cardiomyopathy, or sudden cardiac death.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: Temp: 98.1 BP: 114/76 HR: 56 RR: 18 SaO2: 95% RA
GENERAL: lying comfortably in bed, no acute distress
HEENT: AT/NC, no conjunctival pallor, anicteric sclera, MMM
NECK: supple, non-tender, no JVP elevation
CV: RRR, S1 and S2 normal, no murmurs/rubs/gallops
RESP: CTAB, no wheezes/crackles
___: soft, non-tender, no distention, BS normoactive
EXTREMITIES: warm, well perfused, no lower extremity edema
NEURO: A/O x3, moving all four extremities with purpose, CNs
grossly intact
DISCHARGE PHYSICAL EXAM
24 HR Data (last updated ___ @ 602)
Temp: 97.4 (Tm 98.6), BP: 120/69 (103-128/64-79), HR: 76
(53-76), RR: 16 (___), O2 sat: 98% (95-98), O2 delivery: Ra,
Wt: 225.09 lb/102.1 kg
GENERAL: lying comfortably in bed, no acute distress
HEENT: AT/NC, no conjunctival pallor, anicteric sclera, MMM
NECK: supple, non-tender, no JVP elevation
CV: RRR, S1 and S2 normal, no murmurs/rubs/gallops
RESP: CTAB, no wheezes/crackles
___: soft, non-tender, no distention, BS normoactive
EXTREMITIES: warm, well perfused, no lower extremity edema.
right
radial access no hematoma.
NEURO: A/O x3, moving all four extremities with purpose, CNs
grossly intact
Pertinent Results:
ADMISSION LABS
================
___ 09:55AM BLOOD WBC-8.6 RBC-4.78 Hgb-14.2 Hct-41.8 MCV-87
MCH-29.7 MCHC-34.0 RDW-13.4 RDWSD-42.5 Plt ___
___ 09:55AM BLOOD Neuts-85.6* Lymphs-9.6* Monos-4.2*
Eos-0.1* Baso-0.1 Im ___ AbsNeut-7.34* AbsLymp-0.82*
AbsMono-0.36 AbsEos-0.01* AbsBaso-0.01
___ 09:55AM BLOOD Glucose-157* UreaN-15 Creat-1.0 Na-143
K-4.0 Cl-105 HCO3-19* AnGap-19*
___ 07:06AM BLOOD Calcium-9.0 Phos-3.3 Mg-1.8
___ 01:07PM BLOOD ___ pO2-33* pCO2-46* pH-7.38
calTCO2-28 Base XS-0
INTERVAL LABS
==============
___ 09:55AM BLOOD cTropnT-<0.01
___ 03:36PM BLOOD cTropnT-<0.01
___ 09:35PM BLOOD CK-MB-24*
___ 09:35PM BLOOD cTropnT-0.04*
___ 07:06AM BLOOD CK-MB-38* cTropnT-0.42*
DISCHARGE LABS
===============
___ 07:22AM BLOOD WBC-5.6 RBC-4.29* Hgb-12.7* Hct-37.3*
MCV-87 MCH-29.6 MCHC-34.0 RDW-13.5 RDWSD-42.0 Plt ___
___ 07:22AM BLOOD Glucose-110* UreaN-10 Creat-1.1 Na-142
K-4.1 Cl-108 HCO3-21* AnGap-13
___ 07:22AM BLOOD Calcium-8.5 Phos-2.8 Mg-1.8
MICRO
=======
N/A
IMAGING/STUDIES
================
CARDIAC CATH ___
Coronary Description
The coronary circulation is right dominant.
LM: The Left Main, arising from the left cusp, is a large
caliber vessel. This vessel bifurcates into the Left Anterior
Descending and Left Circumflex systems.
LAD: The Left Anterior Descending artery, which arises from the
LM, is a large caliber vessel.
The Diagonal, arising from the proximal segment, is a medium
caliber vessel.
Cx: The Circumflex artery, which arises from the LM, is a large
caliber vessel.
The ___ Obtuse Marginal, arising from the proximal segment, is a
medium caliber vessel.
The ___ Obtuse Marginal, arising from the mid segment, is a
medium caliber vessel.
RCA: The Right Coronary Artery, arising from the right cusp, is
a large caliber vessel. There is a 100% stenosis in the distal
segment. There is a severe thrombus in the distal segment.
Collaterals from the mid
segment of the LAD connect to the distal segment.
The Right Posterior Descending Artery, arising from the distal
segment, is a medium caliber vessel.
The Right Posterolateral Artery, arising from the distal
segment, is a medium caliber vessel.
Interventional Details
Percutaneous Coronary Intervention: Percutaneous coronary
intervention (PCI) was performed on an ad hoc basis based on the
coronary angiographic findings from the diagnostic portion of
this procedure. A 6
___ JR4 guide provided adequate support. Crossed with a
Runthrough wire into the distal PDA with a Caravel catheter and
Telescope catheter as backup. Predilated with a 2.0 mm balloon
which did not restore flow in the artery. Aspiration
thrombectomy catheter would not enter the Telescope catheter. A
2.5 mm Balloon was used to further predilate and the guide
extension was removed and thrombectomy was performed as there
was still no antegrade flow. A large amount of thrombus was
removed. A 2.5
mm x 18 mm DES was deployed knowing that the outflow was poor.
Advanced the Caravel into the distal RCA to administer
vasodilators as flow was still TIMI 1. Flow was restored with IC
vasodilators and further PTCA revealing a large PL branch.
Placed a Prowater wire in the distal PL. Predilated this lesion
with a 2.5 mm balloon. Deployed 2.5 x 22 mm DES from the distal
RCA into the PL across the PDA. Final angiography revealed
normal flow, no dissection and 0% residual stenosis.
Complications: There were no clinically significant
complications.
Findings
Single vessel coronary artery disease.
Recommendations
ASA 81mg per day.
Ticagrelor 90 mg BIDTirofiban for 2 hours.
TTE ___
The left atrial volume index is normal. There is mild symmetric
left ventricular hypertrophy with a normal cavity size. There is
normal regional and global left ventricular systolic function.
Quantitative biplane left ventricular ejection fraction is 59 %
(normal 54-73%). There is no resting left ventricular outflow
tract gradient. Normal right ventricular cavity size with normal
free wall motion. Tricuspid annular plane systolic excursion
(TAPSE) is normal. The aortic sinus diameter is normal for
gender with normal ascending aorta diameter for gender. The
aortic arch diameter is normal with a normal descending aorta
diameter. There is no evidence for an aortic arch coarctation.
The aortic valve leaflets (3) appear structurally normal. There
is no aortic valve stenosis. There is no aortic regurgitation.
The mitral valve leaflets appear structurally normal with no
mitral valve prolapse. There is mild [1+] mitral regurgitation.
The pulmonic valve leaflets are normal. The tricuspid valve
leaflets appear structurally normal. There is mild [1+]
tricuspid regurgitation. The estimated pulmonary artery systolic
pressure is high normal. There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
normal cavity size and regional/ global biventricular systolic
function. Mild mitral regurgitation. High normal pulmonary
artery systolic pressure. CLINICAL
IMPLICATIONS: Based on the echocardiographic findings and ___
ACC/AHA recommendations, antibiotic prophylaxis is NOT
recommended.
Brief Hospital Course:
PATIENT SUMMARY
===================
___ with a history of hypertension, hyperlipidemia, prediabetes,
achalasia status post repeated esophageal dilations, GERD, and
depression, who presents with NSTEMI in setting of chest
discomfort and light-headedness with elevated troponin and
dynamic ECG changes. He underwent cardiac cath ___ with DES to
distal RCA into PL across PDA.
ACUTE/ACTIVE ISSUES:
====================
# Type I NSTEMI
# Single vessel CAD s/p DES to distal RCA
Presented with chest discomfort, shortness of breath and nausea.
ECG initially demonstrated subtle ST depressions with associated
T wave changes in lateral leads, however troponin negative x2.
Initial plan was for imaging stress test, however repeat ECG
with ST upsloping in V1-V3, similar to previous repolarization
abnormalities noted in ___ and troponin-T elevated to 0.04 and
CK-MB 24, consistent with type I NSTEMI. Cardiac cath ___ with
single veseel CAD, s/p DES from distal RCA into PL across the
PDA. He received tirofiban for 2 hours, then was started on
ticagrelor 90 mg PO BID. He was continued on his home aspirin 81
and atorvastatin 80. He was not initiated on metoprolol in the
setting of bradycardia to the ___. He underwent TTE before
discharge that showed no wall motion abnormalities, and EF 59%,
with mild LV hypertrophy and mild MR, as well as high normal
pulmonary artery systolic pressure
# Orthostatic hypotension
When working with physical therapy on day of discharge, he was
noted to be orthostatic (BP 132/60 --> 100/60). He was
asymptomatic, and improved with 1L IVF.
CHRONIC/STABLE ISSUES:
======================
# Hypertension
Continued amlodipine 10mg daily.
# Hypothyroidism
Continued levothyroxine 175mcg daily.
# Depression
Continued citalopram 20mg daily
TRANSITIONAL ISSUES
======================
[] Please evaluate for resolution of orthostatic hypotension at
follow up appointment.
[] New medications: ticagrelor, aspirin, and atorvastatin.
[] Patient not started on neurohormonal blockade with beta
blocker due to bradycardia. Consider starting as outpatient for
maximal medical therapy if heart rate tolerates.
#CODE STATUS: Full (confirmed)
#CONTACT: ___, wife, ___
- Discharge wt: 102.1 kg (225.09 lb)
- Discharge cr: 1.1
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY
2. Citalopram 20 mg PO DAILY
3. Levothyroxine Sodium 175 mcg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Naproxen 500 mg PO Q12H:PRN Pain - Moderate
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth QPM Disp #*30 Tablet
Refills:*0
3. TiCAGRELOR 90 mg PO BID to prevent stent thrombosis
RX *ticagrelor [Brilinta] 90 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
4. amLODIPine 10 mg PO DAILY
5. Citalopram 20 mg PO DAILY
6. Levothyroxine Sodium 175 mcg PO DAILY
7. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
====================
Non-ST segment elevation myocardial infarction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr ___,
It was a pleasure taking care of you at the ___
___.
Why did you come to the hospital?
- You came to the hospital because you were feeling light headed
and were having chest discomfort. This is because you were
having a type of heart attack called an NSTEMI.
What happened while you were in the hospital?
- You had a procedure done called cardiac catheterization where
they looked at the arteries that bring blood to your heart.
There was a blockage (clot) in one of these arteries, so they
opened it up again by placing a hollow tube called a stent
inside your artery.
- You were started on new medications to help keep this stent
open and prevent future blockages.
- You had another imaging test of your heart done
("echocardiogram" or "TTE") that was an ultrasound of your heart
to look at how it pumps. It pumps well.
What should you do once you leave the hospital?
- Make sure to weigh yourself every day. If your weight goes up
by 3 lb in ___ hours, please call your doctor.
- If you have any more of the symptoms that brought you to the
hospital, or any chest pain, you should go to the emergency room
as this could be a sign of another heart attack.
- Please take your medications as prescribed and go to your
future appointments which are listed below.
We wish you all the best!
- Your ___ Care Team
Followup Instructions:
___
|
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