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19594787-DS-20
| 19,594,787 | 25,131,795 |
DS
| 20 |
2141-01-04 00:00:00
|
2141-01-04 20:14:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Tetanus / Codeine / adhesive tape / Fruit Extracts / atenolol /
latex / Percodan / Zocor / Apples / allopurinol / Augmentin /
lisinopril
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ PMHx of Diastolic heart failure, mild AS severe 4+ MR ___ ___ c/b MS ___ bioMVR ___ who presented with
dyspnea. MVR ___ who presented to ED with DOE, orthopnea
found to have elevated BNP and signs of volume overload.
Ms. ___ notes her cough first started 3 weeks ago
associated
with some increased dyspnea. She presented to her PCP where
chest
___ was clear and she was treated symptomatically. 1 week
later, she called with persistent symptoms with continued
productive cough. At that time, she was prescribed azithromycin
(total 5 day course). Despite these antibiotics, her cough has
continued. The last 4 to 5 days, she is also noted dyspnea, with
associated orthopnea. That the dyspnea has been gradual and is
not associated with chest pain.
She presented to atrium the urgent care ___ with reports of the
symptoms. A repeat chest ___ which was without evidence of
edema or consolidation. Her O2 sat was 96%, 94% on ambulation.
She was prescribed an albuterol and steroid inhaler. She trialed
the albuterol inhaler at the clinic, and subsequently became
very
jittery. She continued to feel unwell and a repeat ambulatory O2
sat was 89 to 92%. In the setting of her hypoxia and discomfort
returning home, she presented to the ED. She does not believe
she
is gaining weight but does not weigh herself regularly and there
is no weight in the emergency room as of yet. No salt
indiscretion.
She was last seen in Cardiology clinic with Dr. ___ in ___.
No significant changes were made at that visit and she continued
PO Furosemide 40mg daily.
On arrival to the floor, Ms. ___ notes improvement in her
symptoms with the nebulizer and diuresis. She denies any chest
pain or dyspnea.
In the ED,
- VS: 97.9 85 173/57 23 ?93% RA
- ECG: SR, TWI I, II, aVR, aVL, V3-V6
- Labs:
CBC: WNL
Chem: Cr 1.2, BUN 29
proBNP: 2700 (previously "250")
TropT 0.01 -> 0.02
Flu negative
UA: WNL
- Imaging:
CTA:
1. No evidence of pulmonary embolism or aortic abnormality.
2. 8 mm left lower lobe pulmonary nodule, new since the prior
study. Multiple additional smaller scattered pulmonary nodules
are unchanged since the prior study.
Past Medical History:
Past Medical History:
Basal Cell Carcinoma
Esophageal Web
Gastroesophageal Reflux Disease
Hyperlipidemia
Hypertension
Iron Deficiency Anemia related to GI bleed recently clipped.
Mitral Regurgitation
Osteoporosis
Pulmonary Hypertension
Pulmonary Nodule
Rheumatic Fever/Scarlet fever
Varicose Veins
Past Surgical History:
Rotator cuff repair
Total Knee replacement (L)
Repair of prolapsed vagina
Repair of left ulnar nerve and left carpal tunnel release
Partial hysterectomy
Bilateral vein sclerosing therapy
Past Cardiac Procedures:
Transseptal MitraClip ___ at ___
___:
1. Mitral valve replacement with a 31-mm Epic tissue mitral
valve.
2. Closure of atrial septal defect.
Social History:
___
Family History:
Family History:
Father passed from ___ CA at ___
Mother passed at ___ from unknown cause
Son passed from pancreatic CA at ___
Physical Exam:
T: 98.2 F, BP: 123 / 63 mmHg, HR: 66 x min, RR: 17 x mix, SaO2:
96% Ra
GENERAL: NAD, pleasant
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
moist MM
NECK: JVP 6 cm, no carotid bruit appreciated
CARDIAC: RRR. s1/s2. ___ RUSB harsh sys murmur
LUNGS: Respiration is unlabored with no accessory muscle use.
Decreased bibasilar breath sounds, crackles on bilateral bases.
ABDOMEN: Soft, non-tender, non-distended.
EXTREMITIES: Warm, well perfused. no ___ edema.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
NEURO: chronic Rt UE sensory deficit, otherwise sensation
intact.
moving ext spont.
Pertinent Results:
___ 06:51AM BLOOD WBC-6.0 RBC-4.19 Hgb-12.4 Hct-39.0 MCV-93
MCH-29.6 MCHC-31.8* RDW-14.5 RDWSD-48.9* Plt ___
___ 06:51AM BLOOD Plt ___
___ 07:16AM BLOOD Glucose-88 UreaN-34* Creat-1.2* Na-142
K-4.4 Cl-101 HCO3-28 AnGap-13
___ 06:55AM BLOOD proBNP-1563*
___ 07:16AM BLOOD Calcium-9.1 Phos-4.5 Mg-2.5
Brief Hospital Course:
Providers:PATIENT SUMMARY
===============
___ w/ PMHx of Diastolic heart failure, mild AS severe 4+ MR ___
Mitraclip ___ c/b MS ___ bioMVR ___ who presented with
dyspnea. MVR ___ who presented to ED with DOE, orthopnea
found to have elevated BNP and signs of volume overload and
found to have newly reduced EF with concern for LV
pseudoaneurysm.
ACUTE ISSUES
============
# Acute on Chronic Systolic CHF:
Patient previously with preserved EF now newly reduced to 35%.
During hospital course, patient remained stable with signs of
adequate perfusion/cardiac output.
On her initial days after admission, developed ___ likely in the
secondary of acute tubular necrosis secondary to contrast
induced nephropathy after CTA. This resolved with conservative
measures and IVF.
After normalization of kidney function, she was diuresed with IV
Lasix 40 mg BID with a goal of ___ L per day (net negative),
until achieving euvolemic status.
___ was deferred to the outpatient setting.
# LV Pseuodaneursym:
Evidence of likely pseudoaneurysm found on ECHO ___ vs
diverticulum or crypt (although these less likely given lack of
presence on previous ECHOs). This finding was discussed
extensively during this admission with the patient(daughter
informed patient) and her daughter with Dr. ___.
Further image review (of pre-existing chest CTA) demonstated
outpouching of posterior LV wall, but it seems like the
myocardial layers are preserved (although thinned). Based on
this, it could be a true ventricular aneurysm and management
would involve medications with no procedures. Plan is to obtain
C-MRI as an outpatient once her CHF exacerbation has cleared to
better elucidate this.
Dr. ___ has communicated with Dr. ___
cardiologist) and Dr. ___ (C-surgeon). Patient is not a
surgical candidate and if this is a really a pseudoaneurysm, an
endovascular procedure may be considered (as an outpatient).
***Need to be cautious of further contrast use in this patiet
given GFR***
# ___ on CKD- RESOLVED:
Last Sr Cr 1.0 as of ___ in Atrius records. After contrast
load, Cr. at 1.2 and slowly rose up to 1.9. Recovered back to
baseline with conservative measures and IVF. Tolerated IV
diuresis adequately. While in the hospital, her meds were
renally dosed.
# Dyspnea, cough:
Likely viral bronchitis with reactive airway disease and
subsequent heart failure exacerbation. Some concern for valvular
pathology contributing to current symptoms however based on
ECHO, valve appeared stable although BNP elevated and EF newly
reduced.
CTA with no evidence of PE.
Patient described significant improvement of symptoms following
initial diuresis. Symptoms also improved with use of
antitussives. She remained stable, free of respiratory distress
and Sating above 92% on RA. Symptoms likely a combination of
bronchitis and heart failure exacerbation (with volume
overload).
CHRONIC ISSUES
==============
#Chronic pain
-continued home Gabapentin 200 mg PO DAILY
#Anxiety/Insomnia
-continued LORazepam 0.5 mg PO QHS
#GERD
-continued home Pantoprazole 40 mg PO Q24H
#HLD
-continued home atorvastatin 10mg qd
#Restless leg syndrome
-continued home pramipexole 0.25-0.75mg QHS
#MEDREC
-continued home azelastine
TRANSITIONAL ISSUES
===================
[ ] Consider starting Losartan 12.5 once ___ has resolved.
[ ] MR ___ should call you to schedule your study. If you do
not hear from them in 48 hours, please call ___.
[ ] follow up outpt BMP on ___ to be drawn at At___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 200 mg PO QHS
2. Furosemide 40 mg PO DAILY
3. Pramipexole 0.25-0.75 mg PO QHS
4. LORazepam 0.5 mg PO QHS:PRN insomina
5. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
6. Astepro (azelastine) 0.15 % (205.5 mcg) nasal BID
7. Atorvastatin 10 mg PO QPM
8. Pantoprazole 40 mg PO Q24H
9. Nystatin-Triamcinolone Cream 1 Appl TP BID:PRN rash
10. Acetaminophen 500 mg PO Q4H:PRN Pain - Mild/Fever
11. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Furosemide 60 mg PO DAILY Duration: 3 Days
Starting ___, until ___. Then return to original
dose of 40 mg a day.
2. Acetaminophen 500 mg PO Q4H:PRN Pain - Mild/Fever
3. Aspirin 81 mg PO DAILY
4. Astepro (azelastine) 0.15 % (205.5 mcg) nasal BID
5. Atorvastatin 10 mg PO QPM
6. Gabapentin 200 mg PO QHS
7. LORazepam 0.5 mg PO QHS:PRN insomina
8. Nystatin-Triamcinolone Cream 1 Appl TP BID:PRN rash
9. Pantoprazole 40 mg PO Q24H
10. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
11. Pramipexole 0.25-0.75 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
Congestive heart failure exacerbation
SECONDARY DIAGNOSIS
===================
- Hypertension
- Dyslipidemia
- ___ mitraclip ___ & ___ bioMVR ___
- Moderate pulmonary artery systolic hypertension
- History of GI bleeding
- History of acute diastolic heart failure
- Restless leg syndrome
- Mild aortic stenosis
- Mild mitral regurgitation
- Diverticulosis
- GERD
- Osteoporosis
- Anxiety
- TMJ syndrome
- HLD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ was a pleasure taking care of you at the ___
___!
WHY WAS I IN THE HOSPITAL?
==========================
- You were admitted because of shortness of breath
WHAT HAPPENED IN THE HOSPITAL?
==============================
- We performed images of your heart and your chest to rule out
the need for any urgent interventions. We have scheduled an MRI
of your heart (as an outpatient in ___ weeks) to better
visualize the walls in your heart.
- You received IV Lasix to remove excessive amounts of fluid
from your lungs.
WHAT SHOULD I DO WHEN I GO HOME?
================================
- Please have labs drawn at your Atrius (___)
clinic on ___
- Please take 60mg of furosemide (Lasix) once a day starting on
___, until ___. On ___ please return to original
dose of 40 mg once a day.
- Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. Your weight on discharge was: 131 lbs.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Your ___ Healthcare Team
Followup Instructions:
___
|
19595757-DS-6
| 19,595,757 | 23,628,784 |
DS
| 6 |
2171-06-05 00:00:00
|
2171-06-05 14:52:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Heparin Agents
Attending: ___.
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ CAD s/p 2 vessel CABG in ___, HTN, DM2, HTN, with one week
of cough, fever, sweats, chills, nausea and vomiting with
malaise and weakness. Fever to 101.3, poor oral intake for two
days. He also c/o inability to urinate after getting lasix in
ER. He lives in ___ living and reports that many people are
sick. He endoreses dyspnea on exertion. He denies any CP,
orthopnea, PND, palpitations, syncope.
In the ED, initial vitals were 101.3 97 180/103 18 97%. CXR with
increased vascularity and possibly L lingular pneumonia. Labs
notable for BNP of 21,000 and trop 0.10, flu positive. EKG:
afib, LAD, poor R wave, TWF inf/lat, c/w old ECG from ___.
Pt. received 40 mg IV lasix.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, hemoptysis, black stools or red stools. He
denies exertional buttock or calf pain. All of the other review
of systems were negative.
Past Medical History:
-Coronary artery disase, s/p 2 vessel CABG in ___ (left
internal mammary artery to the left anterior descending and
saphenous vein to the obtuse marginal); s/p catheterization in
___, which revealed EF of 74%, normal wall motion, 100%
proximal right coronary artery lesion, normal left main, 100%
mid left anterior descending lesion, 90% proximal left
circumflex, and a dominant left system. Cath in ___ showed
patent grafts. Normal exercise test ___, normal persantine
stress test ___. Several episodes of unstable angina.
- Hypertension (diagnosed in ___)
- Type 2 diabetes mellitus (diet controlled)
- Hypercholesterolemia
- ___, s/p dilation x3-4, most recently ___
- h/o DVT, previously on coumadin
- h/o sigmoid diverticulitis
- Hemorrhoids (negative colonoscopy ___
- Previous hiatal hernia.
- Peptic ulcer disease
- Transient vertigo
- Glaucoma, s/p cataract resection ___, s/p left iridectomy
1992s, dx ___
Social History:
___
Family History:
Father died of myocardial infarction at age ___.
Physical Exam:
Admission Exam
VS: 98.6, 159/81, 81, 14, 99% RA weight 82.6
GENERAL: WDWNM in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. dry mucous membranes.
NECK: Supple with JVP of 8 cm.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: Resp were unlabored, no accessory muscle use. Diffuse
crackles and decreased sounds on Right with some scattered
wheezingf.
ABDOMEN: Soft, tender over bladder and distended. No HSM or
tenderness. Abd aorta not enlarged by palpation. No abdominal
bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
Discharge Exam
VS: 98.0 106-126/60-65 ___ 94-96%RA
I/O: 1078/1310 Wt: 79.1 kg <-- 79.2 kg
GENERAL: NAD. Alert and oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric.
NECK: Supple with JVP of 6 cm.
CARDIAC: RRR, normal S1, S2. No murmurs or gallops
LUNGS: CTAB. No crackles or wheezing noted
ABDOMEN: Soft, NT, ND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits.
Pertinent Results:
___ 11:35AM BLOOD WBC-4.3 RBC-4.31* Hgb-13.3* Hct-40.1
MCV-93 MCH-30.8 MCHC-33.1 RDW-14.9 Plt ___
___ 10:55AM BLOOD WBC-5.4 RBC-4.22* Hgb-12.7* Hct-39.6*
MCV-94 MCH-30.2 MCHC-32.2 RDW-15.0 Plt ___
___ 05:10AM BLOOD WBC-4.3 RBC-3.97* Hgb-12.0* Hct-37.3*
MCV-94 MCH-30.3 MCHC-32.2 RDW-14.7 Plt Ct-97*
___ 05:30AM BLOOD WBC-4.7 RBC-4.08* Hgb-12.2* Hct-38.5*
MCV-95 MCH-29.9 MCHC-31.6 RDW-15.0 Plt ___
___ 05:41AM BLOOD WBC-5.4 RBC-4.18* Hgb-12.5* Hct-39.4*
MCV-94 MCH-29.8 MCHC-31.6 RDW-14.9 Plt ___
___ 11:35AM BLOOD Neuts-74.5* Lymphs-16.9* Monos-7.5
Eos-0.8 Baso-0.4
___ 10:55AM BLOOD Neuts-72.4* ___ Monos-7.0 Eos-0.2
Baso-0.3
___ 08:15PM BLOOD ___ PTT-31.5 ___
___ 11:35AM BLOOD Glucose-103* UreaN-14 Creat-1.1 Na-139
K-4.1 Cl-102 HCO3-25 AnGap-16
___ 05:10AM BLOOD Glucose-102* UreaN-18 Creat-1.0 Na-140
K-3.6 Cl-102 HCO3-32 AnGap-10
___ 05:30AM BLOOD Glucose-105* UreaN-19 Creat-1.0 Na-139
K-3.8 Cl-99 HCO3-30 AnGap-14
___ 05:41AM BLOOD Glucose-100 UreaN-18 Creat-0.9 Na-141
K-4.0 Cl-102 HCO3-31 AnGap-12
___ 10:55AM BLOOD CK-MB-3 ___
___ 11:35AM BLOOD CK-MB-2 cTropnT-0.04*
___ 10:55AM BLOOD cTropnT-0.10*
___ 08:15PM BLOOD CK-MB-4 cTropnT-0.12*
___ 05:10AM BLOOD CK-MB-3 cTropnT-0.11*
___ 05:10AM BLOOD Calcium-8.2* Phos-2.7 Mg-2.2
___ 05:30AM BLOOD Calcium-8.6 Phos-2.6* Mg-2.1
___ 05:41AM BLOOD Calcium-8.5 Phos-2.6* Mg-2.0
___ 01:15PM URINE RBC-6* WBC-1 Bacteri-NONE Yeast-NONE
Epi-<1
___ 01:15PM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-2* pH-5.5 Leuks-NEG
___ 01:15PM URINE Color-Yellow Appear-Clear Sp ___
___ Influenza A/B by ___ DIRECT INFLUENZA A
ANTIGEN TEST-FINAL {POSITIVE FOR INFLUENZA A VIRAL ANTIGEN};
DIRECT INFLUENZA B ANTIGEN TEST-FINAL
CXR: Chronic mild congestive heart failure with small bilateral
pleural effusions and mild interstitial pulmonary edema.
Brief Hospital Course:
___ year old male with CAD presents with few days of fever and
nonspecific symptoms. He was intially placed in observation in
the ED for respiratory culture which came back as influenza A
though was subsequently admitted to cardiology service when he
was noted to have elevated troponins and BNP. We started him on
tamiflu for influenza and diuresed him with IV lasix.
# Acute left sided likely diastolic heart failure: We diuresed
him with IV lasix and transitioned him to home lasix 40 mg
daily. Dry weight on dishcarge was 79.1 kg.
#. Influenza - Tamiflu for planned 5 day course ___ -
___
#. CAD - Stable, s/p 2 vessel CABG in ___. Trop 0.1-->
0.12-->0.11; MB 3.4. He never reported chest pain. We
attributed the elevated troponin to demand secondary to acute
left sided heart failure and influenza. He was continued on
aspirin, statin and metoprolol.
#. BPH: Continue on home tamsulosin.
#. Atrial fibrillation - Patient is currently rate controlled.
He is not currently taking warfarin, but used to in the past.
CHADS2 score 3 or 4. Per PCP, he had hemoptysis on warfarin
previously, so if restarted he would need to be at a low target
INR. Newer agents (eg rivaroxaban) not studied in this age group
and of higher concern for bleeding risk given lack of
reversibility.
- consider initiating coumadin therapy with low goal INR
#. Type II DM- Diet controlled.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. clotrimazole-betamethasone *NF* ___ % Topical BID PRN
to affected area
2. Furosemide 40 mg PO DAILY
3. Gabapentin 100 mg PO HS
4. Hydrocortisone (Rectal) 2.5% Cream ___ID
5. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
7. Lisinopril 10 mg PO DAILY
8. Metoprolol Tartrate 25 mg PO BID
9. Omeprazole 40 mg PO BID
10. Simvastatin 40 mg PO DAILY
11. Tamsulosin 0.4 mg PO DAILY
12. Aspirin 81 mg PO DAILY
13. Critic-Aid Clear AF *NF* (miconazole nitrate) 2 % Topical
BID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Gabapentin 100 mg PO HS
3. Hydrocortisone (Rectal) 2.5% Cream ___ID
4. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
6. Lisinopril 10 mg PO DAILY
7. Metoprolol Tartrate 25 mg PO BID
8. Omeprazole 40 mg PO BID
9. Simvastatin 40 mg PO DAILY
10. Tamsulosin 0.4 mg PO DAILY
11. clotrimazole-betamethasone *NF* ___ % Topical BID PRN
to affected area
12. Critic-Aid Clear AF *NF* (miconazole nitrate) 2 % Topical
BID
13. Furosemide 40 mg PO DAILY
14. Oseltamivir 75 mg PO Q12H
RX *oseltamivir [Tamiflu] 75 mg 1 capsule(s) by mouth twice a
day Disp #*3 Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: influenza, acute heart failure
Secondary : coronary artery disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Mr. ___,
It was a pleasure taking care of you at ___. You were admitted
with the flu and heart failure. You were treated with antiviral
and diuretic medications.
Please weigh yourself every morning, call MD if weight goes up
more than 3 lbs.
Medication changes :
START TAMIFLU 75 mg twice a day for your influenza for one more
day (STOP DATE: ___
Followup Instructions:
___
|
19596034-DS-11
| 19,596,034 | 25,788,363 |
DS
| 11 |
2157-01-18 00:00:00
|
2157-01-18 11:48:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Advil / Penicillins
Attending: ___
Chief Complaint:
Facial and arm numbness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: The pt is a ___ y/o RHF with no relevant prior medical
history who presented with L facial and arm numbness.
She first noted L lower lip numbness last night after waking
from
a nap, which is still persistent now. This morning upon awaking
she noticed numbness of her L lower lip, L cheek, and L arm. She
describes the numbness as a novocaine feeling, and describes
that
her arm also feels tingly. She localizes the paresthesias mostly
to her medial L lower arm, but feels that it involved most of
her
arm earlier this morning.
No weakness, no vision changes, no constipation or urinary
retention. Endorses a sore throat yesterday, and diarrhea
earlier
today.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies difficulties
producing or comprehending speech. Denies focal weakness. 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, constipation or
abdominal
pain. No recent change in bowel or bladder habits. No dysuria.
Denies arthralgias or myalgias. Denies rash.
Past Medical History:
none
Social History:
___
Family History:
No FH of neurologic or autoimmune conditions, no
clotting disorders, no early strokes.
Physical Exam:
Physical Exam:
Vitals: T:98.1 P:86 R: 16 BP:134/87 SaO2:98% on RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, MMM.
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally
Cardiac: RRR, nl. S1S2
Abdomen: soft, NT/ND.
Extremities: No edema or deformities.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward
without
difficulty. Language is fluent with intact repetition and
comprehension. There were no paraphasic errors. Pt. was able
to name ___ card items and read ___ card scentences. Speech
was not dysarthric. Able to follow both midline and appendicular
commands. Pt. was able to register 3 objects and recall ___ at 5
minutes. There was no evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation. Funduscopic
exam revealed no papilledema, exudates, or hemorrhages. Acuity
___ b/l.
III, IV, VI: EOMI with b/l endgaze nystagmus, more pronounced on
gaze to the L. Normal saccades.
V: Facial sensation intact to light touch and pinprick on
forehead, reduced to LT and pinprick on L cheek and L chin
(80%).
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, asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5- 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5
-Sensory: No deficits to vibratory sense, proprioception
throughout. No extinction to DSS. Reduced sensation (80%) to
light touch and pinprick on L cheek and L chin, as well as L
medial lower arm (T1 distribution).
-DTRs:
Bi Tri ___ Pat Ach
L 2+ 2 2+ 3 2
R 2+ 2 2+ 3 2
Plantar response was flexor bilaterally, no clonus.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem without difficulty. Romberg test
without swaying.
Pertinent Results:
___ 06:30PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 10:10AM GLUCOSE-104* UREA N-15 CREAT-0.7 SODIUM-142
POTASSIUM-4.2 CHLORIDE-107 TOTAL CO2-26 ANION GAP-13
___ 10:10AM estGFR-Using this
___ 10:10AM WBC-8.6 RBC-4.62 HGB-13.7 HCT-42.3 MCV-92
MCH-29.7 MCHC-32.4 RDW-12.3
___ 10:10AM NEUTS-69.5 ___ MONOS-4.4 EOS-4.2*
BASOS-0.2
___ 10:10AM PLT COUNT-244
___ 10:10AM ___ PTT-30.6 ___
___ 10:00AM URINE HOURS-RANDOM
___ 10:00AM URINE HOURS-RANDOM
___ 10:00AM URINE UCG-NEGATIVE
___ 10:00AM URINE GR HOLD-HOLD
___ 10:00AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 10:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
MRI C-Spine:
1. No evidence for cervical demyelinating disease.
2. Minimal disc bulge at C6-7 without spinal canal or neural
foraminal
narrowing.
MRI Head w and w/o contrast:
1. Scattered small foci of high T2 signal in the corpus
callosum,
periventricular, and subcortical white matter of the cerebral
hemispheres are
nonspecific. They may be asymptomatic, or they may be related
to
demyelination, prior inflammation, or migraines. Please
correlate clinically
and with laboratory data.
2. Two small developmental venous anomalies, located in the
right parietal
subcortical white matter and in the left lentiform nucleus.
Brief Hospital Course:
___ RHF with no relevenat prior medical history, who presented
with progressive numbness and some paresthesias since last
night, first involving only her L lower lip, since this morning
also her L cheek and her L arm. Her neurologic exam is notable
for decreased sensation to light touch and pinprick (about 20%
less compared to R side) of L chin, L cheek and L medial lower
arm in a T1 distribution.
As two simultaneous problems affecting T spine and brain/C-spine
are less likely, and she had difficulties exactly describing
which area of the arm was affected, the sensory changes might
involve more than just the T1 area. This could localize to the
thalamus, sensory cortex (although no other symptoms on exam
suggesting a cortical process), or the C-spine. Given her age
and the progression of her symptoms a demyelinating disorder was
suspected and she was admitted for imaging, and decide on
further therapy based on the imaging results.
Her MRI findings were not concerning for demyelination. Her
history and distribution of symptoms are consistent with nerve
compression, very likely due to her sleep position given the
onset of symptoms after her nap. Her symptoms resolved within 24
hours of onset. She was discharged with no new medications and
with instructions to call the neurology clinic if any new
symptoms arise.
Medications on Admission:
None
Discharge Medications:
None
Discharge Disposition:
Home
Discharge Diagnosis:
NERVE ROOT COMPRESSION
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ were admitted to ___ after ___ presented with sensory
changes in your left arm and face. ___ had a MRI of your brain
and cervical spine that was unremarkable. Your symptoms improved
overnight. We believe your symptoms were due to compression of
the nerve roots. On ___ your symptoms had resolved and there
was no need for further neurological interventions.
No changes were made to your medications
Followup Instructions:
___
|
19596157-DS-19
| 19,596,157 | 27,650,464 |
DS
| 19 |
2140-07-30 00:00:00
|
2140-08-13 11:09:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Hydrochlorothiazide / Demerol / Ambien / Strawberry / Wheat Bran
/ Aldactone / INSPRA / Torsemide
Attending: ___.
Chief Complaint:
Flank Pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Pt is a ___ year old male with PMH of HTN, DM2 and vfib arrest
s/p biv pacer, Ischemic cardiomyopathy (EF ___ s/p stent of
AAA in ___, presented to ___ ER ___ with acute
onset R flank pain.
.
Pt was transferred to ___ for work up of potential AAA
dissection. He had CT of abd and pelvis at ___ which showed
stable AAA- infrarenal abdominal aortic aneurysm status post
endograft repair, with maximal AP diameter of 3.3 cm (Image
2:46). The proximal right common iliac artery is also
aneurysmal, measuring 3.4 cm (Image 2:56) which were unchanged
from prior imaging. His AAA is stable and AAA rupture was RO. He
is currently HD stable. (BP runs in in 110s/30s-40s).
.
He was also found to be in Acute on chronic renal failure with
creatine at baseline of 1.7-2.0 (peaked at 3.4) now trending
down to 3.1. Pt states that he was on very high doses of lasix
and this was recently decreased since he was below his dry wt.
Lasix has been held during this admission. He also had a renal
US this AM which showed renal cysts.
.
Pt reports that his flank pain started at 7AM yesterday, when he
woke up with a sharp, spasm type pain upon waking. He denies
any recent fall or trauma to the area. He is able to ambulate
with pain and denies dysuria or hematuria. Pt describes that
the pain is located in one particular spot over lateral
hip/gluteus medius area. Pain does not radiate.
.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.
Past Medical History:
Past Medical History:
1. DM
2. Hypertension
3. Hyperlipidemia
4. History of VFib arrest; BiV pacer for ventricular arrhythmias
5. CAD s/p CABG (4 vessel CABG on ___ (LIMA to LAD, SVG to
OM, ramus, RCA); Ischemic cardiomyopathy (EF ___
6. Prostatitis
7. Melanoma s/p excisions
8. Afib in past, prior to BiV pacer
9. GERD
10. gout
11. Sleep apnea
12. s/p hemorrhoidectomy
13. bilateral Iliac artery aneurysm s/p repair (___),
Infrarenal AAA of 3 cm s/p repair ___
14. Hypertensive cardiomyopathy
15. Cervical radiculopathy
16. Recurrent PNA
Social History:
___
Family History:
Father with MI at ___ yo
Mother with mild dementia
2 brothers with CAD
Physical Exam:
Vitals: T: 98.5 BP: 113/47 P: 57 R: 18 O2: 96%
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: basilar crackles
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
MSK: right sided point tenderness over gluteus medius, ROM of
hip limited slightly ___ pain. R knee is not erythematous or
apparently swollen but it is very tender to palpation along
medial aspect
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNs2-12 intact, motor function grossly normal
Pertinent Results:
___ 09:30PM URINE RBC-<1 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 09:30PM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 09:30PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 09:30PM ___ PTT-34.8 ___
___ 09:30PM PLT COUNT-118*
___ 09:30PM NEUTS-75.7* LYMPHS-14.7* MONOS-5.9 EOS-3.3
BASOS-0.4
___ 09:30PM WBC-6.1 RBC-4.17* HGB-10.1* HCT-31.4*
MCV-75*# MCH-24.3* MCHC-32.3 RDW-17.7*
___ 09:30PM CALCIUM-8.1* PHOSPHATE-3.1 MAGNESIUM-2.3
___ 09:30PM estGFR-Using this
___ 09:30PM GLUCOSE-127* UREA N-57* CREAT-3.4*#
SODIUM-141 POTASSIUM-3.1* CHLORIDE-97 TOTAL CO2-31 ANION GAP-16
.
___: Renal U/S
1) Bilateral renal cysts; otherwise normal renal sonogram with
no evidence of
hydronephrosis.
2) Splenomegaly.
.
ECG ___
Atrial and ventricular sequential pacing with frequent
ventricular ectopy.
Compared to the previous tracing of ___ ventricular ectopy
is new.
.
Brief Hospital Course:
Pt is a ___ year old male with PMH of HTN, DM2 and vfib arrest
s/p biv pacer, Ischemic cardiomyopathy (EF ___ s/p stent of
AAA in ___, presented to ___ ER ___ with acute
onset R flank pain.
.
# Flank Pain: CT abdomen at ___ was unremarkable for
worsening of his AAA. He has no evidence of kidney stone given
that no dysuria and U/A was clear. He has clear point
tenderness over hip, which suggests that this is likely
musculoskeletal in nature. Vascular surgery was consulted and
they did not believe that pt had evidence of worsening
dissection. Given clear CT and no lack of clinical signs,
unlikely that he has intrabdominal process. Pt's pain was
treated with oxycodone and flexeril. Pain improved by time of
discharge.
.
# ___: On admission Cr was 3.4. Urine lytes from AM are
consistent with prerenal etiology (Fena is 0.6). Renal US was
unremarkable (with exception of b/l renal cysts) and UA clear.
Could be in setting of overdiuresis. His lasix was held and
maintenance IVF were started and pt's ___ improved. At time of
d/c cr improved to 2.1. ___ from ___ clinic was
called prior to discharge and it was agreed that his diuretics
should be restarted but at a lower dose. He was discharged on
lasix 40mg daily and will follow up in ___ clinic to readjust
diuretics as needed.
.
# Gout: During hospitalization, pt's left knee demonstrated
extreme point tenderness and was mildly swollen and
erythematous. He has had prior gout flares in this knee before.
He was started on prednisone 50mg taper and his pain improved.
Uloric was held and NSAIDS/colchicine avoided because of ___.
He will need to restart uloric when he follows up with PCP.
Etiology of gout flare most likely ___ overdiuresis.
.
CHF: Pt was euvolemic on admission. After holding lasix for
several days, he was restarted on lasix at 40mg daily as
mentioned above. He did not have any signs of CHF exacerbation
during hospitalization. He was discharged on toprol, lasix and
his digoxin dose was halved.
.
HTN: On admission pt was normotensive. Given his ___, valsartan
was held initially. He remained normotensive and given recent
___, valsartan was not restarted. This medication should be
restarted as an outpt, perhaps at a lower dose.
.
Afib: On presentation, INR was supratherapeutic. He did not
have any signs of bleed. Coumadin was held initially but
restarted on HD as his INR returned to therapeutic range. At
time of discharge, INR was subtherapeutic, most likely secondary
to holding dose at time of admission. He will need a repeat INR
check in three days time and coumadin should be adjusted to
titrate INR between 2 and 3. He was continued on toprol and
digoxin for rate control.
.
vfib hx. Pt has ICD in place. He was continued with
amiodorone.
.
Diabetes: Pt was put on sliding scale insulin + basal lantus
during hospitalization. His insulin requirements were
uptitrated given hyperglycemia secondary to prednisone. At time
of discharge, his BG had normalized and he was discharged on
home lantus and humalog dosing.
.
CODE: FULL
.
Transitional:
- needs follow up INR
- follow up in ___ clinic to adjust lasix dosing as needed.
- will need to restart losartan (possibly at lower dose)
Medications on Admission:
Furosemide 40mg ___ pills) BID
Metoprolol XR 50mg Daily
Valsartan 20mg Daily
Rosuvastatin 40mg Daily
Oxycodone 5mg prn
Febuxostat 80mg Daily
Excitalopram 10mg Daily
Coumadin 2.5mg Daily
Omeprazole 20mg Daily
Digoxin 125mcg Daily
Colchcine 0.6mg prn
ASA 81mg Daily
NTG prn
Flomax 0.4mg QHS
Insulin Humalog
Amiodarone 200mg Daily
Flexeril 10mg prn
Clonazepam 0.5mg BID
Ezetimibe 10mg Daily
Lantus 70 units BID
Humalog Sliding Scale 75/25
Discharge Medications:
1. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
7. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed for back pain.
10. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO DAYS
(___).
11. digoxin 125 mcg Tablet Sig: ___ Tablet PO DAILY (Daily).
12. prednisone 20 mg Tablet Sig: Two (2) Tablet PO once a day
for 3 days.
Disp:*6 Tablet(s)* Refills:*0*
13. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
14. Lantus 100 unit/mL Solution Sig: Sixty (60) units
Subcutaneous twice a day.
15. Humalog Mix ___ 100 unit/mL (75-25) Suspension Sig: per
sliding scale units Subcutaneous per sliding scale.
16. Outpatient Lab Work
Chem 10
INR
CBC
please collect on ___ and fax to Dr ___ at ___
17. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
musculoskeletal pain
gout flare
acute kidney injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you. You were admitted to the
hospital for flank pain and acute kidney injury. We worked up
your flank pain with imaging, and the vascular team did not see
any evidence of worsening of your aortic aneurysm. We also do
not believe that you are having a kidney stone or any
intraabdominal process. Your back pain is most likely
musculoskeletal in nature and we encourage rest and your home
pain medication regimen.
During your hospitalization your were also found to have an
acute kidney injury secondary to dehyrdation from your home
lasix dose. After speaking with ___ we decided to
restart your lasix at discharge at a dose of 40mg daily.
.
You also had a gout flare while inpatient. We started you on
prednisone, which you will take for an additional three days.
.
We have made the following changes to your home medications:
1. decrease lasix to 40 mg daily
2. start prednisone 40 mg daily for three days
3. change digoxin from 0.125mg to 0.0625mg daily
4. stop uloric until you follow up with your PCP
5 stop diovan until you follow up with your PCP
.
We have made follow up appointments for you and then information
is outlined below. Please call or email ___ earlier
to discuss your daily weights.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
19596157-DS-20
| 19,596,157 | 27,312,826 |
DS
| 20 |
2141-02-03 00:00:00
|
2141-02-04 11:02:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Hydrochlorothiazide / Demerol / Ambien / Strawberry / Wheat Bran
/ Aldactone / INSPRA
Attending: ___.
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ with history of IDDM, CHF, CAD, Afib who
presents after falling. He states that he was in his USOH until
yesterday. While he was cleaning dishes, he suddenly experienced
a ringing in ears. The next thing he remembers was waking up on
the ground. He immediately realized he had fallen. He awoke with
head and epigastric pain. He denies prodromal syncopal symptoms
including chest pain, shortness of breath, palpitations, fevers,
chills, or neurologic symptoms. This event was unwitnessed. He
called his neighbor who then called EMS. Does not recall AICD
firing. Denied prior to events. No bowel or bladder
incontinence. Of note patient recently had ICD replaced in
___.
In the ED, initial vitals were: 97.9 90 102/54 18 97%. EKG
showed paced rhythm at 67. The patient was given full strength
ASA x 1. HCT and creat at baseline. The patient underwent CXR
that did not show evidence of pneumothorax. CT head negative. He
underwent CT abdomen which did not show acute process. FAST scan
negative.
While in the ED, the patient experienced 9 beats of nonsustained
vtach, asymptomatic during it. VS at the time of transfer:
Temperature 97.8 °F (36.6 °C). Pulse 60. Respiratory Rate 22.
Blood Pressure 121/65. O2 Saturation 96. Pain Level 5.
On the floor, patient was complaining of ___ epigastric pain.
He was easily distracted from the pain however and stated that
when he is still that his pain is better.
ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, shortness
of breath, chest pain, abdominal pain, nausea, vomiting,
diarrhea, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria. The ten point review of systems is otherwise
negative.
Past Medical History:
CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
CARDIAC HISTORY:
-CABG: CAD, s/p CABG (4 vessel CABG on ___ (LIMA
to LAD, SVG to OM, ramus, RCA); Ischemic cardiomyopathy (EF
___
-PACING/ICD: BiV pacer for ventricular
arrhythmias
OTHER PAST MEDICAL HISTORY:
1. HTN
2. Prostatitis
3. Melanoma s/p excisions
4. DM2
5. Afib in past, prior to BiV pacer
6. GERD
7. gout
8. Sleep apnea
9. s/p hemorrhoidectomy
10. bilateral Iliac artery aneurysm s/p repair (___),
Infrarenal AAA of 3 cm s/p repair ___
11. Hypertensive cardiomyopathy
12. Hypercholesterolemia
13. Cervical radiculopathy
14. Recurrent PNA
Social History:
___
Family History:
Father with MI at ___ yo
Mother with mild dementia
2 brothers with CAD
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - T 99.8 HR 64 BP 120/53 RR 22 SpO2 93% RA
GENERAL - pleasant man in NAD, uncomfortable and c/o pain in
epigastric area and under the ribs
HEENT - NC/AT, PERRLA, EOMI, MMM
NECK - supple, no thyromegaly, no JVD
HEART - PMI displaced to the L chest wall, RRR, nl S1-S2, no MRG
LUNGS - CTAB, no r/rh/wh, no crackles appreciated
ABDOMEN - NABS, soft, non-distended, tender to palpation in the
epigastric area
EXTREMITIES - WWP, 1+ pitting edema bilaterally, swelling,
warmth, and tenderness of the R lateral malleolus, cold toes, 2+
___ pulses
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric
DISCHARGE PHYSICAL EXAM:
VS: 97.4 117/56 61 18 98%/RA
Weight- 92.3kg
Lungs CTA, no wheezes/crackles
JVP not elevated
1+ pitting edema in lower extremities bilaterally
Exam otherwise unchanged
Pertinent Results:
Admission labs:
WBC-7.9 RBC-4.42* Hgb-9.8* Hct-34.7* MCV-78* MCH-22.1*
MCHC-28.1* RDW-17.4* Plt ___
Glucose-178* UreaN-32* Creat-1.8*# Na-142 K-3.7 Cl-100 HCO3-34*
AnGap-12
Calcium-8.6 Phos-4.0# Mg-2.2
Microbiology:
Blood culture ___- no growth x 2
Blood culture ___- no growth x 2
Imaging:
Cardiac cath ___-
1. Limited resting hemodynamics revealed elevated left and right
sided filling pressures with RVEDP 10 mmHg and mean PCWP 30
mmHg. There is moderate pulmonary arterial hypertension with PA
pressure ___ with a mean of 38 mmHg. The cardiac index is
mildly depressed at 2.27 L/min/m2 (using an assumed oxygen
consumption).
FINAL DIAGNOSIS:
1. Biventricular diastolic dysfunction.
2. Moderate pulmonary arterial hypertension.
3. Mildly depressed cardiac index.
CXR ___
1. Marked cardiomegaly, unchanged. No acute cardiopulmonary
pathology.
2. If there is high concern for nondisplaced rib fracture,
dedicated rib
series can be performed with marker placed at the site of
maximum tenderness.
CT Head ___
1. No acute intracranial hemorrhage or fracture.
2. Large left parieto-occipital subgaleal hematoma.
CT Abdomen: ___
1. No acute solid organ injury identified in this limited
non-contrast CT of the abdomen and pelvis. Small amount of
complex pelvic free fluid is seen. Recommended follow up of
hematocrit values, and if needed a contrast enhanced CT is
recommended for further asssessment. This finding was discussed
with ___ at 10:30 A.M on ___ via telephone.
2. Cirrhosis and splenomegaly. 3. Status post EVAR, with stable
appearance of the aortoiliac stent graft.
4. Multiple hypodense renal lesions, majority of which represent
simple renal cysts and are similar in appearance to the prior.
Extensive colonic
diverticulosis, without evidence of acute diverticulitis.
Moderate
cardiomegaly.
Right ankle x-ray: ___ AP, lateral, oblique views of the
right ankle were provided. There is no acute fracture or
dislocation. Diffuse edema in the imaged soft tissues is noted,
reflecting patient's underlying congestive heart failure. Heel
spurs are noted.
IMPRESSION: No acute fracture or dislocation. Soft tissue edema
noted.
Rib x-ray ___: No definite displaced rib fracture. If
further evaluation is needed, recommend CT.
Brief Hospital Course:
___ y/o man with h/o CHF (EF ___, CAD s/p CABG, Afib, on
biventricular pacer who presents with likely cardiogenic
syncope.
# Syncope: Patient had sudden loss of consciousness with
prodrome of ringing in ears. On pacer interrogation, patient
developed ventricular tachycardia, failing ATP, thus resulting
in 2x ICD firings. He was loaded with dofetilide, and QTc
increased from 450 to >500. Patient developed polymorphic
ventricular tachycardia, again with 2 ICD firings. Dofetilide
was therefore stopped. Per preliminary EP consult recs following
pacer interrogation, the ICD did fire on the night prior to
admission following tachyarrythmia with rate >180, confirming
this. Other possible causes of syncope are much less likely: not
orthostatic, no classic prodrome to suggest vasovagal syncope,
and no post-ictal state or seizure history to suggest neurologic
syncope. His ICD fired x 2 on ___ in the setting of V. fib/
V. tach. He was then transferred to the EP service. Dofetilide
was started on ___, but patient developed prolonged QT with
further episodes of VT, so dofetilide was discontinued.
Metoprolol was changed to carvedilol 12.5mg BID for better
rhythm control. Patient underwent a right heart catheterization
which was notable for elevated PCWP consistent with volume
overload. He did not have significantly elevated PA pressures.
Patient was therefore diuresed aggressively for volume
overload with lasix drip, in order to prevent during
arrhythmias. Once he was euvolemic, lasix drip was discontinued
and patient was transitioned to 80mg torsemide daily. He
maintained euvolemia on this regimen. He had occasional
non-sustained runs of VT, but none sustained, and had no further
ICD firings.
# Congestive heart failure: Patient has known EF ___. As
above, he was significantly volume overloaded on admission,
approximately 20lb up from dry weight. He was diuresed with
lasix drip to euvolemia. Weight at the time of discharge was
92.3 kg. In addition, medication management included changing
metoprolol to carvedilol and continuing digoxin.
# Acute on chronic renal failure: Creatinine rose during
admission, likely related to poor forward flow in setting of low
EF. Once lasix drip was initiated, creatinine trended down.
Creatinine at the time of discharge was 2.4.
# Fever: Febrile to 101.1 on ___. UA negative, CXR with no
PNA, blood cultures without growth. Likely related to
atelectasis in the setting of splinting secondary to pain in
ribs. Patient had no further episodes of fever following
admission.
# ?Cirrhosis: Abdominal CT showed cirrhosis and small amount of
free fluid in the abdomen without signs of trauma. His
hematocrit was stable. His liver function tests were normal.
Likely related to vascular congestion secondary to severe
cardiomyopathy.
# CAD: s/p four-vessel CABG in ___. Troponins 0.02, 0.04, 0.03.
No chest pain, and patient does have chronic renal disease. He
was continued on metoprolol, aspirin, Crestor.
# Chest wall tenderness: Localized to left side of ribs, related
to fall. No fractures on films. Pain was controlled with
tylenol, lidocaine patch, prn oxycodone and cyclobenzaprine.
# Diabetes type 2: On insulin standing and sliding scale at
home. Patient self adjusted insulin glargine and sliding scale
throughout admission. He was discharged on significantly less
glargine (45 units qAM from 65 units BID).
# Anxiety/Depression: Stable. He was continued lexapro, ativan.
# CODE: Patient full code but does not want prolonged life
support.
# Transitional issues:
- will need hepatology follow-up regarding new diagnosis
cirrhosis
- weight on discharge was 92.3 kg, patient sent home with
telemedicine for close weight management.
Medications on Admission:
(Confirmed with patient)
ALLOPURINOL ___ mg PO QD
CLONAZEPAM [KLONOPIN] 0.5 mg PO BID
CYCLOBENZAPRINE [FLEXERIL] 10 mg PO QD
DIGOXIN 125 mcg Tablet QOD
ESCITALOPRAM [LEXAPRO] 10 mg PO QD
EZETIMIBE [ZETIA] 10 mg PO QD
FUROSEMIDE 40 mg BID (adjusts per weight up to 80 mg BID)
INSULIN GLARGINE [LANTUS] 65 units BID
INSULIN LISPRO PROTAM & LISPRO [HUMALOG MIX 75-25] per sliding
scale
IPRATROPIUM-ALBUTEROL [COMBIVENT] INH 18 mcg-103 mcg 2 puffs BID
PRN
METOPROLOL SUCCINATE XR 50 mg
NITROGLYCERIN 0.3 mg Tablet, Sublingual PRN chest pain
OMEPRAZOLE 20 mg Capsule PO QD
OXYCODONE 5 mg Tablet QID PRN back pain
ROSUVASTATIN [CRESTOR] 20 mg Tablet PO QD
TAMSULOSIN [FLOMAX] 0.4 mg PO QHS
VALSARTAN [DIOVAN] 40 mg Tablet PO QD
ASPIRIN 81 mg PO QD
Discharge Medications:
1. allopurinol ___ mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
3. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) as needed for back pain.
4. digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
5. escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*10 Tablet(s)* Refills:*0*
8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
9. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
11. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
12. carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
13. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
14. ipratropium-albuterol ___ mcg/actuation Aerosol Sig: Two
(2) Inhalation twice a day as needed for shortness of breath or
wheezing.
15. insulin lispro 100 unit/mL Cartridge Sig: per sliding scale
Subcutaneous QACHS.
16. insulin glargine 100 unit/mL Solution Sig: ___ (45)
units Subcutaneous qAM.
17. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation BID (2 times a day).
Disp:*1 Disk with Device(s)* Refills:*2*
18. torsemide 20 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
Disp:*120 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
# Cardiogenic syncope
# Ventricular tachycardia/ventricular fibrillation s/p ICD
firing
# Acute on chronic systolic heart failure
Secondary:
# Diabetes mellitus
# Chronic kidney disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
It was a pleasure taking care of you during your recent
hositalization.
You were admitted after suddenly losing consciousness. This was
because your heart went into an abnormal rhythm, and your ICD
(defibrillator) fired in order to restore a normal rhythem.
This likely occured because of too much fluid in your system.
You were given lasix (furosemide) to get all of that extra
volume off. Your medications were also altered slightly in
order to prevent further arrhythmias.
The following changes were made to your medication regimen:
- STOP metoprolol
- START carvedilol twice a day
- STOP lasix
- START torsemide once daily
- DECREASE insulin glargine (LANTUS) to 45 Units in the morning
- START fluticasone-salmeterol inhaler twice a day
Weigh yourself daily. If your weight increases more than 3lbs,
please call Dr. ___.
You have been given a prescription for oxycodone for the pain
from your gout. Please be aware that this is a sedating
medication and you should not drive or participate in hazardous
activities after taking oxycodone.
Followup Instructions:
___
|
19596157-DS-22
| 19,596,157 | 26,820,051 |
DS
| 22 |
2141-03-20 00:00:00
|
2141-03-20 14:45:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Hydrochlorothiazide / Demerol / Ambien / Strawberry / Wheat Bran
/ Aldactone / INSPRA / Torsemide
Attending: ___.
Chief Complaint:
Low back pain
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
This is a ___ gentleman with a pmhx. significant for
CAD, hyperlipidemia, and recent admission for pre-syncope in the
setting of electrolyte abnormalities and ventricular
tachycardia, who is admitted with severe right lower extremity
radicular pain.
On night prior to admission, patient woke up with severe back
pain radiating down the lateral and posterior aspect of his
right lower extremity. Also noted lower extremity weakness and
parasthesias. Went to urinate and was able to sit on the toilet
to do so. However, noticed worsening pain when getting up.
Denied saddle anasthesia or urinary or bowel incontinence. He
was seen by neurology in the ED who thought that the symptoms
were consistent with severe radiculopathy.
ROS: Positive for low back pain with R>L lower extremity
weakness and sensory changes. No chest pain, shortness of
breath, fevers, chills, nausea, vomiting, diarrhea, or other
concerning signs or symptoms.
Past Medical History:
CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
CARDIAC HISTORY:
-CABG: CAD, s/p CABG (4 vessel CABG on ___ (LIMA
to LAD, SVG to OM, ramus, RCA); Ischemic cardiomyopathy (EF
___
-PACING/ICD: BiV pacer for ventricular
arrhythmias
OTHER PAST MEDICAL HISTORY:
1. HTN
2. Prostatitis
3. Melanoma s/p excisions
4. DM2
5. Afib in past, prior to BiV pacer
6. GERD
7. gout
8. Sleep apnea
9. s/p hemorrhoidectomy
10. bilateral Iliac artery aneurysm s/p repair (___),
Infrarenal AAA of 3 cm s/p repair ___
11. Hypertensive cardiomyopathy
12. Hypercholesterolemia
13. Cervical radiculopathy
14. Recurrent PNA
Social History:
___
Family History:
Father with CAD. Mother with mild dementia.
Physical Exam:
PHYSICAL EXAM:
VS: 98.2, 99/52, 59, 16, 99% on RA
GENERAL: Alert, pleasant gentleman, no acute distress
CHEST: Clear to auscultation bilaterally
CARDIAC: RRR, ___ systolic murmur
ABDOMEN: +BS, soft, non-tender, non-distended
EXTREMITIES: No edema bilaterally
NEURO: Alert and oriented x3, subjective senory impa, 4+/5
strength in right lower extremity, gait deferred (had been
checked by multiple other providers during the day).
Pertinent Results:
___ 12:20PM GLUCOSE-196* UREA N-32* CREAT-2.2* SODIUM-138
POTASSIUM-4.8 CHLORIDE-100 TOTAL CO2-30 ANION GAP-13
___ 12:20PM WBC-9.5# RBC-4.66 HGB-10.7* HCT-35.5* MCV-76*
MCH-23.0* MCHC-30.2* RDW-18.9*
___ 12:20PM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-OCCASIONAL OVALOCYT-1+
___ 12:20PM PLT SMR-LOW PLT COUNT-114*#
___ 07:45AM BLOOD WBC-4.4 RBC-4.16* Hgb-9.6* Hct-31.8*
MCV-77* MCH-23.0* MCHC-30.1* RDW-18.7* Plt ___
___ 08:00AM BLOOD Glucose-115* UreaN-43* Creat-2.3* Na-140
K-4.1 Cl-101 HCO3-28 AnGap-15
.
___ CT L-Spine
IMPRESSION:
1. Mild degenerative changes of the lumbar spine. No fracture
or alignment abnormality.
2. Metallic infrarenal aortobiiliac stent in position similar
to prior.
Brief Hospital Course:
HOSPITAL COURSE:
This is a ___ gentleman with a pmhx. significant for CHF
(EF ___, CAD s/p CABG, Afib, on biventricular ICD with acute
onset of weakness in the right leg since since day prior with
acute radicular symptoms. He was discharged on a new pain
regimen. Neurology saw the patient while admitted.
.
# L5 RADICULOPATHY: Patient with acute onset of radicular
symptoms, with exam and CT not concern for acute cord
compression. His history and exam most consistent with L5
radiculopathy with remaining weakness likely due to pain
limitation. CT of his L-spine showed mild degenerative changes
with mild bilateral neural foraminal narrowing at L5-S1 and a
broad-based disc bulge at L4-5. Given his significant pain, he
was admitted for pain control. By HD 4 he had good pain control
on gabapentin 300mg qHS, tizanidine 2mg BID and tylenol. He was
otherwise discharged on his home pain regimen with PCP
___. He will see physical therapy in the outpatient
setting. Neurology was consulted in the inpatient setting.
.
INACTIVE ISSUES
# CAD: Patient with severe CAD and CHF, without acute
exacerbation. He was continued on his home regimen including
carvedilol, lasix, spironolactone and aspirin.
.
# DMII, CONTROLLED: Continued on home insulin regimen
.
# ANXIETY, CHRONIC: Continued on home clonazepam.
.
TRANSITIONAL ISSUES:
- Code Status: Full
- Primary Care
Medications on Admission:
allopurinol ___ PO qd
aspirin 81mg PO qd
carvedilol 12.5mg x2 PO qd
Crestor 20mg qd
digoxin 0.125mg qd
flexeril 10mg PRN back pain
Flomax 0.4mg qd
IC-Klor-Con 10mg x2 tabs qd
Klonopin 0.5 x2 qd PRN anxiety
Lasix 40mg PO qd
Lexapro 10mg PO qd
Nitroglycerin 0.3mg PRN chest pain
Oxycodone 5mg PRN back pain
Prednisone 40mg PO PRN gout flare
IC spironolactone 25mg ___ daily
Zetia 10mg qd
LANTUS 65 UNITS BID
HUMALOG 75/25 PER SCALE
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Carvedilol 12.5 mg PO BID
hold for SBP < 90 or HR < 60
4. Clonazepam 0.5 mg PO BID:PRN anxiety
5. Cyclobenzaprine 10 mg PO HS:PRN back pain
6. Escitalopram Oxalate 10 mg PO DAILY
7. Ezetimibe 10 mg PO DAILY
8. Furosemide 80 mg PO DAILY
hold for SBP < 90
9. Glargine 65 Units Breakfast
Glargine 65 Units Dinner
10. Omeprazole 20 mg PO DAILY
11. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN back pain
hold for RR< 12 or evidence of somnolence
12. Rosuvastatin Calcium 20 mg PO 1X Duration: 1 Doses
13. Spironolactone 12.5 mg PO DAILY
14. Tamsulosin 0.4 mg PO HS
15. Digoxin 0.125 mg PO DAILY
please stop this medication and call your physician immediately
if your vision turns yellow
16. Potassium Chloride 20 mEq PO DAILY Duration: 24 Hours
Hold for K > 5.0
17. Nitroglycerin SL 0.3 mg SL PRN chest pain
DO NOT TAKE WITH VIAGRA, CIALIS, OR ANY OTHER PHOSPHODIESTERASE
INHIBITOR
18. Acetaminophen 650 mg PO Q4H:PRN pain
Please do not exceed 4gm per day. Hold for elevated
transaminases.
19. Tizanidine 2 mg PO BID pain
Hold for anticholinergic toxidrome: sedation, fever, red skin,
vision problems, confusion, urinary retention, constipation.
RX *tizanidine 2 mg 1 Capsule(s) by mouth twice a day Disp #*30
Capsule Refills:*0
20. Gabapentin 300 mg PO HS
RX *gabapentin 300 mg 1 Capsule(s) by mouth every evening Disp
#*30 Tablet Refills:*0
21. Outpatient Physical Therapy
please provide physical therapy for radicular pain (ICD ___
___.2).
Name: ___.
Location: PERSONAL PHYSICIANS HEALTH CARE, P.C.
Address: ___, ___
Phone: ___
Fax: ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
L5 radiculopathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you while you were hospitalized
at the ___. As you know, you were admitted
with lower extremity weakness and severe back pain. The
neurology service ruled out a compression of your spinal cord
and diagnosed you with a nerve-root compression (called a
radiculopathy) that may involve several levels. Over the course
of your hospitalization, your pain abated and your strength
increased greatly. We had the physical therapists see you and
they concluded that you were able to safely walk independently
at home.
In addition, your kidney function was briefly impaired and your
digitalis level increased beyond a range we would like to see
(its peak level was 1.9). However, we gave you a small amount of
fluid to help your kidneys and your digitalis level came down to
a better level (1.5). Please follow up with your physician as
directed below to ensure that your kidney function and digitalis
levels are appropriate.
Your heart failure medication regimen was also continued. Weigh
yourself every morning and call your physician if weight goes up
more than 3 lbs.
You have two new medications:
START tizanidine 2mg twice daily as needed for pain
START Tylenol ___ every four hours as needed for pain (do not
exceed 4 grams per day)
START gabapentin 300mg in the evening. (Discuss titration of
this medication with your primary care physician)
Followup Instructions:
___
|
19596157-DS-24
| 19,596,157 | 25,194,326 |
DS
| 24 |
2141-04-30 00:00:00
|
2141-04-30 17:22:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Hydrochlorothiazide / Demerol / Ambien / Strawberry / Wheat Bran
/ INSPRA / Torsemide
Attending: ___.
Chief Complaint:
syncope and fall injury
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ yo M with ischemic cardiomyopathy w EF ___ with AICD,
multiple recent admissions for ICD firing, low back pain
secondary to L4 disc herniation, presenting s/p syncopal event.
Patient reports that he was standing in his kitchen this evening
when he became lightheaded and lost consciousness. He hit both
the wall and the ground, striking the back of his head, his
right knee and right posterior shoulder. He is not sure if his
AICD fired.
He otherwise has been feeling well. He has weaned off of several
pain medications including gabapentin, tizanidine and oxycodone.
His weight has been stable at 189-192lbs. He denies fever,
chills, SOB, chest pain, chest pressure.
In the ED, initial VS were T 96.6 BP 122/58 HR 72 RR 16 O2 100%.
Labs were notable for WBC 7.5, Cr 2.0 (baseline), negative u/a,
Trop 0.02 (baseline). CXR showed no intrathoracic process, xray
of knee showed large hemarthrosis without fracture, abdominal
ultrasound showed no evidence of a AAA, and CT head was negative
for acute intracranial bleed. His right knee was aspirated with
unknown amount of blood.
VS prior to transfer were T 97.1 BP 111/54 HR 63 RR 20 O2 100%RA
On arrival to the floor, vital signs were T98.7 BP 117/53 HR 60
RR 16 O2 99% RA. Patient complaining of right knee pain but
otherwise feels well.
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, chest pain,
abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria.
Past Medical History:
CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
CARDIAC HISTORY:
-CABG: CAD, s/p CABG (4 vessel CABG on ___ (LIMA
to LAD, SVG to OM, ramus, RCA); Ischemic cardiomyopathy (EF
___
-PACING/ICD: BiV pacer for ventricular
arrhythmias
OTHER PAST MEDICAL HISTORY:
1. HTN
2. Prostatitis
3. Melanoma s/p excisions
4. DM2
5. Afib in past, prior to BiV pacer
6. GERD
7. gout
8. Sleep apnea
9. s/p hemorrhoidectomy
10. bilateral Iliac artery aneurysm s/p repair (___),
Infrarenal AAA of 3 cm s/p repair ___
11. Hypertensive cardiomyopathy
12. Hypercholesterolemia
13. Cervical radiculopathy
14. Recurrent PNA
Social History:
___
Family History:
Father with CAD. Mother with mild dementia.
Physical Exam:
ADMISSION EXAM
PHYSICAL EXAMINATION:
VITALS: T98.7 BP 117/53 HR 60 RR 16 O2 99% RA
Weight: 90.1kg
GENERAL: chronically ill appearing in NAD
HEENT: NCAT (no hematoma or laceration on posterior skull),
PERRL, EOMI, MMM
NECK: no carotid bruits, no JVD
LUNGS: CTAB
HEART: RRR, normal S1 S2, with holosystolic apical murmur
ABDOMEN: Soft, NT, NABS, no organomegaly
EXTREMITIES: 1+ edema right>left, b/l hyperpigmentation
- Right knee is wrapped in pressure ACE, there is an injection
site on the lateral aspect of the joint without erythema. There
is no fluctuance. There is limited ROM secondary to pain.
- Right deltoid with ecchymosis (old)
- Right posterior shoulder with mild tenderness, no ecchymosis
or deformity
NEUROLOGIC: A+OX3, CN II-XII intact, strength limited secondary
to pain but intact bilaterally
DISCHARGE EXAM:
VITALS: Tmax 98.4 BP 105-123/58-73 HR ___ RR 18 O2sat 98% RA
I/O Yesterday: ___
Weight: 90.2
GENERAL: NAD
HEENT: MMM
NECK: no elevation in JVP
LUNGS: CTABL, no wheezes
HEART: RRR, normal S1 S2, with crescendo systolic murmur at LLSB
ABDOMEN: Soft, NT, NABS, no organomegaly
EXTREMITIES: no pitting edema.
- Right knee improved, ROM full, mild tenderness to palpation
Pertinent Results:
___ 03:40PM CK(CPK)-44*
___ 03:40PM CK-MB-2 cTropnT-0.02*
___ 11:16AM CK(CPK)-47
___ 11:16AM CK-MB-3 cTropnT-0.02*
___ 11:16AM CALCIUM-9.0 PHOSPHATE-3.0 MAGNESIUM-2.0
___ 11:16AM DIGOXIN-2.5*
___ 10:42PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 10:42PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
___ 10:08PM GLUCOSE-222* UREA N-37* CREAT-2.0* SODIUM-140
POTASSIUM-3.8 CHLORIDE-103 TOTAL CO2-28 ANION GAP-13
___ 10:08PM estGFR-Using this
___ 10:08PM cTropnT-0.02*
___ 10:08PM WBC-7.5 RBC-4.41* HGB-10.1* HCT-33.7* MCV-76*
MCH-22.9* MCHC-30.1* RDW-18.6*
___ 10:08PM NEUTS-84.1* LYMPHS-9.6* MONOS-3.4 EOS-2.5
BASOS-0.4
___ 10:08PM PLT SMR-LOW PLT COUNT-93*
Troponin-T 0.02 x3
CK-MB wnl ___ CXR- Mild vascular prominence suggesting pulmonary venous
hypertension without frank edema. Cardiomegaly. Unchanged
configuration of AICD device.
___ Right knee xray- Large joint effusion. Apparently anomalous
course of the quadriceps tendon as it approaches the patella,
not necessarily abnormal, but correlation with physical findings
is recommended regarding any potential concern for quadriceps
injury. No evidence of fracture. Extensive vascular
calcifications.
___ CT head w/o contrast- No evidence of acute intracranial
process.
___ US Aorta
Much of the aorta is obscured by overlying bowel
gas. A segment in the mid to distal aorta at the region of
graft bifurcation measures 3 cm in AP diameter. This is
unchanged from the examination of ___. The aortic
bifurcation and iliac arteries are not visualized due
tooverlying bowel gas. Left renal cysts are again noted.
ICD Interrogation report
Date of Interrogation: ___
Reason for interrogation: Question of ICD shock in setting of
syncope
Device Brand: ___
Model: ___ XT CRT-D D314TRG
Presenting rhythm: A-Paced, BiV-Paced
Intrinsic Rhythm: Sinus bradycardia with intact AV conduction
with a PR interval of 320 ms.
___ Mode: DDDR 60-120 bpm
Battery Voltage: 3.13 V
RA lead
Intrinsic amplitude: 2.5 mV
Pacing impedance: 342 ohms
Pacing threshold: 0.25 V at 0.5 ms
% Pacing: 95.9%
RV lead
Intrinsic amplitude: 14.1 mV
Pacing impedance: 418 ohms
Pacing threshold: 0.25 V at 0.5 ms
%pacing: 99.6%
LV lead
Pacing impedance: 437 ohms
Pacing threshold: 1.25 V at 0.6ms
%pacing: 99.6%
Diagnostic information:
- One episode of ventricular tachyarrythmia since ___,
on ___ at 19:37 lasting 22 seconds with a cycle length of
270-300 with polymorphic ventriculgrams.
- Failed episode of ATP with acceleration and degeneration,
after
second sequence, followed by successful 35 J defibrillation to
sinus rhythm.
Programming changes (details):
1. VT zone turned on with integral of 370 ms with therapy 1 -
ramp, 8 pulses 10ms decrement, 5 sequences, followed by maximal
defibrillation x5.
2. Fast VT zone changed to 240 ms with therapy 1 - ramp, 8
pulses
10ms decrement, 5 sequences, followed by maximal defibrillation
x5.
3. No change in VF zone.
Summary (normal / abnormal device function):
1. Sustained ventricular tachycardia with failed ATP
degenerating
to polymorphic VT and successful defibrillation to sinus rhythm.
2. Normally functioning device with stable lead parameters.
3. Not pacemaker dependent.
Brief Hospital Course:
___ yo M with h/o ischemic cardiomyopathy with EF ___ with
AICD and multiple recent firings of AICD, presenting s/p
syncopal event with another incidence of AICD firing.
# VT with appropriate AICD firing- The patient presented with an
episode of syncope, which correlated with an episode of V tach
and AICD firing. Frequent of recent AICD firing and episodes of
VT. Troponins flat at baseline, MB not elevated. Study drug was
discontinued becaues of prolonged JT interval, digoxin was also
DCed, and the patient was slowly started on mexiletine and
quinidine with adjustments for side effects and close monitoring
of QT interval with daily EKGs. The possibility of ablation
procedure was dicussed, but the patient did well on
antiarrythmic therpy without events on tele, so ablation was
decided against.
# Right knee hemarthrosis- s/p aspiration in ED, no fracture on
xray. Soft tissue swelling is present but the area is not tense
or discolored, no area of fluctuance. Pain was controlled with
po dilaudid, and was advanced to po oxycodone. ___ evaluated the
patient, and the patient was encouraged to ambulate, and did
ambulate frequently around the halls without use of a cane or
walker.
# Cardiomyopathy- patient was euvolemic, continued home dose of
lasix and spirinolactone.
# HL
- continued rosuvastatin, ezetimibe for HL
# Gout
- continued allopurinol
# DMII
- continue insulin glargine ___ BID with regular SS
- diabetic diet
- QACHS ___
# Depression
- continue escitalopram with clonazepam prn anxiety
# GERD
- continue omeprazole
# BPH
- continue tamsulosin
# FEN: no IVFs, cardiac/diabetic diet, replete lytes prn
# PPX:
- DVT with heparin SQ
- bowel with omeprazole
- pain with tylenol and dilaudid
# ACCESS: PIV
# CODE STATUS: full
# EMERGENCY CONTACT: wife ___ ___ cell (HCP)
# DISPO: ___ for now
Transitional issues
--Patient will call and make own PCP appointment per his request
--patient will follow up with reguarly scheduled cardiology
appts.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Allopurinol ___ mg PO DAILY
3. Carvedilol 12.5 mg PO BID
please hold for SBP<90, HR<60
4. Clonazepam 0.5 mg PO BID:PRN anxiety
5. Aspirin 81 mg PO DAILY
6. Digoxin 0.125 mg PO DAILY
7. Escitalopram Oxalate 10 mg PO DAILY
8. Furosemide 40 mg PO DAILY
9. Glargine 65 Units Breakfast
Glargine 65 Units Dinner
Insulin SC Sliding Scale using REG Insulin
10. Omeprazole 20 mg PO DAILY
11. Rosuvastatin Calcium 20 mg PO DAILY
12. Spironolactone 12.5 mg PO DAILY
13. Tamsulosin 0.4 mg PO HS
14. Ezetimibe 10 mg PO DAILY
Discharge Medications:
1. quiniDINE Gluconate E.R. 324 mg PO BID
RX *quinidine gluconate 324 mg 1 tablet(s) by mouth Twice A Day
Disp #*60 Tablet Refills:*0
2. Mexiletine 150 mg PO Q12H
RX *mexiletine 150 mg 1 capsule(s) by mouth Twice A Day Disp
#*60 Tablet Refills:*0
3. Acetaminophen 650 mg PO Q6H:PRN pain
4. Allopurinol ___ mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Carvedilol 12.5 mg PO BID
please hold for SBP<90, HR<60
7. Clonazepam 0.5 mg PO BID:PRN anxiety
8. Escitalopram Oxalate 10 mg PO DAILY
9. Ezetimibe 10 mg PO DAILY
10. Furosemide 40 mg PO DAILY
11. Glargine 65 Units Breakfast
Glargine 65 Units Dinner
Insulin SC Sliding Scale using REG Insulin
12. Omeprazole 20 mg PO DAILY
13. Rosuvastatin Calcium 20 mg PO DAILY
14. Spironolactone 12.5 mg PO DAILY
15. Tamsulosin 0.4 mg PO HS
16. Albuterol-Ipratropium ___ PUFF IH Q6H:PRN wheezing
17. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth q4h as needed for pain
Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
syncope, VT with ICD firing
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at ___
___. You were admitted after an episode of syncope,
when your ICD fired. You were taken off your study drug and
started on new antiarrythmics. Your EKG was monitored closely
for changes. You also injured your knee when you fell, but you
improved greatly during the time you were admitted and were able
to walk well at discharge.
It is important that you take all medications as prescribed, and
keep all follow up appointments. We discussed but decided
against an ablation procedure at this time.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
19596157-DS-29
| 19,596,157 | 21,385,662 |
DS
| 29 |
2141-10-21 00:00:00
|
2141-10-21 17:24:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Hydrochlorothiazide / Demerol / Ambien / Strawberry / Wheat Bran
/ INSPRA / Torsemide
Attending: ___.
Chief Complaint:
syncope
Major Surgical or Invasive Procedure:
Right heart catheterization
Right PICC line insertion
History of Present Illness:
___ CAD s/p CABG, systolic heart failure (EF 15 %, NYHA III)
with BiV ICD, AAA s/p repair ___, HLD, HTN, DM presenting with
syncope. Per report, pt was sitting on his bed this morning, got
up to look out window, felt weak and fell to the ground. He
denies LOC, denies head strike, no amnesia, no post-event
confusion, no bowel/bladder incontinence. He also denied any
preceeding events - no chest pain, shortness of breath,
palpitations. He unfortunately also had a recent fall onto his
left arm yesterday ___ shortly after leaving dialysis
(tripped over a curb), suffering a fracture of his left humerus.
(Deemed non-operative candidate by ortho surgery, planned f/u in
2 weeks). He also had a recent fall at home approximately one
week ago after tripping over a rug.
He was recently admitted from ___ for chronic lower back
pain and weakness. During this recent admission, he was started
on dialysis after his RHC showed normal cardiac output. He was
continued on furosemide on last discharge (does still make some
urine). Neverthless, he reports his outpatient nephrologist has
stopped his furosemide as well as his carvedilol secondary to
hypotension. His baseline BP range is ___, baseline dry
weight ~92kg.
In the ED, initial vitals were 97.0 81 81/54 20 100%. His ICD
was interogated with no events noted. Pt was given 250 cc NS
though no orthostatics were documented. He was admitted because
he continued to feel "weak".
REVIEW OF SYSTEMS:
(+) Per HPI.
(-) Cardiac: Denies chest pain, palpitations, dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, peripheral
edema/swelling.
(-) General: Denies weight change, fatigue, subjective fevers at
home, chills, rigors, night sweats, headache, diplopia,
odynophagia, dysphagia, lymphadenopathy, prior history of stroke
or TIA, cyanosis, cough, hemoptysis, pleuritic chest pain,
nausea, vomiting, diarrhea, melena, hematochezia, hematemesis,
known pulmonary embolism or DVT, myalgias, joint pains, new
bleeding, dysuria, exertional buttock or calf pain.
Past Medical History:
-CAD s/p CABG ___ (LIMA-LAD, SVG-OM, SVG-RI, SVG-RCA)
-PACING/ICD: BiV pacer for ventricular arrhythmias ___ BiV
ICD, ___ XT CRT-D D314TRG,
Last evaluated on ___ per webOMR and functioning
appropriately
- systolic CHF (EF 15 %, NYHA III)
RHC (___): RA ___, RV 60/10, PA 62/22/38, PCW ___,
PVR 150, CO/I 4.8/2.3
ECHO (___): EF ___, mild LVH, LVEDD 8.2, dilated RV w HK,
___, mild AS, 2+ MR, 1+ TR, PASP 22mmHg
- Dyslipdemia
- IDDM
- Bilateral iliac artery aneurysm s/p repair ___
- Infrarenal AAA s/p repair ___
- GERD
- HTN
- Prostatitis
- Melanoma s/p excisions
- Afib in past, prior to BiV pacer
- gout
- Sleep apnea - does not comply with CPAP
- s/p hemorrhoidectomy
- Hypercholesterolemia
- Cervical radiculopathy
Social History:
___
Family History:
Father with CAD. Mother with mild dementia.
Physical Exam:
ADMISSION:
VS: 98.8/98.1, ___, 73-76, 20, 100% RA
Wt: (89.5kg admission)
GENERAL: somnolent, sitting up in chair
HEENT: NCAT
CARDIAC: RRR no m/r/g
LUNGS: CTAB, no r/r/w
ABDOMEN: Soft, NTND, no hsm, no r/g.
EXTREMITIES: No clubbing, ___ pitting edema BLE. L arm in
sling.
SKIN: No stasis dermatitis, ulcers, scars. Line insertion site
mildly TTP, but clean, dry, no erythema or purulence.
PULSES: 2+ DP pulses bilaterally.
.
DISCHARGE:
VS: 97.5 87/55 76 18 98%RA
WT: 86<-85<-85<-83.3 <- 86.0kg (89.5kg on admission)
GENERAL: A+Ox3, No acute distress.
HEENT: NCAT, no JVP seen sitting.
CARDIAC: RRR no m/r/g
LUNGS: decreased breath sounds at bases but no crackles,
Speaking in full sentences without AMU. Nl posture.
ABDOMEN: Soft, NTND, no hsm, no r/g.
EXTREMITIES: No clubbing, 2+ pitting edema BLE. L arm swollen
SKIN: No stasis dermatitis, ulcers.
Pertinent Results:
ADMISSION LABS:
___ 02:30AM BLOOD WBC-6.0 RBC-3.77* Hgb-8.5* Hct-30.2*
MCV-80* MCH-22.5* MCHC-28.1* RDW-20.8* Plt Ct-83*
___ 02:30AM BLOOD Neuts-82* Bands-0 Lymphs-7* Monos-7 Eos-3
Baso-0 Atyps-1* ___ Myelos-0 NRBC-2*
___ 02:30AM BLOOD Hypochr-3+ Anisocy-2+ Poiklo-2+
Macrocy-NORMAL Microcy-2+ Polychr-1+ Spheroc-2+ Ovalocy-2+
Schisto-OCCASIONAL Pencil-OCCASIONAL Ellipto-2+
___ 02:30AM BLOOD ___ PTT-32.5 ___
___ 02:30AM BLOOD Glucose-126* UreaN-39* Creat-4.5* Na-141
K-4.9 Cl-100 HCO3-31 AnGap-15
___ 11:45AM BLOOD CK(CPK)-227
___ 07:22AM BLOOD ALT-25 AST-34 LD(LDH)-405* AlkPhos-107
TotBili-1.7*
___ 11:45AM BLOOD CK-MB-2
___ 11:45AM BLOOD cTropnT-0.04*
___ 11:45AM BLOOD Calcium-8.6 Phos-4.3 Mg-2.2
___ 07:22AM BLOOD Albumin-3.7 Calcium-9.4 Phos-6.0*# Mg-2.3
.
MICRO:
DIRECT INFLUENZA A ANTIGEN TEST (Final ___:
Negative for Influenza A.
DIRECT INFLUENZA B ANTIGEN TEST (Final ___:
Negative for Influenza B.
.
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay
.
EKG ___:
Atrio-ventricular sequential pacing. Compared to the previous
tracing of ___ there is no significant change.
___
___
.
Humerus XRay ___: There is an oblique fracture of the
surgical neck of the left humerus with mild displacement. Mild
degenerative changes of the AC joint are noted. The
glenohumeral joint is not well seen in profile. A left pectoral
pacemaker obscures visualization of the left hemithorax.
IMPRESSION: Minimally displaced oblique fracture of the
surgical neck of the left humerus.
.
Shoulder XRay ___: There is an oblique fracture of the
surgical neck of the left humerus with mild displacement. Mild
degenerative changes of the AC joint are noted. The
glenohumeral joint is not well seen in profile. A left pectoral
pacemaker obscures visualization of the left hemithorax.
IMPRESSION: Minimally displaced oblique fracture of the
surgical neck of the left humerus.
.
CXR ___: Single AP upright portable view of the chest was
obtained. Per the radiology technologist, these are the best
radiographs obtainable. Patient stated he would pass out if
standing and has a sling.
Left side of the AICD is again seen with leads in stable
position. The cardiac silhouette remains markedly enlarged.
There is prominence of the central pulmonary vessels. There is
likely a trace left pleural effusion. No definite focal
consolidation is seen. Mediastinal and hilar contours are
stable. IMPRESSION: Severe enlargement of the cardiac
silhouette again seen. Prominence of the central pulmonary
vasculature without overt pulmonary edema. Likely trace left
pleural effusion.
.
Humerus and Elbow XRays ___: Left humerus: Note is again
made of an oblique fracture of the surgical neck of the left
humerus with mild displacement, similar in appearance to the
most recent prior study. No additional fracture is identified.
Mild degenerative changes of the acromioclavicular joint are
again seen. A left pectoral pacemaker is partially visualized.
Left elbow: Evaluation for joint effusion is limited due to
difficulty with patient positioning and lack of a true lateral
radiograph. Within this limitation, no acute fracture or
dislocation is detected. IMPRESSION: 1. Unchanged minimally
displaced fracture of the surgical neck of the left humerus. 2.
No additional fracture detected on this limited study of the
left elbow.
.
CXR ___: AP chest compared to ___ through
___: Severe cardiomegaly is chronic. Pulmonary
vascular engorgement is restricted to pulmonary arteries. There
is no particular mediastinal venous or pulmonary venous
distention and no edema. Pleural effusion is small if any on
the left. There may be left lower lobe atelectasis, but there
are no findings to suggest pneumonia. Transvenous right atrial
and left ventricular pacer and right ventricular pacer
defibrillator leads are in standard placements. Dialysis
catheters end in the right atrium. No pneumothorax.
echo ___
. The left atrium is moderately dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity is severely
dilated. Overall left ventricular systolic function is severely
depressed (LVEF= ___. No masses or thrombi are seen in the
left ventricle. Tissue Doppler imaging suggests an increased
left ventricular filling pressure (PCWP>18mmHg). The aortic
valve leaflets are mildly thickened (?#). There is no aortic
valve stenosis. No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. An eccentric, posteriorly
directed jet of moderate (2+) mitral regurgitation is seen. Due
to the eccentric nature of the regurgitant jet, its severity may
be significantly underestimated (Coanda effect). Moderate to
severe [3+] tricuspid regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Suboptimal image quality. Normal left ventricular
wall thickness with severe left ventricular cavity dilation and
severely depressed global left ventricular systolic function.
Dilated and hypokinetic right ventricle. At least moderate
mitral regurgitaiton. Moderate to severe tricuspid
regurgitation. Moderate pulmonary artery systolic hypertension.
Compared with the prior study (images reviewed) of ___,
the severity of tricuspid regurgitation and pulmonary
hypertension have increased. The right ventricle is not well
seen on either study but is dilated/hypokinetic on both.
ECHO ___: The left atrium is moderately dilated. Left
ventricular wall thicknesses are normal. The left ventricular
cavity is severely dilated. Overall left ventricular systolic
function is severely depressed (LVEF= ___. No masses or
thrombi are seen in the left ventricle. Tissue Doppler imaging
suggests an increased left ventricular filling pressure
(PCWP>18mmHg). The aortic valve leaflets are mildly thickened
(?#). There is no aortic valve stenosis. No aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. An
eccentric, posteriorly directed jet of moderate (2+) mitral
regurgitation is seen. Due to the eccentric nature of the
regurgitant jet, its severity may be significantly
underestimated (Coanda effect). Moderate to severe [3+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is a trivial/physiologic
pericardial effusion. IMPRESSION: Suboptimal image quality.
Normal left ventricular wall thickness with severe left
ventricular cavity dilation and severely depressed global left
ventricular systolic function. Dilated and hypokinetic right
ventricle. At least moderate mitral regurgitaiton. Moderate to
severe tricuspid regurgitation. Moderate pulmonary artery
systolic hypertension.
d/c labs
___ 02:55AM BLOOD WBC-9.9 RBC-3.75* Hgb-8.7* Hct-29.2*
MCV-78* MCH-23.2* MCHC-29.8* RDW-20.4* Plt ___
___ 08:23AM BLOOD Neuts-82* Bands-0 Lymphs-5* Monos-13*
Eos-0 Baso-0 ___ Myelos-0
___ 08:44AM BLOOD ___ PTT-100.3* ___
___ 02:55AM BLOOD Glucose-151* UreaN-26* Creat-2.6* Na-134
K-3.8 Cl-98 HCO3-30 AnGap-10
___ 07:22AM BLOOD ALT-25 AST-34 LD(LDH)-405* AlkPhos-107
TotBili-1.7*
___ 02:55AM BLOOD Calcium-8.4 Phos-3.4 Mg-1.9
___ 06:27AM BLOOD %HbA1c-6.6* eAG-143*
Brief Hospital Course:
___ year old male with CAD s/p CABG, systolic heart failure (EF
15 %, end-stage) with BiVICD, AAA s/p repair ___, HLD, HTN, DM
and ESRD with recent initiation of HD, presenting with syncope
from home. Pt felt weak and collapsed at home, fell onto
recently fractured left humerus, with suspicion that he may have
been overdialyzed. We decided to repeat a right heart cath (was
also done on recent admission) b/c the cardiac output that was
calculated as 4.89L/min on the recent cath was calculated using
an assumed, rather than actually measured, O2 consumption.
Repeat RHC using a calculated O2 consumption showed a CO of
4.3L/min and CI 2.1 LPM/m2 (however PA O2 was markedly depressed
at 34%). He was transfered to CCU for monitoring with initiation
of dopamine drip and then transferred back to the cardiology
floor when PICC was placed for dopamine drip. Now in stable
condition being transferred to ___ Kindred for further care.
# Acute on Chronic CHF (EF 15 %, NYHA III, biV ppm): Due to
ischemic cardiomyopathy. Baseline weight is 92 kg. Baseline
systolic BP 70-100's. His lasix and carvedilol were held in the
setting of hypotension. He received hemodialysis for diuresis.
After right heart cath, patient transferred to CCU on ___
after initiation of dopamine therapy at 5/hr. Since patient had
cordis catheter, needed to be in ICU for monitoring. R PICC
placed ___, and cordis catheter pulled shortly after. Patient
remained hemodynamically stable, and had blood pressures
80-110's. He reported improvement in his energy with the
dopamine. He had an ECHO on ___ while on dopamine, which
showed severe LV dilation, severely depressed LVEF 15%, 2+ MR,
3+ TR, and moderate pulmonary artery systolic hypertension.
Patient will be discharged on a dopamine infusion.
#Hypotension: patient had episode where his SBPs would be as low
as the ___. He often had orthostatic hypotension. We felt this
was likely related to dialysis. Patient should sit in a chair
for a few hours after HD and not walk around because of concern
of a fall. 250cc bolus over ___ minute was given sometimes
during these episodes with improvement.
# CAD s/p CABG ___ (LIMA-LAD, SVG-OM, SVG-RI, SVG-RCA):
stable. He was continued on Aspirin 81mg and Rosuvastatin 20mg.
His carvedilol was held in the setting of hypotension. He was
not on an ACE-I at home, and was not started on an ACE-I in the
setting of hypotension.
# S/P Fall: He presented after an unwitnessed fall at home after
feeling weak, and was found to have a minimally displaced
fracture of the surgical neck of the left humerus. Ortho was
consulted and recommended no surgical intervention, sling, and
f/u in ___ wks w/ Ortho. It was thought that his syncope was
secondary to his hypotension and to hypovolemia (too much fluid
taken off at dialysis), which was treated with dopamine drip
(see CHF). His pain was treated with oxycodone prn.
#L upper ext DVT: Pt has a fracture of left humerus (late ___
had new swelling in arm and u/s showing DVT at left brachial
vein. Heparin drip was started as well as coumadin. Plan for
patient to be on anticoagulation for 3 months. Patient will
follow with ortho regarding the fracture.
# ESRD: He was continued on hemodialysis during this admission
for his renal failure, as well as to remove fluid for his CHF.
He was continued on nephrocaps. While here there was a famiy
meeting with Dr ___ Dr ___ decision was made for
patient to go to a rehab with dopamine infusion and eventually
if he goes home and transitions to outpatient HD he has decided
to be DNR DNI (there was concern initially because ___ clinic
does now have nurses trained in ACLS)
#Code status: DNR DNI
# DM: Insulin dependent. He was treated with HISS during this
admission.
# Anemia: Likely due to CKD. He was continued on EPO per HD
protocol, and his hematocrit remained stable during this
admission.
# Dyslipidemia: Stable. He was continued on ezetimibe 10 mg and
rosuvastatin 20mg daily.
# Hx AFib/Ventricular Arrhythmia: Currently with BiV pacer /
ICD. He was continued on Amiodarone 400mg daily.
# HTN: Patient hypotensive during this admission.
Antihypertensives were held.
# OSA: Does not comply with CPAP.
# GERD: Stable. Continued Omeprazole 20mg daily.
# Gout: Patient had a gout flare that was treated with
prednisone. Continued Allopurinol ___ daily. He has
rheumatology follow up coming in few weeks.
TRANSITIONAL ISSUES:
#orthostasis from HD
#DVT in left arm - will need anticoagulation for 3 months
#CHF: on dopamine infusion
#ESRD: continue HD
#Left humeral fracture: sling, non-weight bearing till seen by
___ clinic
#Code: DNR/DNI
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Albuterol-Ipratropium ___ PUFF IH Q6H:PRN SOB/wheeze
3. Amiodarone 400 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Carvedilol 6.25 mg PO BID
Hold for SBP<80 or hr<60 and hold on dialysis days
6. Cyclobenzaprine 10 mg PO BID:PRN back pain
7. Escitalopram Oxalate 10 mg PO DAILY
8. Ezetimibe 10 mg PO DAILY
9. Ferrous Sulfate 325 mg PO DAILY
occasionally not taking, c/o "hard stools"
10. Fluticasone Propionate NASAL 1 SPRY NU BID
11. Furosemide 60 mg PO BID
hold for sbp<80 and on dialysis days
*pt says was recently stopped by nephrologist*
12. Lorazepam 0.5 mg PO Q8H:PRN anxiety
13. Omeprazole 20 mg PO DAILY
14. Ondansetron 4 mg PO Q8H:PRN nausea
15. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain
16. Rosuvastatin Calcium 20 mg PO DAILY
17. Tamsulosin 0.4 mg PO HS
Pt was only taking approximately 3 nights per week.
18. Epoetin Alfa 3000 UNIT SC 3X/WEEK (___)
19. HydrOXYzine 25 mg PO Q4H:PRN pruritis
20. Nephrocaps 1 CAP PO DAILY
21. Sarna Lotion 1 Appl TP QID:PRN itching
22. Simethicone 40-80 mg PO QID:PRN gas pain, indigestion
23. Glargine 45 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Albuterol-Ipratropium ___ PUFF IH Q6H:PRN SOB/wheeze
3. Amiodarone 400 mg PO DAILY
4. Cyclobenzaprine 10 mg PO BID:PRN back pain
5. Epoetin Alfa 3000 UNIT SC 3X/WEEK (___)
6. Escitalopram Oxalate 10 mg PO DAILY
7. Ezetimibe 10 mg PO DAILY
8. Ferrous Sulfate 325 mg PO DAILY
occasionally not taking, c/o "hard stools"
9. Fluticasone Propionate NASAL 1 SPRY NU BID
10. HydrOXYzine 25 mg PO Q4H:PRN pruritis
11. Glargine 45 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
12. Lorazepam 0.5 mg PO Q8H:PRN anxiety
13. Nephrocaps 1 CAP PO DAILY
14. Omeprazole 20 mg PO DAILY
15. Ondansetron 4 mg PO Q8H:PRN nausea
16. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
17. Rosuvastatin Calcium 20 mg PO DAILY
18. Sarna Lotion 1 Appl TP QID:PRN itching
19. Simethicone 40-80 mg PO QID:PRN gas pain, indigestion
20. Tamsulosin 0.4 mg PO HS
Pt was only taking approximately 3 nights per week.
21. Guaifenesin ___ mL PO Q6H:PRN Cough
22. Aspirin 81 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
- syncope
- end-stage chronic systolic heart failure
- end-stage renal disease
Secondary:
- fractured humerus
- coronary artery disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital for syncope (fainting). This
was likely due to heart failure and hypovolemia (not having
enough fluid in your body). You had a right-heart
catheterization, which showed that your cardiac function
improved with dopamine therapy. Therefore, a PICC was placed
for dopamine infusion. There was a big meeting with Dr ___
___ Dr ___ you going to rehab and then when you go home
that you will continue getting dialysis sessions. You decided
that you wanted to be DNR/DNI
You were diagnosed with gout, which was treated with prednisone.
You should continue taking this until for another 4 days and
then you will follow up with rheumatology.
Weigh yourself every morning, and call your doctor if your
weight goes up more than 3 lbs.
Please see the attached updated medication list, and please take
all medications as prescribed.
You are on a prednisone taper and starting ___ will
decrease the dose of prednisone to 5mg for 3 days and then stop
steroids
It was a pleasure caring for you here at ___. Please see
attached for appointments and medication changes.
Followup Instructions:
___
|
19596467-DS-17
| 19,596,467 | 25,156,869 |
DS
| 17 |
2183-11-17 00:00:00
|
2183-11-18 18:28:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Nausea/Cough/Vommiting/Diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms ___ is a ___ year old woman with PMHx of GERD,
asthma and HIV (CD4 203 ___ and VL not detected on ___
presented to the ___ for evaluation of cough, nausea,
vomiting, diarrhea, dyspnea all for the last 3 days. She reports
that she has myalgias, a cough productive of sputum, and that
she has been having difficulty tolerating eating and drinking.
She reports that she also has some chest pain that is brought on
by coughing. She reports taht she works as caregiver for older
patients, who were also sick with an influenza like illness. At
home her son has been battling a cold and her daughter was
diagnosed with PNA last week.
Of note, she has felt unwell for about 1 month. Initially she
had a "head cold" with congestion and cough. She eventually was
seen in clinic, with a normal CXR. Over the last several days
she has developed fevers and myalgias, as above.
In the ED, initial VS were 103.8, 118, 119/70, 18, 100% RA.
Received 1000mg Tylenol, CXR without focal process, Tamiflu 75mg
PO x1. Transfer VS were 99.6, 102, 129/82, 24, 99% RA.
On arrival to the floor, patient reports continued muscle aches,
some nausea.
Past Medical History:
-GERD
-HIV (CD4 203 ___ and VL not detected on ___. She had a
CD4 count of 455 on ___ and the acute drop was felt to be
due to a infectious process that was ongoing on the prior
admission)
-Asthma
Social History:
___
Family History:
Non-contributory
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
=============================================
VS: 98.6 108/58 97 24 95%RA
General: Awake, alert, lying on side, in mild distress.
HEENT: PERRL. Sclera nonicteric. MMM, no oral lesions. Tonsils
somewhat enlarged, no exudates, no cobblestoning.
Neck: Supple. No LAD or cervical tenderness.
CV: Tachycardic at 100s. Regular rhythm, no murmur appreciated.
Lungs: Late expiratory wheezes in all fields, otherwise clear.
Abdomen: BS+. Soft, mild tenderness over RUQ, nondistended. No
masses or HSM appreciated.
GU: Deferred. No foley.
Ext: Trace edema in LEs.
Neuro: AOx3. CN2-12 grossly intact. No focal deficits.
Skin: Warm, dry. No rashes noted.
PHYSICAL EXAM ON DISCHARGE:
=============================================
VS: 100.1 (Tmax ___ yest) 99 102/64 18 97%RA
General: Awake, alert, more refreshed than previous days.
HEENT: PERRL. Sclera nonicteric. MMM, no oral lesions. Tonsils
somewhat enlarged, no exudates, no cobblestoning.
Neck: Supple. No LAD or cervical tenderness.
CV: Regular rate, regular rhythm, no murmur appreciated.
Lungs: Clear, a few expiratory wheezes at left base. Faint
crackles at bases bilaterally.
Abdomen: BS+. Soft, nontender, nondistended. No masses or HSM
appreciated. Bruising on abdomen noted from SC heparin
injections.
GU: Deferred. No foley.
Ext: No ___ edema.
Neuro: AOx3. CN2-12 grossly intact. No focal deficits.
Skin: Warm, dry. No rashes noted.
Pertinent Results:
LABS:
====================================
___ 02:13PM BLOOD WBC-15.5*# RBC-4.61 Hgb-12.9 Hct-40.2
MCV-87 MCH-28.0 MCHC-32.2 RDW-13.6 Plt ___
___ 02:13PM BLOOD Neuts-86.1* Lymphs-9.6* Monos-3.7 Eos-0.4
Baso-0.3
___ 02:13PM BLOOD Glucose-106* UreaN-13 Creat-0.8 Na-138
K-3.9 Cl-103 HCO3-25 AnGap-14
___ 02:13PM BLOOD ALT-31 AST-24 AlkPhos-137* TotBili-0.3
___ 02:13PM BLOOD Lipase-25
___ 02:13PM BLOOD Albumin-4.6 Calcium-9.4 Phos-1.4*# Mg-1.9
___ 02:30PM BLOOD Lactate-1.5
___ 05:20AM BLOOD WBC-11.8* RBC-3.71* Hgb-10.7* Hct-32.4*
MCV-87 MCH-29.0 MCHC-33.1 RDW-13.9 Plt ___
___ 05:35AM BLOOD WBC-12.4* Lymph-14* Abs ___ CD3%-52
Abs CD3-897 CD4%-19 Abs CD4-332* CD8%-32 Abs CD8-554
CD4/CD8-0.6*
___ 05:35AM BLOOD Glucose-105* UreaN-7 Creat-0.6 Na-142
K-4.3 Cl-108 HCO3-28 AnGap-10
___ 06:45AM BLOOD ALT-24 AST-21 AlkPhos-98 TotBili-0.3
___ 05:35AM BLOOD LD(LDH)-240
___ 05:35AM BLOOD Calcium-8.5 Phos-2.7 Mg-2.4
___ 05:15AM BLOOD WBC-12.5* RBC-3.73* Hgb-10.4* Hct-32.6*
MCV-87 MCH-27.8 MCHC-31.8 RDW-13.6 Plt ___
IMAGING:
====================================
-CHEST (PA & LAT) Study Date of ___:
FINDINGS:
Frontal and lateral views of the chest. Heart size and
cardiomediastinal
contours are normal. Lungs are clear without focal
consolidation, pleural effusion, or pneumothorax.
IMPRESSION:
Normal chest radiographs.
-CHEST (PA & LAT) Study Date of ___:
FINDINGS:
Frontal and lateral radiographs of the chest demonstrate
well-expanded clear lungs. The cardiomediastinal and hilar
contours are unremarkable. There is no pneumothorax,
consolidation, or pleural effusion. Incidental note is made of
mild cervical scoliosis.
IMPRESSION: No pneumonia.
Brief Hospital Course:
PRIMARY REASON FOR HOSPITALIZATION:
===================================================
___ year old woman with PMHx of GERD, asthma and HIV (CD4 203
___ and VL not detected on ___ presented to the ___
for evaluation of fevers, cough, nausea, vomiting, diarrhea,
dyspnea all for 3 days prior to admission.
ACTIVE ISSUES:
===================================================
# Fever/ILI: Patient presented to the ___ for evaluation of
cough, nausea, vomiting, diarrhea, dyspnea all for 3 days prior
to admission. She had had URI symptoms over the previous
3-weeks, with acute worsening and new fevers/myalgias the 3 days
prior to admission. In the ED, initial VS were 103.8, 118,
119/70, 18, 100% RA. CXR was clear. Labs were significant only
for a WBC of 15. She was admitted for presumed influenza and
started on Tamiflu; she completed a 5-day course. Swabs for
respiratory viruses including influenza were collected twice,
however results were indeterminant. She was given supportive
care for her cough and congestion as well as IVFs until she was
tolerating good PO intake. CD4 count was obtained on ___ and
was 332. Blood cultures were drawn upon admission and also
during her stay; final results pending at time of discharge
though no growth to date. She was also started on Augmentin
875mg BID for sinusitis and acute ottitis media; she is to
complete a 10-day course (last day ___.
# HIV: CD4 count was obtained on ___ and was 332. She was
continued on daily Atripla.
# Asthma: She was given albuterol nebs PRN while hopsitalized
for wheeze/SOB.
TRANSITIONAL ISSUES:
===================================================
- Completed 5-day course of Tamiflu.
- Discharged on a 10-day course of Augmentin 875mg BID (last day
___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB/wheeze
2. beclomethasone dipropionate 80 mcg/actuation inhalation BID
3. ATRIPLA (efavirenz-emtricitabin-tenofov) ___ mg oral
daily
4. Omeprazole 40 mg PO DAILY
Discharge Medications:
1. Omeprazole 40 mg PO DAILY
2. Acetaminophen 1000 mg PO Q6H:PRN pain, fever
3. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth twice a day Disp #*17 Tablet Refills:*0
4. Guaifenesin-CODEINE Phosphate 15 mL PO Q6H:PRN cough
RX *codeine-guaifenesin 100 mg-10 mg/5 mL 15 mL by mouth q6hr
Disp #*1 Bottle Refills:*3
5. Sodium Chloride Nasal ___ SPRY NU TID
RX *sodium chloride 0.65 % ___ sprays intranasal three times a
day Disp #*1 Bottle Refills:*3
6. Ondansetron 8 mg PO Q8H:PRN nausea
RX *ondansetron 8 mg 1 tablet,disintegrating(s) by mouth q8hrs
Disp #*30 Tablet Refills:*0
7. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB/wheeze
8. ATRIPLA (efavirenz-emtricitabin-tenofov) ___ mg oral
daily
9. beclomethasone dipropionate 80 mcg/actuation inhalation BID
10. inhalational spacing device miscellaneous with inhaler
RX *inhalational spacing device use with inhaler use with
inhaler Disp #*1 Each Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Influenza like illness
Acute ottitis media
Sinusitis
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 here at ___
___. You were admitted on ___ with fever, body
aches, and congestion. You were treated for influenza with a
medication called Tamiflu, as well as supportive care. Your
symptoms improved, and should continue to improve over the next
___ days.
You were also treated for an ear and sinus infection. You will
continue to take an antibiotic for this (last day ___. You may
continue to have fevers for the next ___ days due to your
infection. It will be important to follow-up with your PCP (see
below for appointments) to ensure resolution of your infection.
Again, it was great to meet you. We wish you all the best.
-Your ___ Team
Followup Instructions:
___
|
19596527-DS-20
| 19,596,527 | 20,846,035 |
DS
| 20 |
2173-01-12 00:00:00
|
2173-01-12 12:20:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamide Antibiotics) / Sulfa (Sulfonamide
Antibiotics) / levofloxacin / tramadol / furosemide / Torsemide
/ ethacrynic acid
Attending: ___
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
___ Cardiac catheterization
___ Coronary artery bypass graft x 2 (Left internal mammary
artery > left anterior descending, saphenous vein graft > obtuse
marginal)
History of Present Illness:
Ms. ___ is an ___ female with a history of diabetes
who is transferred in from ___ for further management of
chest pain that started last night. Patient states that she is
chest pain free at baseline. However she began experiencing
intermittent chest pain on ___ that was worse with activity
and went to her primary care doctor. She had a normal EKG and
was scheduled for a stress test
planned for the ___. Patient continued to experience
intermittent chest pain throughout the week and then awoke last
night in the middle of the night with significant substernal
chest pain and swelling and sweating. She went back to sleep and
then went to ___ in the morning as her symptoms
continued. On evaluation in ___, she was found to have ST
depressions in her lateral leads and an elevated troponin at
0.03. She was treated with aspirin and was transferred to ___
___ for further care.
In the ___ ED, she has no chest pain and is alert and oriented
and in no acute distress. Physical exam was notable for clear
lungs and regular rate and rhythm. She does not have any
peripheral edema and is not in respiratory distress.
CXR report from ___ this AM: Heart size and
mediastinum are stable. Lungs are overall clear with resolution
of previously seen perihilar minimal opacities. Areas of
scarring/ atelectasis in the left lower lobe are unchanged. No
pleural effusion. No pneumothorax.
Patient was transferred in for a possible NSTEMI.
Past Medical History:
Diabetes mellitus type 2
Hypertension
Dyslipidemia
Glaucoma
Restless leg syndrome
Shoulder pain
Colon polyps
Uterine Cancer s/p hysterectomy and radiation
Hip replacement bilateral
Hysterectomy
Bilateral cataract
C section
Social History:
___
Family History:
Father lung cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
======================
VS: T 98.1, BP 135/78, HR 80, RR 18, O2 SAT 100% on RA
GENERAL: WDWN female in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP of 7 cm.
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: No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric
Pertinent Results:
ADMISSION LABS:
================
___ 01:30PM BLOOD WBC-6.2 RBC-4.04 Hgb-11.9 Hct-37.1 MCV-92
MCH-29.5 MCHC-32.1 RDW-12.2 RDWSD-40.9 Plt ___
___ 01:30PM BLOOD Neuts-52.7 ___ Monos-11.6 Eos-2.3
Baso-0.5 Im ___ AbsNeut-3.26 AbsLymp-2.00 AbsMono-0.72
AbsEos-0.14 AbsBaso-0.03
___ 01:30PM BLOOD ___ PTT-27.9 ___
___ 01:30PM BLOOD Glucose-77 UreaN-15 Creat-0.7 Na-140
K-4.1 Cl-102 HCO3-27 AnGap-15
___ 01:30PM BLOOD CK(CPK)-63
___ 01:30PM BLOOD CK-MB-4 cTropnT-0.06*
OTHER RELEVANT LABS:
==================
___ 11:10AM BLOOD CK(CPK)-56
___ 09:15PM BLOOD CK-MB-3 cTropnT-0.04*
___ 03:17AM BLOOD CK-MB-3 cTropnT-0.04*
___ 11:10AM BLOOD CK-MB-3 cTropnT-0.04*
___ 05:40PM BLOOD CK-MB-2 cTropnT-0.04*
___ 03:04AM BLOOD CK-MB-3 cTropnT-0.03*
DISCHARGE LABS:
===================
___ 03:52AM BLOOD WBC-9.3 RBC-3.60* Hgb-10.7* Hct-33.0*
MCV-92 MCH-29.7 MCHC-32.4 RDW-12.7 RDWSD-42.0 Plt ___
___ 03:36AM BLOOD WBC-10.5* RBC-3.47* Hgb-10.4* Hct-31.8*
MCV-92 MCH-30.0 MCHC-32.7 RDW-13.2 RDWSD-43.1 Plt ___
___ 06:14AM BLOOD WBC-11.0* RBC-3.52* Hgb-10.5* Hct-32.2*
MCV-92 MCH-29.8 MCHC-32.6 RDW-13.2 RDWSD-43.8 Plt ___
___ 01:45AM BLOOD WBC-12.4* RBC-4.31 Hgb-13.0 Hct-38.4
MCV-89 MCH-30.2 MCHC-33.9 RDW-13.0 RDWSD-42.5 Plt ___
___ 03:52AM BLOOD Glucose-106* UreaN-13 Creat-0.6 Na-130*
K-3.8 Cl-92* HCO3-28 AnGap-14
___ 02:01PM BLOOD Na-130* K-4.3
___ 03:36AM BLOOD Glucose-133* UreaN-13 Creat-0.5 Na-127*
K-3.9 Cl-90* HCO3-28 AnGap-13
___ 06:14AM BLOOD Glucose-116* UreaN-11 Creat-0.6 Na-132*
K-3.8 Cl-97 HCO3-28 AnGap-11
___ 01:45AM BLOOD Glucose-108* UreaN-11 Creat-0.6 Na-137
K-4.4 Cl-105 HCO3-22 AnGap-14
Cardiac Catheterization ___
Coronary Anatomy
The LMCA had distal 70% ulcerated stenosis into the LAD which
had origin 60% stenosis and mild
luminal irregularities thereafter. The Cx had origin 80-90%
stenosis into a moderate sized OM. The RCA
had proximal 40% stenosis.
Carotid Ultrasound ___
RIGHT:
The right carotid vasculature has severe heterogeneous
atherosclerotic plaque
involving the proximal internal carotid artery.
The peak systolic velocity in the right common carotid artery is
45 cm/sec.
The peak systolic velocities in the proximal, mid, and distal
right internal
carotid artery are 535, 157, and 61 cm/sec, respectively. The
peak end
diastolic velocity in the right internal carotid artery is 233
cm/sec.
The ICA/CCA ratio is 12.0.
The external carotid artery has peak systolic velocity of 92
cm/sec.
The vertebral artery is patent with antegrade flow.
LEFT:
The left carotid vasculature has moderate heterogeneous
atherosclerotic plaque
involving the proximal internal carotid artery.
The peak systolic velocity in the left common carotid artery is
77 cm/sec.
The peak systolic velocities in the proximal, mid, and distal
left internal
carotid artery are 95, 130, and 108 cm/sec, respectively. The
peak end
diastolic velocity in the left internal carotid artery is 45
cm/sec.
The ICA/CCA ratio is 1.7.
The external carotid artery has peak systolic velocity of 98
cm/sec.
The vertebral artery is patent with antegrade flow.
IMPRESSION:
Greater than 70% stenosis of the right internal carotid artery.
50-69%
stenosis of the left internal carotid artery.
Echocardiogram ___
Left Ventricle - Ejection Fraction: 55% >= 55%
Aorta - Ascending: *3.9 cm <= 3.4 cm
LEFT ATRIUM: No mass/thrombus in the ___.
RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal regional LV systolic function. Overall
normal LVEF (>55%). [Intrinsic LV systolic function likely
depressed given the severity of valvular regurgitation.]
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Mildly dilated
ascending aorta. Simple atheroma in descending aorta.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate
(2+) MR.
___ VALVE: Mild [1+] TR.
Conclusions
Prebypass
No mass/thrombus is seen in the left atrium or left atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler. Regional left ventricular wall motion is normal.
Overall left ventricular systolic function is normal (LVEF>55%).
[Intrinsic left ventricular systolic function is likely more
depressed given the severity of valvular regurgitation.] Right
ventricular chamber size and free wall motion are normal. The
ascending aorta is mildly dilated. There are simple atheroma in
the descending thoracic aorta. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic stenosis. No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Moderate (2+) mitral
regurgitation is seen. Dr. ___ was notified in person of the
results on ___ at 1430
Post bypass
Patient is A paced and receiving an infusion of Phenylephrine.
Biventricular systolic function is unchanged. Mild mitral
regurgitation present. Aorta is intact post decannulation. Rest
of examination is unchanged.
Brief Hospital Course:
Ms. ___ is an ___ female presenting with substernal
chest pressure. At admission, patient had a trop elevation 0.03
-> 0.06. She was started on a heparin drip, ASA 81 mg,
sublingual nitroglycerin prn pain, and metoprolol 6.25 mg BID.
Her dose of atorvastatin was increased from 40 to 80 mg qPM
daily. On ___, Patient had an episode of chest pain overnight
on ___ and had a repeat EKG that showed deepening of ST
depressions from prior. Patient had trop elevation 0.03 -> 0.06
-> 0.04 > 0.04 > 0.04 > 0.04. Repeat EKG showed ST elevation in
aVR and ST depression in anterolateral leads concerning for L
main or ___ LAD disease so patient was sent to CCU for closer
observation and possible IABP. Her chest pain was controlled
with nitroglycerin drip. She underwent cardiac catheterization
on ___ which revealed left main coronary artery disease. That
evening she developed chest pain when off nitroglycerin drip.
In am ___ she had no chest pain continued on nitrogylerin and
heparin drips. She was taken to the operating room that
afternoon due to chest pain overnight. Prior to OR carotid
ultrasound revealed significant disease and vascular surgery was
consulted with recommended outpatient followup. She was taken
to the operating room ___ for coronary artery bypass graft
surgery. See operative report for further details. Post
operative she was taken to the intensive care unit for
hemodynamic monitoring. That evening she was weaned from
sedation, awoke neurologically intact and was extubated without
complications. On post operative day one she was started on
betablocker and diuretic. Chest tubes were removed per protocol.
She was transferred to the floor. Chest tubes and pacing wires
were discontinued without complication. She did have a burst of
atrial fibrillation that self resolved - Lopressor was
increased. She was placed on a fluid restriction for
hyponatremia, which was improving at the time of discharge. The
patient was evaluated by the physical therapy service for
assistance with strength and mobility. By the time of discharge
on POD **** the patient was ambulating with assistance, the
wound was healing and pain was controlled with oral analgesics.
The patient was discharged to ___ at ___ -
___ rehab in good condition with appropriate follow up
instructions.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. MetFORMIN (Glucophage) 500 mg PO BID
2. Atorvastatin 40 mg PO QPM
3. Lisinopril 40 mg PO DAILY
4. amLODIPine 2.5 mg PO DAILY
5. rOPINIRole Dose is Unknown PO Frequency is Unknown
6. Aspirin 81 mg PO DAILY
7. Ascorbic Acid Dose is Unknown PO Frequency is Unknown
8. Cyanocobalamin Dose is Unknown PO Frequency is Unknown
9. Vitamin B Complex Dose is Unknown PO Frequency is Unknown
Discharge Medications:
1. Acetaminophen 650 mg PO/PR Q4H:PRN pain or temperature >38.0
2. Bisacodyl 10 mg PR QHS:PRN constipation
3. Chlorothiazide 500 mg PO BID
4. Docusate Sodium 100 mg PO BID
5. Metoprolol Tartrate 12.5 mg PO TID
Hold for SBP<100 HR<60
6. Milk of Magnesia 30 mL PO DAILY
7. Nystatin Oral Suspension 5 mL PO QID:PRN thrush
8. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ capsule(s) by mouth Q 4 hours Disp #*30
Capsule Refills:*0
9. Potassium Chloride 20 mEq PO DAILY
Hold for K > 4.5
10. Ranitidine 150 mg PO BID
11. Senna 17.2 mg PO BID:PRN constipation
12. Atorvastatin 80 mg PO QPM
13. rOPINIRole 0.25 mg PO BID
14. Vitamin B Complex 1 CAP PO DAILY
15. Aspirin EC 81 mg PO DAILY
16. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
17. Lumigan (bimatoprost) 0.01 % ophthalmic QPM
18. MetFORMIN (Glucophage) 500 mg PO BID
19. HELD- Lisinopril 40 mg PO DAILY This medication was held.
Do not restart Lisinopril until directed by PCP
___:
Extended Care
Facility:
___
Discharge Diagnosis:
Coronary artery disease s/p coronary revascularization
Non ST elevation myocardial infarction
Carotid stenosis
Secondary Diagnosis
Diabetes mellitus type 2
Hypertension
Dyslipidemia
Glaucoma
Restless leg syndrome
Shoulder pain
Colon polyps
Uterine Cancer s/p hysterectomy and radiation
Hip replacement bilateral
Hysterectomy
Bilateral cataract
C section
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Oxycodone
Incisions:
Sternal - healing well, mild erythema at lower pole, no drainage
Leg Right Saph site - healing well, no drainage.
Trace Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns ___
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
Followup Instructions:
___
|
19596777-DS-9
| 19,596,777 | 25,393,562 |
DS
| 9 |
2118-03-30 00:00:00
|
2118-03-30 22:10:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Ativan
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
PICC placement (___)
PICC removal and replacement (___)
History of Present Illness:
___ w/ idiopathic recurrent pancreatitis p/w recurrent abd pain
radiating to back w/ nausea, seen in ED for this ___ and
discharged home w/ PO pain meds on ___. Reports pain worsening
with no relief from PO medications. Has had nausea, no vomiting.
Has required admission in the past requiring PCA pump.
In the ED, initial vitals: T 98.1, HR 89, BP 147/89, RR 16, O2
sat 100% on RA
- Labs notable for: WBC 10.3, lipase 1201
- Imaging notable for: CXR unremarkable
- Pt given: PO dilaudid 2mg, Zofran, 1L IVF, 2mg IV dilaudid
- Vitals prior to transfer:
On the floor, her pain is ___, improved with IV dilaudid per
patient. Describes her pain as epigastric and radiates
bilaterally to the back. No shortness of breath, fevers, or
chest
pain.
Past Medical History:
Recurrent acute pancreatitis (first episode ___ idiopathic)
Incomplete pancreas divisum (thought by GI to be unrelated)
Overweight
tonsillectomy
Social History:
___
Family History:
no pancreatitis
Physical Exam:
=======================
ADMISSION PHYSICAL EXAM:
=======================
VITALS: ___
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Warm, dry, no rashes or notable lesions.
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally.
=======================
DISCHARGE PHYSICAL EXAM:
=======================
Vitals: 98.3 113 / 78 89 18 95 Ra
General: Lying in bed, NAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs
Lungs: Clear to auscultation bilaterally, no wheezes
Abdomen: Soft, non-distended, mild tenderness in epigastric
region without rebound tenderness or guarding, +BS
Ext: WWP. Non-pitting edema of LEs.
Neuro: Moving all 4 extremities spontaneously.
Pertinent Results:
===============
Admission labs
===============
___ 06:14PM BLOOD WBC-10.3* RBC-4.25 Hgb-12.7 Hct-36.5
MCV-86 MCH-29.9 MCHC-34.8 RDW-11.7 RDWSD-36.6 Plt ___
___ 06:14PM BLOOD Neuts-79.9* Lymphs-12.9* Monos-6.5
Eos-0.3* Baso-0.1 Im ___ AbsNeut-8.21*# AbsLymp-1.32
AbsMono-0.67 AbsEos-0.03* AbsBaso-0.01
___ 06:14PM BLOOD Glucose-75 UreaN-8 Creat-0.7 Na-140 K-4.0
Cl-97 HCO3-22 AnGap-21*
___ 06:14PM BLOOD ALT-16 AST-23 AlkPhos-68 TotBili-0.5
___ 06:14PM BLOOD Lipase-1201*
___ 06:14PM BLOOD Albumin-4.7
===============
Pertinent labs
===============
___ 12:17PM BLOOD Glucose-68* UreaN-4* Creat-0.7 Na-136
K-4.4 Cl-94* HCO3-16* AnGap-26*
___ 05:53PM BLOOD Glucose-108* UreaN-3* Creat-0.7 Na-133*
K-4.2 Cl-95* HCO3-17* AnGap-21*
___ 12:17PM BLOOD Lipase-32
___ 05:53PM BLOOD Calcium-9.2 Phos-2.9 Mg-2.1
___ 02:26PM BLOOD Type-MIX pO2-161* pCO2-34* pH-7.29*
calTCO2-17* Base XS--8 Comment-GREEN TOP
___ 06:46PM BLOOD Type-MIX pO2-72* pCO2-34* pH-7.33*
calTCO2-19* Base XS--6
___ 06:46PM BLOOD Lactate-1.0
___ 05:53PM BLOOD BETA-HYDROXYBUTYRATE- 3.3 (elevated)
___ 05:40AM BLOOD Glucose-174* UreaN-<3* Creat-0.6 Na-137
K-4.1 Cl-99 HCO3-23 AnGap-15
___ 12:08PM BLOOD Type-MIX pO2-102 pCO2-39 pH-7.38
calTCO2-24 Base XS--1 Comment-GREEN TOP
===============
Discharge labs
===============
___ 05:52AM BLOOD WBC-6.2 RBC-3.52* Hgb-10.6* Hct-31.3*
MCV-89 MCH-30.1 MCHC-33.9 RDW-12.2 RDWSD-39.3 Plt ___
___ 05:52AM BLOOD Glucose-90 UreaN-5* Creat-0.6 Na-143
K-3.9 Cl-104 HCO3-24 AnGap-15
___ 05:52AM BLOOD Calcium-8.7 Phos-4.5 Mg-2.0
===============
Studies
===============
PICC/MIDLINE placement (___)
1. Indwelling PICC out of position and likely extravascular
after
small contrast injection. 2. The new accessed, right brachial
vein was patent and
compressible. 3. Brachial vein approach double-lumen right PICC
with tip in the
distal SVC.
CXR (___)
Right-sided midline probably resides within the right brachial
vein, just proximal to the axillary vein. Heart size is normal.
Cardiomediastinal silhouette and hilar contours are preserved.
Lungs are clear. Pleural surfaces are clear without effusion or
pneumothorax. There is no acute osseous abnormality.
Brief Hospital Course:
SUMMARY: Ms. ___ is a ___ year old female with recurrent
idiopathic pancreatitis presenting with worsening abdominal
pain, poor p.o. intake, and nausea, found to have a lipase of
1201 and a leukocytosis of 10.3, consistent with recurrent
pancreatitis who was admitted for pain control and IV fluids.
======================
ACUTE MEDICAL PROBLEMS
======================
#Acute on chronic idiopathic pancreatitis
Patient presented with worsening epigastric pain after being
discharged from emergency department recently with oral
medications for same symptoms. Lipase was 1201, and WBC 10.3 on
admission. She was started on IV Dilaudid, IV fluids, and
Zofran/scopolamine patch for nausea. She has had multiple
episodes of pancreatitis with the first episode of ___.
Extensive workup of etiology by gastroenterology has been
negative thus far. She does not use alcohol, smoke, have any
evidence of gallstones, has normal calcium, and normal
triglycerides. Per GI records, genetic evaluation with Ambry
full screen were negative for CFTR and PRSS1. She is
heterozygous for SPINK1 p.N34S mutation and p.C58R variant of
unknown significance. Patient started tolerating regular diet on
___. She discharged with PO pain medication.
# Starvation ketosis
Patient with labs showing anion gap metabolic acidosis with
normal renal function and lactate, consistent with starvation
ketoacidosis. She had not eaten in 5 days on admission. Labs
were also concerning for hypoglycemia with blood glucose 68. She
was started on D5LR with improvement in her glucose. On day #6
of not eating, we recommended NJ tube placement for enteral
feeding which she declined. Her acidosis resolved with D5LR and
electrolytes were monitored and repleted as appropriate.
========================
CHRONIC MEDICAL PROBLEMS
========================
# Insomnia
Continued home mirtazipine 30 mg PO qhs
# Contraception
Continued home OCP, Trinessa.
==================
TRANSITIONAL ISSUES
==================
[] On future admissions, would recommend:
- Placing midline or PICC on admission for IV access. If PICC,
will need ___ placement due to multiple difficulties in the past
- Responded well to ___ mg IV Dilaudid q3h prn but also has done
well with PCAs in the past
- Nausea responded well to Zofran and scopolamine patch
- Consider adding D5 to LR as patient had starvation ketosis on
this admission
[] GI follow-up for further workup and prevention of
pancreatitis
[] Discuss possibility of switching to non-estrogen
contraceptive such as an IUD for possibility of estrogen
exacerbating pancreatitis
[] Discharged with 10 tablets 2mg PO dilaudid and prn zofran
Advanced Care Planning
#Code status: Full
#Health care proxy/emergency contact: ___
(mother):
___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Mirtazapine 30 mg PO QHS
2. TriNessa (28) (norgestimate-ethinyl estradiol)
0.18/0.215/0.25 mg-35 mcg (28) oral DAILY
3. Antioxidant Vitamins (vit A,C and E-lutein-minerals) 1,000
unit-200 mg-60 unit-2 mg oral DAILY
4. Zenpep (lipase-protease-amylase) ___ unit
oral TID W/MEALS
Discharge Medications:
1. Docusate Sodium 100 mg PO BID:PRN constipation
RX *docusate sodium 100 mg 1 capsule(s) by mouth Twice a day
Disp #*30 Capsule Refills:*0
2. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate
RX *hydromorphone 2 mg 1 tablet(s) by mouth Every 4 hours Disp
#*10 Tablet Refills:*0
3. Ondansetron 8 mg PO Q8H:PRN nausea Duration: 5 Doses
RX *ondansetron HCl 8 mg 1 tablet(s) by mouth Every 8 hours Disp
#*10 Tablet Refills:*0
4. Zenpep (lipase-protease-amylase) ___
unit oral TID W/MEALS
5. Antioxidant Vitamins (vit A,C and E-lutein-minerals) 1,000
unit-200 mg-60 unit-2 mg oral DAILY
6. Mirtazapine 30 mg PO QHS
7. TriNessa (28) (norgestimate-ethinyl estradiol)
0.18/0.215/0.25 mg-35 mcg (28) oral DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses
==================
Recurrent acute idiopathic pancreatitis
Secondary diagnoses
==================
Starvation ketosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at the ___
___!
Why was I admitted to the hospital?
=================================
- You were admitted because you had abdominal pain and lab
abnormalities concerning for recurrent pancreatitis.
What happened while I was in the hospital?
====================================
- You were given IV fluids and medications for pain control.
- You were found to be in something called starvation
ketoacidosis, which happens when you do not eat for a long time.
You were given IV fluids with sugar in them to treat this. This
was no longer a problem when you were discharged.
What should I do after leaving the hospital?
====================================
- Please take your medications as listed in discharge summary
and follow up at the listed appointments.
- Return to the hospital if your pain returns in the future.
- If taking dilaudid, do not drink, drive, or operate heavy
machinery. This type of medication can cause constipation so
take stool softeners and stay hydrated if you are using dilaudid
frequently.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Sincerely,
Your ___ Healthcare Team
Followup Instructions:
___
|
19596788-DS-4
| 19,596,788 | 24,528,317 |
DS
| 4 |
2162-08-30 00:00:00
|
2162-09-07 01:38:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Phenergan
Attending: ___.
Chief Complaint:
Perihepatic hematoma
Major Surgical or Invasive Procedure:
Gelfoam embolization of the right hepatic artery
History of Present Illness:
___ with history of ETOH use, HTN, and CAD presenting
with acute onset of abdominal pain that started at midnight 1
___
night. She describes no physical exertion or inciting event. She
denies lightheadness or dizziness. She reports a splenic bleed,
thought to be spontaneous back in ___ which required an
emergent
splenectomy and was complicated by a gastric perforation needing
repair. She has been diagnosed with a "genetic hypercoagulable
disorder" and states is on lifelong Coumadin for this. She had
an MI in
last year and had a catheter done which was negative per
patient.
Soon after this she also developed a pulmonary embolus. She also
has a history
of significant alcohol abuse for many years, had quit, but
recently relapsed. She reports drinking about 1 bottle of Vodka
every 2 or three days.
Past Medical History:
Myocardial infarction, status post negative catheter, history of
alcoholism, hypercoagulability disorder
PSH: splenectomy c/b perforation and repair, multiple back
surgeries
Social History:
___
Family History:
noncontributory
Physical Exam:
GEN: In moderate distress
RESP: Unlabored breaths
___: RRR
ABD: Soft, non-distended, TTP diffusely R > L without rebound
and with voluntary guarding.
EXT: No edema
NEURO: AAOx3, strength and sensation intact bilaterally
Pertinent Results:
___ 06:30PM HCT-26.0*
___ 12:49PM HCT-30.0*
___ 09:59AM WBC-12.2* RBC-3.79* HGB-11.5 HCT-33.6* MCV-89
MCH-30.3 MCHC-34.2 RDW-16.0* RDWSD-51.5*
___ 09:59AM NEUTS-81.7* LYMPHS-6.9* MONOS-10.5 EOS-0.0*
BASOS-0.4 IM ___ AbsNeut-9.99* AbsLymp-0.84* AbsMono-1.29*
AbsEos-0.00* AbsBaso-0.05
___ 09:59AM PLT COUNT-239
___ 09:35AM ___ PTT-27.4 ___
___ 09:22AM ___ PTT-36.7* ___
___ 08:20AM GLUCOSE-159* UREA N-11 CREAT-0.5 SODIUM-133
POTASSIUM-4.5 CHLORIDE-92* TOTAL CO2-28 ANION GAP-18
___ 08:20AM estGFR-Using this
___ 08:20AM ALT(SGPT)-191* AST(SGOT)-248* ALK PHOS-101
TOT BILI-1.0
___ 08:20AM LIPASE-36
___ 08:20AM ALBUMIN-3.9 CALCIUM-9.8 PHOSPHATE-3.9
MAGNESIUM-1.6
___ Hepatic angiogram:
Technically successful right hepatic artery Gel-Foam
embolization to stasis. Although a subtle arterial abnormality
was visualized in a right hepatic artery branch to segment ___,
this is not convincingly the source of the bleed. Therefore
empiric Gelfoam embolization of the right hepatic artery was
performed.
___ Abd MRI/Liver:
Limited partial examination. There is no large hepatic mass
associated with the large hematoma. Assessment for a small
mass, particularly medially within the right lobe would be best
accomplished with repeat MR in 3 months, after allowing for
retraction of the large perihepatic hematoma. Hepatic steatosis.
Brief Hospital Course:
___ was seen and admitted to the hospital on ___
for 24 hours of
acute onset of abdominal pain. Patient was seen in an outside
hospital and found to have a large hematoma behind the liver
with hemoperitoneum. The patient was on Coumadin for a prior
pulmonary embolism. The patient's vital signs were been stable.
On arrival we were notified of the patient's INR was 6.
Given her acute onset and spontaneous hepatic bleed and
perihepatic hematoma with active extravasation on CT, she was
taken to Interventional Radiology for empiric Gelfoam
embolization of the right hepatic artery. She was consented,
prepped, and tolerated the procedure well. She was then admitted
to the TSICU on ACS, with serial hematocrits and abdominal
exams. An abdominal MRI done on ___ showed no hepatic mass
that was associated with the abdominal hematoma. They
recommended a repeat liver MRI in 3 months.
Once she was stable, she was transferred from the TSICU onto the
floor. There, she was seen by hematology for her genetic
hypercoagulabilty on ___. They recommended that given that
she is a heterozygote for the prothombin gene
mutation, and the deep venous thrombosis that she had was
provoked, she should not need life-long anticoagulation. In
addition, the plasminogen-activator 1 inhibitor deficiency is a
bleeding risk, not a thrombotic risk. The risk of bleeding
life-long anticoagulation outweights any benefit. They concluded
that she could go home without any lifelong anti-coagulation
therapy.
She was also seen by pain management for management of her
chronic/acute pain, as well as her Suboxone status. They
recommended decreasing the amount of medication, re-evaluation
with her PCP Dr ___ discharged from the hospital. She
was instructed that if she had any questions regarding pain, she
should call the ___ Pain ___ at
___.
On ___, she was tolerating a regular diet, pain was
adequately controlled, and she expressed desire to go home to
see her family. At this time, she was off her anticoagulation
medications, was abulating without difficulty, voiding without
difficulty, and was medically cleared by ACS service, with
stable vital signs. She was given discharge paperwork,
prescriptions for outpatient medications, and instructions on
what to do if her abdominal hematoma recurs. The patient was
discharged home without services. The patient received discharge
teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL DAILY Opioid
dependence
2. Warfarin 5 mg PO Frequency is Unknown Genetic
hypercoagulability
3. Lisinopril 20 mg PO DAILY
4. Acamprosate 333 mg PO TID
5. Gabapentin 600 mg PO QID
6. Lidocaine 5% Patch 1 PTCH TD DAILY:PRN Pain
7. Magnesium Oxide 280 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Lisinopril 20 mg PO DAILY
2. Gabapentin 600 mg PO QID
3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
Please do not drive or operate heavy machinery when taking
RX *oxycodone 10 mg 1 tablet(s) by mouth every four (4) hours
for pain as needed Disp #*28 Tablet Refills:*0
4. Multivitamins 1 TAB PO DAILY
5. Acamprosate 333 mg PO TID
Discharge Disposition:
Home
Discharge Diagnosis:
Perihepatic hematoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
You were admitted to ___ and
underwent Gelfoam embolization of the right hepatic artery for a
liver bleed. You are recovering well and are now ready for
discharge. Please follow the instructions below to continue your
recovery:
*AVOID contact sports and/or any activity that may cause injury
to your abdominal area for the next ___ weeks.
*If you suddenly become dizzy, lightheaded, feeling as if you
are going to pass out go to the nearest Emergency Room as this
could be a sign that you are having internal bleeding from your
liver or spleen injury.
*AVOID any blood thinners such as Motrin, Naprosyn, Indocin,
Aspirin, Coumadin or Plavix.
*Please understand that there is no need for anti-coagulation,
since during your hospitalization, it was determined that your
risk of bleeding outweighs your risk of coagulation.
Followup Instructions:
___
|
19596808-DS-18
| 19,596,808 | 26,625,509 |
DS
| 18 |
2131-11-16 00:00:00
|
2131-11-16 17:01:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right foot erythema and swelling
Major Surgical or Invasive Procedure:
___
1. Left-sided common femoral ultrasound-guided access.
2. Catheter placement into the right-sided external iliac artery
second order.
3. Abdominal aortogram and right lower extremity angiogram.
History of Present Illness:
___ with known bilateral lower extremity multilevel occlusive
disease presented with a one week history of right lower
extremity swelling and erythema. He initially injured his
plantar surface of his RLE in the ___ while in the garden.
Since then, there has been a small non healing ulcer
managed with local wound care through his podiatrist, Dr
___. He had a debridement 10 days prior to presentation
and was started on keflex for foot erythema and swelling. There
was no resolution over this time and his podiatrist sent him to
the emergency room for IV antibiotics. In he ED, he was having
minimal pain in the right foot, no fevers/chills/SOB/chest
pain/abdominal pain/nausea/vomiting.
Past Medical History:
PAST MEDICAL HISTORY:
- Peripheral vascular disease (Right
SFA/popliteal disease ; Left SFA/popliteal occlusion)
- AAA
- Atrial fibrillation
- Hypertension
- GERD
- Hyperlipidemia
- Right internal carotid occlusion bifurcation to circle of
___
- Left carotid stenosis 40%
- 4.6-cm ascending aorta
- 3.4-cm descending thoracic aorta
- 3.3-cm infrarenal abdominal aortic aneurysm
- Left subclavian aneurysm 2.6 cm
- Duodenal polyps
- prostate cancer s/p XRT
Social History:
___
Family History:
Mother with asthma, father unknown cause of death
Physical Exam:
Upon Admission:
Temp: 97.6 HR: 63 BP: 118/75 Resp: 20 O(2)Sat: 97 Normal
Neuro/Psych: Oriented x3, Affect Normal, NAD.
Neck: No masses, Trachea midline, Thyroid normal size,
non-tender, no masses or nodules, No right carotid bruit, No
left
carotid bruit.
Nodes: No clavicular/cervical adenopathy, No inguinal
adenopathy.
Skin: No atypical lesions.
Heart: Abnormal: Atrial fibrillation.
Lungs: Clear, Normal respiratory effort.
Gastrointestinal: Non distended, No masses, Guarding or rebound,
No hepatosplenomegally, No hernia, No AAA.
Rectal: Not Examined.
Extremities: No popiteal aneurysm, No femoral bruit/thrill, No
LLE Edema, No varicosities.
Pulse Exam (P=Palpation, D=Dopplerable, N=None)
RUE Radial: P. Ulnar: P. Brachial: P.
LUE Radial: P. Ulnar: P. Brachial: P.
RLE Femoral: P. Popiteal: D. DP: D. ___: D.
LLE Femoral: P. Popiteal: D. DP: D. ___: D.
Pertinent Results:
___ 07:35AM BLOOD WBC-5.8 RBC-4.11* Hgb-13.3* Hct-37.7*
MCV-92 MCH-32.3* MCHC-35.3* RDW-13.2 Plt ___
___ 05:30PM BLOOD Neuts-57.0 ___ Monos-8.7 Eos-2.2
Baso-0.6
___ 07:35AM BLOOD ___ PTT-33.8 ___
___ 07:35AM BLOOD Plt ___
___ 07:35AM BLOOD Glucose-94 UreaN-9 Creat-1.0 Na-137 K-3.8
Cl-103 HCO3-23 AnGap-15
___ 07:25AM BLOOD Calcium-9.0 Phos-3.0 Mg-2.1
CHEST X-RAY (___)
Comparison is made to the prior chest radiograph from ___ and chest CT from ___.
There is again seen extensive pleural thickening and plaques,
more prominent along the right chest than the left. There are
no signs for overt pulmonary edema. There is some scarring
involving the right mid lung field and the left base which is
stable compared to the prior CT scans and plain films. There is
hyperexpansion of the lung fields.
CTA AORTA/BIFEMORAL/ILIAC R (___)
1. Abdominal aortic aneurysm to 3.3cm is little changed since
___.
2. 50% stenosis at the origin of the right common iliac artery;
otherwise minimal inflow disease.
3. Multifocal stenoses of the bilateral SFA, particularly
severe at the
adductor canal bilaterally. Degree of stenoses difficult to
accurately assess due to significant calcifications.
4. Occlusion of the left popliteal artery, with reconsitution
via
collaterals. Single vessel runoff on the left, with the
peroneal artery
reconstituting the plantar arch.
5. Single vessel runoff on the right, with posterior tibial
artery supplying the plantar arch. No meaningful anterior
tibial or peroneal artery seen beyond a few cm off the origin of
these vessels.
6. Bilateral pleural plaques, some of which are calcified,
suggest prior
asbestos exposure, unchanged from ___.
7. Coronary artery calcifications of unknown hemodynamic
significance.
RIGHT FOOT X-RAY (___)
No radiographic evidence of osteomyelitis.
RIGHT LOWER EXTREMITY VENOUS ULTRASOUND (___)
No evidence of DVT in the right lower extremity.
Brief Hospital Course:
The patient was admitted to the Vascular Surgical service after
presentation to the ED, as documented above. Full laboratory and
relevant imaging workup was obtained, results of which may be
found in the 'Pertinent Results' section.
Thereafter, he was admitted to the vascular surgical floor for
further care. He was given a regular diet, all his home
medications, IV antibiotics, and local wound care. Laboratory
studies were monitor regularly, and culture data was obtained.
On ___, the patient underwent a CTA aorta/bifem/iliac runoff,
results of which may be found in the 'Pertient Results' section.
Thereafter, upon review of imaging, the patient was explained
the risks/benefits of, and was offered the option of angiogram
for further diagnosis and/or treatment. He expressed interest in
pursuing this.
Therefore, as planned, the patient was taken for a right lower
extremity angiogram on ___. The details of this procedure
may be found in the Operative Notes.
** Of note, the patient's coumadin was held from ___ in
preparation for the procedure. Furthermore, due to a high INR of
4.9 on the morning of the procedure, the patient was given 1 mg
IV Vitamin K, 2 units of FFP pre-operatively, and 1 unit of FFP
intra-operatively, and 1 unit of FFP in the post-anesthesia care
unit. Following this, he returned to the general surgical floor,
where he was maintained on flat bedrest for 6 hours, per
protocol, and routine groin checks were performed. ** Also of
note, the patient was started on a new medication, Cilostazol 50
mg BID post-operatively.
The patient's foley was removed and he voided successfully. He
was given a regular diet, and all his home medications.
Antibiotics were continued. His home coumadin was restarted on
POD#1. He expressed feeling well, with good pain control,
tolerating a regular diet, on all his home medications. He was
continued on antibiotics, in oral form.
Cardiology was consulted due to persistent tachycardia, and
recommended that his home diltiazem ER dose be increased to 300
mg daily. This was done accordingly, with significant
improvement noted.
The patient was also continued on antibiotics, in oral form.
On ___ he expressed feeling prepared to complete his
recovery outside the hospital. He was tolerating a diet, on all
his home medications including coumadin, on additional new
medication cilostazol. He was able to ambulate. He was explained
and expressed agreement with the discharge plan, and was
discharged in good condition. Close follow-up was arranged - he
is to follow-up in 2 weeks in clinic. He is to stay on
antiobiotics for this period, for which he was given a
prescription. He will follow up regarding his coumadin dosing
and for an INR check.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Warfarin 2.5 mg PO DAILY16
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 10 mg PO DAILY
4. Diltiazem Extended-Release 240 mg PO DAILY
5. Lisinopril 2.5 mg PO DAILY
6. Fish Oil (Omega 3) 1000 mg PO DAILY
7. Oxybutynin 5 mg PO DAILY
8. Famotidine 40 mg PO DAILY
9. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Atorvastatin 10 mg PO DAILY
2. Famotidine 40 mg PO DAILY
3. Fish Oil (Omega 3) 1000 mg PO DAILY
4. Oxybutynin 5 mg PO DAILY
5. Warfarin 2.5 mg PO DAILY16
6. Aspirin 81 mg PO DAILY
7. Lisinopril 2.5 mg PO DAILY
8. Vitamin D 1000 UNIT PO DAILY
9. cilostazol *NF* 50 mg ORAL Q12H Reason for Ordering:
Antiplatelet therapy in vasculopathic patient with
contraindication to other agents
RX *cilostazol 50 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*1
10. Diltiazem Extended-Release 300 mg PO DAILY
RX *diltiazem HCl 300 mg 1 capsule(s) by mouth once a day Disp
#*30 Capsule Refills:*0
11. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 capsule(s) by mouth every four (4) hours
Disp #*20 Capsule Refills:*0
12. Ciprofloxacin HCl 750 mg PO Q12H Duration: 14 Days
RX *ciprofloxacin 750 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*28 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Right lower extremity foot ulcers
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the Vascular Surgery Service at ___ for
evaluation of your right lower extremity infection. You
underwent a right lower extremity angiogram on ___. You are
now prepared to complete your recovery outside the hospital,
with the following instructions:
MEDICATION:
Take Aspirin daily as per your home regimen
Please take the new medication Pletal (Cilostazol) 50 mg twice
daily, which you were given a prescription for
Please continue to take your coumadin per your home dose.
Please be sure to see your PCP to have your INR checked within
___ days after discharge.
Please note that your heart/blood pressure medications dose
was increased while in the hospital, based upon Cardiology
specialist input. Your new dose is: DILTIAZEM 300 MG ONCE DAILY.
You have been given a prescription for this. Please discuss this
with your PCP also, when you follow-up with him/her.
Please complete the full course of antibiotic CIPROFLOXACIN
that you have been prescribed.
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:
___
|
19597196-DS-10
| 19,597,196 | 22,415,613 |
DS
| 10 |
2192-04-30 00:00:00
|
2192-05-01 07:15:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
allopurinol / colchicine / metronidazole / hydrochlorothiazide
Attending: ___
Chief Complaint:
___, back pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is an ___ year old man with a h/o HTN, chronic LBP,
leukemia (remission since ___, COPD, who was transferred from
___ for further management of L2 compression
fracture and ___.
The patient reports that 5 days prior to admission, he lost
control of his walker and fell backwards onto his buttocks on
pavement, and also hitting his head but no LOC. He initially
presented to ___ ED, and subsequently discharged to rehab due to
inability to ambulate. Prior to discharge, he was given a
medrol dose pack. Of note, he was also noted to have some AMS
and EEG at that time was compatible with toxic metabolic
encephalopathy, and a CT of the brain showed an old lacunar
infarct.
He was discharged to rehab due to inability to ambulate. While
at rehab, he had persistent back pain, and was noted to be
confused. Laboratory studies revealed a rising BUN/Cr (from 1.2
on ___ to 2.1 on ___. He was transferred to ___ ED for
further evaluation.
At ___, he was noted to have bilateral flank hematomas, so a CT
abdomen was ordered for further evaluation. No RP hemorrhage
was identified but he was found to have an L2 vertebral body
fracture. Foley was placed at the OSH for urinary retention.
The ___ ED was also concerned for absent pulses in the left
lower extremity, so he was transferred to ___ for further
evaluation.
On arrival, patient had palpable right ___ pulses and a
Doppler-able left ___ signal. Bilateral feet were warm and the
patient denied foot pain.
In the ED, initial vitals were: 97.5 174/72 78 18 95%RA
Exam notable for doplerable pulses (as above)
Labs notable for WBC 11, Cr 1.6 > 1.3 (last Cr 1.2 in ___
Imaging notable for OSH CT abdomen showed L2 vertebral body
fracture
Patient was given his home medications, dilaudid and 2L NS
Patient was seen by spine surgery who recommended TLSO brace and
physical therapy.
Decision was made to admit for further management of his L2
fracture and ___
Vitals on arrival to the floor were: 97.2 148/60 76 20 96RA
On the floor, patient reports continued severe LBP that is
non-radiating. He denies sensory deficits. He also reports
that he has several episodes of both urinary and fecal
incontinence over the past few days. Of note, he has a long
history of urinary incontinence for which he receives Botox
injections. He was unable to clarify if bowel defecation was
true incontinence or inability to get to the restroom in time.
He denies any saddle anesthesia.
Review of systems:
(+) Per HPI.
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No dysuria. Denies arthralgias
or myalgias.
Past Medical History:
- h/o chronic LBP.
- HTN
- GERD
- Depression
- Glaucoma
- COPD
- Leukemia (remission since ___
- Penile implant
- Recent hospital admission (___) for toxic metabolic
encephalopathy
- Chronic urinary retention for which he receives botox
PAST SURGICAL HISTORY:
- Back surgery in ___. Patient reports h/o surgery a few years
ago for left foot weakness, likely decompression without fusion
given no hardware identified on imaging.
- Penile implants x 2 (most recent ___
- Ex-lap and SBR for SBP (___)
Social History:
___
Family History:
non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T: 97.2 BP: 148/60 P: 76 R: 20 O2: 96%RA
General: Alert, obese, lying in bed, in no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, systolic murmur
best heard LLSB, no rubs or gallops
Abdomen: soft, tender to palpation diffusely, mostly in LLQ,
non-distended, bowel sounds present, no rebound tenderness or
guarding, no organomegaly
Ext: no clubbing, cyanosis or edema, no ___ pulses palpable on
left (but dopplerable left ___ per ED). Palpable right ___.
Bilateral feet warm. Large left gluteal purpura (marked).
Skin: chronic venous stasis changes in bilateral ___
___: alert and oriented, sensation intact, toes down going
bilaterally
DISCHARGE PHYSICAL EXAM:
Vitals: 98.8 ___ 160s-160/50s-70s ___ 93-98%RA
General: Alert, laying in bed, NAD
HEENT: Sclera anicteric
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, systolic murmur
best heard LLSB, no rubs or gallops
Abdomen: Soft BS+ NT ND
Ext: Warm extremities.
Skin: Chronic venous stasis changes in bilateral ___
___: Alert and oriented, sensation intact
Pertinent Results:
LABORATORY STUDIES ON ADMISSION
====================================
___ 08:50PM BLOOD WBC-11.0*# RBC-4.83 Hgb-14.7 Hct-43.3
MCV-90 MCH-30.4 MCHC-33.9 RDW-13.3 RDWSD-43.6 Plt ___
___ 08:50PM BLOOD ___ PTT-34.0 ___
___ 08:50PM BLOOD Glucose-180* UreaN-74* Creat-1.6* Na-135
K-4.2 Cl-101 HCO3-21* AnGap-17
___ 06:45AM BLOOD ALT-18 AST-15 LD(___)-209 AlkPhos-123
TotBili-0.9
___ 06:45AM BLOOD Calcium-9.0 Phos-2.3* Mg-2.3
___ 08:50PM URINE Color-Straw Appear-Clear Sp ___
___ 08:50PM URINE Blood-TR Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM
___ 08:50PM URINE RBC-3* WBC-3 Bacteri-FEW Yeast-NONE Epi-0
___ 08:50PM URINE CastHy-1*
___ 08:50PM URINE Mucous-RARE
MICRIOBIOLOGY
====================================
cdif (___): negative
Urine culture (___): negative
IMAGING:
====================================
OSH CT abd/pelvis: L2 oblique fracture of vertebral body with
mild distraction of fracture fragments but without significant
retropulsion or canal stenosis
CT HEAD ___ read of OSH study): IMPRESSION: No acute
hemorrhage is seen. Right basal ganglia infarcts are seen
likely chronic to subacute. Small vessel disease and brain
atrophy.
DISCHARGE LABORATORY STUDIES
=====================================
___ 06:45AM BLOOD WBC-12.1* RBC-4.82 Hgb-14.8 Hct-43.8
MCV-91 MCH-30.7 MCHC-33.8 RDW-13.4 RDWSD-44.7 Plt ___
___ 06:45AM BLOOD Glucose-115* UreaN-32* Creat-1.2 Na-136
K-3.9 Cl-100 HC___ AnG___
Brief Hospital Course:
Mr. ___ is an ___ year old man with a h/o HTN, chronic LBP,
leukemia (remission since ___, COPD, who was transferred from
___ for further management of L2 compression
fracture secondary to a mechanical fall.
# L2 compression fracture:
Patient was found to have L2 compression fracture on OSH CT scan
in setting of recent fall. At the OSH, he was also noted to
have bilateral flank hematomas, but the CT was negative for RP
bleed. On transfer to ___, exam showed no focal neurological
deficits. He was evaluated by neurosurgery as well as trauma
surgery, and no acute neurosurgical intervention was indicated.
He was managed with LSO brace, pain management with standing
acetaminophen, standing tramadol, and prn dilaudid. He was also
seen by Physical Therapy. He was discharged to ___
___ in ___.
# ___:
At the OSH, he was found to have ___ with a creatinine of 2.1
(increased from 1.2). He was given intravenous fluids with
resolution of his ___. His ___ was likely related to prerenal
azotemia. He was given intravenous fluids and his Lasix was
held with resolution of creatinine back to his baseline.
# Delirium:
Over the week preceding admission, he had episodes of confusion,
with waxing and waning mental status, consistent with delirium.
At an OSH, EEG was compatible with toxic metabolic
encephalopathy, and a CT of the brain showed an old lacunar
infarct. These symptoms developed in the setting of
polypharmacy, including narcotics, muscle relaxant, and recent
medrol dosepack. During admission, these medications were held
with improvement of his mental status.
# HTN:
Continued home losartan. Lasix was initially held and then
restarted once kidney function stabilized.
# Leukocytosis:
On admission, patient had mild leukocytosis that normalized. He
remained afebrile, and did not endorse any infectious symptoms.
It is likely that the leukocytosis was related to recent Medrol
dose pack.
# Concern for LLE vascular occlusion:
At OSH there was a concern for LLE vascular occlusion. On
transfer to ___, he was found to have warm lower extremities
without evidence of ischemia. He was noted to have a
discrepancy in his lower extremity pulse exam, with palpable
pulses on the RLE and only dopplerable LLE ___ signal. Given lack
of symptoms such as acute LLE foot pain, it is possible if his
left DP artery has been chronically occluded. His LLE remained
asymptomatic during admission.
CHRONIC ISSUES:
==========================
# GERD: Continued home omeprazole.
# OSA: CPAP during admission.
# Depression: Continued home bupropion, and sertraline. Held
home quetiapine in setting of delirium.
# Glaucoma: Continued home eye drops.
# Restless legs: Continued home Carbidopa-Levodopa. Held home
gabapentin in setting of delirium.
TRANSITIONAL ISSUES:
- Needs PCP ___ 1 week of discharge
- Needs ___ with Dr. ___ in outpatient ___
Clinic in
6 weeks with repeat CT L-Spine
- Needs ___ with vascular surgery for further management
of chronic PVD
- ___ increase tramadol to 100mg TID if needed
- Seroquel held on discharge because may worsen confusion. If
having trouble sleeping, may restart at lower dose (25mg QHS).
- Code: Full code (if reversible)
- Contact: ___ (wife) ___
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Methocarbamol 500 mg PO QID
2. Celebrex ___ mg oral DAILY
3. HYDROmorphone (Dilaudid) 1 mg PO Q4H:PRN pain
4. Polyethylene Glycol 17 g PO DAILY:PRN constipation
5. Lidocaine 5% Patch 2 PTCH TD QAM
6. Acetaminophen 500 mg PO Q6H
7. Aspirin 81 mg PO DAILY
8. Carbidopa-Levodopa (___) 1 TAB PO BID
9. Omeprazole 20 mg PO DAILY
10. Gabapentin 300 mg PO QHS
11. Docusate Sodium 200 mg PO DAILY
12. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
13. Clotrimazole Cream 1 Appl TP BID
14. Efudex (fluorouracil) 5 % topical BID
15. Multivitamins 1 TAB PO DAILY
16. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
17. Losartan Potassium 100 mg PO DAILY
18. QUEtiapine Fumarate 75 mg PO QHS
19. saw ___ 320 mg oral BID
20. Hypotears (polyethyl glycol-polyvinyl alc) ___ % ophthalmic
BID
21. Sertraline 200 mg PO QHS
22. BuPROPion 100 mg PO DAILY
23. Furosemide 20 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO TID
RX *acetaminophen 500 mg 2 tablet(s) by mouth Three Times Per
Day Disp #*30 Tablet Refills:*0
2. Aspirin 81 mg PO DAILY
3. BuPROPion 100 mg PO DAILY
4. Carbidopa-Levodopa (___) 1 TAB PO BID
5. Clotrimazole Cream 1 Appl TP BID
6. Docusate Sodium 200 mg PO DAILY
7. Furosemide 20 mg PO DAILY
8. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
9. Lidocaine 5% Patch 2 PTCH TD QAM
10. Losartan Potassium 100 mg PO DAILY
11. Multivitamins 1 TAB PO DAILY
12. Omeprazole 20 mg PO DAILY
13. Sertraline 200 mg PO QHS
14. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
15. Efudex (fluorouracil) 5 % topical BID
16. TraMADOL (Ultram) 75 mg PO TID pain
RX *tramadol 50 mg 1 tablet(s) by mouth TID PRN Disp #*15 Tablet
Refills:*0
17. Senna 17.2 mg PO DAILY:PRN constipation
hold for loose stool
RX *sennosides [senna] 8.6 mg 2 tablets by mouth DAILY:PRN Disp
#*60 Tablet Refills:*0
18. Hypotears (polyethyl glycol-polyvinyl alc) ___ % ophthalmic
BID
19. Polyethylene Glycol 17 g PO DAILY:PRN constipation
20. saw ___ 320 mg oral BID
21. Gabapentin 300 mg PO QHS
22. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN severe pain
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth Every
4 Hours As Needed Disp #*10 Tablet Refills:*0
23. Alendronate Sodium 70 mg PO QMON
RX *alendronate 70 mg 1 tablet(s) by mouth Every ___ Disp #*5
Tablet Refills:*0
24. Vitamin D ___ UNIT PO DAILY
RX *ergocalciferol (vitamin D2) 2,000 unit 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY:
- L2 compression fracture
- Delirium
- Acute kidney injury
SECONDARY:
- Hypertension
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at ___. You were transferred
from ___ for management of your lumbar
compression fracture. You initially had some kidney injury, but
this resolved with giving you fluids. You also had some
confusion, which was likely from your back pain, and the
medications needed to treat your pain.
It is important for you to ___ with your primary care
physician within one week of discharge. You also need to follow
up with neurosurgery in 6 weeks. Please see below "recommended
follow up" section below for further details.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19597377-DS-14
| 19,597,377 | 27,456,898 |
DS
| 14 |
2186-05-22 00:00:00
|
2186-05-22 14:00:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lidocaine / benzocaine / cephalexin / zolpidem / sunscreen
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Bilateral thoracentesis ___
Septal ablation ___
History of Present Illness:
___ woman w/ history of diastolic heart failure
secondary
to severe mitral regurgitation, mitral stenosis, mild aortic
regurgitation, RBBB/LAFB, breast cancer s/p mastectomy (never
required XRT or chemo), CLL (never required chemotherapy) who
presents with shortness of breath.
Patient initially presented to ___ after being
transferred from nursing facility (___ in ___ for
progressively worsening shortness of breath. Patient states that
for the past 5 or 6 days she has felt more shortness of breath
with swelling in her feet. The SOB worsens with activity and
lying flat; improves with sitting up and resting. At ___ she was noted to be hypoxic with increased work of
breathing and was started on BiPAP with improvement of her
symptoms. After trial of nasal cannula she was seen to have
worsening work of breathing and was again placed on BiPAP and
transferred to ___. Chest x-ray at ___ was notable for
bilateral pleural effusion, she was started on 40 mg of IV Lasix
and a Foley was placed. She had a systolic blood pressure
greater
than 180 and she was started on a nitro drip prior to transfer.
Patient takes 60 mg of Lasix at home. No recent changes to her
Lasix dosage. She endorses nonproductive cough over the past
several days as well. Denies fever/chills, chest pain. CXR from
___ showed pulmonary edema with bilateral pleural effusions
and bibasilar atelectasis. Upper lung fields grossly clear.
In ___, she was evaluated by cardiac surgery and deemed high
risk for conventional surgical mitral valve replacement given
advanced age and frailty. She is referred to the structural
heart
service for mitral valve treatment options and thought to be a
candidate for ethanol septal ablation followed by TMVR (___).
On the floor, she was on 2L NC, gets a little SOB when she tries
to speak too quickly. She is alert and oriented. Really wants to
have the Foley removed; but her son (a retired ___)
convinced her to keep it for now.
Past Medical History:
- mitral regurgitation
- aortic regurgitation
- cervical radiculopathy
- cervical spine stenosis
- cholecystectomy
- CLL
- diverticulosis
- history of breast cancer s/p mastectomy
- hysterectomy
- insomnia
- osteoporosis
- RBBB/LAFB
Social History:
___
Family History:
Her father had heart attack at ___.
Sister has CLL.
Physical Exam:
ADMISSION PHYSICAL EXAM:
=========================
VS: 97.6 PO 101 / 61 L Sitting 88 22 95 2 liters nasal cannula
GENERAL: Thin, elderly woman in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: Normocephalic atraumatic. Sclera anicteric.
NECK: Supple. JVP elevated to mid-neck while at 45 degrees.
CARDIAC: Prominent systolic murmur best heard at the apex.
LUNGS: CTAB, faint breath sounds at the bases.
ABDOMEN: Soft, non-tender, non-distended.
EXTREMITIES: Cool feet, warm legs. 1+ pitting edema in bilateral
feet.
SKIN: No significant skin lesions or rashes.
NEURO: CN III-XII grossly intact
DISCHARGE PHYSICAL EXAM:
=========================
VS: T 98.4, HR 85, BP 113/52, RR 22, O2 sat 90% on RA
GENERAL: Thin, elderly woman in NAD. Oriented x3.
HEENT: Normocephalic atraumatic. Sclera anicteric.
NECK: Supple. JVP not elevated.
CARDIAC: Prominent systolic murmur best heard at the apex.
LUNGS: CTAB
ABDOMEN: Soft, non-tender, non-distended.
EXTREMITIES: No edema in bilateral feet. Temporary pacer in
place
SKIN: No significant skin lesions or rashes.
NEURO: CN III-XII grossly intact
Pertinent Results:
ADMISSION LABS:
=================
___ 01:00AM BLOOD WBC-15.0*# RBC-4.39 Hgb-13.8 Hct-42.1
MCV-96 MCH-31.4 MCHC-32.8 RDW-13.9 RDWSD-49.1* Plt ___
___ 01:00AM BLOOD Neuts-68.2 ___ Monos-2.7*
Eos-0.1* Baso-0.3 Im ___ AbsNeut-10.24* AbsLymp-4.21*
AbsMono-0.40 AbsEos-0.01* AbsBaso-0.04
___ 01:00AM BLOOD Glucose-146* UreaN-25* Creat-1.0 Na-141
K-4.3 Cl-98 HCO3-27 AnGap-16
___ 01:00AM BLOOD cTropnT-0.38*
___ 05:08PM BLOOD Calcium-9.3 Phos-4.2 Mg-2.0
INTERVAL LABS
==============
___ 05:08AM BLOOD CK(CPK)-887*
___ 05:08AM BLOOD CK-MB-143* MB Indx-16.1* cTropnT-8.09*
___ 03:50AM BLOOD CK-MB-19* cTropnT-4.60*
DISCHARGE LABS
===============
___ 05:53AM BLOOD WBC-15.0* RBC-3.72* Hgb-11.8 Hct-35.7
MCV-96 MCH-31.7 MCHC-33.1 RDW-14.6 RDWSD-51.4* Plt ___
___ 05:53AM BLOOD Plt ___
___ 05:53AM BLOOD Glucose-101* UreaN-24* Creat-1.0 Na-140
K-4.0 Cl-98 HCO___ AnGap-13
___ 05:53AM BLOOD Calcium-8.5 Phos-3.4 Mg-2.2
IMAGES/STUDIES
===============
___ CXR
No previous images. There are low lung volumes accentuate the
transverse
diameter of the heart. Large pleural effusions with compressive
atelectasis are seen bilaterally. No evidence of vascular
congestion.
There is a dense band of opacification projected over the left
ribs at the
lower margin of the cardiac silhouette. This could represent
extensive
calcification of the mitral annulus.
___ CXR
In comparison with the study of ___, there has been a
thoracentesis,
presumably on the left, with removal of substantial pleural
fluid. No
evidence of post procedure pneumothorax. The the amount of
pleural effusion on the right also appears to have decreased,
though there is some residual with atelectatic changes at the
bases. Cardiomediastinal silhouette is stable. No definite
vascular congestion or acute focal pneumonia.
___ TTE
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is normal (LVEF>55%). There is severe mitral
annular calcification. Severe (4+) mitral regurgitation is seen.
There is no pericardial effusion.
IMPRESSION: Focused study shows opacification of the proximal
interventricular septum with contrast prior to ethanol septal
ablation. There is no opacification of the distal septum, RV
free wall or RV moderator band.
___ CXR
IMPRESSION:
Left-sided dual-chamber pacemaker placement, with the leads in
the expected location of the right atrium and right ventricle.
No evidence of
pneumothorax.
MICROBIOLOGY
=============
___ Urine culture: No growth
___ Blood culture: No growth
___ Pleural fluid culture: No growth
Brief Hospital Course:
Ms. ___ is a ___ woman w/ history of diastolic
heart failure secondary to severe mitral regurgitation, mitral
stenosis, mild aortic regurgitation, RBBB/LAFB, breast cancer
s/p mastectomy (never required XRT or chemo), CLL (never
required chemotherapy) who presented with shortness of breath in
heart failure exacerbation now s/p septal ablation complicated
by complete heart block with plans for TMVR at a later
admission.
# Severe mitral regurgitation:
Patient with severe MR with flail leaflet and plan for TMVR. S/p
septal ablation on ___, with cardiac enzymes peaking on ___. The
procedure was complicated with complete heart block as below.
Currently planning for TMVR at a future admission.
# Diastolic heart failure, EF>55% in ___: Patient presented
with progressive SOB with exertion and also at rest. She
required BiPAP initially, but was able to be weaned to nasal
cannula and then room air. Held home medications initially due
to low BP. Her breathing improved and vitals stabilized with
diuresis and bilateral thoracentesis. She was discharged on
carvediol and maintenance diuretic torsemide.
# Complete Heart Block:
Developed transient complete heart block during alcohol septal
ablation procedure on ___ with complete recovery of AV
conduction in the hours following the procedure. However, pt
reverted back to complete heart block ___, so had a permanent
pacemaker placed on ___.
# GERD: She was continued home omeprazole.
# Leukocytosis: Most likely patient's chronic CLL. UA in the ED
showed large blood, no RBCs, trace bacteria. CXR not compelling
for pneumonia. The patient remained afebrile, denied any
localizing symptoms without antibiotics. CBC was monitored
daily.
TRANSITIONAL ISSUES:
====================
Discharge weight: 43.6kg
Discharge Cr: 1.0
Discharge WBC: 15.0
Medication changes:
[ ] Torsemide 40 mg qd was started
[ ] Furosemide 60mg qd was stopped
OTHER:
[ ] Plan to repeat CT scan in 6 weeks to evaluate LVOT.
[ ] Plan for TMVR in the future
[ ] Recommend nutrition consult for low appetite
#CODE STATUS: full, confirmed
#CONTACT: ___ (SON CELL)
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. LORazepam 0.25 mg PO BID:PRN anxiety
3. Omeprazole 20 mg PO DAILY
4. Ondansetron 8 mg PO Q8H:PRN nausea
5. Senna 17.2 mg PO DAILY:PRN constipation
6. Mirtazapine 30 mg PO QHS
7. Vitamin D 1000 UNIT PO DAILY
8. Carvedilol 6.25 mg PO BID
9. Furosemide 60 mg PO DAILY
10. GuaiFENesin ER 600 mg PO Q12H:PRN cough
Discharge Medications:
1. Torsemide 40 mg PO DAILY
2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
3. Carvedilol 6.25 mg PO BID
4. GuaiFENesin ER 600 mg PO Q12H:PRN cough
5. LORazepam 0.25 mg PO BID:PRN anxiety
6. Mirtazapine 30 mg PO QHS
7. Omeprazole 20 mg PO DAILY
8. Ondansetron 8 mg PO Q8H:PRN nausea
9. Senna 17.2 mg PO DAILY:PRN constipation
10. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Primary:
Diastolic heart failure
Mitral regurgitation
Bilateral pleural effusions
Secondary:
GERD
leukocytosis
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 presented to ___ because you were feeling
short of breath.
You were treated with a diuretic medication and you received a
procedure which removed fluid from your lungs and your breathing
improved. You also had a procedure called a septal ablation
which you needed in preparation for your possible valve
replacement procedure planned in the future. A permanent
pacemaker was placed to help keep the rhythm of your heart
regular.
It is important that you continue to take your medications as
prescribed after leaving the hospital. Weigh yourself every
morning, and call your doctor if your weight goes up more than 3
lbs over two days.
We wish you the best,
Your ___ Care Team
Followup Instructions:
___
|
19597426-DS-10
| 19,597,426 | 23,266,638 |
DS
| 10 |
2169-02-05 00:00:00
|
2169-02-06 20:31:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
L arm and mid back pain, referral given findings of PE
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with hx of PE in ___ no longer anticoagulated presenting
with recurrent back and L arm pain, sent in by PCP for ___
segmental PE.
Pt notes onset of symptoms ___ with low back pain, which she
initially attributed to sleep position or bra strap. On ___
she woke up with pain traveling down L arm, ___, sharp,
stabbing, similar in quality to low back pain, constant,
nonpleuritic. She called urgent care, as symptoms reminded her
of pneumonia in ___. She was advised to go to the ED, but pt
declined, requesting initial evaluation at urgent care. She went
to urgent care on day of presentation; a CT-PE was performed,
and pt was found to have L sided segmental PE. She endorses mild
DOE, ongoing back pain without chest pain.
With respect to her prior PE in ___, she was initially advised
to be on anticoagulation for ___ years, but second opinion at ___
suggested 3 months was sufficient, as PE thought to be in
setting of pneumonia.
She traveled to ___ to ___ for her family ___,
flight was 2.5 hours, direct, returning ___. She did not
notice any ___ or ___ edema. She is not taking estrogen in any
form, including OCPs. Thrombophilia workup in ___ was
reportedly unrevealing. She is not aware of hx of blood clots in
the family. Mother had one miscarriage at 6 months. She has two
sisters who have not had miscarriages. Pt had a single pregnancy
loss at 5 months.
With respect to her menorrhagia, she passes blood clots, lasts 5
days, occur q21 one days, soaks through 4 pads in 1 day. Today
is day 5 of her menses. She regularly gets associated headache
without lightheadedness. Denies hematochezia, melena, hematuria.
She previously took iron, but rx was not renewed and she did not
pursue further treatment. She has never received IV iron.
In the ___ ED:
VS 99.0->101.2, HR 107, 144/85->173/97, 100% RA
Labs notable for WBC 11.2, Hb 5.9->6.2, MCV 60, Plt 419
K 3.1, Chem 7 otherwise WNL
TnT<0.01
proBNP 150
Lactate 3.6
INR 1.2
BCx sent
Started on heparin gtt, consented for blood but did not receive.
On the floor, pt describes ___ back pain, arm pain is ___.
Denies lightheadedness, dizziness.
ROS: all else negative
Past Medical History:
Iron deficiency anemia due to heavy menstrual cycles
PE and pneumonia in ___
Social History:
___
Family History:
Mother died ___ after lung transplant, htn
Diabetes - Type II
Physical Exam:
On Admission:
VS 99.0 PO 150 / 89 91 18 99 RA
Gen: Delightful female lying in bed, alert, interactive, NAD
HEENT: PERRL, EOMI, clear oropharynx, MMM
Neck: supple, no cervical or supraclavicular adenopathy
CV: RRR, no murmurs, rubs, or gallops
Lungs: Poor inspiratory effort, clear to auscultation
throughout, no wheeze or rhonchi
Abd: soft, nontender, nondistended, no rebound or guarding
GU: No foley
Ext/MSK: TTP over L scapula and low thoracic region L of
midline, without spinal tenderness, +palpable muscle spasm. ___
___, no clubbing, cyanosis or edema, well-healed scars at RLE
from childhood MVA (hit by school bus)
Neuro: grossly intact
On Discharge:
VITALS: 98.8 PO 152 / 95 97 18 96 ra
GEN: Sitting up in bed, eating breakfast, in NAD
HEENT: EOMI, sclerae anicteric, MMM, OP clear
NECK: No LAD, no JVD
CARDIAC: Regular rate, normal rhythm, no M/R/G
PULM: Decreased breath sounds at the left lung base
GI: soft, NT, ND, NABS
MSK: No visible joint effusions or deformities.
DERM: No visible rash. No jaundice.
NEURO: AAOx3. No facial droop, moving all extremities.
PSYCH: Full range of affect
EXTREMITIES: ___, no edema
Pertinent Results:
Tsat 4%
Ferritin 11.
Hgb 5.9 (increased to 7.2 after one unit of blood)
EKG: Sinus tachycardia at 117, normal axis, normal intervals,
TWI in III, J point elevation in V2, submm ST segment
depressions in V3, V4, Q wave in III
CTPA ___ Atrius:
1. Pulmonary emboli at the segmental branching of the LEFT lower
lobe pulmonary artery with associated parenchymal changes within
the LEFT lower lobe and small pleural effusion
___ ECHO
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thicknesses
and cavity size are normal. Regional left ventricular wall
motion is normal. Overall left ventricular systolic function is
low normal (LVEF 50-55%). There is no ventricular septal defect.
Right ventricular chamber size and free wall motion are normal.
The diameters of aorta at the sinus, ascending and arch levels
are normal. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic stenosis or
aortic regurgitation. The mitral valve appears structurally
normal with trivial mitral regurgitation. The pulmonary artery
systolic pressure could not be determined. There is no
pericardial effusion.
___ CXR PA/LA
In comparison with the study of ___, the cardiac
silhouette
remains at the upper limits of normal in size without
appreciable vascular
congestion. Again there is increased opacification at the left
base, which
could reflect merely atelectasis and pleural effusion. However,
in the
appropriate clinical setting, superimposed pneumonia could be
considered.
Atelectatic changes are seen at the right base.
___ CT Chest
Parenchymal opacity in the left lower lobe reflecting pneumonia
superimposed atelectasis although an evolving infarct in this
region would be in the differential.
Segmental atelectasis in the right lower lobe, right middle
lobe, and lingula.
Brief Hospital Course:
Ms. ___ is a ___ year old woman with a history of PE
previously on anticoagulation, abnormal uterine bleeding, and
iron deficiency anemia who was referred to ___ after findings
on CTA of PE, course complicated by HCAP.
# Pulmonary embolism: Patient was found to have LLL PE. This is
a recurrent, unprovoked PE. She was treated with IV heparin for
several days while monitoring her H/H in the setting of known
iron deficiency anemia and menorrhagia. Given that she required
3 units of blood transfusions while she was in-house the
decision was made not to transition her to a NOAC yet (she
prefers apixaban to warfarin). She is discharged on lovenox with
plan to follow up in ___ clinic. If her blood counts
remain stable, then she should be transitioned to apixaban.
___ pharmacy was called and apixaban would cost the
patient $10 per month. She is scheduled for heme/onc follow up
on ___.
# Iron deficiency anemia: Patient has known iron deficiency
anemia secondary to abnormal uterine bleeding. She had her
menses while she was in-house and her blood counts were closely
monitored while she was on heparin gtt. She was confirmed to
be profoundly iron deficient on laboratory testing and received
1g IV dextran, though would not expect to see its effect
immediately. She required a total of 3 pRBC tranfusions while
she was in-house. She always remained asymptomatic and
hemodynamically stable. Her hemoglobin on discharge was 8.7. She
should have H/H rechecked at her heme/onc follow up appointment
on ___. If stable, consideration should be made to transition to
apixaban. Consideration should also be made for GI workup as
another possible source of anemia (no GI bleeding in-house). Did
not have a bowel movement in-house to gui___.
# HCAP: Patient developed fevers, worsening left sided pleuritic
chest pain, and leukocytosis. CXR was equivocal. CT scan
revealed evidence of pneumonia. She was started on levofloxacin
___ with significant improvement in her
symptoms on ___. She is discharged to complete a 7 day course of
antibiotics.
Transitional Issues:
- Please recheck H/H on ___ at heme/onc follow up to ensure H/H
stable. Consider switching patient to apixaban once H/H
confirmed stable
- Of note: CT scan to evaluate for pneumonia incidentally
revealed 46 x 45 mm cyst in the left kidney though the study was
not tailored to subdiaphragmatic evaluation. Consideration
should be made for repeat imaging as an outpatient. She was
also noted to have a 16 mm right thyroid nodule and should
undergo thyroid US as an outpatient.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Enoxaparin Sodium 80 mg SC Q12H
Start: ___, First Dose: Next Routine Administration Time
RX *enoxaparin 80 mg/0.8 mL 0.8 ml SC every 12 hours Disp #*14
Syringe Refills:*0
2. Ferrous Sulfate 325 mg PO DAILY
RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
3. Levofloxacin 750 mg PO DAILY
RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*5
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Pulmonary embolism
Iron deficiency anemia
Hospital acquired pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You came to the hospital with a pulmonary embolism and with
severe anemia.
We treated your pulmonary embolism with blood thinners. We had
to be careful with the blood thinner because of your severe
anemia. At this time it is safest to send you home with a blood
thinner called lovenox. If your blood counts remain stable in
follow up with the hematology team, you will likely be switched
to apixaban, which will be easier for you to take. According to
your pharmacy the apixaban will cost $10 per month.
With respect to your anemia- you were found to be quite iron
deficient. This is likely from your uterine bleeding. You
received a dose of IV iron while you were in the hospital, but
the effects of this on your blood counts often take some time to
see. In the meantime you received blood transfusions while you
were in the hospital to help boost your blood counts. Your
counts looked better on the day of your discharge, but you will
need to have your labs rechecked when you are seen in follow up
with the hematology team.
Finally, you were found to have a pneumonia. You will be
discharged on antibiotics for this.
Please follow up with the appointments listed below. It was a
pleasure to be a part of your care and we wish you the best of
luck,
Your ___ treatment team
Followup Instructions:
___
|
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2146-08-09 00:00:00
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2146-08-13 09:31:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Vancomycin
Attending: ___.
Chief Complaint:
Abdominal Pain and distention
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with h/o missed enterotomy during a diagnostic laparoscopy
s/p SBR, ___, subsequent reversal, h/o bezoar SBO s/p
SBR. Following her abdominal surgeries, she has also been having
a h/o chronic intermittent episodes of bloating, N/V which have
been managed and worked-up by her gastroenterologist. Around
noon today, she noticed increased abdominal pain and distension,
similar to prior episodes if more severe, mild nausea but no
vomiting. She had 2 bowel movements following the onset of pain,
but can't recall if she had flatus. Last ate ~noon, had a small
amount of burger. No fevers or chills. Because her
gastroenterologist was not in the office today, she instead went
to the ___ for evaluation. There, a CT scan was done
showing a dilated loop of small bowel in her pelvis, and she was
transferred to ___ for further management.
Past Medical History:
Iron deficiency anemia, CCY ___, laparoscopy in ___? w/
incidental bowel perforation, s/p large bowel rxn, small bowel
anastomosis w/loop dilatation proximal to anastomosis,
psoriasis,
scoliosis, pSBO, HTN, ___ colonoscopy: Grade 1 internal
hemorrhoids, Diverticulosis of proximal descending colon
Social History:
___
Family History:
Father with colon and lung ca; brother with
colitis
Physical Exam:
Admission Physical Exam:
VS: 97.8 70 150/78 16 99% RA
Gen: NAD
CV: RRR, no M/R/G
Resp: No respiratory distress, CTAB
Abd: soft more distended than usual, happens frequently.
nontender
Ext: WWP
Discharge Physical Exam:
VS: 98.2, HR 75, BP 158/78, 18, 99RA
Gen: Awake, alert, sitting up in bed. Anxious but pleasant.
HEENT: no deformity. PERRL, EOMI. Neck supple, trachea midline.
CV: RRR
Pulm: Clear to auscultation bilaterally.
Abd: Soft, mildly tender bilateral lower quadrants,
non-distended. Active bowel sounds x 4 quadrants.
Ext: Warm and dry. no edema. 2+ ___ pulses.
Neuro: A&Ox3. Follows commands and moves all extremities equal
and strong. Speech is clear and fluent.
Pertinent Results:
___ 04:30AM BLOOD WBC-9.1 RBC-3.83* Hgb-11.4 Hct-35.0
MCV-91 MCH-29.8 MCHC-32.6 RDW-13.2 RDWSD-43.7 Plt ___
___ 06:08AM BLOOD WBC-8.1 RBC-3.58* Hgb-11.0* Hct-34.4
MCV-96 MCH-30.7 MCHC-32.0 RDW-13.2 RDWSD-46.7* Plt ___
___ 12:35AM BLOOD WBC-10.0 RBC-3.92 Hgb-12.2 Hct-36.3
MCV-93 MCH-31.1 MCHC-33.6 RDW-13.2 RDWSD-45.1 Plt ___
___ 12:35AM BLOOD ___ PTT-28.1 ___
___ 04:30AM BLOOD Glucose-58* UreaN-14 Creat-0.6 Na-138
K-3.7 Cl-102 HCO3-19* AnGap-21*
___ 06:08AM BLOOD Glucose-80 UreaN-11 Creat-0.6 Na-140
K-3.6 Cl-106 HCO3-24 AnGap-14
___ 04:30AM BLOOD Calcium-8.6 Phos-3.0 Mg-1.9
___ 06:08AM BLOOD Calcium-8.0* Phos-2.6* Mg-1.8
___ 12:48AM BLOOD Lactate-0.9
___ 12:35AM URINE Color-Straw Appear-Clear Sp ___
___ 12:35AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ EKG: Sinus rhythm. Left atrial abnormality. Otherwise,
normal ECG. Compared to
the previous tracing of ___ left atrial abnormality is new.
Otherwise, findings are similar.
___ CT Torso:
Partial small bowel obstruction, similar in configuration to
that of ___, likely from adhesions. No evidence of
closed loop obstruction.
___ Abd Xray: Dilated small bowel loops, concentrated in
the right lower quadrant have notsubstantially changed. Slight
increase in gaseous distension of small bowel loops in the left
upper quadrant.
Brief Hospital Course:
Ms. ___ is a ___ yo F who was admitted to the Acute Care
Surgery Service on ___ with abdominal pain and distention.
She has a past medical history significant for a small bowel
resection with ___ status post reversal, and chronic
intermitted episodes of bloating for which she is being managed
by a gastroenterologist. She had a CT scan of her abdomen that
showed a partial small bowel obstruction. She was given IV
fluids, made NPO and admitted to the floor for further
management.
On HD1 she had an episode of vomiting. On HD2 her diet was
advanced progressively to regular which she tolerated well. She
had return of bowel function and passed stool and flatus. On HD3
her abdominal bloating was resolved and she was tolerating a
regular diet without nausea or abdominal pain.
Throughout this hospitalization she remained alert and oriented.
She remained afebrile and hemodynamically stable. Her vital
signs were monitored routinely. She ambulated early and
frequently, was adherent with respiratory toilet and incentive
spirometry, and actively participated in the plan of care. The
patient received subcutaneous heparin and venodyne boots were
used during this stay.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan. She was encouraged to follow up with her
gastroenterologist and the Acute Care Surgery Service for
further longterm management.
Medications on Admission:
Humira (due ___, every other week dosing), Fosamax
(___), latanoprost 1gtt ___, ambien 12.5mg ER prn sleep,
vit D3 qWk, biotin qWk, clobetasol ointment for psoriasis,
citrucel
Discharge Medications:
1. Alendronate Sodium 70 mg PO QSUN
2. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES ___
3. Zolpidem Tartrate ___ mg PO ___
4. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID psoriasis
apply to affected area
5. Humira Pen (adalimumab) 40 mg/0.8 mL subcutaneous every other
week
Discharge Disposition:
Home
Discharge Diagnosis:
Small Bowel Obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the Acute Care Surgery service on ___
with abdominal pain, nausea, and bloating. You had a CT scan
that showed a small bowel obstruction. You were given IV fluids
and bowel rest. You had return of bowel function. You are now
tolerating a regular diet and your pain is improved. You are now
ready to be discharged to home to continue your recovery.
Please follow up in the General Surgery Clinic with Dr. ___
at your appointment listed below to further discuss surgical
options. While in the hospital we discussed potential surgical
interventions such as an exploratory laparotomy and with
probable lysis of adhesions. Another surgical intervention
discussed was an exploratory laparscopy. These options, risks,
and benefits can be further discussed at your outpatient
appointment. If you have any questions or concerns after
discharge please call the number listed below.
Please note the following discharge instructions.
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Followup Instructions:
___
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2123-09-28 22:08:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Weakness, melena
Major Surgical or Invasive Procedure:
R chest tube placement
History of Present Illness:
Mr. ___ is a ___ yo gentleman with DM2 (on actos, Hg A1c 6.8%),
and atrial fibrillation (not on aspirin), recently hospitalized
last week from ___, who developed progressively worsening
SOB for 3 weeks, CXR showed R pleural effusion, this was
followed by a CT chest which demonstrated as well a LUL
spiculated lesion highly suggestive of primary lung Ca s/p IP
drainage of pleural effusion on ___ presenting with weakness. He
was shaving and felt weak all over. His denies any chest pain
but maybe had some shortness of breath. He denies any difficulty
lying flat; he is not needing more pillows at night. He denies
any fevers, chills, pain when he urinates. He states that he has
been feeling weak for about a week but became acutely worse
today. he does report he was less active this week than usual.
He denies any focal weakness. He lives alone. He has home ___ and
OT.
He has been constipated x3 days. His daughter also reports that
he had been previously noted to have dark stool but is not sure
what further work-up was performed. In speaking with his PCP,
she states she was not aware of dark stools.
He is not sure if he took his metoprolol today.
In the ED, initial vital signs were: 99.0 110 130/67 22 97% RA
- Exam was notable for: no crackles, no murmurs, 2+ ___ to knee,
abdomen distended but non-tender, melena on guaic exam
- Labs were notable for: leukocytosis (12.5), anemia
(___), hyponatremia (131). Trop neg x 1. U/A with large
___, tr Prot, pyuria, fever bacteria, 1 epi. Urine lytes without
Na avild
- Imaging: CXR with Bilateral pleural effusions, right greater
than left, appear increased; redemonstration of LUL
- The patient was given: IV pantoprazole
- Consults: none
Vitals prior to transfer were: 97.9 109 ___ 97% RA
Upon arrival to the floor patient states that he was in his
normal state of health until the last couple of weeks, but
really noted a progression of his weakness today. His daughter
adds that he was so weak he could not brush his teeth today. He
notes black stool x 2 weeks, denies hematochezia. Denies h/o
GIB. Not on anticoagulation other than 325 ASA. No h/o clotting
disordered. Denies fever, chills, abdominal pain, s/s of
infection. ROS +constipation
Past Medical History:
Hypertension
Hyperlipidemia
Diabetes
Hypothyroidism
Glaucoma
Atrial fibrillation not on coumadin
Mild aortic stenosis, Mild mitral regurgitation, mild tricuspid
regurgitation
Moderate pulmonary hypertension
Rheumatoid arthritis.
LUL spiculated lesion
Social History:
___
Family History:
He has no history of early coronary disease or sudden cardiac
death
Physical Exam:
ADMISSION:
GENERAL - pleasant, well-appearing, in no apparent distress
HEENT - normocephalic, atraumatic, no conjunctival pallor or
scleral icterus, PERRLA, EOMI, OP clear
NECK - supple, no LAD, no thyromegaly, JVP =
CARDIAC - regular rate & rhythm, normal S1/S2, no murmurs rubs
or gallops
PULMONARY - clear to auscultation bilaterally, without wheezes
or rhonchi
ABDOMEN - normal bowel sounds, soft, non-tender, non-distended,
no organomegaly
EXTREMITIES - warm, well-perfused, no cyanosis, clubbing or
edema
SKIN - without rash
NEUROLOGIC - A&Ox3, CN II-XII grossly normal, normal sensation,
with strength ___ throughout. Gait assessment deferred
PSYCHIATRIC - listen & responds to questions appropriately,
pleasant
DISCHARGE:
Vitals: 99.8 103/56 82 18 95RA
General: NAD, sitting up in bed
HEENT: NCAT, PERRL 3->2, EOMI, sclera anicteric, MMM, no
pharyngeal exudate or erythema
Neck: supple, no LAD
Lungs: (+) decreased breath sounds at b/l bases
CV: Tachycardic, irregular rhythm, III/VI systolic murmur
loudest over sternal borders
Abdomen: mildly distended, non-tender, no rebound or guarding,
normoactive bowel sounds
Ext: WWP. Left great toe folded over lateral toes; pitting edema
up to knees
Skin: a few hemangiomas on legs but otherwise no lesions
appreciated
Neuro: A/Ox3, responds appropriately to questions
Pertinent Results:
ADMISSION:
___ 06:25PM WBC-12.5* RBC-3.11* HGB-8.7* HCT-27.6* MCV-89
MCH-28.0 MCHC-31.5* RDW-16.8* RDWSD-50.9*
___ 06:25PM NEUTS-84.2* LYMPHS-5.3* MONOS-7.5 EOS-1.4
BASOS-0.2 IM ___ AbsNeut-10.56* AbsLymp-0.66* AbsMono-0.94*
AbsEos-0.17 AbsBaso-0.02
___ 06:25PM proBNP-2340*
___ 06:25PM cTropnT-<0.01
___ 06:25PM GLUCOSE-122* UREA N-15 CREAT-0.7 SODIUM-131*
POTASSIUM-4.5 CHLORIDE-96 TOTAL CO2-26 ANION GAP-14
DISCHARGE:
___ 07:10AM BLOOD WBC-12.9* RBC-2.88* Hgb-8.2* Hct-25.4*
MCV-88 MCH-28.5 MCHC-32.3 RDW-17.0* RDWSD-52.9* Plt ___
___ 07:10AM BLOOD Glucose-121* UreaN-10 Creat-0.6 Na-125*
K-3.6 Cl-93* HCO3-26 AnGap-10
___ 07:10AM BLOOD Calcium-7.1* Phos-3.0 Mg-1.8
___ 02:50PM BLOOD Glucose-124* UreaN-10 Creat-0.8 Na-129*
K-4.1 Cl-97 HCO3-26 AnGap-10
IMAGING:
-CXR (___): IMPRESSION: Bilateral pleural effusions, right
greater than left, appear increased relative to CT dated ___, allowing for differences in modality. Known left
upper lung spiculated nodule suspicious for malignancy is again
seen.
-CXR (___): IMPRESSION: Compared to chest radiographs since
___, most recently ___. Right pleural
effusion has large hiatus hernia and adjacent left pleural
effusion. Loculated right basal pneumothorax may be present.
The severity of right lower lobe atelectasis is difficult to
assess. It could be limited to the posterior basal segment.
Left lower paraspinal region is filled by large hiatus hernia
and paraspinal pleural fluid.
Brief Hospital Course:
Mr. ___ ___ yo M with history of Afib on Asa 325, diastolic
CHF, and recent recurrent pleural effusion in setting of known
LUL lung mass who presents with weakness and melena, found to
have Hgb 7.2. Treated with 1 unit of PRBCs and bid PPI with
stabilization of Hgb to 8.2. R pleural effusion treated with
temporary chest tube and has follow up scheduled with IP.
Investigations/Interventions:
1. Anemia: patient had a reported history of ~2 weeks of daily
melena and had guaiac positive exam in ED, but no stools for the
past 3 days. Hgb 8.7 --> 7.2 on admission. Given one unit
PRBCs with stabilization of Hgb to 8.2. GI consulted and
suggested as there is no evidence of ongoing bleed (no current
melena), there was no indication for endoscopy (unless his
counts dropped or he continued to have bleeding). They
recommended treatment should be 40 mg bid PPI x 12 weeks which
was initiated while inpatient, with outpatient monitoring after
discharge. Patient remained hemodynamically stable throughout
hospitalization, with stable blood counts and no signs of
ongoing bleeding.
2. R pleural effusion: patient has known LUL lung spiculated
lesion and has had recent reaccumulation of R pleural effusion.
Cytology of recent thoracentesis x 2 is inconclusive, though
pleural fluid studies are consistent with malignancy. IP
consulted who placed a chest tube for 24 hours, draining 1.6L
sero-sanguinous fluid. Pleural fluid show pH 7.19, high WBC
with lymphocytic predominance, high LDH, all concerning for
malignant effusion. Cytology pending. Has follow up with the
IP doctors on ___.
3. Diabetes mellitus: patient's A1C is 7.1. Home medication
pioglitazone discussed with ___ endocrinologist as
this is usually contraindicated in heart failure patients. We
agreed to stop this medication on discharge and he can discuss
with Dr. ___ other medication is needed for diabetes
management.
4. Atrial fibrillation: patient's home metoprolol succinate
fractionated while inpatient. He is on an odd anticoagulation
regimen of Asa 325 daily. This was suggested by ___
cardiologist during a past visit to ED. Made this a
transitional issue to be discussed with PCP.
5. Chronic diastolic CHF: patient's home lisinopril and lasix
held in setting of GI bleed but resumed on discharge.
Discontinued pioglitazone as above.
6. Hyponatremia: on morning of discharge, patient's sodium noted
to be 125. Sosm and urine electrolytes consistent with SIADH.
Patient fluid restricted for the day and on recheck in pm Na up
to 129. Discharged with plan to recheck labs on ___.
Transitional Issues:
[] Patient should continue on omeprazole 40 mg bid x 12 weeks
for treatment for GI bleed
[] Patient has follow up appointment with pulmonary team on ___
___
[] Discontinued pioglitazone after discussion with patient's
___ physician ___, as this is contraindicated in HF
patients. Please discuss at follow up appointments if any other
medication needed for diabetes
[] Patient had high TSH, low FT4 as inpatient; please consider
recheck as outpatient
[] Patient was found to be hyponatremic to 125 on day of
discharge, improved to 129 on recheck; started on fluid
restriction of 1.5L due to concern for SIADH. Will have labs
re-checked on ___.
[] Will have CBC rechecked on ___
# CONTACT: ___ (___, daughter) ___
# CODE STATUS: FULL
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 2.5 mg PO DAILY
2. Methotrexate Sodium P.F. 15 mg IT 1X/WEEK (___)
3. Atorvastatin 20 mg PO QPM
4. Multivitamins 1 TAB PO DAILY
5. flaxseed oil 1,000 mg oral DAILY
6. garlic 1,000 mg oral DAILY
7. bimatoprost 0.01 % ophthalmic DAILY
8. fluorouracil 5 % topical BID
9. Pioglitazone 30 mg PO DAILY
10. Levothyroxine Sodium 150 mcg PO DAILY
11. FoLIC Acid 1 mg PO DAILY
12. Ascorbic Acid ___ mg PO DAILY
13. Vitamin D ___ UNIT PO DAILY
14. Metoprolol Succinate XL 50 mg PO DAILY
15. Albuterol Inhaler 2 PUFF IH BID
16. Fluticasone Propionate 110mcg 2 PUFF IH BID
17. Furosemide 20 mg PO DAILY
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH BID
2. Ascorbic Acid ___ mg PO DAILY
3. Atorvastatin 20 mg PO QPM
4. FoLIC Acid 1 mg PO DAILY
5. Levothyroxine Sodium 150 mcg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. bimatoprost 0.01 % ophthalmic DAILY
8. flaxseed oil 1,000 mg oral DAILY
9. fluorouracil 5 % topical BID
10. Fluticasone Propionate 110mcg 2 PUFF IH BID
11. Furosemide 20 mg PO DAILY
12. garlic 1,000 mg oral DAILY
13. Lisinopril 2.5 mg PO DAILY
14. Metoprolol Succinate XL 50 mg PO DAILY
15. Methotrexate Sodium P.F. 15 mg IT 1X/WEEK (___)
16. Vitamin D ___ UNIT PO DAILY
17. Omeprazole 40 mg PO BID Duration: 12 Weeks
RX *omeprazole 40 mg 1 capsule(s) by mouth twice a day Disp #*60
Capsule Refills:*3
18. Outpatient Lab Work
Please check CBC and Na, K, Cl, HCO3, BUN, Cr, Gluc
Dx: Electrolyte abnormalities, ICD-10: E87.8
Please fax results to Dr. ___ at ___.
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Primary:
Acute blood loss anemia
Pleural effusion
Secondary:
Atrial fibrillation
Diabetes mellitus
Rheumatoid arthritis
Chronic diastolic CHF
Hypertension
Hyperlipidemia
Discharge Condition:
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Discharge Instructions:
Mr. ___,
You were hospitalized for weakness. We found your blood counts
to be quite low, likely related to recent bleeding from your GI
tract. We gave you blood through an IV, and your blood levels
stabilized. We also found that fluid around your lungs had
reaccumulated, so the pulmonary team placed a chest tube for a
day to drain the fluid. You should follow up with their team on
___ to discuss the cause of the fluid accumulation
and to discuss further options.
In addition, while you were in the hospital, your sodium level
was noted to be low. It is important to not take in more than
1.5L of fluid per day. You will need to have your labs rechecked
in x2 days.
It was a pleasure taking care of you!
Your ___ team
Followup Instructions:
___
|
19598719-DS-2
| 19,598,719 | 20,785,120 |
DS
| 2 |
2136-02-21 00:00:00
|
2136-02-21 14:44:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Shellfish Derived
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization (___)
History of Present Illness:
Ms. ___ is a ___ year old woman with a history of hyperlipidemia
who presents with chest pain and dyspnea on exertion. She
developed substernal chest pain and dyspnea while exercising 2
days ago that resolved with rest then again twice on the day
prior to ED presentation, followed by left shoulder and arm
discomfort.
In the ED, initial vitals were Pain ___ HR 72 BP 114/75 RR
16 100% RA.
Labs were notable for CBC Hct 35.2 otherwise WNL, chemistry
panel WNL, Troponin negative x2, INR 1.0. EKG without ischemic
changes. She received 325 aspirin. CXR unremarkable. She
underwent a stress test in the ED, which was positive, and she
is admitted to ___ for further management.
Vitals on admission: T 97.8, 111/71 71 16 100%RA
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.
Cardiac review of systems is notable for absence of paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope
or presyncope.
Past Medical History:
BABESIOSIS ___
BPPV
OSTEOPENIA ___
SCHATZKI RING ___: Presented with dysphagia; ring found and
dilated at EGD ___ by Dr ___
___ (high LDL)
Social History:
___
Family History:
Father died of MI at age ___
Mother died of MI in her ___
No family history of arrhythmia, cardiomyopathies, or sudden
cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: T 97.8, 111/71 71 16 100%RA
General: Anxious middle aged woman in NAD
HEENT: Anicteric sclera, MMM
Neck: No JVD
CV: RRR w/o m/r/g
Lungs: CTAB
Abdomen: Soft, NTND
GU: No foley
Ext: No clubbing, cyanosis, edema
Neuro: A&Ox3, moving all exremities
PULSES: 2+ ___ pulses bilaterally
DISCHARGE PHYSICAL EXAM:
VS: Tm 97.9, 113/75, 55-75, 16, 100%RA
General: Anxious middle aged woman in NAD
HEENT: Anicteric sclera, MMM
Neck: No JVD
CV: RRR w/o m/r/g
Lungs: CTAB
Abdomen: Soft, NTND
GU: No foley
Ext: No clubbing, cyanosis, edema
Neuro: A&Ox3, moving all extremities
PULSES: 2+ ___ pulses bilaterally, radial cath site
intact without hematoma
Pertinent Results:
==== ADMISSION LABS ====
___ 11:50AM BLOOD WBC-4.4 RBC-3.65* Hgb-11.8* Hct-35.2*
MCV-96 MCH-32.3* MCHC-33.5 RDW-12.9 Plt ___
___ 11:50AM BLOOD Neuts-68.0 ___ Monos-5.8 Eos-3.7
Baso-0.2
___ 11:50AM BLOOD ___ PTT-29.8 ___
___ 11:50AM BLOOD Glucose-97 UreaN-16 Creat-0.9 Na-140
K-4.2 Cl-103 HCO3-29 AnGap-12
___ 05:55AM BLOOD Mg-1.9
___ 11:50AM BLOOD cTropnT-<0.01
___ 06:00PM BLOOD cTropnT-<0.01
==== IMAGING ====
EKGs:
___: Sinus rhythm. Within normal limits. Compared to the
previous tracing of ___ T wave flattening is no longer
present.
___: Sinus rhythm. Within normal limits. Compared to the
previous tracing there is no significant change.
___
CXR ___:
No acute intrathoracic process.
EXERCISE STRESS TEST (___):
INTERPRETATION: This ___ y.o. woman with family h/o CAD was
referred
to the lab for evaluation of chest pain and dyspnea. The patient
exercised for 7.5 minutes of ___ protocol (~ ___ METS),
representing
a good exercise tolerance for her age. The test was stopped due
to a
slight drop in systolic blood pressure in association with
dizziness,
chest discomfort, and ST segment changes. During exercise, the
patient
noted ___ substernal chest tightness/heaviness, unchanging with
inspiration or palpation. As exercise continued, this discomfort
progressed to ___ and radiated more centrally. This discomfort
improved in recovery to baseline, however, the patient initially
denied
any rest discomfort. At peak exercise, there was 1-2 mm of
upsloping/horizontal ST segment depression in the inferior leads
and
leads V3-6, resolving by minute 7 of recovery. The rhythm was
sinus
with no ectopy throughout the study. Drop in systolic blood
pressure in
association with dizziness at peak exercise. Appropriate heart
rate
response to exercise.
IMPRESSION: Ischemic EKG changes in the presence of probable
anginal
type symptoms. Drop in systolic BP in association with
lightheadedness.
Good exercise tolerance.
Brief Hospital Course:
___ female with history of hyperlipidemia who presented with
chest pain and dyspnea on exertion and was found to have
unstable angina and concerning findings on exercise stress test.
# Unstable Angina: New onset of typical anginal symptoms two
days prior to admission. Not present at rest, only with
exertion. Resolve over several minutes with rest. Negative
troponins x2 and no ischemic changes on resting EKG in the ___
ED. Concerning findings on ETT, including symptomatic drop in
systolic BP during exercise, as well as 1-2 mm of
upsloping/horizontal ST segment depression in the inferior leads
and leads V3-6, resolving by minute 7 of recovery. Underwent
cardiac catheterization on ___ and received a DES to the LAD
for an 80% stenosis in proximal LAD. She was loaded with Plavix
and continued on Plavix 75mg qday and ASA 81mg qday at
discharge. Both metoprolol and atorvastatin were highly
recomended to the patient as there is significant evidence,
especially for atorvastatin, that there are reductions in both
incidence of ACS and mortality in patients s/p ACS who take
these medications. Nevertheless, the patient refused to take
these medications and stated that she would discuss it with her
PCP at follow up appointment. We offered to schedule a
cardiology follow up appointment for the patient but she
declined, stating that she wanted to see her PCP ___
___ prior to deciding on a cardiologist. We scheduled a
follow up appointment with Dr. ___ the patient on ___
and urged her to see a cardiologist within ___ weeks after
discharge, at which time she should also have an echo performed.
==== TRANSITIONAL ISSUES ====
# Unstable Angina / CAD:
- PCP follow up with Dr. ___ on ___ at 11:30 AM.
- Please urge the patient to see a cardiologist within ___ weeks
and have a TTE performed at that time. We offered to schedule
cardiology follow up for the patient but she declined this.
- Patient has declined atorvastatin and metoprolol despite
informing her of the strong evidence of benefit of these
medications, especially atorvastatin. Please counsel her at
follow up that she is very likely to benefit from taking these
medications.
- Continue ASA 81mg qday, Plavix 75mg qday
# CODE: FULL
# CONTACT: Patient, Husband ___, ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Vitamin D ___ UNIT PO DAILY
2. cranberry unknown oral unknown
3. Glucosamine (glucosamine sulfate) 1500 mg oral DAILY
4. Fish Oil (Omega 3) 1000 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth qday Disp #*30 Tablet
Refills:*0
2. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth qday Disp #*30 Tablet
Refills:*1
3. cranberry 0 unknown ORAL Frequency is Unknown
4. Fish Oil (Omega 3) 1000 mg PO DAILY
5. Glucosamine (glucosamine sulfate) 1500 mg oral DAILY
6. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
- Unstable Angina
- CAD
Secondary Diagnosis:
- Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ on ___ with new chest pain. You
underwent an exercise stress test which revealed significant
abnormalities that prompted our cardiologists to perform a
cardiac catheterization. This revealed extensive narrowing of
one of the arteries supplying blood to your heart. A stent was
placed in this artery resulting in significant improvement to
the blood supply to this area.
It was a pleasure to take care of you during your hospital stay.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19598719-DS-3
| 19,598,719 | 25,347,122 |
DS
| 3 |
2137-07-25 00:00:00
|
2137-07-25 13:52:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Shellfish Derived
Attending: ___
Chief Complaint:
Chest discomfort
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with hx of CAD (s/p DES to pLAX for 80% stenosis on ___,
otherwise normal coronaries) presenting with vague chest
discomfort and fatigue. Although in the ED the report was "chest
discomfort" which began 10 days ago and is intermittent, she
later tells me that it is more just fatigue and she denies any
actual chest pain or nausea, or chest tightness. She also denies
that any of her symptoms are exertional. Denies leg swelling,
fevers, chills, dysuria, hematuria. Last took ASA 81mg on
evening of ___.
In the ED initial vitals were: T 98.5, 82, 92/62, 16, 99% RA
- EKG: NSR @ 65bpm. Isolated sub-millimeter STE in V2 without
changes in contiguous leads. No other new ischemic changes and
otherwise unchanged from prior of ___. Repeat EKG at 8PM is
withOUT the before-mentioned STE in V2 but there is TWI in V2
which is new from prior.
- Labs/studies notable for: WBC 5.2, proBNP 61, Cr 1.0, K 3.8,
Trop < 0.01 x1 (from 2pm). CXR w/o acute abnormality.
- Patient was given: ASA 324mg, heparin bolus followed by drip.
Vitals on transfer: HR 65, 112/62, 16, 97% RA
The patient was seen on ___ by her PCP for complaint of
vague nausea and abdominal discomfort. At that time had a
negative UA.
Of note, patient has a history of medication non-compliance.
Specifically, refused to take metoprolol or atorvastatin on
discharge after ___ placed in pLAD during ___
admission.
She is no longer on Plavix as she recently completed 14 months
of treatment after her ___ year.
On arrival to the floor, patient tells me that she does not
have any chest pain and has not had any chest pain leading up to
this admission. She endorses a vague sense of fatigue that does
not appear to have an exertional component.
ROS:
Cardiac review of systems is notable for absence of paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope
or presyncope. Denies exertional buttock or calf pain.
Past Medical History:
CAD (s/p DES to LAD for 80% stenosis in pLAD in ___ for
unstable angina with ischemic EKG changes and drop in SBP on
exercise stress)
BABESIOSIS ___
BPPV
OSTEOPENIA ___
SCHATZKI RING ___: Presented with dysphagia; ring found and
dilated at EGD ___ by Dr ___
___ (high LDL)
HX OF MEDICATION NON-COMPLIANCE
Social History:
___
Family History:
Father died of MI at age ___
Mother died of MI in her ___
No family history of arrhythmia, cardiomyopathies, or sudden
cardiac death; otherwise non-contributory.
Physical Exam:
Admission Physical Exam:
VS: T 97.7, 127/78, 64, 16, 100%RA
GENERAL: WDWN woman in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: PERRL, EOMI
NECK: Supple with no JVD.
CARDIAC: RRR w/o m/r/g
LUNGS: Clear to auscultation.
ABDOMEN: Soft, NTND.
EXTREMITIES: No c/c/e. Warm and well perfused.
DISCHARGE PHYSICAL EXAM:
VS:97.4 98/62 55 16 99%RA
GENERAL: WDWN woman in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: PERRL, EOMI
NECK: Supple with no JVD.
CARDIAC: RRR w/o m/r/g
LUNGS: Clear to auscultation.
ABDOMEN: Soft, NTND.
EXTREMITIES: No c/c/e. Warm and well perfused.
LABS: reviewed, see below
Pertinent Results:
Pertinent Labs
___ 07:40AM BLOOD WBC-4.5 RBC-3.66* Hgb-11.5 Hct-36.0
MCV-98 MCH-31.4 MCHC-31.9* RDW-12.5 RDWSD-45.3 Plt ___
___ 07:40AM BLOOD Glucose-78 UreaN-15 Creat-1.0 Na-139
K-4.5 Cl-99 HCO3-29 AnGap-16
___ 07:40AM BLOOD CK-MB-2 cTropnT-<0.01
___ 08:04PM BLOOD cTropnT-<0.01
___ 01:55PM BLOOD cTropnT-<0.01
___ 01:55PM BLOOD proBNP-61
CXR: No acute cardiopulmonary abnormality.
EKG: NSR
Brief Hospital Course:
___ with history of CAD s/p DES in ___ who presented with
atypical chest pain. By history not concerning for ACS. No EKG
changes and troponin negative x 3. Initially started on heparin
in the ED but stopped on the floor.
Transitional Issues:
-Consider exercise treadmill test to evaluate for inducible
ischemia; However, history not consistent with cardiac chest
pain
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Pravastatin 10 mg PO QPM
2. Aspirin 81 mg PO DAILY
3. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Pravastatin 10 mg PO QPM
3. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Chest Pain
CAD
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 chest discomfort. We found that your
symptoms are not due to heart disease. You should follow up with
your cardiologist to discuss the utility of a stress test.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19598913-DS-6
| 19,598,913 | 28,410,026 |
DS
| 6 |
2152-11-24 00:00:00
|
2152-11-24 12:55:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
lower abdominal pain
Major Surgical or Invasive Procedure:
___ laparoscopic appendectomy
History of Present Illness:
___ F w/ 48 hrs of lower abd pain. Pain started ___,
initially ___ umbilical then migrating to RL and LLQ. Pain is
sharp, continuous, associated with nausea and vomiting,
nonradiating. First episode. No fevers or chills. Passing flatus
but no BM today.
Past Medical History:
none
Social History:
___
Family History:
noncontributory
Physical Exam:
On admission:
99.2 75 83/41 18 100%
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, nontender, no rebound or guarding,
normoactive bowel sounds, no palpable masses
Ext: No ___ edema, ___ warm and well perfused
On discharge:
97.1 53 86/50 16 99%RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, appropriately tender at incision sites,
no rebound or guarding, lap sites x's 3 with dressing c/d/i
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
___ CT ABD & PELVIS WITH CONTRAST
Uncomplicated acute appendicitis.
___ 09:54AM WBC-14.7*# RBC-3.53* HGB-11.4* HCT-34.8*
MCV-99* MCH-32.3* MCHC-32.8 RDW-12.0
___ 09:54AM NEUTS-91.8* LYMPHS-6.4* MONOS-1.7* EOS-0
BASOS-0.1
___ 09:54AM PLT COUNT-295#
___ 09:54AM ___ PTT-26.5 ___
___ 09:54AM GLUCOSE-132* UREA N-16 CREAT-0.9 SODIUM-137
POTASSIUM-4.2 CHLORIDE-101 TOTAL CO2-27 ANION GAP-13
Brief Hospital Course:
Ms. ___ was admitted on ___ under the Acute Care
Service for management of her acute appendicitis. She was taken
to the operating room that day for a laparoscopic appendectomy.
Please see operative note from Dr. ___ details of the
procedure. She tolerated the procedure well and was extubated
upon completion. She was transferred to the PACU initially
postoperatively, and then to the surgical floor when
hemodynamically stable.
Her pain level was routinely assessed and she was given IV
analgesics initially as needed to control her pain. She was
later transitioned to oral narcotics when tolerating PO's. She
was started on clear liquids postoperatively and given
additional IV fluids for hydration. On POD 1 she was started on
a regular diet, which she tolerated without increased abdominal
pain or nausea. Her vital signs were routinely monitored.
Initially her urine output was borderline and she was noted to
be slightly hypotensive in the low 80's systolic; however, it
was noted that the patient's basline systolic BP's are in the
90's. By the day of discharge on POD 2, she was making adequate
amounts of urine and her SBP's remained in the high 80's-90's.
She remained afebrile without any signs of infection. She was
started on IV ciprofloxacin and flagyl initially postoperatively
for ruptured appendicitis noted in the OR, and was transitioned
to PO antibiotics prior to discharge. She was encouraged to
mobilize out of bed and ambulate, which she was able to do
independently.
On postop day 2 she is tolerating a regular diet and
hemodynamically stable. Her pain is well controlled with PO pain
medications and she is out of bed ambulating independently. She
is being discharged home with scheduled follow up in the ___
clinic on ___.
Medications on Admission:
doxycycline hyclate 100 mg Capsule Sig: One (1) Capsule PO Q12H
Discharge Medications:
1. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
2. metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 7 days.
Disp:*21 Tablet(s)* Refills:*0*
3. oxycodone 5 mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
4. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
5. doxycycline hyclate 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours).
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
8. Milk of Magnesia 400 mg/5 mL Suspension Sig: Five (5) ml PO
four times a day as needed for constipation.
Discharge Disposition:
Home
Discharge Diagnosis:
Ruptured acute appendicitis with suppurative peritonitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with acute appendicitis. You
were taken to the operating room and had your appendix removed
laparoscopically. You tolerated the procedure well and are now
being discharged home with the following instructions:
ACTIVITY:
Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
You may climb stairs.
You may go outside, but avoid traveling long distances until you
see your surgeon at your next visit.
Don't lift more than ___ lbs for 6 weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
Heavy exercise may be started after 6 weeks, but use common
sense and go slowly at first.
HOW YOU MAY FEEL:
You may feel weak or "washed out" for 6 weeks. You might want to
nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You might have trouble concentrating or difficulty sleeping. You
might feel somewhat depressed.
You could have a poor appetite for a while. Food may seem
unappealing.
All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressings you have small plastic bandages
called steristrips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
Your incisions may be slightly red around the stitches. This is
normal.
You may gently wash away dried material around your incision.
It is normal to feel a firm ridge along the incision. This will
go away.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing or clothes. If the staining is severe, please call
your surgeon.
You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
Ove the next ___ months, your incision will fade and become
less prominent.
YOUR BOWELS:
Constipation is a common side effect of narcotic pain
medicaitons. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
If you go 48 hours without a bowel movement, or have pain moving
the bowels, call your surgeon.
PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your surgeon.
You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. Do not
take it more frequently than prescribed. Do not take more
medicine at one time than prescribed. Do not drink alcohol or
drive while taking narcotic pain medication.
Your pain medicine will work better if you take it before your
pain gets too severe.
Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
Remember to use your "cough pillow" for splinting when you cough
or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
DANGER SIGNS:
Please call your surgeon if you develop:
- worsening abdominal pain
- sharp or severe pain that lasts several hours
- temperature of 101 degrees or higher
- severe diarrhea
- vomiting
- redness around the incision that is spreading
- increased swelling around the incision
- excessive bruising around the incision
- cloudy fluid coming from the wound
- bright red blood or foul smelling discharge coming from the
wound
- an increase in drainage from the wound
Followup Instructions:
___
|
19598941-DS-12
| 19,598,941 | 27,198,141 |
DS
| 12 |
2190-05-05 00:00:00
|
2190-05-05 11:30:00
|
Name: ___ / ___. ___: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Iodine / Codeine
Attending: ___.
Chief Complaint:
R arm cellulitis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ ___ female with h/o DMII, s/p breast
cancer s/p right mastectomy and LN resection c/b chronic
lymphedema, recurrent cellulitis in R arm who now presents with
1 day of R forearm pain, redness, and swelling. Per her daughter
who She was in her usual state of health until this morning when
she developed fever to 101.4 and shaking chills. She complained
of pain in her right forearm, and her daughter noted an area of
erythema which rapidly spread up forearm over the course of the
morning. Her daughter called EMS and she was transported to the
ED.
.
Of note, pt recently hospitalized in ___ for right arm
cellulitis treated with vancomycin/zosyn, narrowed to Bactrim
for 10 day course. Per daughter she was also very confused
during that hospitalization. Did not have high fevers during
that episode.
.
In the ED, initial VS were T 101.6 HR 106 BP 134/90 RR 18 O2 sat
97% RA. Pt was found to be tachy up to 120s and a Tmax of 104.5
during ED stay. Labs were remarkable for WBC 12.4 (78% N, ___
bands) and lactate of 5.6. Pt was given 4L NS, with improvement
in HR to ___ and lactate to 2.8. UA was neg for infection.
Borders of erythema were marked. Blood and urine cx were sent.
Surg was consulted, who felt this is not nec fasc. Pt was
started on Vanc/Cefepime/Clinda to broadly cover the cellulitis.
Pt was also given Tylenol PR, Morphine and Zofran for
symptomatic treatment. Xray of forearm showed ___ subcutaneous
air. Erythema was starting to improve with the abx and pt was
then admitted to ICU for further management. On trasnfer, VS
were T 101.2, HR 83, BP 112/49, RR16, Sat 95% 4L NC.
.
On arrival to the MICU, vitals are 97.8 129/56 68 26 93% RA.
Patient is AAOx2 (person, place, not time). She appears
uncomfortable, daughter states ___ chronic back pain, improved
somewhat with repositioning. States right arm pain has improved
somewhat. In the MICU, her antibiotic coverage was changed to
vancomycin and augmentin. Her HR went up to the 120s and she
was given 4L NS with HR improving to the ___. Her BPs remained
was stable, and she did not require pressors. She was Percocet
and IV Dilaudid for her pain (refused to take PO meds). Ms.
___ was also given haldol for agitation. Her urine
output has been ___ cc/hour. Her initial lactate was elevated
at 5.9 but has since improved.
.
On transfer to the floor, ___ was hemodynamically
stable with improved erythema. She complained of pain and some
discomfort with her bed position.
Past Medical History:
-H/O breast cancer s/p right mastectomy with LN dissection ___
yrs ago) c/b chronic right arm lymphedema and recurrent R arm
cellulitis
-Type II IDDM
-CAD
-Angina
-Hypertension
-Osteoarthritis
-Chronic Back Pain
-Gout
Social History:
___
Family History:
Not available due to patients confusion on admission
Physical Exam:
ADMISSION
General: obese elderly F, appears uncomfortable but NAD, AAOx2
(person, place, not time)
HEENT: pupils 1mm reactive ___, EOMI, dry mucus membranes
Neck: supple, ___ JVD, ___ LAD
Cardiac: RRR S1 S2 ___ rubs/murmurs/gallops
Lungs: CTAB ___ crackles/wheezes/rhonchi
___: obese, nontender, softly distended, +BS, ___ peritoneal
signs
Extrem: cool extrem, 2+ pulses, 2+ pitting pedal edema, ___
clubbing or cyanosis
Neuro: face symmetric, PERRL, moving all extremities equally
Discharge exam:
obes
right upper extremity with edema, erythema limited to just
forearm.
Pertinent Results:
ADMISSION
___ 03:50PM BLOOD WBC-12.4*# RBC-4.20# Hgb-12.4 Hct-37.7
MCV-90 MCH-29.6 MCHC-33.0 RDW-15.7* Plt ___
___ 03:50PM BLOOD Neuts-78.2* ___ Monos-1.5*
Eos-0.7 Baso-0.3
___ 03:50PM BLOOD ___ PTT-32.1 ___
___ 03:50PM BLOOD Glucose-204* UreaN-22* Creat-1.0 Na-138
K-4.0 Cl-101 HCO3-17* AnGap-24*
___ 03:50PM BLOOD CK(CPK)-31
___ 02:32AM BLOOD Calcium-7.7* Phos-4.0 Mg-1.5*
.
PERTINENT
___ 03:54PM BLOOD Glucose-197* Lactate-5.6*
___ 06:16PM BLOOD Lactate-2.8*
___ 03:15AM BLOOD Lactate-1.9
.
DISCHARGE
___ 06:24AM BLOOD WBC-7.8 RBC-3.78* Hgb-11.0* Hct-34.4*
MCV-91 MCH-29.0 MCHC-31.9 RDW-15.6* Plt ___
___ 06:24AM BLOOD Glucose-173* UreaN-20 Creat-1.2* Na-141
K-3.6 Cl-104 HCO3-24 AnGap-17
___ 06:24AM BLOOD Calcium-9.1 Phos-3.1 Mg-1.8
.
CXR ___
Single portable view of the chest is compared to previous exam
from
___. The lungs are grossly clear. Cardiac
silhouette is
enlarged, potentially accentuated by portable technique and low
inspiratory effort. There is ___ large effusion. Degenerative
changes noted at the right shoulder. Osseous and soft tissue
structures are otherwise grossly unremarkable.
IMPRESSION: ___ definite acute cardiopulmonary process.
.
FOREARM (AP & LAT) SOFT TISSUE RIGHT ___
Diffuse soft tissue swelling of the right forearm without
subcutaneous gas or radiopaque foreign body. Unusual contour at
the base of the fourth metacarpal, potentially projectional,
however, if concern for fracture, dedicated views should be
performed.
.
Micro:
Blood cultures ___ pending
urine culture ___ negative
Brief Hospital Course:
___ ___ female with h/o DMII, s/p breast cancer
s/p right mastectomy and LN resection c/b chronic lymphedema,
recurrent cellulitis in R arm who now presents with 1 day of R
forearm pain, redness, and swelling.
Discharge diagnoses:
Sepsis due to Right arm cellulitis
Chronic lymphedema
Acute encephalopathy/delerium
Type II diabetes mellitus with complications
Below is a brief review of her hospitalization:
1. Right arm cellulitis. She was initially admitted to the ICU
with sepsis. ED evaluation was performed by surgery due to
possibility for necrotizing fascitis.
Regarding her right arm erythema, the appearance was consistent
with nonpurulent cellulitis, with primary risk factor being her
underlying chronic lymphedema and h/o IDDM. She was seen in the
ED by surgery who felt appearance not concerning, x-ray showed
___ subcutaneous air. In the ED, she was started on vancomycin,
cefepime, and clindamycin. The patient was initially admitted
to the ICU for a sepsis like picture (Tmax 104.5). In the MICU,
her antibiotic coverage was changed to vancomycin and augmentin.
She was aggressively rehydrated and did not require pressors.
She was given Percocet and IV Dilaudid for her pain (refused to
take PO meds) and haldol for agitation. Her initial lactate
was elevated at 5.9 but has since improved. With clinical
improvement (defervesced with abx and Tylenol), she was
transferred to the medicine floor. We continued her antibiotics
and switched her to a PO regimen of bactrim and augmentin. Her
erythema in her right arm greatly improved with time. General
surgery saw the patient and recommended obtaining a MRI of her
arm to rule out angiosarcoma (given recurrent cellulitus and
history of breast cancer/lymphedema). We deferred obtaining a
MRI at this time based on patient's wishes (refused procedure)
and radiology's comments on the difficulty with positioning her
for the MRI.
The remainder of her medical conditions remained stable.
Issues for follow up -
The patient should follow-up with her PCP regarding this matter
and obtain a MRI in the future, as documented above.
Medications on Admission:
1. simvastatin 5 mg daily
2. atenolol 50 mg BID
3. ranolazine 500 mg ER BID
4. cholecalciferol (vitamin D3) 800 unit daily
6. lantus 26 units SC qHS
7. glucotrol 10 mg twice a day
8. isosorbide-hydralazine ___ mg daily (unclear dose?)
9. allopurinol ___ mg once a day
10. metformin 1000mg PO BID
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Lantus 26 Units Bedtime
3. Simvastatin 5 mg PO DAILY
4. Vitamin D 800 UNIT PO DAILY
5. Amoxicillin-Clavulanic Acid ___ mg PO Q8H
6. Isosorbide Dinitrate 20 mg PO DAILY
7. HydrALAzine 37.5 mg PO DAILY
8. GlipiZIDE 10 mg PO BID
9. Atenolol 50 mg PO BID
10. MetFORMIN (Glucophage) 1000 mg PO BID
11. Sulfameth/Trimethoprim DS 1 TAB PO BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis: Cellulitis
Secondary diagnosis: Type II diabetes, Hypertension
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Mental Status: Clear and coherent.
Discharge Instructions:
You were admitted for an infection of your right arm.
Initially, you appeared to be very ill with high fevers so you
were admitted to the intensive care unit for monitoring. You
were transferred to a regular medical floor when you began to
look better clinically. We gave you some antibiotics to help
treat your infection. We also carefully monitored the area to
see if it improved. When you go home, you are to continue
taking the antibiotics and monitor the arm for any changes.
Followup Instructions:
___
|
19599027-DS-8
| 19,599,027 | 21,922,945 |
DS
| 8 |
2133-03-27 00:00:00
|
2133-03-28 22:18:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Acute Liver Failure from OSH
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a ___ without significant ___ transferred from ___.
___ for new onset liver failure.
She originally had had root canal surgery on ___, and
reported taking "a lot" of ibuprophen for about 4 days. She then
returned to normal and continued to work in her job as a
___ for the elderly. Of note, about two weeks ago, a ___
year old man gave her what may have been a mushroom and she ate
it. Then, about 7 days ago she began to feel ill with diffuse
myalgias/arthralgias. On ___ she presented to PCP who drew
labs. On ___ she went to ___ who suspected a
virus and prescribed Naproxen. On ___ her PCP called her -
the labs were back and she had liver injury. He instructed her
to go to the ED.
___ US performed at ___ showed:
"1. No intra or extrahepatic biliary ductal dilatation. 2.
Abnormal gallbladder with a markedly thickened wall but no
sonographic evidence of cholelithiasis. This finding is
nonspecific but may represent diffuse adenomyomatosis. 3.
Ascites and rightpleural effusion. The findings on this
examination do not explan the patient's jaundice and LFT
abnormality"
-ALT 6190, AST 5726, T bili 6.9, D bili 5.3 INR 2.9.
.
In OUR ED - ALT: 5748 AP: 122 Tbili: 7.9 Alb: 3.7 AST: 5103
Dbili: 5.6 and she was admitted to the SICU.
Past Medical History:
HTN, migraines, h. pylori+, endometrial polyps
Social History:
___
Family History:
Migraines; the patient mother had opisthorchiasis
Physical Exam:
ADMISSION EXAM:
PHYSICAL EXAMINATION:
VS: 98.3 68 136/84 18 94%ra
GENERAL: Well appearing female in NAD. Jaundiced
HEENT: Sclera icteric. MMM.
CARDIAC: RRR with no excess sounds appreciated
LUNGS: CTA b/l with no wheezing, rales, or rhonchi.
ABDOMEN: Distended but Soft, non-tender to palpation.
EXTREMITIES: No Edema. Warm and well perfused, no clubbing or
cyanosis.
NEUROLOGY: no Asterixis. A+Ox3. CN2-12 intact. Sensation normal.
D/C EXAM:
PHYSICAL EXAMINATION:
VS: 97.9/98.2, afebrile x 24hr, HR 77-80, 108-145/77-98, 98%ra
GENERAL: Well appearing female in NAD. Can communicate in
___ well, need for ___ translator in the past, althout I
spoke ___ with her as needed.
HEENT: No Sclera icterus. MMM.
CARDIAC: RRR with no M/R/G.
LUNGS: Unlabored, good air movement, CTA b/l.
ABDOMEN: Obese, soft, non-tender. Normoactive BS. No rebound. No
splenomegaly appreciated. No ascites.
EXTREMITIES: Minimal edema of ___. Pulses 2+ UE and ___ b/l and
symmetric. Warm and well perfused.
NEUROLOGY: no Asterixis. A+Ox3. CN2-12 intact. Sensation normal.
Pertinent Results:
ADMISSION LABS
___ 07:15PM BLOOD WBC-7.9 RBC-5.43* Hgb-15.6 Hct-46.5
MCV-86 MCH-28.7 MCHC-33.5 RDW-13.2 Plt ___
___ 07:15PM BLOOD ___ PTT-38.0* ___
___ 03:20AM BLOOD ___
___ 07:15PM BLOOD Glucose-97 UreaN-14 Creat-0.7 Na-135
K-3.8 Cl-100 HCO3-26 AnGap-13
___ 07:15PM BLOOD ALT-5748* AST-5103* AlkPhos-122*
TotBili-7.9* DirBili-5.6* IndBili-2.3
___ 09:16PM BLOOD Lactate-2.5*
D/C LABS
___ 06:00AM BLOOD WBC-9.8 RBC-4.04* Hgb-11.9* Hct-36.1
MCV-89 MCH-29.6 MCHC-33.1 RDW-14.9 Plt ___
___ 06:00AM BLOOD ___ PTT-46.6* ___
___ 06:00AM BLOOD ___ 03:10PM BLOOD ___ 06:00AM BLOOD Glucose-109* UreaN-10 Creat-0.7 Na-136
K-3.9 Cl-103 HCO3-26 AnGap-11
___ 06:00AM BLOOD ALT-875* AST-215* AlkPhos-100
TotBili-4.7*
MICRO
HBV Viral Load (Final ___:
8,911 IU/mL.
HCV VIRAL LOAD (Final ___:
HCV-RNA NOT DETECTED.
HIV-1 Viral Load/Ultrasensitive (Final ___:
HIV-1 RNA is not detected.
R/O VANCOMYCIN RESISTANT ENTEROCOCCUS (Final ___:
No VRE isolated.
STUDIES
TTE
The left atrium is normal in size. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (?#) appear
structurally normal with good leaflet excursion. The mitral
valve leaflets are structurally normal. There is an anterior
space which most likely represents a prominent fat pad.
LIVER OR GALLBLADDER US IMPRESSION:
1. The gallbladder is abnormal with findings most suggestive of
a markedly
thickened wall which can be seen in the setting of acute
hepatitis. Recommend
repeat ultrasound after the acute issues have resolved to
exclude underlying
pathology.
2. Unremarkable liver without increased echogenicity or focal
masses.
3. Patent portal vein with normal hepatopetal flow
Brief Hospital Course:
___ female who moved from ___ in ___, with acute hepatitis
with liver failure (ALT/AST > 5000/5000), found to have mushroom
exposure, mother with opisthorchiasis, and serology consistent
with acute hepatitis B. Based on patient's history, it was
unlikely that she ingested significant amount of Acetaminophen.
# Acute Liver failure - patient's serology and viral load is
consistent with acute HepB seroconversion, and this is the most
likely etiology of the liver failure. Pt has no history of
vaccination and does not have a clear history of transmission.
Based on recommendations from Infections Disease and Toxicology
teams, the Pt was started on Tenofavir, IVF, and bed rest. Her
LFTs trended down significantly ALT/AST 875/215 on discharge
from ___ on admission.
.
On the day of discharge we decided to D/C Tenofavir and allow
the patient to mount her own response to the HBV virus. We
believe she will have a significant chance to clear the virus on
her own. She will of course be followed closely by Hepatology
as an outpatient.
.
On the day of discharge the patient was back to her baseline
health. She was tolerating a full diet, ambulating on her own.
On the day of discharge she was without the
malaise/arthralgia/vague-diffuse pain that she felt initially.
On the day of discharge she was without jaundice, scleral
icterus or asterixis.
.
On the day of discharge ___ HIV Viral load was pending and
she we told her that the results will be communicated with her
within one to two weeks.
.
Transitional issues
1. Repeat HepB serology
2. F/U HIV Viral Load
Medications on Admission:
None
Discharge Medications:
None
Discharge Disposition:
Home
Discharge Diagnosis:
Acute hepatitis B infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms ___,
It was a pleasure taking care of you at ___. You were admitted
for liver injury. This was found to be from a hepatitis B
infection. For this, you were given medications, and your liver
improved. It is not completely recovered yet. You will need to
follow up in the liver clinic.
Avoid ALL medications for now, unless you talk with your doctor.
Do not drink any alcohol. Use no herbals or supplements.
The following changes have been made to your medications:
Followup Instructions:
___
|
19599196-DS-9
| 19,599,196 | 25,893,125 |
DS
| 9 |
2148-06-26 00:00:00
|
2148-06-26 20:23:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
weakness
Major Surgical or Invasive Procedure:
THROMBECTOMY
History of Present Illness:
Mr. ___ is a ___ year old male with recent history of R CEA
___ and pipeline for right ICA aneurysm ___- discharged
on
___ on Asa, Plavix ( Normal Dc Neuro exam per note) presented
as transfer from ___ after being found down with
left
sided weakness and unknown last known normal estimated at 0900
(3
and ___ hours prior to presentation) found to have R ICA distal
occlusion.
He was found outside his home on ___ with initially unknown
last
known normal with reported left sided weakness. He was later
about to say he woke up around ___ and was ok at that time.
Further history somewhat limited by dysarthria. He was taken to
___ where CTA showed R ICA distal occlusion. He was
subsequently transferred to ___ for further care. Of note, per
EMS call in, pt had "vfib" intermittently in transport. However,
upon review of strip, this appears to be artifact.
On arrival to ___ he was severely dysarthria with forced
right gaze deviation. He was able to say he stopped taking his
ASA and Plavix ___ days ago because he was "bleeding from my
___. He says he thinks he woke up at 9AM feeling fine and then
walked outside when this happened. Further history limited by
his
dysarthria.
He was taken to emergent thrombectomy, found to have L
intracranial ICA - in-stent thrombosis of the pipeline stent and
required 3 passes to recannulate. TICI score was 2A. He received
Integrilin 15mg early in the procdure, and at the termination of
the procedure he received verapamil (unk dose). He aslo
received
loading dose of Asa- 650mg , Brillinta 180 mg and transferred to
Neuro - ICU for continued care.
Past Medical History:
Carotid stenosis
R ICA aneurysm s/p pipeline embolization in ___
Pituitary mass
Daily alcohol use
Social History:
___
Family History:
NC
Physical Exam:
ADMISSION PHYSICAL EXAM
========================
Vitals: from call in 98.___-178/107-98% 2 L
General: eyes open, forced gaze to right, ill appearing
HEENT: NC/AT, no scleral icterus noted
Cardiac: RRR
Abdomen: Soft, obese
Extremities: scattered ecchymoses in upper extremities, edema in
legs
Neurologic:
-Mental Status: Eye open spontaneously, oriented to ___
but not further, knows he is at the hospital, difficult relating
history given dysarthria and some attention issues. Language is
sparse but fluent and he can repeat and follow simple commands
only. He neglects left side. Able to relate history without
difficulty. Attentive, able to
-Cranial Nerves: Pupils are 3->2 and brisk. There is forced gaze
deviation to the right which cannot be overcome with VORs. No
BTT
on left. Facial droop on left. Tongue is midline. Speech is
dysarthric but 75% is comprehensible.
-Motor: RUE antigravity and RLE antigravity. LUE with only
proximal movement noted, LLE with TFs, some adduction in plane
of
bed to commands to move.
-Sensory: says ___ to noxious stimuli in all extremities
-Reflexes:
toe up on left, down on right
-Coordination: no dysmetria on right, unable to test on left
-Gait: unable to test
DISCHARGE PHYSICAL EXAM
=========================
VS - RR 14 not apneic
Gen - appears comfortable, eyes open. denying complaints.
Pertinent Results:
Pt discharge to hospice
Brief Hospital Course:
Mr. ___ is a ___ yo male with recent history of R CEA ___
and pipeline for right ICA aneurysm ___ tx from ___
___ s/p found down + L sided weakness, found to have distal
ICA occlusion s/p thrombectomy w/ poor re-perfusion w/ prolonged
hospital course including hypoxic respiratory failure, septic
shock, and aspiration pneumonia. Ultimately he was transitioned
to comfort measures and discharged to hospice.
Transitional Issues
===============
[ ] Ensure patient is comfortable
[ ] Pt does not have a known next of kin
[] guardian: ___, email: ___, phone
___
#Guardianship/GOC: Patient's friend ___ was listed as Health
care proxy who consented for the thrombectomy. Post procedure
while discussing further consents he expressed that he is not
comfortable making the decisions and he did not fully understand
the responsibilities. Medical certificate for Guardianship was
approved by the court, however a second expansion of
guardianship was filed on ___ to allow patient to be made
DNR/DNI or even CMO given it was unlikely that he would have
wanted to be ventilatory dependent, or even have a trach and
PEG. Ultimately he was made CMO, he appeared comfortable while
in the hospital and was given PRN dilaudid and ativan, in
addition to scopolamine. He was discharged to hospice.
#Acute ischemic stroke:
Imaging revealed R ICA distal occlusion on CTA. NIHSS
16.(Etiology likely ASA/Plavix non-compliance given patients
report of not taking medications due to recent urethral
bleeding). The pt underwent emergent thrombectomy +3 passes with
inadequate perfusion to distal circulation, ultimately a TICI
2a. Received Integrilin and ASA/Plavix load intra-operatively.
He was monitored closely with Neurochecks, started on Asa 81 mg
Daily and Brillinta 90 mg BID per Neurosurgery recommendations.
Post procedure he had persistent Right gaze deviation,
Dyarthria, left facial droop, left sided weakness, left Neglect.
Follow up MRI showed Acute infarction involving the entire right
MCA territory and part of thePCA territories. His mental status
continued to deteriorate and required intubation with mechanical
ventilation. His clinical course also complicated by development
of malignant cerebral edema with 4 mm midline shift, started on
hypertonic saline and his Na levels were monitored closely.
Follow up imaging showed stable findings and he was slowly
weaned off of hypertonic saline by post procedure day 7.
Ultimately his brillanta was discontinued given lack of
therapeutic benefit with a complete ICA occlusion. He continued
to be minimally verbal once extubated, and still had
considerable difficulty w/ aspiration and dysphagia. Ultimately
a PEG was not pursued given clarification of his goals of care
once extended guardianship was confirmed.
#Acute hypoxic respiratory failure
#Aspiration pneumonia
#ARDS
The patient was initially intubated on arrival for airway
protection in the setting of his large territory infarct. He was
febrile as early as hospital day 2 which was initially
attributed to SIRS in the setting of large territory cerebral
infarct and delerium tremens from alcohol withdrawl. Given
ongoing fevers and negative culture (blood, sputum, urine) he
was ultimately started on empiric treatment for aspiration
pneumonia/VAP with broad spectrum antibiotics
Vancomycin/Cefepime/Flagyl. As part of this workup CT chest
(performed to r/o PE given ongoing hypoxia) revealed likely RLL
/ lingual PNA. Infectious disease was consulted who recommended
stopping the vancomycin and completing a course for VAP. He was
overall improving, and noted to have some evidence of fluid
overload on CXR (pleural effusions, pulmonar edema) and was
periodically treated w/ IV lasix. He was ultimately extubated on
___ and initially doing well on nasal cannula. However, he
became acutely tachypneic, hypoxic and hypotensive on ___. He
was found to have worsening infiltrates on CXR, spiked a fever
to 103 and was reintubated. Low P/F ratio, new bilateral
opacities, and ongoing pressor-depenedent shock were concerning
for ARDS and septic shock in the setting of recurrent aspiration
pneumonia. Low TV-high PEEP ventilation was pursued.
Vancomycin/Cefepime and Flagyl were restarted for empiric
coverage of presumed aspiration pneumonia. Ultimately BAL
cultures grew Enterobacter and he completed a 7 day course of
Cefepime (___). His respiratory status was slower to
improved, but he was ultimately diuresed w/ IV lasix to improve
his oxygenation until he was on minimal vent settings. He was
doing well on pressure support ventilation and he was ultimately
re-extubated on ___. He remained a high aspiration risk.
#Septic Shock
As above, developed pressor dependent hypotension iso ARDS ___
pneumonia -- he required levophed, phenylephrin, and vasopressin
for hemodynamic support to maintain MAP > 65. He was also
started on hydrocortisone and fludrocortisone for refractory
septic shock. His hemodynamics slowly improved and he was weaned
off pressors. His lisinopril was never restarted.
#EtOH withdrawal: On post-op day 1, the patient showed signs of
alcohol withdrawal (h/o daily use and last drink night prior to
arrival) and received loading dose of phenobarbitol. The patient
was started on thiamine, folate, and multivitamin.
#Abdominal aortic aneurysm: 5.7 cm AAA was found on the CT chest
obtained to evaluate for a possible PE. The patient's systolic
blood pressure was kept below 140 when clinically appropriate,
and further management was deferred to outpatient.
=====
Transitional issues:
[]
=====
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed () No. If no, reason why:
2. DVT Prophylaxis administered? (x) Yes - () No. If no, why not
(I.e. bleeding risk, hemorrhage, etc.)
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No. If not, why not? (I.e. bleeding risk,
hemorrhage, etc.)
4. LDL documented? () Yes (LDL = ) - (x) No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 70) (x) Yes - () No [if LDL
>70, reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
6. Smoking cessation counseling given? () Yes - (x) No [reason
() non-smoker - (x) unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given in written
form? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(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: discharge to hospice
[ ] Statin medication allergy
[ x] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
10. Discharged on antithrombotic therapy? () Yes [Type: ()
Antiplatelet - () Anticoagulation] - (x) No -- discharge to
hospice
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - If no, why not (I.e.
bleeding risk, etc.) (x) N/A
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild/Fever
2. Aspirin 325 mg PO DAILY
3. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line
4. Clopidogrel 75 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Senna 17.2 mg PO QHS:PRN Constipation - First Line
Discharge Medications:
1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Artificial Tears Preserv. Free ___ DROP BOTH EYES Q4H:PRN
dry eyes
3. Morphine Sulfate (Concentrated Oral Solution) 20 mg/mL ___
mg PO Q1H:PRN moderate-severe pain or respiratory distress
RX *morphine concentrate 10 mg/0.5 mL 0.25 ml by mouth Q1H PRN
Disp #*5 Syringe Refills:*0
4. Scopolamine Patch 1 PTCH TD ONCE Duration: 72 Hours
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
ACUTE ISCHEMIC STROKE
Secondary diagnoses
==========
ARDS
Septic shock
Pneumonia
Hypoxia respiratory failure
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Dear Mr. ___,
You were hospitalized due to symptoms of unconsciousness and
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.
Stroke can have many different causes, in your case it was due
to a clot in the stent previously placed for your aneurysm. You
underwent emergent clot removal procedure but without
significant improvement in left sided weakness. You were started
on aspirin to prevent future strokes.
You were ultimately transitioned to hospice after a long
hospitalization.
We hope that you will be comfortable.
- Your ___ Neurology team
Followup Instructions:
___
|
19599211-DS-14
| 19,599,211 | 22,388,743 |
DS
| 14 |
2116-08-15 00:00:00
|
2116-08-15 21:40:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
aspirin
Attending: ___.
Chief Complaint:
Chest Pain and Fatigue
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old M visiting ___ from ___ with a
past medical history significant for a PTX X 2 who presents with
acute central chest pain. The pain began yesterday morning and
is located substernally. It is non-radiating and worse with deep
inspiration. He also felt fatigue and chills at home. He had
mild shortness of breath with exertion due to the pain he felt
with deep inspiration but no dyspnea at rest. He also denies
nausea, vomiting, diarrhea, urinary symptoms, leg swelling or
calf pain. He reports a mild sore throat yesterday and a cold
___ weeks prior to this presentation. In the ED, initial vital
signs were: T:100.4 (Tm: 101.4F) 85 131/85 16 100RA. ED course
was notable for a negative D-dimer and negative UA as well as
negative Troponin X 3. Initial EKG was unremarkable but
subsequent EKGs showed diffuse ST elevations without reciprocal
depression. He received about 4L of fluid during his ED course
and was started on ibuprofen and colchicine. Blood cultures were
initially sent but later canceled. Upon arrival to the floor,
the patient was hemodynamically stable with vitals of 98.4F, RR
16, O2 Sat 97% RA. He reports feeling much improved since
arrival but continues to report focal central chest pain without
radiation, worse with deep inspiration.
Past Medical History:
Pneumothorax X 2 (age ___ and ___ years)
Social History:
___
Family History:
Father died of an MI, also had diabetes mellitus and alcoholism.
His maternal grandmother also had diabetes.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals:
GEN: no acute distress, sitting up in bed
HEENT: PERRL, EOMI, anicteric
Neck: no LAD, no JVD
CV: RRR, no friction rub appreciated, no m/r/g.
Lungs: CTAB
Abdomen: +BS, soft, non-tender, non-distended
Ext: no ___ edema
Neuro: CN II-XII grossly intact
Skin: no rash on back
DISCHARGE PHYSICAL EXAM:
Vitals: T:98.1 BP:110/71 HR:60 RR:18RA tele: SR
General: no acute distress, comfortable, moving aroudn the room
HEENT: MMM, clear sclera
Neck: no LAD
Lungs: CTAB, no crackles or wheezes, good aeration
CV: RRR, S1 and S2 present, no m/g or friction rubs.
Abdomen: +BS, soft, NT, ND
Ext: WWP, no ___ edema
Neuro: motor and sensory function grossly intact
Pertinent Results:
ADMISSION LABS
___ 07:52PM WBC-12.4* RBC-4.77 HGB-13.7* HCT-41.5 MCV-87
MCH-28.6 MCHC-32.9 RDW-14.1
___ 07:52PM NEUTS-81.6* LYMPHS-12.3* MONOS-3.5 EOS-1.5
BASOS-1.0
___ 07:52PM PLT COUNT-161
___ 07:52PM D-DIMER-393
___ 07:52PM cTropnT-<0.01
___ 01:14AM cTropnT-<0.01
___ 07:52PM cTropnT-<0.01
___ 07:52PM GLUCOSE-99 UREA N-30* CREAT-1.2 SODIUM-136
POTASSIUM-4.3 CHLORIDE-102 TOTAL CO2-22 ANION GAP-16
___ 09:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 09:00PM URINE COLOR-Straw APPEAR-Clear SP ___
IMAGING
CT OF THE CHEST ___
Final Report
INDICATION: ___ year old man with history of pneumothorax, now
acute onset pleuritic chest pain and fever, recent travel on
plane
TECHNIQUE: Axial helical MDCT images were obtained from the
suprasternal
notch to the upper abdomen during the early arterial phase
scanning after the administration of 100 cc of Omnipaque
contrast material. Multiplanar
reformatted images in coronal,sagittal and oblique axes were
generated.
COMPARISON: Chest radiograph from ___.
FINDINGS:
The thyroid is unremarkable, and there is no supraclavicular
lymph node
enlargement. The airways are patent to the subsegmental level.
There is no mediastinal, hilar or axillary lymph node
enlargement by CT size criteria. The heart, pericardium, and
great vessels are within normal limits. No hiatal hernia or any
other esophageal abnormality is present.
Lung windows show bilateral lower lobe atelectasis. There is no
focal
consolidation. There is mild paraseptal and centrilobular
emphysema. There is no pneumothorax, and suture material is
noted in the left upper lobe.
CTA: The aorta and main thoracic vessels are well opacified. The
aorta
demonstrates normal caliber throughout the thorax without
intramural hematoma or dissection. The pulmonary arteries are
opacified to the subsegmental level. There is no filling defect
in the main, right, left, lobar or subsegmental pulmonary
arteries. No arteriovenous malformation is seen.
BONES: No focal osseous lesion concerning for malignancy. There
is no acute fracture with degenerative changes noted in the
thoracic spine.
Although this study is not designed for assessment of
intra-abdominal
structures, the visualized organs are unremarkable.
IMPRESSION:
1. No acute cardiopulmonary process. No pulmonary embolism.
2. Mild paraseptal and centrilobular emphysema.
CHEST X-RAY ___
FINDINGS:
Heart size is normal. Mediastinal and hilar contours are
unremarkable. The pulmonary vasculature is normal. No focal
consolidation, pleural effusion or pneumothorax is identified.
Chain sutures are seen within the left lung apex. Mild
degenerative changes are noted in the thoracic spine.
IMPRESSION:
No acute cardiopulmonary abnormality.
DISCHARGE LABS
___ 06:50AM BLOOD WBC-7.1 RBC-4.57* Hgb-12.8* Hct-39.0*
MCV-85 MCH-28.0 MCHC-32.8 RDW-14.1 Plt Ct-UNABLE TO
___ 06:50AM BLOOD Neuts-65 Bands-0 ___ Monos-4 Eos-9*
Baso-1 Atyps-1* ___ Myelos-0
___ 06:50AM BLOOD Glucose-110* UreaN-16 Creat-0.8 Na-140
K-4.2 Cl-106 HCO3-24 AnGap-14
___ 03:03PM BLOOD CRP-145.5*
___ 06:50AM BLOOD Calcium-9.0 Phos-2.7 Mg-2.0
___ 05:58PM BLOOD HIV Ab-NEGATIVE
___ 07:59PM BLOOD Lactate-1.5
___ 03:03PM BLOOD SED RATE-PND
___ 03:03PM BLOOD QUANTIFERON-TB GOLD-PND
Brief Hospital Course:
Mr. ___ is a ___ year old man on vacation in ___ from
___ with a past medical history significant for pneumothorax
X 2 and presenting with acute-onset substernal chest pain with
negative cardiac enzymes, clear CXR and negative CTA; now
clinically stable and being treated for pericarditis.
#ACUTE PERICARDITIS
Mr. ___ presented with signs and symptoms concerning for
pericarditis, namely central pleuritic chest pain worse with
deep inspiration, a fever to ___ on admission, fatigue and
classic diffuse ST elevations/PR depressions on EKG. The
differential initially included ACS, though this was ruled out
based on the EKG findings and negative cardiac enzymes X 3.
Pulmonary Embolism was also ruled out with a negative D-dimer
and negative CTA of the Chest. Of note, UA was also negative.
These findings, in combination with a history of recent viral
symptoms were most consistent with pericarditis. Mr. ___
underwent multiple laboratory studies and the results of these
studies at the time of discharge are contained elsewhere in this
report. He was also given ample fluid resuscitation and started
on a regimen of Ibuprofen 800mg q8hrs and Colchicine 0.6mg twice
daily for presumed pericarditis. He remained afebrile and
clinically stable during his admission and was discharged home
on this medication regimen.
TRANSITIONAL ISSUES:
- Mr. ___ is being discharged on ibuprofen and colchicine with
a planned course of several weeks please reassess symptoms in
the outpatient setting as soon as patient returns
- Mr. ___ may benefit from an Echocardiogram in the near
future.
- A TB Test was performed but the result was not yet available
at the time of discharge. It may be beneficial to repeat this
test in the outpatient setting.
- consider repeating CRP, elevated to 145 on admission
Medications on Admission:
None
Discharge Medications:
1. Ibuprofen 800 mg PO Q8H Duration: 30 Days
2. Colchicine 0.6 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Pericarditis
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 for pain in your chest caused
by an inflammation around the outside of your heart
(pericarditis). You were treated with fluids, ibuprofen and
colchicine.
You should continue to take these medications for ___ months. We
also would strongly recommend that you follow-up with your
regular doctor once you return home from your travels, ideally
within 1 month of this hospitalization.
Best wishes,
Your ___ Team
Followup Instructions:
___
|
19599279-DS-19
| 19,599,279 | 29,588,231 |
DS
| 19 |
2192-11-28 00:00:00
|
2192-12-28 00:22:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / clonidine patch / Erythromycin Base / Amoxicillin
/ hydrochlorothiazide / aspirin
Attending: ___.
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
___ debridement, vac placement
___ bedside debridement
History of Present Illness:
___ with complex PMH including recent (___) CVA secondary to
bleed with resulting aphasia, HTN, DM2, AFib, CAD s/p stenting,
COPD, and recent admission for Enterococcus and S. epidermidis
bacteremia presents with fever from rehab after discharge on
___. He was discharge with a course of vancomycin that he
completed on ___.
The patient was unable to provide any history on the floor and
not accompanied by family. Based on report from ED, the patient
had appeared altered with intermittent fevers at rehab for the
past week. He had been having increased somnolence with less
verbalization. Because of the stroke, he had been bed bound
since discharge in ___.
In the ED, initial vitals were: 99.6 68 153/83 15 98% RA. Tmax
was 102.
Exam notable for LUE PICC line without redness or purulence at
the site, large deep sacral ulcer without surrounding cellulitis
but with foul-smell and mild purulence.
Patient had multiple LP attempts but due to body habitus was
unable to obtain.
Patient received: IV Acetaminophen IV 1000 mg, IVF 1000 mL NS
1000 mL, IH Albuterol 0.083% Neb Soln 1 NEB, IV CeftriaXONE 2
gm, IV Vancomycin 1500 mg.
Vitals prior to transfer were: 99.8 70 127/39 18 98% RA.
On arrival to the floor, patient appears alert but does not
respond to well to questioning. He was able to grunt "nah-uh"
when asked if he has any pain. He yells out when attempts were
made to assess his sacral wound.
REVIEW OF SYSTEMS:
Unable to be obtained from patient
Past Medical History:
Type 2 DM
CVA with aphasia in ___
Subdural hematoma
Atrial fibrillation formerly on Coumadin but no longer
CAD s/p RCA DES in ___
COPD
Gout
HLD
Obesity
Spermatocele
OSA
TTE ___: LVH with EF >60%
B/L knee replacements
Social History:
___
Family History:
Brother died of heart failure in ___, sister of cancer (type
unknown) in ___.
Physical Exam:
ADMISSION EXAM
Vitals: T 100.0 BP 120/45 HR 72 RR 18 SAT 97 O2 on RA
GENERAL: Laying down in bed, tracks occasionally, opens eyes,
no apparent distress
HEENT: Sclera anicteric, MM's moist, EOMI grossly intact based
on eye movement, PERRL; known right facial droop
CARDIAC: RRR, S1/S2, ___ systolic murmur
LUNG: Crackles throughout with diminished breath sounds
ABDOMEN: Obese, no obvious tenderness or distension, +BS,
G-tube
site intact without erythema or drainage
GU: Foley in place
EXTREMITIES: Obese, no pitting edema, warm and well perfused,
has L arm PICC in place with no erythema or fluctuance
SKIN: warm and well perfused, no rash; very large sacral ulcer
wound that goes deep into muscle but does not probe to bone with
purulence and very foul smell
NEURO: Patient unable to comply with neuro exam
DISCHARGE EXAM
VS 98.9 146/54 20 100%/CPAP
I/O: 2456+300IV/3200+BM 24H, 782/600 8H
General: NAD, makes eye contact, tracks
HEENT: EOMI, Sclera anicteric without injection
Neck: Supple, no JVD
CV: RRR, no M/R/G
Lungs: breathing comfortably on RA, clear bilaterally
Abdomen: obese, soft, no obvious tenderness, nondistended, +BS,
G tube in place, c/d/no drainage, erythema
GU: Foley in place
Ext: WWP, no pitting edema; PICC in LUE, c/d, non-tender
Neuro: unable to participate in full neuro exam, tracks
Pertinent Results:
ADMISSION LABS
==============
___ 06:37PM BLOOD WBC-8.3 RBC-3.80*# Hgb-10.8*# Hct-34.5*#
MCV-91 MCH-28.4 MCHC-31.3* RDW-15.3 RDWSD-49.7* Plt ___
___ 06:37PM BLOOD Neuts-75.4* Lymphs-11.5* Monos-8.6
Eos-3.3 Baso-0.4 Im ___ AbsNeut-6.23*# AbsLymp-0.95*
AbsMono-0.71 AbsEos-0.27 AbsBaso-0.03
___ 06:37PM BLOOD Ret Aut-3.8* Abs Ret-0.15*
___ 06:37PM BLOOD Glucose-188* UreaN-20 Creat-0.8 Na-135
K-3.9 Cl-99 HCO3-29 AnGap-11
___ 06:37PM BLOOD Iron-17*
___ 06:37PM BLOOD calTIBC-217* Ferritn-210 TRF-167*
___ 06:46PM BLOOD Lactate-1.7
___ 08:20PM URINE Color-Straw Appear-Clear Sp ___
___ 08:20PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 08:20PM URINE RBC-1 WBC-1 Bacteri-FEW Yeast-NONE Epi-0
___ 08:20PM URINE CastHy-3*
___ 08:20PM URINE Mucous-RARE
MICROBIOLOGY
============
___ 6:12 pm SWAB Source: sacral ulcer.
**FINAL REPORT ___
WOUND CULTURE (Final ___:
GRAM NEGATIVE ROD(S). SPARSE GROWTH.
MIXED BACTERIAL FLORA.
This culture contains mixed bacterial types (>=3) so an
abbreviated workup is performed. Any growth of
P.aeruginosa,
S.aureus and beta hemolytic streptococci will be
reported. IF
THESE BACTERIA ARE NOT REPORTED, THEY ARE NOT PRESENT
in this
culture.
Work-up of organism(s) listed discontinued (excepted
screened
organisms) due to the presence of mixed bacterial flora
detected
after further incubation.
___ 11:51 pm TISSUE Source: sacral decubitus wound.
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
2+ ___ per 1000X FIELD): GRAM POSITIVE ROD(S).
TISSUE (Final ___:
MIXED BACTERIAL FLORA.
Due to mixed bacterial types [>=3] an abbreviated
workup is
performed; all organisms will be identified and
reported but only
select isolates will have sensitivities performed.
PROTEUS MIRABILIS. MODERATE GROWTH.
KLEBSIELLA PNEUMONIAE. SPARSE GROWTH.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
ENTEROCOCCUS SP.. SPARSE GROWTH.
ESCHERICHIA COLI. RARE GROWTH.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
| KLEBSIELLA PNEUMONIAE
| | ENTEROCOCCUS
SP.
| | |
ESCHERICHIA COLI
| | | |
AMPICILLIN------------ =>32 R <=2 S =>32 R
AMPICILLIN/SULBACTAM-- 8 S 8 S =>32 R
CEFAZOLIN------------- 16 R <=4 S <=4 S
CEFEPIME-------------- <=1 S <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S <=1 S
CIPROFLOXACIN--------- =>4 R =>4 R 0.5 S
GENTAMICIN------------ <=1 S <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S <=0.25 S
PENICILLIN G---------- 1 S
PIPERACILLIN/TAZO----- <=4 S 8 S <=4 S
TOBRAMYCIN------------ <=1 S <=1 S <=1 S
TRIMETHOPRIM/SULFA---- =>16 R <=1 S <=1 S
VANCOMYCIN------------ 1 S
ANAEROBIC CULTURE (Final ___:
UNABLE TO R/O PATHOGENS DUE TO OVERGROWTH OF SWARMING
PROTEUS SPP..
Blood Culture, Routine (Final ___: NO GROWTH.
URINE CULTURE (Final ___: NO GROWTH.
REPORTS
=======
CXR ___. Linear mid to lower lung opacities likely reflect
atelectasis.
2. Congested hila. Clinical correlation is recommended.
Noncon CT Head ___. No evidence for acute intracranial abnormalities.
2. Previously demonstrated large left
parietal/occipital/posterior temporal hematoma has slightly
decreased in size and density compared to ___, with
decreased mass effect
MRI Brain ___
1. Unchanged left temporo-occipital intraparenchymal hematoma
with local mass effect and no evidence of enhancement.
Follow-up to resolution is
recommended.
2. Chronic subarachnoid hemorrhage in the right frontal lobe.
3. No new hemorrhage.
4. Unchanged 3 mm aneurysm of the proximal basilar artery.
DISCHARGE LABS:
==============
___ 06:04AM BLOOD WBC-8.2 RBC-2.89* Hgb-8.3* Hct-27.2*
MCV-94 MCH-28.7 MCHC-30.5* RDW-18.2* RDWSD-60.7* Plt ___
___ 06:04AM BLOOD Neuts-62.4 Lymphs-15.7* Monos-11.3
Eos-8.8* Baso-0.5 Im ___ AbsNeut-5.09 AbsLymp-1.28
AbsMono-0.92* AbsEos-0.72* AbsBaso-0.04
___ 04:54AM BLOOD Glucose-136* UreaN-33* Creat-0.7 Na-135
K-4.2 Cl-95* HCO3-31 AnGap-13
___ 04:54AM BLOOD Calcium-9.8 Phos-3.0 Mg-2.3
PERTINENT LABS:
==============
___ 04:02AM BLOOD Vanco-15.0
___ 06:37PM BLOOD Ret Aut-3.8* Abs Ret-0.15*
___ 05:38AM BLOOD ALT-15 AST-18 LD(LDH)-135 AlkPhos-135*
TotBili-0.2
___ 06:37PM BLOOD calTIBC-217* Ferritn-210 TRF-167*
___ 04:57AM BLOOD CRP-48.5*
Brief Hospital Course:
___ with a h/o recent admission for Enterococcus and Staph Epi
bacteremia, CVA ___ with resultant aphasia, HTN, DM, HLD, CAD,
who presented from rehab with fevers and change in mental
status.
ACTIVE PROBLEMS
# Sepsis/Sacral Wound Ulcer Infection/Osteomyelitis: Most
obvious source of infection is his sacral decubitus ulcer. CXR
w/o PNA, UA negative, LFT's normal. Other sources to consider
include PICC (nontender, not obviously infected), knee
replacement, and less likely intra-abdominal or meningitis. Had
fevers first several days after admission. WBC initially
uptrended, later downtrending, and of note WBC was lower than
prior hospitalization. Initially started on meningitis dosing of
Cefepime by the ED given concern for meningitis, but this was
changed as meningitis was not felt to be high on DDx. Was then
started on Vanc, Cefepime, Flagyl for broad spectrum coverage.
S/p bedside debridement of sacral wound ___ by ACS. Further
surgical management by ___ on ___ of sacral wound notable for
bone involvement concerning for osteomyelitis. Patient had wound
vac placed by surgery. Patient narrowed to CTX on ___.
Otherwise, patient has been afebrile, no leukocytosis, and
clinically improving. Plan per ID is IV Vanc/Ceftriaxone/Flagyl
x 6 weeks after source control for osteo (last day ___,
with weekly lab monitoring (see transitional issues), and
outpatient ID follow up. Will need wound vac dressing changes
MWF until surgery follow up ___
# Altered Mental Status: Patient had large L territorial
(involving temporal, parietal, and occipital lobe) hemorrhagic
CVA with resulting aphasia. Patient has had waxing and waning
episodes of inattention. Likely hypoactive delirium in the
setting of infection. Admission noncontrast head CT unremarkable
for new infarcts. DDx also includes seizure activity as pt was
on Cefepime which lowers seizure threshold, in addition to
independent effects of Cefepime-induced encephalopathy. Cefepime
was thus changed to Ceftriaxone. Patient had scheduled head MRI
w/o contrast performed while inpatient which revealed no acute
change since prior imaging. His mental status waxed and waned
throughout the admission. Per MRI read follow-up of L
temporo-occipital IPH is recommended on repeat scan (time-frame
undefined).
# Anemia: Stable. Not entirely clear why patient is anemic. MCV
is normal, Ferritin normal (but acutely inflamed), Iron low,
TIBC low, Retic Index <2%. Jehovah's witness, so no blood
transfusions. Tried to minimize lab draws (not every day) once
the patient was clinically stabilized.
# Chronic Diastolic CHF: On Furosemide 60mg BID at rehab, which
was continued here. Became fluid overloaded during a prior
admission when Lasix was held.
CHRONIC PROBLEMS
# Nutrition: nutrition consulted for tube feeds. Per nutrition,
given Zinc 220mg x14 days and Vitamin C 500mg x14 days.
DISCHARGE DIET:
Tubefeeding: Glucerna 1.5 Cal Full strength;
Starting rate: 30 ml/hr; Advance rate by 20 ml q8h Goal rate:
60 ml/hr
Residual Check: q4h Hold feeding for residual >= : 200 ml
Flush w/ 200 ml water q4h
# CVA and history of IPH: CT head on admission improved, MRI
with no change. Keppra 750 mg PO BID for seizure prophylaxis.
# CAD/HTN: Continued Aspirin 81 mg, Atorvastatin 10mg,
labetalol. No active issues. Labetalol dose was lowered and
lisinopril was started to replace hydralazine.
# Paroxysmal A-Fib: Not on anticoagulation due to prior
hemorrhagic stroke, also because of anemia as above. Aspirin was
continued.
# Gout: Continued Allopurinol ___ mg daily
# OSA: CPAP at night.
# Depression, NOS: Fluoxetine 10 mg daily
# GERD: Lansoprazole 30mg daily was stopped in favor of
famotidine BID. This may be stopped in 6 weeks if no indication
to continue. Stool guaiac negative here.
# Diabetes: Blood glucoses currently well controlled on regimen
of Glargine 8 Units Bedtime, and Regular 6 Units Q6H, plus ISS.
Held home metformin, but restarted on discharge.
# BPH: Continued Tamsulosin 0.4 mg QHS
# Insomnia: Continued Trazodone 50 mg QHS PRN
TRANSITIONAL ISSUES
[] Discharge antibiotics: IV Vancomycin, IV Cefriaxone, IV
Metronidazole x6 weeks (last day ___
[] For outpatient antibiotic monitoring, please check the
following weekly: CBC with differential, BUN, Cr, AST, ALT,
Total Bili, Alk Phos, Vancomycin trough, ESR, CRP. Fax results
to ATTN: ___ CLINIC - FAX: ___
[] Will need continued wound vac, with dressing changes every
MWF
[] Can consider bowel diversion and consideration of skin flap
to further enable wound healing and prevent recurrence
[] Recommend to continue discussions with family about goals of
care given the poor long term prognosis for Mr. ___ because
of his numerous chronic medical problems, recent serious stroke,
and multiple infectious complications in the past several
months. Palliative care was consulted this hospital stay, and
can assist with goals of care and/or symptom management moving
forward.
[] Full Code
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q4H:PRN pain, fever
2. Allopurinol ___ mg PO DAILY
3. Atorvastatin 10 mg PO QPM
4. Bisacodyl ___AILY:PRN constipation
5. Fluoxetine 10 mg PO DAILY
6. Furosemide 60 mg PO BID
7. HydrALAzine 25 mg PO Q6H
8. Labetalol 600 mg PO QID
9. Lactulose 15 mL PO BID
10. LeVETiracetam 750 mg PO BID
11. Milk of Magnesia 30 mL PO Q8H:PRN constipation
12. Senna 17.2 mg PO BID
13. Tamsulosin 0.4 mg PO QHS
14. TraZODone 50 mg PO QHS:PRN insomnia
15. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
16. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO Q6H:PRN GI
distress
17. Brovana (arformoterol) 15 mcg/2 mL inhalation BID:PRN SOB
18. Fleet Enema ___AILY:PRN constipation
19. MetFORMIN (Glucophage) 500 mg PO BID
20. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
21. Vitamin D3 (cholecalciferol (vitamin D3)) 2,000 unit oral
DAILY
22. Potassium Chloride 10 mEq PO DAILY
23. Glargine 8 Units Bedtime<br> Regular 6 Units Q6H
Insulin SC Sliding Scale using HUM Insulin
24. Aspirin 81 mg PO DAILY
25. Heparin 5000 UNIT SC BID
26. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
27. Docusate Sodium (Liquid) 100 mg PO BID
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO Q6H:PRN GI
distress
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 10 mg PO QPM
5. Bisacodyl ___AILY:PRN constipation
6. Docusate Sodium (Liquid) 100 mg PO BID
7. Fleet Enema ___AILY:PRN constipation
8. Fluoxetine 10 mg PO DAILY
9. Furosemide 60 mg PO BID
10. Heparin 5000 UNIT SC BID
11. Glargine 8 Units Bedtime<br> Regular 6 Units Q6H
Insulin SC Sliding Scale using HUM Insulin
12. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
13. Labetalol 200 mg PO BID
hold for HR<50, BP<100
14. LeVETiracetam 750 mg PO BID
15. Milk of Magnesia 30 mL PO Q8H:PRN constipation
16. Senna 17.2 mg PO BID
17. TraZODone 50 mg PO QHS:PRN insomnia
18. Acetaminophen 650 mg PO Q4H:PRN pain, fever
19. Brovana (arformoterol) 15 mcg/2 mL inhalation BID:PRN SOB
20. Lisinopril 10 mg PO DAILY
hold for BP<100
21. Vitamin D3 (cholecalciferol (vitamin D3)) 2,000 unit oral
DAILY
22. Tamsulosin 0.4 mg PO QHS
23. MetFORMIN (Glucophage) 500 mg PO BID
24. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
25. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
26. Collagenase Ointment 1 Appl TP Q8H:PRN debridement
27. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
last day ___
28. Vancomycin 1250 mg IV Q 24H
last day ___
29. Famotidine 20 mg PO Q12H Duration: 6 Weeks
30. CeftriaXONE 2 gm IV Q24H
last day ___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
#Sepsis secondary to infected sacral decubitus ulcer
#Sacral osteomyelitis
#Toxic-metabolic encephalopathy
Secondary:
#Aphasia and incomplete hemiplegia
#History of intraparenchymal Hemorrhage ___
#Traumatic right SAH/SDH ___
#PEG and chronic urinary catheter
#Coronary artery disease s/p RCA DES ___
#Atrial fibrillation
#Chronic diastolic heart failure
#Diabetes mellitus type II
#COPD
#Gout
#Obesity
#OSA
Discharge Condition:
Activity Status: Bedbound.
Level of Consciousness: Lethargic but arousable.
Mental Status: Confused - always.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure participating in your care at ___. You were
admitted to our hospital because of fevers. You were found to
have an soft tissue and bone infection of your back wound. This
was treated with antibiotics, and the surgical team did
debridements to help the area heal. You will need to continue
antibiotics for six weeks, in addition to your wound vac. You
will see the surgeons in clinic for ongoing management of your
wound. You will also follow up with Infectious Diseases for
management of your antibiotics.
Once again, it was a pleasure participating in your care, and we
wish you nothing but the best.
___ Medicine Team
Followup Instructions:
___
|
19599279-DS-20
| 19,599,279 | 26,587,716 |
DS
| 20 |
2193-01-23 00:00:00
|
2193-01-23 13:18:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / clonidine patch / Erythromycin Base / Amoxicillin
/ hydrochlorothiazide / aspirin
Attending: ___.
Chief Complaint:
encephalopathy
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with hx of DM, AF, CAD, COPD, SAH, L temporal CVA in
___, and recent bacteremia from urinary source/decubitus
ulcer s/p IV abx with vanc/CTX/flagyl (ended ___ presents
from ___ with encephalopathy.
Per Patient's daughter patient's speech was muffled and he was
twitching more. Per recent discharge summary patient has
significant deficits after his hemmorhgaic CVA and requires PEG
tube, non verbal at baseline. Patient was taken to the ED where
he was noted to have WBC of 12 and a dirty UA. Given this, he
received 1g CTX and admitted to medicine.
ROS: unable to obtain secondary to mental status
Past Medical History:
Type 2 DM
CVA with aphasia in ___
Subdural hematoma
Atrial fibrillation formerly on Coumadin but no longer
CAD s/p RCA DES in ___
COPD
Gout
HLD
Obesity
Spermatocele
OSA
TTE ___: LVH with EF >60%
B/L knee replacements
Social History:
___
Family History:
Brother died of heart failure in ___, sister of cancer (type
unknown) in ___.
Physical Exam:
ADMISSION EXAM:
Gen: NAD
HEENT: NCAT
CV: RRR, no mrg
Resp: CTA ___, no wheezes/rhonchi
Abd: soft, nt, nd
Ext: no CCE
Neuro: no focal deficits but not compliant with exam, non verbal
DISCHARGE EXAM:
VITALS: weight 125 kg, T99 130/46 P78 R 18 93% on RA
GEN: NAD, comfortable appearing, sleeping but opens eyes to
voice and tracks to my face mostly when I am standing on the
patient's left side
HEENT: ncat anicteric MMM
NECK: no JVD
CV: irregularly irregular rhythm, no m/r/g
RESP: CTA ___, no wheezes/rhonchi
ABD: +bs, soft, NT, ND, no guarding or rebound, PEG tube
appears clean/dry/intact
GU: deferred
EXTR: LUE PICC line is clean/dry/intact
DERM: large sacral decubitus ulcer with granulation tissue
NEURO: face symmetric, non verbal (baseline AOx0, can sometimes
open eyes to voice, but non verbal)
PSYCH: calm, cooperative
Pertinent Results:
ADMISSION:
___ 02:50PM WBC-12.7*# RBC-3.80* HGB-10.6* HCT-35.0*
MCV-92 MCH-27.9 MCHC-30.3* RDW-15.6* RDWSD-52.4*
___ 02:50PM GLUCOSE-152* UREA N-35* CREAT-0.8 SODIUM-146*
POTASSIUM-4.0 CHLORIDE-105 TOTAL CO2-32 ANION GAP-13
___ 03:30PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-7.5 LEUK-LG
IMAGING:
LEFT UPPER EXTREMITY U/S:
IMPRESSION:
Left basilic vein not definitively identified and thus not
assessed. No
evidence of deep vein thrombosis elsewhere in the left upper
extremity.
MRI ___:
FINDINGS:
There is patchy hyperintense STIR signal involving the majority
of the muscles
about the pelvis. There is enlargement of the right obturator
internus
muscle, which contains a discrete nonenhancing area with
peripheral rim
enhancement measuring 6.3 x 1.3 x 0.9 cm and 2.6 x 1.0 x 3.9 cm.
In addition,
there is edema in the right gluteus maximus muscle with a
nonenhancing area
with peripheral rim enhancement measuring 4.7 x 2.0 x 3.4 cm (9,
28). There
is fluid in the left greater trochanteric bursa with peripheral
rim
enhancement measuring 3.5 x 1.9 x 4.3 cm.
There is a large ulcer within the subcutaneous tissues extending
to the
inferior sacrum and coccyx measuring approximately 5.3 x 5.0 cm.
The
underlying bone marrow signal in the sacrum is normal without
evidence of
edema or enhancement. Evaluation of the coccyx is limited due
to the lack of
sagittal images and osteomyelitis cannot ruled out in the
coccyx. There is no
fracture or stress fracture. There is no suspicious osseous
lesion.
There is mild levoscoliosis of the visualized lower lumbar spine
and moderate
degenerative changes. There are minimal degenerative changes in
the hips
bilaterally. The proximal hamstring tendon origins are intact.
The prostate is enlarged measuring 5.6 x 4.5 x 5.6 cm. A Foley
catheter is in
the bladder. The rectum is distended with stool. Otherwise the
visualized
intrapelvic structures are within normal limits.
IMPRESSION:
Large ulcer within the subcutaneous tissues extending to the
sacrum and
coccyx. No evidence of osteomyelitis in the sacrum. Evaluation
of the coccyx
is limited due to the lack of sagittal images and osteomyelitis
cannot ruled
out in the coccyx.
Areas of nonenhancing muscle with peripheral rim enhancement in
the right
obturator internus and right gluteus maximus laterally may
represent diabetic
myonecrosis or pyomyositis. Patchy areas of edema in the
majority of the
remaining musculature of the pelvis.
Small amount of fluid with peripheral rim enhancement of the
left trochanteric
bursa.
Enlarged prostate.
Brief Hospital Course:
Mr. ___ is a ___ man with hx of DM, AF, CAD, COPD, SAH, L
temporal CVA in ___ (baseline AOx0, can sometimes open eyes
to voice, but non verbal) s/p PEG tube on tube feeds, and recent
bacteremia from urinary source/decubitus ulcer s/p IV abx with
vanc/CTX/flagyl (ended ___ who presented from ___ with
encephalopathy. Sacral wound did not appear overtly infected
however the patient developed low grade fevers so MRI was
obtained which showed areas concerning for pyomyositis in his
right obturator internus andnright gluteus with no evidence of
sacral osteo but unable tonexclude coccygeal osteo. ACS and
ortho were consulted for debridement and deep tissue biopsy but,
given the morbidity of the procedure and potential of creating a
much larger wound, the risks benefits were discussed with the
patient's daughter and intervention was deferred. Decision was
made to restart vanc/ceftriaxone/flagyl with plan to trend his
inflammatory markers with eventual consideration of flap closure
based on clinical improvement. Overall he remained stable,
afebrile after resumption of abx (although unclear if true
deviation for baseline for the patient since A/O x 0). Rest of
hospital course/plan are outlined below by issue.
ACTIVE PROBLEMS
# Acute encephalopathy: unclear whether this is a true deviation
from baseline for the patient. Likely source is sacral wound or
hypovolemia and hypernatremia as a source. Patient had large L
territorial (involving temporal, parietal, and occipital
lobe)hemorrhagic CVA with resulting aphasia. Patient has had
waxing and waning episodes of inattention. Likely hypoactive
delirium
-received 1x dose of CTX in ED, no longer on abx per ID
-ESR/CRP grossly elevated
-appears to be close to recent baseline per nursing home
communication, however per daughter he is worse than prior
#Fever: unclear source, UA showed moderate leuks, wbc, and
bacteria. Urine culture grew yeast and <100,000 CFUs of
enterococcus which likely represent contaminant and his wound is
the most likely source of his fever and appeared to respond to
restarting antibiotics. per ID, the VRE in his urine seemed more
likely to be contaminant/colonization, especially given no
worsening of pyuria on UA obtained at time of culture. ___
exchanged on ___. MRI of the pelvis showed no osteo, however
did show areas of myonecrosis vs. pyonecrosis. Had family
meeting with daughter and wife at bedside with orthopedics, Dr.
___. Discussed the high risk of morbidity of debridement
procedure for possible myo/pyonecrosis of the hip musculature.
Given that patient is bedbound and unlikely to gain significant
function, in conjunction with family the decision was made to
not pursue surgery but instead consider longer course of
antibiotics in even that this might be infectious.
-f/u ID recs, likely OPAT with long term antibiotics
-Vanc/Ceftriaxone/flagyl ___-
-developed Leukocytosis on ___, however had just started broad
spectrum abx the night before. WBC to continue to be trended
#Sacral decubitus ulcer: present on admission. Seen by ACS and
wound nurse. They have disagreed on the degree of necrotic
tissue. ACS felt wound did not have significant necrosis and did
not need debridement while wound nurse felt there was
significant necrosis. Patient originally had wound vac when
arrived, but was taken off on arrival and wound care nurse did
not feel it is appropriate given the presence of necrotic
tissue. He did have significant drainage from wound and wound
vac was reconsidered however based on appearance of necrotic
tissue and subsequent improvement of the drainage over several
days while inpatient, dry dressing was preferred with daily
saline cleanse (see specific wound recs in transitional issues
below).
#Mynecrosis/pyonecrosis of hip muscles: Discussed the high risk
of morbidity of debridement procedure for possible
myo/pyonecrosis of the hip musculature. Given that patient is
bedbound and unlikely to gain significant function, in
conjunction with family the decision was made to not pursue
surgery but instead consider longer course of antibiotics in
even that this might be infectious.
-vanc/ceftriaxone/flagyl
-Vanc/CTX/Flagyl long term, seen by ID and followed by OPAT.
-vanco trough on the day of discharge was 21.5. I discussed
dosing with pharmacy who felt that the trough was drawn about a
half hour early and goal trough is ___ and so this dose is
likely appropriate (1g q12h). Recommending repeat vanco trough
be drawn within 24 h after discharge. His renal function as
stable. Antibiotics will be followed by OPAT.
#Hyponatremia: resolved with increased free water flushes
-increased free water flushes to 250 q4
#Subacute/Chronic Anemia: CBC has slowly declined over the
course of this hospitalization (from hb 10.6 on ___ to 8.0 on
___. His last BM was on ___ and was non-melenic so acute GI
bleeding is unlikely. Most likely anemia of chronic disease
relating to chronic infection with elevated inflammatory markers
+/- frequent lab draws obtained while inpatient. Ddx also
includes small amounts of blood lost through his wound which may
contribute as well. CBC was stable on the day of discharge.
-iron studies showed ferritin 223 and low TIBC which is
consistent with the diagnosis of ACD so treatment is management
of the underlying infection with antibiotics.
#Chronic Diastolic CHF: resumed home lasix 60mg BID
CHRONIC PROBLEMS
#CVA and history of IPH: CT head on admission improved, MRI
with no change. Keppra 750 mg PO BID for seizure prophylaxis.
#CAD/HTN: Continued Aspirin 81 mg, Atorvastatin 10mg,
labetalol, lisinopril. No active issues.
#Paroxysmal A-Fib: on Aspirin given hx of hemorrhagic stroke
#Gout: Continued Allopurinol ___ mg daily
#OSA: CPAP at night.
#Depression, less than ___ years: continued on Fluoxetine 10 mg
daily
#GERD: famotidine BID
#Diabetes: Glargine 8 Units qhs and RISS, Held home metformin.
Resumed 6 units q6h regular insulin as well.
#BPH: hold Tamsulosin 0.4 mg QHS for now given indwelling foley
catheter
#Insomnia: Continue Trazodone 50 mg QHS PRN
#ACCESS: ___ placed ___ in LUE
#Nutrition: Tubefeeding: Glucerna 1.5 Cal Full strength;
-Starting rate: 60 ml/hr; Do not advance rate Goal rate: 60
ml/hr
-Residual Check: q4h Hold feeding for residual >= : 200 ml
Flush w/ 250 ml water q4h Supplements:
Beneprotein: Mix each packet with 60 cc water & stir until
dissolved
-Administer by syringe through feeding tube. Flush each packet
with 30 ml water; #packets: 1; times/day
#DVT PPx: HSQ
#CODE: FULL
#Transitional:
-needs CBC drawn within ___ weeks after discharge to follow up
anemia.
-daughter requested speech and swallow re-eval which will be
ordered to be performed at facility
-should have repeat CBC drawn within ___ weeks after discharge
to trend anemia.
-has OPAT appointment scheduled for ___
-outpatient wound care: per wound consult note: Cleans wounds
with normal saline then pat dry with gauze, apply criticaid
clear to periwound tissue, pack loosely with ___ AMD Kerlix
(supply room ___ and cover with sofsorb and secure with
medipore tape (pink hytape inferior to protect from stooling.
Change dressings BID. air mattress. Turn and reposition every
___ hours and PRN off affected area. Heels off bed with waffle
booths.
-he will need a vancomycin trough drawn within 24h after
transfer to ___ to follow levels, goal trough ___.
#Contact: ___ ___. I called ___
___ because she requested to speak with me on ___
and had a long conversation with her over the phone about her
father and answered all questions. I discussed the full plan
with her in regards to management of her father's wound
including outpatient OPAT follow up.
spent > 30 minutes seeing patient and organizing discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO Q6H:PRN GI
distress
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 10 mg PO QPM
5. Bisacodyl ___AILY:PRN constipation
6. Docusate Sodium (Liquid) 100 mg PO BID
7. Fleet Enema ___AILY:PRN constipation
8. Fluoxetine 10 mg PO DAILY
9. Furosemide 60 mg PO BID
10. Heparin 5000 UNIT SC BID
11. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
12. Labetalol 200 mg PO BID
13. LeVETiracetam 750 mg PO BID
14. Milk of Magnesia 30 mL PO Q8H:PRN constipation
15. Senna 17.2 mg PO BID
16. TraZODone 50 mg PO QHS:PRN insomnia
17. Acetaminophen 650 mg PO Q4H:PRN pain, fever
18. Brovana (arformoterol) 15 mcg/2 mL inhalation BID:PRN SOB
19. Lisinopril 10 mg PO DAILY
20. Vitamin D3 (cholecalciferol (vitamin D3)) 2,000 unit oral
DAILY
21. Tamsulosin 0.4 mg PO QHS
22. MetFORMIN (Glucophage) 500 mg PO BID
23. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
24. Collagenase Ointment 1 Appl TP Q8H:PRN debridement
25. Famotidine 20 mg PO Q12H
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN pain, fever
2. Allopurinol ___ mg PO DAILY
3. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO Q6H:PRN GI
distress
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 10 mg PO QPM
6. Bisacodyl ___AILY:PRN constipation
7. Docusate Sodium (Liquid) 100 mg PO BID
8. Famotidine 20 mg PO Q12H
9. Fleet Enema ___AILY:PRN constipation
10. Fluoxetine 10 mg PO DAILY
11. Furosemide 60 mg PO BID
12. Heparin 5000 UNIT SC BID
13. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
14. Labetalol 200 mg PO BID
15. LeVETiracetam 750 mg PO BID
16. Lisinopril 10 mg PO DAILY
17. Milk of Magnesia 30 mL PO Q8H:PRN constipation
18. Senna 17.2 mg PO BID
19. TraZODone 50 mg PO QHS:PRN insomnia
20. CeftriaXONE 2 gm IV Q24H
21. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H
22. Vancomycin 1000 mg IV Q 12H
23. Zinc Sulfate 220 mg PO DAILY
24. Brovana (arformoterol) 15 mcg/2 mL inhalation BID:PRN SOB
25. Collagenase Ointment 1 Appl TP Q8H:PRN debridement
26. MetFORMIN (Glucophage) 500 mg PO BID
27. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
28. Tamsulosin 0.4 mg PO QHS
29. Vitamin D3 (cholecalciferol (vitamin D3)) 2,000 unit oral
DAILY
30. Ascorbic Acid ___ mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Myonecrosis
Sacral decubitus ulcer
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ for evaluation of lethargy. You were
found to have necrosis of numerous muscles of the hip, however
we are unsure whether this is myonecrosis from an infection or
not from an infection. After discussing this with your family,
the decision was made to not pursue aggressive surgery, but to
instead treat empirically with antibiotics. Please follow up
with the infectious disease doctors and continue to take
anitbiotics until they see you.
Followup Instructions:
___
|
19599279-DS-21
| 19,599,279 | 29,952,765 |
DS
| 21 |
2193-02-01 00:00:00
|
2193-02-05 18:28:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Penicillins / clonidine patch / Erythromycin Base / Amoxicillin
/ hydrochlorothiazide / aspirin
Attending: ___
Chief Complaint:
right facial droop
Major Surgical or Invasive Procedure:
___ line replacement ___
History of Present Illness:
___ Stroke Scale - Total [22]
1a. Level of Consciousness - 0
1b. LOC Questions - 2
1c. LOC Commands - 2
2. Best Gaze - 1(left preference)
3. Visual Fields - 2 (right homonymous hemianopsia)
4. Facial Palsy - 2 (right facial droop in upper and lower
division)
5a. Motor arm, left - 2 (limited by cooperation)
5b. Motor arm, right - 2 (limited by cooperation)
6a. Motor leg, left - 2 (limited by cooperation)
6b. Motor leg, right - 2 (limited by cooperation)
7. Limb Ataxia - 0
8. Sensory - 0
9. Language - 3
10. Dysarthria - 2
11. Extinction and Neglect -0
HPI:
Mr. ___ is an ___ with an extensive past medical
history
including DM, AF, CAD s/p Stent, COPD, prior traumatic Right
frontal SAH, L temporal Hemorrhage in ___ in the setting of
likely CAA with recent admission for infected sacral decubitus
ulcer and myonecrosis on chronic antibiotics who presents with
acute onset facial droop.
History is quite limited. At his baseline, Mr. ___ is
non-verbal and to my understanding does not follow verbal
commands. he has a chronic right hemiparesis, mild right lower
face weakness/droop and likely right field cut. He resides in
an
assisted living facility where is is PEG dependent.
Today, Mr. ___ presented to an outpatient Infectious Disease
appointment from his facility by ambulance. Per conversation
with Dr. ___ fellow, he was doing well at the time of
his
appointment (roughly 9am) without new deficits. He was last
seen
by the physician shortly before 10am and was being taken via
ambo
back to his facility. Roughly between ___, he was seen by
EMS to have acute onset right facial droop. He was subsequently
brought to the ___ ED.
Of note, Mr. ___ was recently admitted to ___ on the
medicine service from ___ in the setting of AMS,
subsequently found to have a sacral decubitus ulcer with
evidence
of myonecrosis/pyonecrosis. He was deemed to be a high
morbidity
risk for debridement and instead is undergoing long term
antibiotic therapy per ID.
RoS unable to be gathered from the patient.
Past Medical History:
- Type 2 DM
- Hemorrhagic infarction of Left Temporo-parietal lobe with
aphasia in ___
- Possible CAA
- Right frontal SAH.
- Atrial fibrillation formerly on Coumadin but no longer
- CAD s/p RCA DES in ___
- COPD
- Gout
- HLD
- Obesity
- Spermatocele
- OSA
- TTE ___: LVH with EF >60%
- B/L knee replacements
Social History:
___
Family History:
Brother died of heart failure in ___, sister of cancer (type
unknown) in ___.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 97.8 73 178/79 18 95% RA
General: Awake, NAD.
HEENT: NC/AT
Neck: Supple. No nuchal rigidity
Pulmonary: CTABL
Cardiac: Irregularly Irregular.
Abdomen: soft, nontender, nondistended. PEG in place.
Extremities: WWP. B/l knee replacement scars
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Spontaneously awake and looks to provider on
his
left. Non-verbal and follows no commands. Makes groaning
noises.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 2 to 1.5mm, both directly and consentually; brisk
bilaterally. Decreased blink to threat on the right.
III, IV, VI: Eyes midline with left gaze preference. Can cross
to right briefly..
V: Corneals present bilaterally, blink to corneal slightly
slower on right.
VII: Right facial droop at rest and with grimace with weakness
of eye closure and decreased blink rate.
VIII: Appears to react to loud voice..
IX, X: Not assessed.
XI: Turns head.
XII: Tongue rests in midline.
-Motor: Normal bulk. Increased tone with flexure posturing of
RUE. Increase tone in RLE. Tone normal on left side.
Lmited exam due to patient cooperation/understanding, appears to
withdraw Right>Left in both upper and lower extremity.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 0 /
R 2+ 2 2+ 0 /
- Plantar response was upgoing bilaterally.
-Sensory: Responds to noxious in all 4 ext
=
=
=
=
=
=
================================================================
DISCHARGE PHYSICAL EXAM:
VS: 98.8 BP 137-165/51-72 HR ___ RR 18 O2 sat 96 RA
MS: Awake, alert, regards examiner. Tracks face. Right facial
droop. Responds "no" to pain. Does not answer other questions.
Inconsistently follows commands, does not stick out tongue or
close eyes but tries to give thumbs up on the right hand.
CN: Pupils equal, round and reactive. Bilateral blink to threat.
Right facial droop.
Sensorimotor: RUE antigravity spontaneously. RLE withdraws to
noxious stimuli. LUE with minimal movement to noxious stimuli.
LLE withdraws to noxious stimuli.
Coordination and Gait: deferred
Pertinent Results:
ADMISSION LABS:
___ 10:59AM BLOOD WBC-10.6* RBC-3.31* Hgb-9.3* Hct-30.5*
MCV-92 MCH-28.1 MCHC-30.5* RDW-15.9* RDWSD-52.2* Plt ___
___ 10:59AM BLOOD ___ PTT-31.4 ___
___ 05:20AM BLOOD Glucose-157* UreaN-25* Creat-0.6 Na-149*
K-4.3 Cl-111* HCO3-30 AnGap-12
___ 10:59AM BLOOD ALT-14 AST-18 CK(CPK)-23* AlkPhos-104
TotBili-0.2
___ 10:59AM BLOOD Lipase-45
___ 10:59AM BLOOD CK-MB-2 cTropnT-0.08* proBNP-992*
___ 10:59AM BLOOD Albumin-2.8*
___ 05:20AM BLOOD Calcium-10.8* Phos-2.9 Mg-2.4
___ 05:20AM BLOOD %HbA1c-6.8* eAG-148*
___ 05:20AM BLOOD HDL-40
___ 05:20AM BLOOD TSH-2.0
___ 12:57AM BLOOD Vanco-16.0
IMAGING:
CTA HEAD AND NECK ___:
1. Continued evolution of a large left parietal occipital
posterior temporal hematoma with developing encephalomalacia.
No new or enlarging hemorrhage.
2. Moderately dilated ventricles which are mildly out of
proportion to the
degree of cortical sulcation and mildly increased comparison to
___ CT. Given the interval change, findings may
represent hydrocephalus with differential including central
volume loss. Recommend clinical correlation.
3. Diffuse beaded stenosis of the intracranial vasculature,
consistent with intracranial atherosclerosis. This is most
severe within the vertebral basilar system where there is severe
stenosis with occlusion versus slow flow at the mid to superior
basilar artery. These findings are relatively unchanged
comparison to prior CTA.
4. Unchanged 3 mm aneurysm at the right vertebral basilar
junction.
5. Patent neck vasculature with 40% stenosis at the right
carotid bulb by
NASCET criteria.
6. Periapical lucencies involving the right maxillary central
incisor and
second molar tooth. Recommend follow-up with dentistry.
CXR ___:
1. Malpositioned left upper extremity PICC line.
2. Hilar congestion without frank edema.
3. Bibasilar atelectasis.
MRI BRAIN ___:
1. No acute infarction.
2. Decreased left parietal/ occipital/ posterior temporal
hematoma compared to ___. Decreased effacement of
the occipital horn of the left lateral ventricle.
3. Unchanged siderosis in the right central sulcus related to
prior
subarachnoid hemorrhage. Unchanged scattered punctate
microhemorrhages in the brain parenchyma, with distribution
compatible with a combination of
hypertensive etiology and amyloid angiopathy.
CXR ___:
Successful placement of a 48 cm left arm approach double lumen
PowerPICC with tip in the lower SVC. The line is ready to use.
Brief Hospital Course:
Mr. ___ is an ___ man with an extensive past
medical history including DM, AFib not on anticoagution due to
prior ICP, CAD s/p Stent, COPD, prior traumatic Right frontal
SAH, L temporal hemorrhage with residual right sided weakness in
___ in the setting of likely CAA with recent admission for
infected sacral decubitus ulcer, osteomyelitis and myonecrosis
on chronic antibiotics who presented with acute onset right
facial droop and possible left sided weakness without evidence
of acute stroke on MRI.
Initial exam was notable for right-sided facial droop, felt to
be acute by the EMS providers transporting him to his clinic
appointment, but later felt to be chronic per his daughter. ___
was difficult to interpret given baseline limited participation
and residual right sided weakness from prior stroke. However,
initial exam was concerning for possible new left sided
weakness. He was admitted for stroke work-up and continued on
home aspirin.
He underwent CTA which demonstrated extensive atherosclerotic
diease with concern for basilar occlusion and retrograde filling
from the anterior circulation. ___ does not demonstrate any
evidence of new or clear ischemia. A follow-up MRI was done,
which did not show any acute infarct. The facial droop was
therefore felt to be chronic per collateral from daughter, and
the weakness on the left was unclear to begin with.
Additionally, he was admitted with a mild troponinemia to 0.08,
which may have represented a small cardiac event causing
worsening of symptoms. The troponin quickly trended down to
normal value after 3 sets.
Infectious work-up was unrevealing, though CXR did show that his
PICC line was malpositioned. This was replaced with
interventional radiology to complete his course of antibioitics
for osteomyelitis.
He will continue on aspirin for stroke prevention and follow-up
with Atrius neurology as previously planned.
Transitional issues:
-continue Aspirin 81mg
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Docusate Sodium 100 mg PO BID
2. Famotidine 20 mg PO BID
3. Fluoxetine 10 mg PO DAILY
4. Furosemide 60 mg PO BID
5. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
6. Labetalol 200 mg PO BID
7. LeVETiracetam 750 mg PO BID
8. Ascorbic Acid ___ mg PO BID
9. CeftriaXONE 2 gm IV Q24H
10. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H
11. Vancomycin 1000 mg IV Q 12H
12. Zinc Sulfate 220 mg PO DAILY
13. Allopurinol ___ mg PO DAILY
14. aspirin 81 mg oral DAILY
15. Atorvastatin 10 mg PO QPM
16. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO QID:PRN GI
upset
17. Brovana (arformoterol) 15 mcg/2 mL inhalation BID:PRN
dyspnea
18. Heparin 5000 UNIT SC BID
19. Tamsulosin 0.4 mg PO QHS
20. Lisinopril 10 mg PO DAILY
21. MetFORMIN (Glucophage) 500 mg PO BID
22. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
23. Senna 17.2 mg PO BID
24. TraZODone 50 mg PO QHS:PRN insomnia
25. Vitamin D ___ UNIT PO DAILY
26. Acetaminophen 650 mg PO Q6H:PRN pain, fever
27. Milk of Magnesia 30 mL PO DAILY:PRN constipation
28. Bisacodyl ___AILY:PRN constipation
29. Fleet Enema ___AILY:PRN constipation
30. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using REG Insulin
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 10 mg PO QPM
4. CeftriaXONE 2 gm IV Q24H
5. Docusate Sodium 100 mg PO BID
6. Famotidine 20 mg PO BID
7. Fluoxetine 10 mg PO DAILY
8. Furosemide 60 mg PO BID
9. Heparin 5000 UNIT SC BID
10. Labetalol 200 mg PO BID
11. LeVETiracetam 750 mg PO BID
12. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H
13. Senna 17.2 mg PO BID
14. Tamsulosin 0.4 mg PO QHS
15. Vancomycin 1000 mg IV Q 12H
16. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using REG Insulin
17. Acetaminophen 650 mg PO Q6H:PRN pain, fever
18. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO QID:PRN GI
upset
19. Ascorbic Acid ___ mg PO BID
20. Bisacodyl ___AILY:PRN constipation
21. Brovana (arformoterol) 15 mcg/2 mL inhalation BID:PRN
dyspnea
22. Fleet Enema ___AILY:PRN constipation
23. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
24. Lisinopril 10 mg PO DAILY
25. MetFORMIN (Glucophage) 500 mg PO BID
26. Milk of Magnesia 30 mL PO DAILY:PRN constipation
27. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
28. TraZODone 50 mg PO QHS:PRN insomnia
29. Vitamin D ___ UNIT PO DAILY
30. Zinc Sulfate 220 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right facial droop
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ with right facial droop. You had a CT
scan and MRI which did not show any new stroke. Your daughter
feels this facial droop is old so you were continued on your
home aspirin for stroke prevention.
On chest x-ray, it was found that your PICC line was in the
wrong position. This was replaced during the hospital stay.
Please follow-up with your PCP and neurologist as previously
planned through your skilled nursing facility.
It was a pleasure taking care of you,
Your ___ Neurologists
Followup Instructions:
___
|
19599279-DS-22
| 19,599,279 | 24,802,395 |
DS
| 22 |
2193-03-19 00:00:00
|
2193-03-20 12:07:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / clonidine patch / Erythromycin Base / Amoxicillin
/ hydrochlorothiazide / aspirin
Attending: ___.
Chief Complaint:
increased lethargy, restlessness
Major Surgical or Invasive Procedure:
___ exchange
History of Present Illness:
Mr. ___ is a ___ y/o M with medical history significant for
neurological devastation due to traumatic R frontal subarachnoid
hemorrhage, recent left temporal hemorrhage in ___ with two
recent admissions in ___ for infected sacral decubitus ulcers
and myonecrosis and later for right sided facial droop and left
sided weakness without new findings of CVA on head CT and MRI
who presents today from his ___ with concern for change in
mental status.
He was sent today from his ___ for increased lethargy noted this
morning and increased restlessness. His foley catheter which is
permanently indwelling was leaking. Foley last changed on
___ due to clots. ___ RN note from today states that pt's
bladder appeared to be distended and tender to touch this
morning. Vitals at ___ were BP 88/47, T 99.3, SpO2 99%, HR 97,
RR 24. Was put on O2 2L for comfort due to increased
respiratory rate.
In the ED, VS were Tm 99.8, HR 87, BP 125/66, RR 20, 100% on 2L
NC. CXR showed no focal consolidations. UA was positive for
moderate ___, 22 RBC, 85 WBC, few bacteria, no yeast. No
nitrites. CT abdomen pelvis significant for hyperemic,
thickened bladder walls with adjacent fat stranding and fluid
tracts along b/l ureters and distal ureter w/ urothelial
thickening and hyperemia, all findings consistent with possible
urinary tract infection. Due to these findings and elevated
temperatures and report of increased lethargy, pt was
empirically started on ciprofloxacin for a urinary tract
infection and given 1000 ml NS. He was admitted for medical
management.
On arrival to the floor, pt is alert and at similar baseline as
when he was discharged in early ___ per nursing. He is
unable to meaningfully answer questions.
Past Medical History:
Type 2 DM
Hemorrhagic CVA with aphasia in ___
Subdural hematoma and subarachnoid hemorrhage ___
Atrial fibrillation formerly on Coumadin but no longer
CAD s/p RCA DES in ___
COPD
Gout
HLD
Obesity
Spermatocele
OSA
B/L knee replacements
S. epi and enterococcus BSI (___) thought due to urinary
source
Sacral osteo (___) as above
TTE ___: EF > 60%
Social History:
___
Family History:
Brother died of heart failure in ___, sister of
cancer (type unknown) in ___.
Physical Exam:
VS: t 98.2, hr 94, bp 150/96, RR 22, sPO2 95% RA
GEN: obese male lying in bed, NAD.
HEENT: PERRL. no conjunctival injection, no scleral icterus
CV: distant heart sounds, regular rate and rhythm. ___ murmur
at LUSB.
PULM: CTAB, no w/r/r, no increased work of breathing
ABD: soft, obese, hypoactive bowel sounds. No wincing with
palpation. G tube in place, no surrounding erythema or drainage
GU: ___ catheter in place, small amnt leakage. Small amnt
yellow, slightly cloudy urine in foley bag
EXT: warm, well perfused
SKIN: Sacral decubitus ulcer, Stage IV. 8 cm x 7 cm x 4 cm
deep. wound base with healthy pink granulation tissue at base,
no sloughing or exudate. No tunneling/ tracking except for
about 0.___t 11:00. No surrounding erythema, edges
clean.
NEURO: tracks with eyes, can squeeze with right hand when
examiner's hand placed in it. Murmurs to questions but words
are unintelligible.
Pertinent Results:
- significant for WBC 11.0, 72.9% neutrophils. Cr 0.8, BUN 40,
no other abnormalities.
- UA significant for moderate ___, no nitrite, moderate amnt
blood, 85 WBC, 22 WBC, few bacteria. This is different from
previous UA on ___ which was negative, 4 WBC and 3 RBC.
CXR ___
FINDINGS:
The cardiac silhouette is enlarged. Lung volumes are decreased
with
associated crowding of the bronchovascular structures. There is
also
bibasilar atelectasis. No focal consolidation is identified.
There is no pneumothorax in this portable chest radiograph.
IMPRESSION:
1. Low lung volumes with bibasilar atelectasis. No focal
consolidation.
2. Stable cardiomegaly.
CT ___ ___:
1. Hyperemic, thickened bladder walls with adjacent fat
stranding. Fluid tracks along bilateral ureters, and the distal
ureters demonstrate urothelial thickening and hyperemia.
Findings are concerning for urinary tract infection, for which
correlation with urinalysis is recommended.
2. Consolidation in the medial basal segment of the right lower
lobe may be due to atelectasis, however superimposed infection
is not excluded.
3. Indeterminate 2.0 cm left lower pole renal cyst, with a
slightly high internal attenuation. This may reflect hemorrhagic
or proteinaceous products. However, nonemergent renal
ultrasound could be performed for further characterization.
MICRO:
Time Taken Not Noted Log-In Date/Time: ___ 3:27 pm
URINE TAKEN FROM ___.
URINE CULTURE (Preliminary):
PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION. OF TWO COLONIAL
MORPHOLOGIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 16 I
CEFTAZIDIME----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ 8 I
MEROPENEM------------- 8 R
TOBRAMYCIN------------ <=1 S
Brief Hospital Course:
___ y/o male with extensive medical history including neurologic
devestation due to traumatic subarachnoid hemorrhage and
subdural hemorrhage in ___ and hemorrhagic CVA in ___ with
known sacral decubitus ulcer now s/p 6 weeks antibiotic therapy
with metronidazole and vancomycin presenting today with
increased lethargy per his ___, found to have leukocytosis,
elevated temperatures, and UA, ___ consistent with UTI.
# Complicated UTI:
Has chronic indwelling foley catheter. UA positive for ___,
bacteria, WBC and blood today whereas negative on last study on
___. CT shows bladder wall and ureteral thickening
consistent with infection. Started on ciprofloxacin in ED. The
patient's foley was changed in the emergency department. He was
initially treated with ciprofloxacin but then changed to
extended infusion cefepime given urine culture growing
pseudomonas. He will need to continue antibiotics for a total of
10 days.
#Sacral decubitus wound:
The patent was seen by the wound care nurses and by infectious
disease. There were no signs of active wound infection. The
patent should continued local wound care
Chronic issues:
- HTN: continue lisinopril, atenolol. HOld furosemide while
infected, until BUN/Cr improves
- CAD: continue aspirin, atorvastatin
- BPH: continue tamsulosin
- TBI: continue levetiracetam
- GERD: continue famotidine
- DM: hold metformin while inpatient, SSI
- continue home tube feeds
Transitional issues
=============
held lisinopril while on Bactrim to prevent hyperkalemia.
FULL CODE, has MOLST in chart
Medications on Admission:
Outpatient medications from ___ paperwork:
- Aspirin 81 mg PO DAILY
- Atorvastatin 10 mg PO QPM
- Docusate Sodium 100 mg PO BID
- Famotidine 20 mg PO BID
- Fluoxetine 10 mg PO DAILY
- Furosemide 60 mg PO BID
- Heparin 5000 UNIT SC BID
- Labetalol 200 mg PO BID
- LeVETiracetam 750 mg PO BID
- Senna 17.2 mg PO BID
- Tamsulosin 0.4 mg PO QHS
- metformin 500 mg BID
- Ascorbic Acid ___ mg PO BID
- Bisacodyl ___AILY:PRN constipation
- duonebs Q6H
- Fleet Enema ___AILY:PRN constipation
- Lisinopril 10 mg PO DAILY
- Vitamin D ___ UNIT PO DAILY
- Zinc Sulfate 220 mg PO DAILY
Discharge Medications:
1. Ascorbic Acid ___ mg PO BID
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 10 mg PO QPM
4. Docusate Sodium (Liquid) 100 mg PO BID
5. Famotidine 20 mg PO BID
6. FLUoxetine 10 mg PO DAILY
7. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using REG Insulin
8. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN shortness of
breath
9. Labetalol 200 mg PO BID
10. levETIRAcetam 750 mg oral BID
11. MetFORMIN (Glucophage) 500 mg PO BID
12. Senna 17.2 mg PO BID
13. Tamsulosin 0.4 mg PO QHS
14. Vitamin D ___ UNIT PO DAILY
15. CefePIME 2 g IV Q8H
infuse over 3hrs
16. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 7 Days
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Catheter associated UTI
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic and not arousable.
Activity Status: Bedbound.
Discharge Instructions:
Mr. ___,
You were admitted with change in mental status and concern for
urinary tract infection. You had a CT scan which showed a
urinary tract infection. Your foley catheter was changed. You
were seen by infectious disease who recommended treating your
urinary tract infection with 10 days of intravenous antibiotics.
You were also seen by the wound care nurse who recommended
continued wound care to your sacrum.
You will return to your rehab for ongoing care.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
19599279-DS-23
| 19,599,279 | 25,772,609 |
DS
| 23 |
2193-06-21 00:00:00
|
2193-06-21 21:57:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / clonidine patch / Erythromycin Base / Amoxicillin
/ hydrochlorothiazide / aspirin
Attending: ___.
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ M w/extensive past medical history including
DM, AF, CAD s/p Stent, COPD, traumatic subarachnoid hemorrhage
and subdural hemorrhage in ___ and hemorrhagic CVA in ___
with known sacral decubitus ulcer, recent admission for
complicated UTI in ___, presents with altered mental status
from health care facility.
Patient is nonverbal, but gurgles incomprehensible speech at
baseline, per EMS. Patient usually tracks with his eyes, but
today he stopped tracking. Also has labored breathing with
moaning. No other focal neuro symptoms that are new. Patient has
right-sided paralysis from prior strokes. Patient is unable to
provide history. Per patient's family, for the past 3 weeks,
patient was seen in ED on ___ for increased work of breathing
with drooling. A CXR was done at his rehab facility with no
evidence of PNA. He was prophylactically covered with a 1 week
course of Vantin and nebs, with minimal improvement. He was
discharged from the ED with cipro x7 days for UTI.
In the ED, initial VS were 97.6 70 189/108 26 100% on Nasal
Cannula.
Exam notable for crackles in lung bases R>>L, nontender abdomen,
sacral decubitus ulcer present.
Labs showed WBC 9.6 75% N, H/H 10.3/37.5, Na 146, K 4.9, Bicarb
38, BUN 29, Cr 0.6, lactate 1.5, troponin 0.07, MB 4, proBNP
1613. EKG with STE on lateral leads stable from prior.
UA with 115 WBC, 55 RBC, leuks, nitrites, protein.
CT head w/ no intracranial hemorrhage.
Received 1g IV vancomycin. Left IJ placed.
Transfer VS were 98.4 68 128/67 19 100% on NC.
Decision was made to admit to medicine for further management.
Past Medical History:
Type 2 DM
Hemorrhagic CVA with aphasia in ___
Subdural hematoma and subarachnoid hemorrhage ___
Atrial fibrillation formerly on Coumadin but no longer
CAD s/p RCA DES in ___
COPD
Gout
HLD
Obesity
Spermatocele
OSA
B/L knee replacements
S. epi and enterococcus BSI (___) thought due to urinary
source
Sacral osteo (___) as above
TTE ___: EF > 60%
Social History:
___
Family History:
Brother died of heart failure in ___, sister of cancer (type
unknown) in ___.
Physical Exam:
ADMISSION EXAM:
===============
VS - 98.7 180 / 95 72 20 100% 1.5L
GENERAL: Moaning, no increased work of breathing
GEN: obese male lying in bed, NAD.
HEENT: PERRL. No scleral icterus. L pupil reactive to light, R
pupil minimally reactive
CV: distant heart sounds, regular rate and rhythm. ___ murmur
at LUSB.
PULM: CTAB, no w/r/r, no increased work of breathing
ABD: soft, obese, hypoactive bowel sounds. No wincing with
palpation. G tube in place, no surrounding erythema or drainage
GU: Foley in place, clear urine in foley bag
EXT: warm, well perfused
SKIN: Sacral decubitus ulcer per family, unable to assess due
to pt posisiton
NEURO: Can squeeze with right hand on command. Withdraws to
pain. Toes downwards bilaterally.
DISCHARGE EXAM:
===============
VS - Temp: 97, BP: 158/71, P 61, RR 20, O2 sat 98% on RA
GENERAL: Intermittently moaning, but improved with no evidence
of discomfort
GEN: Obese male lying in bed, NAD.
HEENT: PERRL. No scleral icterus. Opens eyes with speech or
touch.
CV: Distant heart sounds, but regular rate and rhythm.
PULM: CTAB, no increased work of breathing
ABD: Soft, obese, normoactive bowel sounds. No wincing with
palpation.
EXT: Warm, well perfused
SKIN: 10x10cm Stage IV decubitus with well healing granulation
tissue or pus. Mild morbilliform eruption on the trunk with no
oral or ocular desquamation. No bullae or vesicles.
NEURO: Tracking eyes to voice, intermittently vocalizing or
attempting to vocalize words, PEERL, intermittently grasping
hands on command, diminished reflexes, negative Babinski,
limited left sided movement. Overall improved from admission.
Pertinent Results:
Admission LABS:
===============
___ 10:12AM ___ PTT-30.4 ___
___ 10:12AM NEUTS-75.6* LYMPHS-11.9* MONOS-7.1 EOS-4.8
BASOS-0.3 IM ___ AbsNeut-7.25* AbsLymp-1.14* AbsMono-0.68
AbsEos-0.46 AbsBaso-0.03
___ 10:12AM WBC-9.6 RBC-4.08* HGB-10.3* HCT-37.5* MCV-92
MCH-25.2* MCHC-27.5* RDW-15.9* RDWSD-54.0*
___ 10:12AM CRP-16.3*
___ 10:12AM CALCIUM-10.7* PHOSPHATE-2.6* MAGNESIUM-2.5
___ 10:12AM CK-MB-4 proBNP-1613*
___ 10:12AM cTropnT-0.07*
___ 10:12AM GLUCOSE-130* UREA N-29* CREAT-0.6 SODIUM-146*
POTASSIUM-4.9 CHLORIDE-101 TOTAL CO2-38* ANION GAP-___ 10:20AM LACTATE-1.5
___ 11:00AM URINE RBC-55* WBC-115* BACTERIA-FEW YEAST-NONE
EPI-0
___ 11:00AM URINE BLOOD-MOD NITRITE-POS PROTEIN-300
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-LG
___ 02:00PM ALBUMIN-3.8
___ 02:00PM ALT(SGPT)-14 AST(SGOT)-18 LD(LDH)-222 ALK
PHOS-96 TOT BILI-0.2
___ 07:37PM ___ PO2-136* PCO2-62* PH-7.39 TOTAL
CO2-39* BASE XS-10
DISCHARGE LABS:
===============
___ 06:23AM BLOOD WBC-7.6 RBC-3.30* Hgb-8.3* Hct-29.2*
MCV-89 MCH-25.2* MCHC-28.4* RDW-16.5* RDWSD-52.9* Plt ___
___ 04:15AM BLOOD WBC-6.8 RBC-3.25* Hgb-8.3* Hct-29.4*
MCV-91 MCH-25.5* MCHC-28.2* RDW-16.3* RDWSD-54.4* Plt ___
___ 05:40PM BLOOD WBC-7.1 RBC-3.26* Hgb-8.3* Hct-29.3*
MCV-90 MCH-25.5* MCHC-28.3* RDW-16.3* RDWSD-53.5* Plt ___
___ 04:15AM BLOOD ___ PTT-28.9 ___
___ 06:50AM BLOOD ___ PTT-26.0 ___
___ 06:23AM BLOOD Glucose-121* UreaN-35* Creat-0.6 Na-142
K-4.2 Cl-98 HCO3-39* AnGap-9
___ 07:03PM BLOOD Glucose-150* UreaN-33* Creat-0.5 Na-144
K-4.2 Cl-102 HCO3-39* AnGap-7*
___ 04:15AM BLOOD Glucose-160* UreaN-32* Creat-0.5 Na-145
K-4.2 Cl-102 HCO3-39* AnGap-8
___ 06:50AM BLOOD ALT-15 AST-13 LD(LDH)-155 AlkPhos-84
TotBili-<0.2
___ 01:00AM BLOOD CK(CPK)-87
___ 12:48PM BLOOD cTropnT-0.08*
___ 06:30AM BLOOD cTropnT-0.10*
___ 01:00AM BLOOD CK-MB-3 cTropnT-0.10*
___ 07:00PM BLOOD CK-MB-3 cTropnT-0.09*
___ 06:23AM BLOOD Calcium-10.2 Phos-2.6* Mg-2.4
___ 07:03PM BLOOD Calcium-10.0 Phos-2.5* Mg-2.4
___ 04:15AM BLOOD Calcium-10.3 Phos-2.3* Mg-2.6
___ 04:39AM BLOOD PTH-175*
___ 06:23AM BLOOD Vanco-22.4*
___ 07:25PM BLOOD Vanco-22.5*
___ 06:50AM BLOOD Vanco-20.9*
___ 09:32AM BLOOD Lactate-1.0
___ 07:37PM BLOOD Lactate-1.2
IMAGING:
========
CXR ___. No evidence of pneumonia.
2. Low lung volumes. Probable moderate right effusion. Moderate
cardiomegaly with pulmonary vascular congestion suggests mild
heart failure.
3. Right basilar linear opacity likely represents chronic
atelectasis or fissural thickening.
CXR ___
IMPRESSION:
Right basilar opacity likely represents atelectasis or fluid in
the fissure. No pneumonia.
CT head ___. No acute intracranial hemorrhage.
2. Sequela of prior left parieto-occipital intraparenchymal
hemorrhage.
EEG ___
IMPRESSION: abnormal portable EEG due to the slow and
disorganized background rhythm with occasional bursts of
generalized slowing. These findings indicate a widespread
encephalopathy. Medications, metabolic disturbances, and
infection are among the most common causes. There were no areas
of prominent focal slowing, but encephalopathies may obscure
focal findings. There were no epileptiform features.
ECHO ___:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. Regional left
ventricular wall motion is normal. Quantitative (biplane) LVEF =
63 %. Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). The diameters of
aorta at the sinus, ascending and arch levels are normal. The
number of aortic valve leaflets cannot be determined. The aortic
valve leaflets are moderately thickened. No masses or
vegetations are seen on the aortic valve, but cannot be fully
excluded due to suboptimal image quality. There is mild aortic
valve stenosis (valve area 1.2-1.9cm2). Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. No masses or
vegetations are seen on the mitral valve, but cannot be fully
excluded due to suboptimal image quality. No mitral
regurgitation is seen. Trivial mitral regurgitation is seen. No
masses or vegetations are seen on the tricuspid valve, but
cannot be fully excluded due to suboptimal image quality. There
is moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Suboptimal image quality. No echocardiographic
evidence of endocarditis. If clinically indicated, a
transesophageal echocardiogram may better assess for valvular
vegetations. Mild symmetric left ventricular hypertrophy with
preserved regional/global systolic function. Elevated PCWP. Mild
aortic stenosis. Mild aortic regurgitation. At least moderate
pulmonary hypertension.
Compared with the prior study (images reviewed) of ___,
pulmonary artery pressures are higher. Aortic valve stenosis is
detected.
___ 2:00 pm URINE Site: CLEAN CATCH RED HOLD #
___.
URINE CULTURE (Final ___:
PSEUDOMONAS AERUGINOSA. >100,000 CFU/mL.
Piperacillin/Tazobactam sensitivity testing performed
by ___
___.
ACINETOBACTER BAUMANNII COMPLEX. >100,000 CFU/mL.
"Note, for Amp/sulbactam, higher-than-standard dosing
needs to be
used, since therapeutic efficacy relies on intrinsic
activity of
the sulbactam component".
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
| ACINETOBACTER BAUMANNII
COMPLEX
| |
AMPICILLIN/SULBACTAM-- 8 S
CEFEPIME-------------- 16 I 32 R
CEFTAZIDIME----------- =>64 R =>64 R
CIPROFLOXACIN---------<=0.25 S =>4 R
GENTAMICIN------------ <=1 S 8 I
LEVOFLOXACIN---------- =>8 R
MEROPENEM-------------<=0.25 S 8 I
PIPERACILLIN/TAZO----- R
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
___ 2:00 pm BLOOD CULTURE
Blood Culture, Routine (Preliminary):
STAPHYLOCOCCUS EPIDERMIDIS.
COAG NEG STAPH does NOT require contact precautions,
regardless of
resistance.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
FINAL SENSITIVITIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS EPIDERMIDIS
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ 8 I
LEVOFLOXACIN---------- 4 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
VANCOMYCIN------------ 2 S
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN CLUSTERS.
Reported to and read back by ___ @ ___ ON
___.
BCx (___): Negative to Date
Brief Hospital Course:
___ M w/extensive past medical history including DM, AF, CAD s/p
Stent, COPD, traumatic subarachnoid hemorrhage and subdural
hemorrhage in ___ and hemorrhagic CVA in ___ with known
sacral decubitus ulcer, recent admission for complicated UTI in
___, presents with altered mental status from health care
facility found to have a UTI and staph epi bacteremia.
ACTIVE ISSUES:
==============
# Altered Mental Status
Significant history of stroke and SAH/SHD leading to prominent
neurological deficits with patient being more somnolent with
difficulties tracking while at the nursing home. Limited
baseline neurological exam. Etiology was found to be most likely
due to UTI and staph epi bacteremia that were treated, as below,
with significant improvement noted. No evidence of osteomyelitis
or infection from known sacral ulcer. Has history of partial
seizures on keppra, but EEG was performed with no evidence of
seizures. On day of discharge, patient able to track, open eyes
to voice and showed evidence of attempting to vocalize words.
Has planned follow-up arranged with neurology.
# Complicated UTI
Postive for PSEUDOMONAS AERUGINOSA and ACINETOBACTER BAUMANNII
COMPLEX that has been present prior but with increased
resistance. Does have chronic foley but thought to be a possible
etiology for his AMS. As a result, patient was started on IV
cefepime (___) before being transitioned to ultimately
cipro and Bactrim ___ -) based on sensitivities given
(indeterminate sensitivities to cefepime) for planned 14 day
course given complicated UTI. Last day of antibiotics is ___.
Foley changed prior to discharge. Follow-up with his outpatient
ID doctor arranged.
# Staph Epi Bacteremia
Positive blood cultures on first set of blood cultures.
Potential source being skin contaminant from left IJ line
placed. However, given history of prior positive blood cultures
and AMS, patient was treated with IV vancomycin for planned 14
day course (___) to treat as a possible pathological
organism. ID consulted and followed during admission. TTE was
performed with no gross evidence of vegetations with low
suspicion for endocarditis to warrant TEE. Vanc dose was
adjusted prior to discharge with repeat vanc trough to be drawn
for dose adjustment. ID follow-up arranged.
# Morbilliform Rash
Most consistent with a mild drug hypersensitivity possibly to
one of his antibiotics without prior known allergy to PCN,
cephalosporins or sulfs. Began a few days after Cefepime was
started (and after its discontinuation), and one day after
beginning Bactrim. However no evidence of DRESS, fever, SJS/TEN,
therefore recommended continuing to monitor with CBC w/diff,
LFTs and BUN/Cr and exam, but will treat through as the present
antibiotic regiment is presently ideal without concern for
systemic issue. Plan reviewed prior to discharge with ID
consultant, who agreed.
# Acute on chronic dCHF:
BNP elevated at 1613. Moderate pulmonary vascular congestion on
CXR. TTE showed mildly elevated pulmonary artery pressures.
Received intermittent IV Lasix boluses. Resumed on his home
Lasix, ACE and beta blocker. Recommended continuing optimization
of blood pressures. Continue to track daily weights and fluid
status.
# HTN:
Mildly elevated BPs in the 160-180s during admission that
improved with increased dose of his lisinopril and labetalol.
Continue to optimize blood pressures to reach goal of <140/90.
# Metabolic alkalosis:
Bicarb at 38 on admission. Has long standing metabolic alkalosis
with stable values. VBG with pH 7.39 pCO2 62. Possible
compensation for chronic respiratory acidosis given COPD. No
signs of PNA on CXR.
# Demand ischemia:
Trop 0.07 x2 on admission. Peaked at 0.1 with improvement.
Likely in the setting of infection but no evidence of acute EKG
changes. TTE without new focal wall motion abnormalities.
Continue cardiac optimization with BP and fluid status.
CHRONIC ISSUES:
===============
# OSA: Continue CPAP at night
# Sacral decubitus wound: Stage 4. Bone visualized. No
purulence. Continue local wound care.
# CAD: Continue aspirin, atorvastatin
# BPH: Continue tamsulosin
# TBI: Continue levetiracetam
# GERD: continue famotidine
# Depression: Continue fluoxetine
# Gout: Continue allopurinol
# DM: Hold metformin. Continue lantus, ISS
# Nutrition: Continue tubefeeds: Glucerna 1.5 @ 60 mL/hr, strict
I/Os
TRANSITIONAL ISSUES:
====================
- Continue planned follow-up with ID outpatient as scheduled
- Please check vancomycin trough on ___ AM with goal trough
___. Can touch base with ID for dose adjustment as appropriate
- Please continue vancomycin for staph epi bacteremia ___ -
___
- Please continue cipro and Bactrim (___) for complicated
UTI
- Please continue to titrate BPs for goal <140/90 given dCHF
- Please continue to monitor daily weights to monitor fluid
status. Can adjust Lasix as needed
- Follow-up on final blood cultures, but negative to date
- Rash is likely a benign drug exanthema. Monitor for blisters
or vesicles for SJS/TEN. Can also check CBC w/diff, LFTs and
BUN/Cr on ___ to evaluate for evidence of DRESS. Otherwise can
continue to treat through.
- Please continue CPAP at night given OSA
- Recommend continued follow-up with his outpatient neurologist
as scheduled
- Continue wound care for sacral ulcer
- Continue to optimize nutrition
- Continue overall goals of care discussion
FULL CODE (confirmed)
EMERGENCY CONTACT HCP: ___ wife ___ (H) ___ (C). ___ (daughter)
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Docusate Sodium 100 mg PO BID
2. Jevity 1.5 Cal (lactose-reduced food with fibr) 0.06 gram-1.5
kcal/mL oral by mouth once a day 65ml/hr ON:12pm OFF 10am
3. LevETIRAcetam 750 mg PO BID
4. Lantus (insulin glargine) 8 units subcutaneous QHS
5. NovoLIN R (insulin regular human) per sliding scale units
injection QIDACHS
6. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
DAILY
7. Allopurinol ___ mg PO DAILY
8. Ascorbic Acid ___ mg PO BID
9. Aspirin 81 mg PO DAILY
10. Atorvastatin 20 mg PO QPM
11. Vitamin D ___ UNIT PO DAILY
12. Famotidine 20 mg PO BID
13. FLUoxetine 10 mg PO EVERY OTHER DAY
14. Furosemide 40 mg PO DAILY
15. Heparin 5000 UNIT SC BID
16. Labetalol 200 mg PO BID
17. Lisinopril 10 mg PO DAILY
18. MetFORMIN (Glucophage) 500 mg PO BID
19. Senna 17.2 mg PO DAILY
20. tamsuLOSIN 0.4 mg oral QHS
21. Fluticasone Propionate NASAL 2 SPRY NU DAILY
Discharge Medications:
1. Ciprofloxacin HCl 750 mg PO Q12H
Last dose scheduled for ___.
2. Sulfameth/Trimethoprim DS 1 TAB PO BID
Please take last dose on ___.
3. Vancomycin 750 mg IV Q 12H
Last day ___
4. Labetalol 400 mg PO TID
5. Lisinopril 40 mg PO DAILY
6. Allopurinol ___ mg PO DAILY
7. Ascorbic Acid ___ mg PO BID
8. Aspirin 81 mg PO DAILY
9. Atorvastatin 20 mg PO QPM
10. Docusate Sodium 100 mg PO BID
11. Famotidine 20 mg PO BID
12. FLUoxetine 10 mg PO EVERY OTHER DAY
13. Fluticasone Propionate NASAL 2 SPRY NU DAILY
14. Furosemide 40 mg PO DAILY
15. Heparin 5000 UNIT SC BID
16. Jevity 1.5 Cal (lactose-reduced food with fibr) 0.06
gram-1.5 kcal/mL oral by mouth once a day 65ml/hr ON:12pm OFF
10am
17. Lantus (insulin glargine) 8 units SUBCUTANEOUS QHS
18. LevETIRAcetam 750 mg PO BID
19. MetFORMIN (Glucophage) 500 mg PO BID
20. NovoLIN R (insulin regular human) per sliding scale units
INJECTION QIDACHS
21. ProAir HFA (albuterol sulfate) 90 mcg/actuation INHALATION
DAILY
22. Senna 17.2 mg PO DAILY
23. tamsuLOSIN 0.4 mg oral QHS
24. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Metabolic encephalopathy
UTI
Gram positive bacteremia
acute on chronic dCHF
HTN
Chronic:
Sacral decubitus wound
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at ___. You were admitted
because you had a change in your mental status, likely due to a
urinary tract infection and infection in your blood. We gave you
antibiotics to treat your infections with improvement. You had a
___ line placed so that you could receive antibiotics through
the IV outside of the hospital. There was no evidence of
seizures.
Please continue to follow-up with infectious disease and
neurology after leaving the hospital.
Sincerely,
Your ___ care team
Followup Instructions:
___
|
19599496-DS-18
| 19,599,496 | 20,663,676 |
DS
| 18 |
2160-05-30 00:00:00
|
2160-05-30 17:11:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Type A aortic dissection
Major Surgical or Invasive Procedure:
___ - Resection of ascending aorta, repair of dissection,
and ascending aortic replacement with a 28 mm Gelweave tube
graft.
History of Present Illness:
Mr. ___ is a ___ year old man with a past medical history of
cigarette smoking and esophageal cancer status post chemotherapy
and radiation (last dose ___. He initially presented to ___
___ on ___ with complaints of 5 days of fever,
productive cough, and upper abdominal pain. He noted that
his wife had the flu (diagnosed at ___ ___ about ___ weeks
ago and that he developed acute symptoms 5 days prior to
presentation. He noted above symptoms also associated with
intermittent shortness of breath and then also noticed dark
colored stools. Prior to onset of these symptoms, he was feeling
well without recent hospitalizations or procedures.
At ___, he was febrile to 101.1, mildly tachycardic to 106. Flu
PCR returned FluB+. A CT torso at demonstrated 5.2 x 5.1 cm
thoracic aortic aneurysm and dissection; also noted ___
ground-glass opacities in inferior right upper lobe and superior
right lower lobe. Given this finding he was transferred to ___
for urgent dissection repair.
Past Medical History:
Anal Fissure
___ Cyst
___ Esophagus
Bullous Emphysema
Dermatitis
Esophageal Cancer status post chemo and radiation
Hyperlipidemia
Hypothyroidism
Inguinal Hernia, bilateral
Migraines
Myopia
Pulmonary Nodules
Salivary Secretion Disturbance
Thrombocytosis
Transient Ischemic Attack ___
Social History:
___
Family History:
Unable to assess as patient intubated and sedated
Physical Exam:
Unable to obtain PE upon admission due to emergent nature of
case
Discharge PE
24 HR Data (last updated ___ @ 1059)
Temp: 97.8 (Tm 98.6), BP: 99/61 (85-162/61-102), HR: 76
(62-152), RR: 18, O2 sat: 94% (___), O2 delivery: 2L,
Wt: 64 kg (65)
In/Out: 1160/1050
Physical Examination:
___: NAD [x] A/O x3 [] non-focal [x]
Cardiac: RRR [] Irregular [x] Nl S1 S2 []
Lungs: CTA[x] No resp distress
Abd: NBS [x]Soft [x] ND [x] NT [x]
Left inguinal hernia site tender to touch
Extremities: warm no edema
Wounds: Sternal: CDI [x] no erythema or drainage [x]
Sternum stable [x]
Pertinent Results:
Chest CT ___
1. Ascending aortic dissection, extending from the site just
superior to the left main coronary artery origin. The dissection
spans approximately 4.5 cm in the craniocaudal dimension. No
evidence of aortic arch or descending aortic dissection.
2. Ascending aortic aneurysm, measuring up to 5.7 cm in maximal
diameter.
3. Extensive bronchiectasis, most predominant in the bilateral
lower lobes, where there are areas of peripheral nodular
opacification and ground-glass opacification. Findings are
compatible with small airways disease and acute infection. Hilar
lymphadenopathy is likely reactive in this setting.
Transesophageal Echocardiogram ___
PRE BYPASS No spontaneous echo contrast or thrombus is seen in
the body of the left atrium/left atrial appendage or the body of
the right atrium/right atrial appendage. No atrial septal defect
is seen by 2D or color Doppler. There is mild 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%). The
right ventricle displays normal free wall contractility. The
aortic root is moderately dilated at the sinus level. The
ascending aorta is moderately dilated. There are simple atheroma
in the ascending aorta. There are complex (>4mm) atheroma in the
aortic arch. There are simple atheroma in the descending
thoracic aorta. A calcified density is seen in the ascending
aorta consistent with an intimal flap/aortic dissection. It
appears to be contained to the area just above the left main
coronary ostium extending several centimeters up the ascending
aorta. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Mild to moderate (___) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Physiologic mitral regurgitation is seen (within
normal limits). There is no pericardial effusion. Dr. ___
was notified in person of the results in the operating room at
the time of the study.
POST BYPASS The patient is atrially paced. The patient is
receiving epinephrine by IV infusion. There is normal
biventricular systolic function. An ascending aortic tube graft
has been placed. There is trace aortic regurgitation. The rest
of valvular function is unchanged from the prebypass setting.
The thoracic aorta is intact after decannulation.
___ 02:00AM BLOOD WBC-9.1
___ 04:40AM BLOOD WBC-9.6 RBC-3.18* Hgb-9.7* Hct-28.6*
MCV-90 MCH-30.5 MCHC-33.9 RDW-13.5 RDWSD-44.5 Plt ___
___ 04:58AM BLOOD WBC-8.5 RBC-3.02* Hgb-9.1* Hct-26.8*
MCV-89 MCH-30.1 MCHC-34.0 RDW-13.6 RDWSD-44.1 Plt ___
___ 05:55AM BLOOD WBC-8.4 RBC-3.15* Hgb-9.6* Hct-27.8*
MCV-88 MCH-30.5 MCHC-34.5 RDW-13.6 RDWSD-43.9 Plt ___
___ 05:35AM BLOOD WBC-7.0 RBC-3.18* Hgb-9.8* Hct-28.7*
MCV-90 MCH-30.8 MCHC-34.1 RDW-13.6 RDWSD-45.3 Plt ___
___ 02:00AM BLOOD ___
___ 04:40AM BLOOD ___
___ 04:58AM BLOOD ___
___ 05:55AM BLOOD ___ PTT-31.6 ___
___ 02:00AM BLOOD UreaN-11 Creat-0.7 Na-137 K-4.6
___ 04:40AM BLOOD UreaN-12 Creat-0.7 Na-138 K-4.5
___ 04:58AM BLOOD Glucose-93 UreaN-13 Creat-0.7 Na-137
K-4.6 Cl-97 HCO3-24 AnGap-16
___ 05:55AM BLOOD Glucose-96 UreaN-10 Creat-0.5 Na-137
K-4.1 Cl-95* HCO3-26 AnGap-16
___ 05:35AM BLOOD Glucose-107* UreaN-15 Creat-0.7 Na-135
K-4.4 Cl-96 HCO3-28 AnGap-11
___ 04:50AM BLOOD WBC-10.8* RBC-3.06* Hgb-9.3* Hct-27.3*
MCV-89 MCH-30.4 MCHC-34.1 RDW-13.4 RDWSD-43.4 Plt ___
___ 04:50AM BLOOD ___
___ 04:50AM BLOOD K-4.3
___ 03:35PM BLOOD ___
Brief Hospital Course:
___ was admitted on ___ and was taken emergently to
the operating room for ascending aorta replacement. Please see
operative note for full details. He tolerated the procedure well
and was transferred to the CVICU in stable condition for
recovery and invasive monitoring.
He weaned from sedation, awoke neurologically intact and was
extubated on POD 1. He was weaned from inotropic and vasopressor
support. Beta blocker was initiated and he was diuresed toward
his preoperative weight. ID was consulted after a blood culture
obtained in the ED returned positive for coagulase-negative
Staphylococcus bacteremia, as well as positive blood cultures
resulted from OSH. It was initially unclear at this time
whether this represents true infection versus contamination.
However, ID believed that it was likely a contaminate and he was
continued on Vancomycin for a total of 10 days - start date of
___ - no chronic/lifelong suppression was recommended at this
time. He also completed a 5 day course of Tamiflu for Influenza
B diagnosed at the OSH.
He remained hemodynamically stable and was transferred to the
telemetry floor for further recovery. Postoperatively he
developed hematochezia from an anal fissure. He has planned to
have prior treatment for this issue but did not follow up.
Colorectal surgery was consulted for anal fissures and
recommended resuming his anticoagulation that he was placed on
for postop arrhythmia, as long as he did not develop a
transfusion requirement. He will follow-up with Dr. ___ as
an outpatient. Dr ___ will contact patient with
appointment time and date. Postoperatively he went into rapid
atrial fibrillation requiring anticoagulation. He was treated
with Amiodarone and Lopressor. Cardiology was consulted for
TEE/CV but patient converted to sinus rhythm before this was
necessary and his rate remained in 60-70's. He was started on
Coumadin for atrial fibrillation with goal INR 2.0-3.0. He was
evaluated by the physical therapy service for assistance with
strength and mobility. By the time of discharge on POD 9 he was
ambulating with assistance, the wound was healing, and pain was
controlled with oral analgesics.
***Plan was to discharge ___ to rehab. However, the pt has
since refused this plan. He has decided to leave ___ despite
staff trying to explain the need for continued stay at this
time. ___ has been arranged to follow up INR draw tomorrow.
___ will dose Coumadin tomorrow while we can confirm PCP,
___ to follow thereafter.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Tamsulosin 0.4 mg PO QHS
2. Levothyroxine Sodium 100 mcg PO DAILY
3. TraMADol 25 mg PO DAILY:PRN Pain - Moderate
Discharge Medications:
1. Amiodarone 200 mg PO BID
x 7 days then decrease to 200 mg daily until reeval by
Cardiologist
RX *amiodarone 200 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*1
2. Aspirin EC 81 mg PO DAILY
RX *aspirin [Adult Aspirin Regimen] 81 mg 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*1
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*1
4. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Mild
RX *hydromorphone 2 mg ___ tablet(s) by mouth q4h prn Disp #*50
Tablet Refills:*0
5. Metoprolol Tartrate 100 mg PO TID
RX *metoprolol tartrate 100 mg 1 tablet(s) by mouth three times
a day Disp #*90 Tablet Refills:*1
6. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*2
7. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 [Miralax] 17 gram 1 powder(s) by
mouth daily Disp #*24 Packet Refills:*1
8. Senna 17.2 mg PO DAILY
RX *sennosides [senna] 8.6 mg 2 tabs by mouth daily Disp #*60
Tablet Refills:*1
9. ___ MD to order daily dose PO DAILY16 postop Afib
RX *warfarin [Coumadin] 1 mg Daily per MD ___ by mouth
DAILY Disp #*150 Tablet Refills:*1
10. Warfarin 0 mg PO ONCE Duration: 1 Dose
11. Levothyroxine Sodium 100 mcg PO DAILY
RX *levothyroxine 100 mcg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*1
12. Tamsulosin 0.4 mg PO QHS
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth HS Disp #*30 Capsule
Refills:*1
Discharge Disposition:
Home with Service
Facility:
___
Discharge Diagnosis:
Aortic Dissection, Type A
Anal Fissure
Atrial Fibrillation
Influenza B
___ Cyst
___ Esophagus
Bullous Emphysema
Dermatitis
Esophageal Cancer status post chemo and radiation
Hyperlipidemia
Hypothyroidism
Inguinal Hernia, bilateral
Migraines
Myopia
Pulmonary Nodules
Salivary Secretion Disturbance
Thrombocytosis
Transient Ischemic Attack ___
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with assistance
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Discharge Instructions:
Please shower daily -wash incisions gently with mild soap, no
baths or swimming, look at your incisions daily
Please - NO lotion, cream, powder or ointment to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics
Clearance to drive will be discussed at follow up appointment
with surgeon
No lifting more than 10 pounds for 10 weeks
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:
___
|
19599525-DS-5
| 19,599,525 | 26,503,819 |
DS
| 5 |
2134-01-04 00:00:00
|
2134-01-04 16:38:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
___: Cardiac catherization with no apparent CAD
History of Present Illness:
Ms. ___ is a ___ year old woman with a history of
thyroidectomy and osteoporosis who presents with chest pain.
Ms. ___ was in her usual state of health until around
10:30AM on ___ when she was in exercise class which she attends
twice every week. She felt diaphoretic and was laboring
throughout the class and decided to sit down. She then felt like
she had a pulled muscle in her chest which persisted throughout
the day. She took one baby aspirin and continued on with her
day,
but continued to feel diaphoretic with a chest tightness. She
took a second aspirin. The pain resolved spontaneously at 7:30pm
yesterday evening.
She presented to ___ this morning and was
found to have an elevated troponin with T wave inversions and an
ST elevation in a single isolated lead. She was chest pain free
at that time. She was therefore transferred to ___.
EMERGENCY DEPARTMENT COURSE
Initial vital signs were notable for:
- T 98.7, HR 91, BP 136/85, RR 18, O2 97% RA
Exam notable for:
- General: in NAD
- Chest: Clear to auscultation bilaterally
- Cardiac: Systolic murmur appreciated
- Abdomen: Soft, nondistended, nontender
- Extremities: No pedal edema
Labs were notable for:
- Trop-T 0.23 -> 0.20.
- proBNP 3534
- TSH 0.35
Patient was given:
- Heparin gtt
- Atorvastatin 80mg
- Metoprolol tartrate 6.25mg
- Clopidogrel 300mg
Consults: Cardiology
Vital signs prior to transfer:
- T 98.2, HR 77, BP 119/78, RR 18, O2 96% Ra
Upon arrival to the floor: She is asymptomatic.
=================
REVIEW OF SYSTEMS
=================
Complete ROS obtained and is otherwise negative.
Past Medical History:
- Thyroid cancer s/p total thyroidectomy
- Schwanommatosis s/p removal of multiple benign spine lesions
- Osteoporosis
- Chronic heart murmur
Social History:
___
Family History:
- Sister had MI in early ___. Had a second MI around age ___.
Similarly had no apparent risk factors.
- Father had MI late in life. Also had aortic aneurysm.
Physical Exam:
=======================
ADMISSION PHYSICAL EXAM
=======================
VITALS: T 98.2, BP 119/78, HR 77, RR 18, O2 96 RA
GENERAL: Well appearing, sitting up in bed in no distress
HEENT: Pupils equal and reactive. No scleral icterus. Moist
mucous membranes.
NECK: No JVD
CARDIAC: S1/S2 regular with ___ systolic murmur throughout
precordium with preserved S2. Strong pedal and radial pulses.
LUNGS: Clear bilaterally.
ABDOMEN: Soft, non-tender.
EXTREMITIES: Warm. No edema.
SKIN: Warm and dry.
NEUROLOGIC: A+Ox3. Appropriate affect.
=======================
Discharge PHYSICAL EXAM
=======================
GENERAL: Well appearing, sitting up in bed in no distress
HEENT: Pupils equal and reactive. No scleral icterus. Moist
mucous membranes.
NECK: No JVD
LUNGS: Clear bilaterally.
ABDOMEN: Soft, non-tender.
EXTREMITIES: Warm. No edema.
SKIN: Warm and dry.
NEUROLOGIC: A+Ox3. Appropriate affect.
Pertinent Results:
Labs:
___ 11:51AM BLOOD WBC-6.0 RBC-4.99 Hgb-14.5 Hct-44.1 MCV-88
MCH-29.1 MCHC-32.9 RDW-13.8 RDWSD-44.4 Plt ___
___ 06:55AM BLOOD WBC-4.2 RBC-4.82 Hgb-13.8 Hct-42.2 MCV-88
MCH-28.6 MCHC-32.7 RDW-13.9 RDWSD-44.5 Plt ___
___ 11:51AM BLOOD ___ PTT-150* ___
___ 06:55AM BLOOD PTT-65.6*
___ 11:51AM BLOOD Glucose-108* UreaN-14 Creat-0.6 Na-139
K-3.9 Cl-102 HCO3-24 AnGap-13
___ 06:55AM BLOOD Glucose-90 UreaN-13 Creat-0.7 Na-139
K-3.6 Cl-101 HCO3-23 AnGap-15
___ 11:51AM BLOOD proBNP-3534*
___ 11:51AM BLOOD cTropnT-0.23*
___ 01:50PM BLOOD cTropnT-0.20*
___ 11:51AM BLOOD Calcium-9.5 Phos-3.4 Mg-2.2 Cholest-215*
___ 06:55AM BLOOD Calcium-9.2 Phos-3.9 Mg-2.2
___ 02:48PM BLOOD %HbA1c-5.4 eAG-108
___ 11:51AM BLOOD Triglyc-56 HDL-69 CHOL/HD-3.1
LDLcalc-135*
___ 11:51AM BLOOD TSH-0.35
___ CXR:
IMPRESSION:
No evidence of focal consolidation, pulmonary edema or pleural
effusions.
___ TTE:
CONCLUSION:
The left atrial volume index is mildly increased. There is no
evidence for an atrial septal defect by 2D/color
Doppler. The estimated right atrial pressure is ___ mmHg. There
is normal left ventricular wall thickness with
a normal cavity size. Overall left ventricular systolic function
is mildly-to-moderately depressed secondary to
extensive circumferential apical hypokinesis sparing only the
basal segments. The visually estimated left
ventricular ejection fraction is 40%. There is a mild (peak 19
mmHg) resting left ventricular outflow tract
gradient with an increase to 29 mmHg (peak) with Valsalva.
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. The aortic valve leaflets (3)
appear structurally normal. There is no aortic
valve stenosis. There is trace aortic regurgitation. The mitral
valve leaflets appear structurally normal with no
mitral valve prolapse. There is valvular systolic anterior
motion (___). There is mild [1+] mitral regurgitation.
The pulmonic valve leaflets are normal. The tricuspid valve
leaflets appear structurally normal. There is
physiologic tricuspid regurgitation. The pulmonary artery
systolic pressure could not be estimated. There is no
pericardial effusion.
IMPRESSION: extensive apical hypokinesis
___ Cardiac Cath:
Findings
No angiographically apparent coronary artery disease.
Normal LVEDP.
Brief Hospital Course:
Ms. ___ is a ___ year old woman with a history of
thyroidectomy and osteoporosis who presents with chest pain and
was found to have an NSTEMI with complete resolution of
symptoms. Coronary cath was non-obstructive.
TRANSITIONAL ISSUES:
[] Repeat TTE in ___ to reassess for improvement in apical
hypokinesis
[] Patient discharged on aspirin 81mg and clopidogrel. Reassess
in ___ months (___) if patient should continue these
medications
[] Started on atorvostatin, metoprolol during admission for CAD.
Will need follow-up for these medications--including appropriate
lab follow up and verification that patient is tolerating the
medications
[] patient hypotensive on Lisinopril 2.5mg PO daily, continue to
assess if patient can restart medication
ACUTE ISSUES:
#NSTEMI:
Presented with typical chest pain and found to have mild
troponin elevation consistent with NSTEMI. Her sister similarly
had no risk factors and had a MI in her early ___. Started on
heparin drip. TTE demonstrated LVEF 40% with extensive apical
hypokinesis. Cardiac cath demonstrated mid LAD with focal 30%
stenosis vs normal variant appearance. Started during admission
on atorvostatin, and metoprolol. Discharged on these medications
in addition to clopidogrel and aspirin. She could not tolerate
2.5mg PO Lisinopril due to hypotension.
#Hyperlipidemia
Total cholesterol 215, LDL 135, HDL 69.
- Atorvastatin 80mg
#Hypotension
after cath patient had bleeding at incision site. BP decreased
to ___ while working with ___ otherwise has had normal BPs. We
discontinued her Lisinopril 2.5mg PO daily and decreased her
metoprolol to 12.5mg PO daily. Monitored overnight with no
issues and discharged with stable BP.
CHRONIC ISSUES:
#Thyroidectomy
- Continued Synthroid
- Continued Alednronate
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 175 mcg PO DAILY
2. Alendronate Sodium 70 mg PO QSUN
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Clopidogrel 75 mg PO/NG DAILY
4. Metoprolol Succinate XL 12.5 mg PO DAILY
5. Alendronate Sodium 70 mg PO QSUN
6. Levothyroxine Sodium 175 mcg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
NSTEMI
Secondary Diagnosis:
Hyperlipidemia
Hypothyroidism
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 because you had a heart attack.
WHAT HAPPENED IN THE HOSPITAL?
==============================
- You were given medications for your heart
- You underwent a procedure to evaluate the blood flow to your
heart. You did not have significant narrowing of the blood
vessels to your heart.
WHAT SHOULD I DO WHEN I GO HOME?
================================
- Be sure to take all your medications and attend all of your
appointments listed below.
- It is very important to take your aspirin and clopidogrel
(also known as Plavix)
- These two medications keep the stents in the vessels of the
heart open and help reduce your risk of having a future heart
attack.
- You are also given other new medications to help your heart
- Please do not take Lisinopril and take metoprolol succinate
12.5mg PO daily.
It was a pleasure taking care of you at the ___
___!
Thank you for allowing us to be involved in your care, we wish
you all the best!
Your ___ Team
Followup Instructions:
___
|
19599661-DS-2
| 19,599,661 | 29,016,425 |
DS
| 2 |
2145-09-25 00:00:00
|
2145-09-25 20:54:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Nonhealing traumatic (nondiabetic) right lower extremity
ulceration with necrosis.
Major Surgical or Invasive Procedure:
___: Debridement of nonhealing right lower extremity calf
ulcer.
___: ___ line placement.
History of Present Illness:
___ y/ female; non diabetic; h/o HTN; struck by car tire in right
lateral lower leg on ___ after car started rolling backwards
without brake on; RT leg dragged on asphalt; subsequently
developed RLE pain; ecchymoses; swelling; erythema; with denuded
area. She was seen by PCP several days after injury; diagnosed
with RLE cellulitis; started on 1 week course of cephalexin and
bactroban ointment for ulcer. She developed worsening RLE pain;
increased swelling of RT lower leg; erythema along the RLE
ulcer; tenderness to palpation of RT lower leg.
She was evaluated by vascular surgery on ___ for worsening RLE
ulcers. The RLE had two ulcers: medial area of RLE ulcer was
4-5 cm in diameter; fibrinous exudate; macerated; malodorous
drainage. There was a smaller ulcer ( 2 x 3cm) inferior to
larger ulcer with serous drainage. Based on progression of
necrotic ulcers; increased swelling and erythema; with severe
tenderness; she was admitted to ___ on ___ for surgical
debridement of RLE ulcers.
Past Medical History:
Essential HTN
Hyperlipidemia
Hypothyroidism
Urticaria
Bipolar disorder
Anxiety
Osteoarthritis (knee, L/S-spine)
C5-6 disc disease
Stress urinary incontinence
Past Surgical History:
Bilateral knee replacements ___
Bilateral tubal ligation
ORIF right wrist ___
Left carpal tunnel release ___
Subdural hematoma s/p craniotomy ___
Lumbar fusion and laminectomy ___, fusion L2-3, ___,
laminectomy ___
Cervical surgery ___
Social History:
___
Family History:
noncontributory
Physical Exam:
PHYSICAL EXAM: ___ -
VITALS: Temp: 97.8 PO; BP: 132/70; HR: 76, RR: 18; 02sat% 100
Ra.
GENERAL: Well appearing, well nourished female in no acute
distress.
NEURO: Alert and oriented x3.
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, nontender, no rebound or guarding,
normoactive bowel sounds, no palpable masses
Ext: LLE WNL, RLE with deep wound to medial calf, apria vac in
place
Pertinent Results:
___ 05:40AM BLOOD WBC-5.2 RBC-3.13* Hgb-9.0* Hct-28.6*
MCV-91 MCH-28.8 MCHC-31.5* RDW-14.2 RDWSD-47.3* Plt ___
___ 12:45PM BLOOD Neuts-64.4 ___ Monos-10.5 Eos-3.0
Baso-0.9 Im ___ AbsNeut-4.34 AbsLymp-1.40 AbsMono-0.71
AbsEos-0.20 AbsBaso-0.06
___ 05:40AM BLOOD Plt ___
___ 05:40AM BLOOD Glucose-110* UreaN-10 Creat-0.6 Na-144
K-4.4 Cl-106 HCO3-28 AnGap-10
___ 12:45PM BLOOD ALT-12 AST-16 AlkPhos-73 TotBili-<0.2
___ 05:40AM BLOOD Calcium-9.0 Phos-3.1 Mg-2.1
___ 12:45PM BLOOD CRP-32.0___ 06:30AM BLOOD Vanco-13.0
___:
EXAMINATION: KNEE (2 VIEWS) RIGHT; TIB/FIB (AP & LAT) RIGHT
IMPRESSION:
In comparison with the study of ___, there is little
change in the appearance of the total knee arthroplasty on the
right. Heterotopic bone is seen in the region of the medial
collateral ligament. No evidence of hardware-related
complication or periprosthetic fracture. Views of the remainder
of the tibia and fibula show no evidence of acute bone
abnormality. There is apparent irregularity of soft tissues
medially in the mid and distal region. However, no evidence of
bone erosion or abnormal periosteal response.
If there are symptoms referable to the ankle, dedicated views of
this region should be obtained.
___ 1:32 pm TISSUE RIGHT LOWER LEG BONE FRAGMENTS.
GRAM STAIN (Final ___:
Reported to and read back by ___ AT 3:30PM
___.
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
TISSUE (Preliminary):
CITROBACTER FREUNDII COMPLEX. SPARSE GROWTH.
PROTEUS HAUSERI. SPARSE GROWTH.
ENTEROCOCCUS SP.. QUANTITATION NOT AVAILABLE.
MIXED BACTERIAL FLORA.
Due to mixed bacterial types [>=3] an abbreviated
workup is
performed; all organisms will be identified and
reported but only
select isolates will have sensitivities performed.
GRAM NEGATIVE ROD #3. RARE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
CITROBACTER FREUNDII COMPLEX
| PROTEUS HAUSERI
| |
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S =>64 R
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
PIPERACILLIN/TAZO----- <=4 S <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
Brief Hospital Course:
Ms ___ was admitted in anticipation of RLE debridement on
___. She underwent the procedure without complications;
please see the operative report for details. She then underwent
daily wet to dry dressing changes for 2 days, and was treated
empirically for polymicrobial infection with vancomycin,
cefipime, and metronidazole per recommendations from the
infectious disease service. The bone tissue culture isolated
gnr x2; gpc; mixed bacterial flora. Path of RLE ulcer
demonstrated granulation tissue with acute and chronic
inflammation; fat necrosis. A wound vac was placed on ___ and
antibiotics were narrowed to ertapenem and vancomycin. She was
discharged on ___ with ___ for vac changes and home
antibiotic infusion. She will follow up with Dr. ___ Dr.
___ infectious disease.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 5 mg PO DAILY
2. Alendronate Sodium 5 mg PO 1X/WEEK (SA)
3. Levothyroxine Sodium 125 mcg PO DAILY
4. PARoxetine 20 mg PO DAILY
5. Calcium 500 With D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit PO BID
6. Ferrous Sulfate 325 mg PO DAILY
7. Gabapentin 600 mg PO TID
8. Hydroxychloroquine Sulfate 200 mg PO DAILY
9. Loratadine 10 mg PO DAILY
10. Naproxen 500 mg PO DAILY
11. Simvastatin 40 mg PO QPM
12. Tizanidine 2 mg PO BID
13. OxyCODONE--Acetaminophen (5mg-325mg) 2 TAB PO Q4H:PRN Pain -
Moderate
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Aspirin 81 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Ertapenem Sodium 1 g IV 1X Duration: 1 Dose
RX *ertapenem [Invanz] 1 gram 1 gm daily Disp #*42 Vial
Refills:*0
5. HYDROmorphone (Dilaudid) 4 mg PO 3X/WEEK (___) for
dressing changes
RX *hydromorphone [Dilaudid] 4 mg 1 tablet(s) by mouth for
dressing changes Disp #*15 Tablet Refills:*0
6. LORazepam 1 mg PO 3X/WEEK (___) dressing changes
RX *lorazepam [Ativan] 1 mg 1 tablet(s) by mouth for dressing
changes Disp #*15 Tablet Refills:*0
7. Vancomycin 1250 mg IV Q 24H
RX *vancomycin 1 gram 1250 mg daily Disp #*42 Vial Refills:*0
8. Alendronate Sodium 5 mg PO 1X/WEEK (SA)
9. amLODIPine 5 mg PO DAILY
10. Calcium 500 With D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit PO BID
11. Ferrous Sulfate 325 mg PO DAILY
12. Gabapentin 600 mg PO TID
13. Hydroxychloroquine Sulfate 200 mg PO DAILY
14. Levothyroxine Sodium 125 mcg PO DAILY
15. Loratadine 10 mg PO DAILY
16. Naproxen 500 mg PO DAILY
17. OxyCODONE--Acetaminophen (5mg-325mg) 2 TAB PO Q4H:PRN Pain
- Moderate
18. PARoxetine 20 mg PO DAILY
19. Simvastatin 40 mg PO QPM
20. Tizanidine 2 mg PO BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Traumatic non-healing right lower ulcer.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of you here at ___
___ where your were cared for by the
Division of Vascular Surgery. You were admitted to our hospital
for management and care of your right lower extremity ulcer.
During this admission your ulcer was debrided in the operating
room, and your were treated with IV antibiotics. Infectious
Disease was consulted and help formulate the duration of
antibiotics. A Peripherally inserted central catheter (PICC)
was placed for the use of IV antibiotics in the outpatient
setting. You are now ready for discharge. Please refer to the
instructions below for your post discharge instructions.
Division of Vascular and Endovascular Surgery
Discharge Instructions
MEDICATION:
Take your medications as prescribed in your discharge
You will take vancomycin and ertapenem daily until
___
You are being prescribed 4mg of dilaudid and 1mg of
Ativan to take by mouth prior to each dressing change.
WOUND CARE AND DRESSING CHANGES:
We have arranged for your to be sent home with ___ who
will assess your wounds, assist with dressing changes, and dose
your IV antibiotics.
Your VAC dressing will need to be changed 3 x weekly.
It is a good idea to take a dose of pain medication
prior to your dressing changes early on in your recovery.
ACTIVITIES:
What activities you can and cannot do:
You may shower; you can unplug the vacuum machine for the
duration of the shower and cover up the wound with a plastic
garbage bag, and then reconnect the machine afterward.
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: ___
Worening pain, numbness or coldness of your right lower
extremities
Temperature greater than 101.5F for 24 hours
New or increased drainage from ulcer or white, yellow or green
drainage from wound
Bleeding from groin puncture site
Followup Instructions:
___
|
19599769-DS-16
| 19,599,769 | 28,584,022 |
DS
| 16 |
2157-08-04 00:00:00
|
2157-08-07 00:41:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ male w/ history of hypertension, hyperlipidemia, diabetes
mellitus who presents with chest pain. Pt was recently admitted
to ___ service on ___ for a STEMI with STE in V2-V4. Cath
showed mid-LAD lesion that was angioplastied and DES was placed.
He was admitted to CCU and monitored and discharged on plavix,
aspirin, metoprolol, continued on lisinopril and was on
pravastatin given financial issues. Pt had no further CP during
that admission. Also started on lovenox bridge to coumadin given
depressed EF of 30% with significant WMA in the LAD
distribution. He was not sent home with SLNG.
.
Tonight he returns with chest pain, lasting about ___ hours
prior to arrival. Denied any associated shortness of breath,
nausea, or other symptoms. Pain started after pt was straining
to have a BM. Pain described as substernal, nonradiating, ___
and similar in character to STEMI but not as severe. Pt didn't
have nitroglycerin at home to take. Denies missing any plavix or
aspirin doses. Denies fevers or chills.
.
In the ED, initial VS were 97.9 92 161/83 18 98%. Pt had taken
aspirin prior to arrival, CXR with no acute process. Pt still
had CP on presentation, cards fellow was called given chest pain
with concerning EKG changes with new TWI in I and TWF in L,
increasing STE in V2-V3 since discharge on ___. Pt given SLNG
x 2, with resolution of chest pain and some improvement in EKG
changes. Per cardiology fellow, pt started on heparin gtt and
admitted to ___ service for possible cath in AM. Trop in ED
0.15, CK/MB pending, on discharge on ___, trop was 4.27.
.
Currently, pt denies any complaints, chest pain has resolved and
has no shorntess of breath, nausea, abd pain or other
complaints. Has felt well overall since discharge since last
night.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. he denies recent fevers, chills or rigors.
S/he denies exertional buttock or calf pain. All of the other
review of systems were negative.
.
Cardiac review of systems is notable for absence of dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: (+)Diabetes, (+)Dyslipidemia,
(+)Hypertension
2. CARDIAC HISTORY:
- CABG: n/a
- PERCUTANEOUS CORONARY INTERVENTIONS: n/a
- PACING/ICD: n/a
3. OTHER PAST MEDICAL HISTORY:
Hypertension, dyslipidemia, diabetes (last A1c 7.8%), benign
prostatic hypertrophy, erectile dysfunction
Social History:
___
Family History:
Father with MI at ___ years old
- No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION EXAM
VS: 99.4 147/90 87 20 97% RA
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa. +right eye cataract
NECK: Supple with no JVD.
CARDIAC: Regular rate and rhythm, normal S1, S2. No m/r/g. No
thrills, lifts. No S3 or S4.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABDOMEN: Obese, soft, NTND. No HSM or tenderness. No abdominial
bruits.
EXTREMITIES: No c/c/e.
PULSES:
Right: DP 2+ ___ 2+
Left: DP 2+ ___ 2+
.
DISCHARGE EXAM
VSS
HEENT: NAD, A & O X3
NECK: Supple, JVP flat
HEART: RRR, no m/r/g
LUNG: CTA ___
ABD: soft, NT/ND,
EXT: no pitting edema
Pertinent Results:
ADMISSION LABS
___ 07:05AM BLOOD WBC-8.8 RBC-3.88* Hgb-11.9* Hct-36.5*
MCV-94 MCH-30.6 MCHC-32.5 RDW-13.3 Plt ___
___ 09:20PM BLOOD ___ PTT-42.0* ___
___ 07:05AM BLOOD Glucose-164* UreaN-21* Creat-1.0 Na-141
K-4.2 Cl-111* HCO3-23 AnGap-11
___ 09:20PM BLOOD CK(CPK)-114
___ 07:05AM BLOOD Calcium-8.9 Phos-2.8 Mg-1.8
.
DISCHARGE LABS
___ 07:05AM BLOOD WBC-7.1 RBC-4.00* Hgb-12.3* Hct-37.4*
MCV-93 MCH-30.8 MCHC-33.1 RDW-13.3 Plt ___
___ 11:00AM BLOOD ___ PTT-40.5* ___
___ 07:05AM BLOOD Glucose-148* UreaN-19 Creat-1.0 Na-141
K-4.2 Cl-108 HCO3-23 AnGap-14
___ 07:05AM BLOOD Calcium-8.9 Phos-3.3 Mg-1.9
.
CARDIAC ENZYMES
___ 09:20PM BLOOD CK-MB-3
___ 09:20PM BLOOD cTropnT-0.15*
___ 07:05AM BLOOD CK-MB-2 cTropnT-0.11*
.
PERTINENT STUDIES
#CXR ___
IMPRESSION: No definite evidence of acute cardiopulmonary
process such as
pneumonia. Mild left costophrenic blunting likely due to
pericardial fat pad. No pneumothorax.
.
#ECHO ___
Conclusions
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is mild
to moderate regional left ventricular systolic dysfunction with
severe hypokinesis of the distal inferior, inferolateral,
anterior and septal walls. The apex is akinetic but not
aneurysmal. The remaining segments contract normally (LVEF =
35%). No masses or thrombi are seen in the left ventricle. Right
ventricular chamber size and free wall motion are normal. The
aortic arch is mildly dilated. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. Mild (1+) mitral regurgitation is seen. The
estimated pulmonary artery systolic pressure is normal. There is
an anterior space which most likely represents a prominent fat
pad.
.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
regional systolic dysfunction c/w CAD (mid-LAD distribution).
Mild mitral regurgitation.
Compared with the prior study (images reviewed) of ___,
the findings are similar.
.
CLINICAL IMPLICATIONS:
The left ventricular ejection fraction is <40%, a threshold for
which the patient may benefit from a beta blocker and an ACE
inhibitor or ___.
Based on ___ AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
Brief Hospital Course:
___ male w/ history of hypertension, hyperlipidemia, diabetes
mellitus, recent STEMI with LAD DES, presents with chest pain.
.
ACTIVE ISSUES
# Unstable angina: Pt's presentation is concerning for ACS given
recent diagnosis of CAD with STEMI and placment of DES in LAD.
However, his EKG only showed subtle STE in V2-V3, although there
were progressing TWI. Cardiac enzymes have been negative. His
symptom resolved after three nitro sl. Pt has not missed any
doses of plavix. An ECHO was done, which did not reveal
interval changes. His risk of restenosis was deemed low enough
that does not warrant another catheterization. We resumed his
coumadin with lovenox bridge, given the apical akinesis despite
the disappearance of aneurysm.
.
# Atrial fibrillation: Pt flipped into atrial fibrillation
rhythm during this admission. We increased his rate control
with metoprolol 100 mg bid. His a-trial fibrillation
spontaneously resolved 12 hours afterwards. . Responded well to
rate control with metoprolol. He is back to sinus rhythm now
.
CHRONIC ISSUES
# HLD: cont'ed pravastatin
.
# diabetes: hold metformin and given sliding scale insulin while
inpatient
.
TRANSITIONAL ISSUES
# CODE: Full
# PENDING STUDIES AT DISCHARGE - none
# MEDICATION CHANGES
- INCREASED metoprolol to 100 mg bid
- STARTED nitro sl prn
- STARTED colace 100 mg bid
- STARTED Miralax qd prn
- CONTINUED coumadin with lovenox bridge
# FOLLOW UP ISSUES
- Re-evaluate the need for anticoagulation given the
resolution of apical aneurysm
- Follow up with Dr. ___
- Pt is in the process of applying for medicaid part D, he
was provided with free care medication coverage for now. Please
follow up on the medication compliance.
Medications on Admission:
1. enoxaparin 100 mg/mL Syringe Sig: One (1) injection
Subcutaneous BID (2 times a day) for 3 days.
2. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. warfarin 7.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
___.
5. metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
6. glipizide 10 mg Tablet Sig: One (1) Tablet PO once a day.
7. enoxaparin 100 mg/mL Syringe Sig: One (1) injection
Subcutaneous twice a day for 4 days.
9. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
10. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
11. pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
.
Discharge Medications:
1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO twice a day.
Disp:*60 Tablet Extended Release 24 hr(s)* Refills:*2*
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
Disp:*60 Capsule(s)* Refills:*2*
5. warfarin 5 mg Tablet Sig: 1.5 Tablets PO Once Daily at 4 ___.
Disp:*45 Tablet(s)* Refills:*2*
6. Miralax 17 gram/dose Powder Sig: One (1) PO once a day as
needed for constipation.
Disp:*30 packets* Refills:*2*
7. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual once a day as needed for chest pain: Please take one
tablet sublingual for chest pain, and may repeat every 5 mins up
to 3 tablets at one time. Please call your MD if your chest
pain is of concern to you.
Disp:*60 tablets* Refills:*2*
8. Lovenox ___ mg/mL Syringe Sig: One (1) injection Subcutaneous
twice a day: please administer until your INR level is
therapeutic.
Disp:*10 injections* Refills:*0*
9. glipizide 10 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet
Extended Rel 24 hr PO once a day.
Disp:*30 Tablet Extended Rel 24 hr(s)* Refills:*2*
10. pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
11. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*2*
12. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis
- coronary artery disease
Secondary diagnosis
- hypertension
- hyperlipidemia
- diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
.
You came to our hospital for chest pain at home, concerning for
heart attack. Your EKG was stable, and your blood test also did
not show evidence of heart attack. You underwent an ultrasound
(ECHO) of your heart, which did not show any interval changes.
We felt that the chance of you having a heart attack is so small
that did not warrants the risk of doing another catheterization
study. After the ECHO, you developed an abnormal heart rhythm
called atrial fibrillation. You were asked to stay for one more
night, and treated with medication to control your heart rate.
You responded very well. Your heart rhythm returned to regular
rhythm the second day. You symptom has completely resolved now,
and we felt that you can safely go home.
.
Please note the following changes to your medication:
- Please START to take nitroglycerin sublingual one tablet under
the tongue when you have chest pain, every 5 minutes for a
maximum of 3 tablets in 15 minutes. You should call your MD or
911 if the pain does not go away.
- Please INCREASE your metoprolol succinate 100 mg by mouth to
twice a day from once a day
- Please START to take Colace 100 mg tablet by mouth twice a day
- Please START to take Miralax 17 g packet by mouth once a day
as needed for constipation
- Please CONTINUE the lovenox injection twice a day, until your
INR level (coumadin level) is therapeutic greater than 2.
- There are no further changes to your medication
.
We have set up an apointment with Dr. ___ on ___ and
with Dr. ___ on ___. Please read below for details. You
should also continue the followup with ___
clinic for INR checks.
.
It has been a pleasure taking care of you here at ___. We wish
you a speedy recovery.
Followup Instructions:
___
|
19599769-DS-18
| 19,599,769 | 29,917,761 |
DS
| 18 |
2164-05-07 00:00:00
|
2164-05-08 08:56:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ male with history of HFrEF (last EF was ___ in
___ HTN, HLD, T2DM (A1C 7.2%, ___, and bladder outlet
obstruction; presenting with generalized weakness. Reports that
about 2 weeks ago, he was working outside ___ and
felt
like he developed "heat stroke"; shirt was drenched in sweat. He
has been feeling generally weak. Reports poor PO intake but has
been drinking a lot of water. Mild non-productive cough. No SOB
or chest pain. Denies n/v abdominal pain. Denies dysuria. Has
been continuing to straight cath BID and during the last 4 days
straight cathed QID. No headache. Had 1 episode of diarrhea on
___.
In the ED:
Initial vital signs were notable for:
T101.3 HR98 BP: 147/77 RR:18 Sat94% RA
Exam notable for: Benign exam
Labs were notable for:
Cr: 2.1 BUN 39
WBC of 15.7 with Neutro 85%.
Hgb: 11.3
U/a with ___, Protein, Neg nitrate, WBC.182. Many bacteria
Lactate 1.5
BCx/UCx pending
Studies performed include:
CXR without pneumonia
Patient was given:
Given 1x vanc 1000mg IV and Zosyn 4.5g IV
Tylenol 1g
1L NS bolus
Consults: None
Upon arrival to the floor, endorses the above history. Denies
chest pain, SOB, nausea, vomiting, abdominal pain. No dysuria.
Continues to straight cath and says that his urologist Dr. ___ do a TURP to help relieve obstruction
Past Medical History:
DIABETES TYPE II
GLAUCOMA
Left eye blindness.
HYPERCHOLESTEROLEMIA
HYPERTENSION
ISCHEMIC CARDIOMYOPATHY (LVEF 35% in ___
CORONARY ARTERY DISEASE h/o MI ___ s/p DES to mid-LAD
BLADDER STONES 6-7mm. S/p Cystoscopy, cystolitholapaxy.
BENIGN PROSTATIC HYPERTROPHY
DIABETIC NEPHROPATHY
H/O HEPATITIS B
S/P APPENDECTOMY
Social History:
___
Family History:
Father with MI at ___ years old
- No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death; otherwise non-contributory.
Physical Exam:
Admission
24 HR Data (last updated ___ @ 2205)
Temp: 98.1 (Tm 98.1), BP: 153/88, HR: 85, RR: 18, O2 sat:
95%, O2 delivery: ra, Wt: 225.09 lb/102.1 kg
GENERAL: Alert and interactive. In no acute distress.
HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without
injection.
MMM. Blind in R eye
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 CVA tenderness.
ABDOMEN: Normal bowels sounds, distended from obesity,
non-tender
to deep palpation in all four quadrants.
EXTREMITIES: No clubbing, cyanosis, or edema. P
SKIN: Warm. No rash.
NEUROLOGIC: CN2-12 intact. ___ strength throughout. AOx3.
Discharge
Vital Signs:
___ 0749 Temp: 98.4 PO BP: 147/82 R Lying HR: 73 RR: 16 O2
sat: 96% O2 delivery: Ra
GEN: Well appearing older man in no acute distress
HEENT: Conjunctiva clear, PERRL, MMM
NECK: No JVD noted
LUNGS: CTAB
HEART: RRR, nl S1, S2. No m/r/g.
ABD: NT/ND, normal bowel sounds. No suprapubic tenderness
BACK: No CVA tenderness.
EXTREMITIES: No edema.
SKIN: No rashes.
NEURO: AOx3.
Pertinent Results:
Admission
==========
___ 05:40PM BLOOD WBC-15.7* RBC-3.82* Hgb-11.3* Hct-35.8*
MCV-94 MCH-29.6 MCHC-31.6* RDW-12.7 RDWSD-43.7 Plt ___
___ 05:40PM BLOOD Neuts-85.0* Lymphs-6.1* Monos-8.0
Eos-0.1* Baso-0.2 Im ___ AbsNeut-13.36* AbsLymp-0.95*
AbsMono-1.26* AbsEos-0.01* AbsBaso-0.03
___ 05:40PM BLOOD Glucose-289* UreaN-39* Creat-2.1* Na-135
K-4.7 Cl-98 HCO3-18* AnGap-19*
Discharge
==========
___ 07:23AM BLOOD WBC-11.2* RBC-3.22* Hgb-9.5* Hct-30.1*
MCV-94 MCH-29.5 MCHC-31.6* RDW-12.8 RDWSD-43.8 Plt ___
___ 07:23AM BLOOD Glucose-231* UreaN-45* Creat-1.7* Na-140
K-4.9 Cl-100 HCO3-19* AnGap-21*
___ 07:23AM BLOOD Calcium-8.9 Phos-3.8 Mg-2.1
___ 05:55AM BLOOD TSH-0.75
___ 05:55AM BLOOD T4-7.5
Studies
=========
URINE CULTURE (Final ___:
RAOULTELLA PLANTICOLA. >100,000 CFU/mL.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
RAOULTELLA PLANTICOLA
|
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
___ ECHO
Mild symmetric left ventricular hypertrophy with mildly
increased LV and RV diameter.
Extensive regional systolic dysfunction most consistent with
multiple vessel coronary artery disease.
Brief Hospital Course:
Mr. ___ is a ___ male with history of HFrEF (EF 30%),
HTN, HL, T2DM,
and chronic bladder outlet obstruction requiring daily self
catheterization, presenting for fever and weakness, with
urinalysis consistent with urinary tract infection. The patient
was give IV antibiotics (starting on ___, with good
improvement in symptoms and laboratory findings.
ACUTE ISSUES:
=============
#Urinary tract infection
Patient's presenting symptoms of subjective fevers and weakness
likely due to UTI, in the setting of chronic urinary obstruction
and daily straight caths. UA in ED
___, bacteria, WBC 182. Recent admission ___ for similar
presentation, which grew MSSA. His urine culture grew GNRs prior
to discharge, however had not speciated out further. He was
started on ceftriaxone 1 g q24 hr (first dose ___, and
will be transitioned to Cefpodoxime 200mg BID for a total course
of 10 days as an outpatient ___ - ___.
#Severe BPH
#Bladder outlet obstruction
# S/p cystolithopexy
Patient with severe BPH and bladder outlet obstruction,
resulting
in chronic urinary retention. Currently self straight caths BID.
Follows with Dr ___ with urology, who is considering TURP. While
hospitalized, we continued the patient on home finasteride and
tamsulosin. He should follow up with Dr. ___ to consider a TURP
further - particularly in the setting of recurrent UTIs. His
obstructive symptoms were at baseline at time of discharge.
#Acute on chronic kidney injury
Baseline Cr is 1.5-1.7, likely due from underlying chronic
obstructive disease or diabetes mellitus. Cr on admission is
2.1, which was considered likely prerenal
given current infection vs. some element of obstruction in the
setting of infection. Creatinine improved with gentle fluids. At
the time of discharge, his Creatinine was downtrending and close
to baseline at 1.7 (baseline 1.5).
# CAD
# CHF with reduced EF:
Last EF was ___. Stable. On no diuretics at home, and appears
euvolemic on exam while hospitalized. We continued home home
isosorbide and metoprolol. His hold lisinopril was held given
___, but was restarted prior to discharge. He was continued on
home aspirin, statin, Lisinopril, and metoprolol. Of note, he
had a TTE which demonstrated a LVEF of 30% (stable) however
overall "extensive regional systolic dysfunction" most
consistent with multi-vessel CAD. Patient was recommended to
follow up with outpatient Cardiology in the near future for
further discussion. He had similar findings documented on prior
TTE.
CHRONIC ISSUES:
===============
# T2DM with hyperglycemia:
On metformin and glipizide in outpatient setting, and was
transitioned to HISS while in house. Restarted on home metformin
and glipizide at discharge.
# HTN:
Continued home metoprolol and isosorbide.
# HL:
Continued home statin.
Transitional Issues
====================
[ ] Follow up Urine Culture (pending at discharge with >100,000
GNRs)
[ ] Obtain a repeat CBC/BMP at PCP follow up, and discuss the
quantity of straight caths daily (as was increased with his
UTI). If still with a leukocytosis or symptoms, consider
prolonging the course of antibiotics to 14 days. Please ensure
Creatinine remains stable, if worsens then recommend obtaining a
Renal ultrasound to evaluate for stability of known
hydronephrosis and need for urgent Urology follow up.
[ ] Will need Urology follow up for further consideration of
TURP, particularly given recurrent UTIs
[ ] Will need Cardiology follow up to discuss extensive CAD -
patient provided with the phone number for ___ Cardiology if
he wishes to be seen here
#CODE: FULL CODE (discussed with patient)
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Finasteride 5 mg PO DAILY
2. Metoprolol Tartrate 100 mg PO BID
3. Pravastatin 80 mg PO QPM
4. GlipiZIDE XL 10 mg PO DAILY
5. Lisinopril 40 mg PO DAILY
6. MetFORMIN (Glucophage) 1000 mg PO BID
7. Tamsulosin 0.4 mg PO QHS
8. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
9. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Cefpodoxime Proxetil 200 mg PO Q12H Duration: 9 Days
Final day ___
RX *cefpodoxime 200 mg 1 tablet(s) by mouth twice a day Disp
#*17 Tablet Refills:*0
2. Aspirin 81 mg PO DAILY
3. Finasteride 5 mg PO DAILY
4. GlipiZIDE XL 10 mg PO DAILY
5. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
6. Lisinopril 40 mg PO DAILY
7. MetFORMIN (Glucophage) 1000 mg PO BID
8. Metoprolol Tartrate 100 mg PO BID
9. Pravastatin 80 mg PO QPM
10. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Urinary Tract Infection
Acute Kidney Injury on Chronic Kidney Disease
Secondary:
Benign prostatic hyperplasia
Bladder outlet obstruction
Coronary artery disease
Chronic Heart Failure with reduced Ejection Fraction
Diabetes mellitus type II
hypertension
hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure to care for you at the ___
___.
Why did you come to the hospital?
- You had weakness
What did you receive in the hospital?
- You were found to have a Urinary Tract Infection ("UTI"), and
were treated with antibiotics
- You are likely getting more UTIs because your prostate is
large and causing obstruction of your bladder.
- Because you were weak, we did an ultrasound of your heart
which showed worsening coronary artery disease.
What should you do once you leave the hospital?
- Please take your antibiotics as prescribed
- Please take all of medications as prescribed
- Go to your follow up appointments as scheduled
- We are working on getting an appointment for you with Dr. ___
___ than scheduled, please call his office to schedule this
if you do not hear back by ___
- Please follow up with a Cardiologist, as your heart shows more
damage from your coronary artery disease. If you do not have a
Cardiologist you see regularly, please call ___ Cardiology at
___ to schedule an appointment.
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
19599798-DS-32
| 19,599,798 | 27,465,930 |
DS
| 32 |
2206-06-04 00:00:00
|
2206-06-04 10:44:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
___ / Quinine / ACE Inhibitors / ___ Receptor
Antagonist
Attending: ___.
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old woman with history of HTN, HLD, DM2, osteoporosis,
CVA with residual R sided weakness presents c/o worsening
weakness and speech difficulties over the past month.
Granddaughter states that she left around 7:30 am and she was
speaking normally. She states that the patient's grandson left
approximately 10am and states she was speaking normally as well.
Granddaughter states she returned home from work and noted
patient was in a blank stare and then began speaking abnormally
similar to prior. She states that patient also was dragging her
right foot when attempting to walk. Given her AMS, she was sent
to the ED for further evaluation.
Past Medical History:
Diabetes, type 2
Dyslipidemia
Hypertension
Arthritis
Asthma
History of stroke ___ with residual R side weakness
Gout
s/p Tonsillectomy
CKD stage III
Pernicious anemia
Urinary incontinence
Polyneuropathy
Osteoporosis, hx vertebral compression fractures
Renal cell carcinoma
Social History:
___
Family History:
Her family history is significant for a history of diabetes.
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
Physical Exam:
PHYSICAL EXAM ON ADMISSION
Vitals: 97.6 186/70 81 16 99%RA
GENERAL: cachetic appearing AAF. non-cooperative with
questions/exam. NAD
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM. OP clear.
Neck: Supple, No LAD, No thyromegaly.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. ___ SEM at
LUSB. LUNGS: CTA anteriorly
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses.
SKIN: No rashes/lesions, ecchymoses.
NEURO: would not answer orientation questions. knows we are in
hospital. ___ strength in RLE. ___ throughout. sensation grossly
in tact. downward toes.
PHYSICAL EXAM ON DISCHARGE
Vitals: 97.4 58 167/44 18 100%RA. FSBG 129.
GENERAL: cachectic AAF in NAD
HEENT: Normocephalic, atraumatic. MMM.
CARDIAC: Regular rhythm, normal rate. ___ SEM at LUSB as well as
wide S2 at base of heart, split S1 at apex. R carotid bruit
unchanged.
LUNGS: Respirations easy. CTAB.
ABDOMEN: Soft, NT, ND.
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis b/l.
SKIN: No rashes or ecchymoses. Vasculopathic changes on b/l LEs.
Soft possibly fluid filled patch on right mid back. non tender.
as per patient, has always been present
NEURO: A&Ox3. Speech unchanged from prior interviews: fluent
with notable latency, often slurred, intermittent stutter,
occasional word-finding difficulties. Discrete left facial
weakness.
Pertinent Results:
LABS ON ADMISSION
___ 12:20AM BLOOD WBC-6.3# RBC-3.69* Hgb-10.2* Hct-32.3*
MCV-88 MCH-27.6 MCHC-31.6* RDW-16.0* RDWSD-50.9* Plt ___
___ 12:20AM BLOOD ___ PTT-31.1 ___
___ 12:20AM BLOOD Glucose-90 UreaN-24* Creat-1.2* Na-137
K-5.1 Cl-101 HCO3-24 AnGap-17
___ 12:20AM BLOOD ALT-16 AST-37 AlkPhos-63 TotBili-0.4
___ 12:20AM BLOOD Lipase-33
___ 12:20AM BLOOD Albumin-4.0
___ 12:36AM BLOOD Lactate-1.1
LABS ON DISCHARGE
___ 04:50AM BLOOD WBC-4.5 RBC-3.94 Hgb-10.8* Hct-33.9*
MCV-86 MCH-27.4 MCHC-31.9* RDW-15.3 RDWSD-48.1* Plt ___
___ 04:50AM BLOOD Glucose-142* UreaN-19 Creat-0.9 Na-136
K-4.5 Cl-100 HCO3-26 AnGap-15
IMAGING
CTA ___
1. Approximately 75% stenosis of the right proximal internal
carotid artery at its bifurcation by NASCET criteria.
2. No evidence of left internal carotid artery stenosis by
NASCET criteria.
3. Occlusion of the left vertebral artery at its origin which
short segments of reconstitution at the C5 and C6 and eventual
reconstitution at C4-C5 with severe, multifocal stenoses
throughout the remainder of the left V2 segment.
4. Severe, multifocal stenoses of the left V4 and mid M1
segments.
5. No acute intracranial abnormality.
CT HEAD ___
1. No acute intracranial abnormality on noncontrast head CT.
Specifically no intracranial hemorrhage.
CXR ___
IMPRESSION:
No acute intrathoracic process.
Brief Hospital Course:
___ yo F w/ PMH of DM2, HTN, CKD stage III, CVA with residual R
sided weakness who presents with AMS in setting of UTI.
#Delirium duet to UTI: Most likely secondary to UTI. Prior Cx
with pansensitve E. coli and she was started on IV CTX as she
preliminarily could not take PO. CT head negative for stroke.
Cefpodoxime started after urine cultures returned. Will finish a
7 day course of Cefpodoxime (end date ___.
#Urinary tract infection: grossly positive U/A and Urine culture
grew E. Coli, Bactrim resistant. Blood cultures with no growth.
CHRONIC ISSUES:
#CAD, PVD, s/p CVA: continued statin, aspirin, plavix, imdur,
beta blocker.
#Gout: Continued allopurinol, vit d/ calcium and tylenol
#Asthma: continued home albuterol prn
#Outpatient supplements: continued folate. Received her monthly
B12 shot while inpatient.
#Incontinence. Held home detrol as it is non-formulary
#DMII: oral meds held per last PCP in setting of frequent falls.
She was monitored by ___ only.
TRANSITIONAL ISSUES
[]Patient had ongoing hypertension in the inpatient setting.
Initially secondary to inability to crush Imdur when patient was
unable to take pills. However, elevated SBPs persisted (160s).
consider alteration to HTN medication
[]granddaughter has noticed cognitive decline lately. ___
benefit from full cognitive evaluation.
[]given her monthly Vit B12 shot while inpatient.
[]Will finish a 7 day course of Cefpodoxime (end date ___
for UTI.
[]FYI on CTA: 75% stenosis of the right proximal internal
carotid artery and Occlusion of the left vertebral artery at its
origin which short segments of reconstitution at the C5 and C6
and eventual reconstitution at C4-C5 with severe, multifocal
stenoses throughout the remainder of the left V2 segment.
Severe, multifocal stenoses of the left V4 and mid M1 segments.
# Code: Full
# Communication: son ___ (___) ___, and Grand
Daughter ___ ___ (alt HCP).
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Allopurinol ___ mg PO DAILY
3. Tolterodine 4 mg PO QHS
4. Metoprolol Tartrate 50 mg PO TID
5. Amlodipine 10 mg PO DAILY
6. Atorvastatin 40 mg PO QPM
7. Isosorbide Mononitrate (Extended Release) 180 mg PO DAILY
8. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
9. Clopidogrel 75 mg PO DAILY
10. Aspirin 325 mg PO DAILY
11. trolamine salicylate 10 % topical DAILY:PRN cramping
12. Calcium Carbonate 500 mg PO BID
13. menthol 4 % topical QHS:PRN cramping
14. Cyanocobalamin 1000 mcg IM/SC Q MONTHLY
15. FoLIC Acid 1 mg PO DAILY
16. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Allopurinol ___ mg PO DAILY
3. Amlodipine 10 mg PO DAILY
4. Aspirin 325 mg PO DAILY
5. Atorvastatin 40 mg PO QPM
6. Calcium Carbonate 500 mg PO BID
7. Clopidogrel 75 mg PO DAILY
8. FoLIC Acid 1 mg PO DAILY
9. Isosorbide Mononitrate (Extended Release) 180 mg PO DAILY
10. Metoprolol Tartrate 50 mg PO TID
11. Vitamin D ___ UNIT PO DAILY
12. Cyanocobalamin 1000 mcg IM/SC Q MONTHLY
13. menthol 4 % topical QHS:PRN cramping
14. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
15. Tolterodine 4 mg PO QHS
16. trolamine salicylate 10 % topical DAILY:PRN cramping
17. Cefpodoxime Proxetil 100 mg PO Q12H
RX *cefpodoxime 100 mg 1 tablet(s) by mouth q12hr Disp #*11
Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
Altered mental status
Urinary tract infection
Hypertension
SECONDARY DIAGNOSIS
===================
Type II Diabetes Mellitus
Coronary artery disease
Peripheral vascular disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___
because of confusion that was caused by an infection in the
urine. You were treated with antibiotics and improved.
It was a pleasure taking part in your care
Your ___ Team
Followup Instructions:
___
|
19599798-DS-33
| 19,599,798 | 25,306,345 |
DS
| 33 |
2207-02-26 00:00:00
|
2207-02-26 13:21:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
___ / Quinine / ACE Inhibitors / ___ Receptor
Antagonist
Attending: ___
Chief Complaint:
Unresponsiveness and difficulty speaking s/p fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
EU Critical Hope aka ___ is a ___ woman with HTN,
HLD, DM2, multiple ischemic strokes (L ACA leading to RLE
weakness, residual gait problems, ?R MCA leading to L hand
clumsiness in ___, CAD, and NSTEMI who presents after a fall
with trouble speaking. She was in her usual state of health and
doing things around the house, walking with her walker when her
grandson heard a loud thump from the kitchen. He found her on
the
ground at 9:03pm, eyes looking up and unresponsive. After about
___ minutes, she started becoming responsive again. He picked
her
up and put her on the couch, but she fell to the side and hit
her
head against the dresser. She seemed unable to keep her balance.
Her words seemed slurred, and she did not know where she was or
who she was. Grandson called ___, and she was brought to ___.
On arrival, a code stroke was called. NIHSS 2 for L NLFF
(chronic) and extinction to DSS. tPA was not given as her NIHSS
was low.
She was previously seen as a code stroke in ___ for worsening
weakness and speech difficulties. An MRI could not be obtained
at
that time due to agitation, and it was thought that this was
likely to be recrudescence. On chart review, she was followed by
Dr. ___ in clinic. Prior L ACA stroke with residual right
leg
weakness in ___, also had stroke in ___ with gait problems and
left hand clumsiness. Her work-up revealed evidence or small
vessel disease and a left ACA infarct. She was on warfarin,
which
was transitioned to ASA/Plavix given her fall risk. In ___,
another code stroke was called for acute onset L arm weakness.
On
imaging at that time, she had no apparent intracranial vascular
occlusion or thrombosis but did have significant multi-vessel
extracranial atherosclerotic stenoses with the most concerning
being a high grade right ICA origin stenosis with soft plaque as
well as bilateral fetal PCAs. She was continued on ASA/Plavix.
Past Medical History:
Diabetes, type 2
Dyslipidemia
Hypertension
Arthritis
Asthma
History of stroke ___ with residual R side weakness
Gout
s/p Tonsillectomy
CKD stage III
Pernicious anemia
Urinary incontinence
Polyneuropathy
Osteoporosis, hx vertebral compression fractures
Renal cell carcinoma
Social History:
___
Family History:
Her family history is significant for a history of diabetes.
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
Physical Exam:
================================
Admission Physical Exam ___
================================
Vitals: T: 98.2F HR: 84 BP: 202/70 RR: 21 SaO2: 100% RA
General: NAD
HEENT: hematoma over R forehead
___: RRR
Pulmonary: breathing comfortably
Abdomen: Soft, NT, ND
Extremities: Warm, no edema
Neurologic Examination:
- Mental status: Awake, alert, oriented to name, birthday, and
month. Has mild difficulty relating history. Speech is fluent
with full sentences, unable to repeat (?attention), able to
follow simple commands. +paraphasia (called glove a hand on the
stroke cards). Unable to name high frequency objects. No
dysarthria. No evidence of hemineglect. ?left-right confusion.
Able to follow both midline and appendicular commands.
- Cranial Nerves: PERRL 3->2 brisk. Blinks to threat
bilaterally.
EOMI, no nystagmus. V1-V3 without deficits to light touch
bilaterally. L NLFF. Hearing intact to finger rub bilaterally.
Palate elevation symmetric. SCM/Trapezius strength ___
bilaterally. Tongue midline.
- Motor: decreased bulk, normal tone. No tremor or asterixis.
Had
difficulty performing full motor exam. Proximal muscles ___,
unable to asses bilateral hamstrings/TA.
- Reflexes:
[Bic] [Tri] [___] [Quad] [Gastroc]
L 2+ 2+ 2+ 0 0
R 2+ 2+ 2+ 0 0
Plantar response extensor bilaterally
- Sensory: withdraws to tickle in all extremities. +DSS on R
- Coordination: No dysmetria with finger to nose testing
bilaterally.
- Gait: deferred
Discharge Physical Exam:
Vitals: T: HR: BP: RR: SaO2: RA
General: NAD
HEENT: hematoma over R forehead
Pulmonary: breathing comfortably
Extremities: Warm, no edema
Neurologic Examination:
- Mental status: Awake, alert, oriented. Able to follow simple
commands.
Speech has returned to baseline but she has multiple paraphasias
and trouble naming high frequency objects. No evidence of
hemineglect
- Cranial Nerves: PERRL 3->2 brisk. Blinks to threat
bilaterally.
EOMI, no nystagmus. V1-V3 without deficits to light touch
bilaterally. L NLFF. Hearing intact to finger rub bilaterally.
Palate elevation symmetric. SCM/Trapezius strength ___
bilaterally. Tongue midline.
- Motor: decreased bulk, normal tone. No tremor or asterixis.
Had
difficulty performing full motor exam. ___ for left ankle
dorsiflexion and plantar flexion and ___ for left toe flexion
and extension
- Reflexes:
[Bic] [Tri] [___] [Quad] [Gastroc]
L 2+ 2+ 2+ 0 0
R 2+ 2+ 2+ 0 0
Plantar response extensor bilaterally
- Sensory: withdraws to tickle in all extremities. +DSS on R
- Coordination: Deferred
- Gait: deferred
===============================
Discharge Physical Exam ___
===============================
Vitals: No new vitals (CMO)
Gen: In bed, NAD, unresponsive.
CV: RRR
Pulm: CTAB
Abd: Hyperactive bowel sounds.
Ext: Stage 2 pressure ulcers on left heel and sacrum.
MS: Unresponsive, opens eyes intermittently, does not regard.
CN: VOR negative. 2.5-->1 bilateral pupils, brisk, -blink to
threat, b/l corneal reflexes.
Sensory: no withdrawal to noxious in bilateral upper
extremities. Minimal foot withdrawal at ankle to stimulation of
bilateral feet.
Pertinent Results:
=============
SELECTED LABS
=============
___ 09:51PM BLOOD WBC-5.7 RBC-4.02 Hgb-11.0* Hct-36.5
MCV-91 MCH-27.4 MCHC-30.1* RDW-15.4 RDWSD-50.6* Plt ___
___ 08:25AM BLOOD WBC-8.1 RBC-2.86* Hgb-8.0* Hct-25.8*
MCV-90 MCH-28.0 MCHC-31.0* RDW-16.2* RDWSD-54.1* Plt ___
___ 07:32AM BLOOD WBC-6.2 RBC-2.70* Hgb-7.5* Hct-24.7*
MCV-92 MCH-27.8 MCHC-30.4* RDW-16.2* RDWSD-54.3* Plt ___
___ 06:40AM BLOOD WBC-9.6 RBC-2.54* Hgb-7.0* Hct-22.6*
MCV-89 MCH-27.6 MCHC-31.0* RDW-16.4* RDWSD-53.6* Plt ___
___ 06:15AM BLOOD WBC-10.9* RBC-2.50* Hgb-6.8* Hct-21.8*
MCV-87 MCH-27.2 MCHC-31.2* RDW-16.3* RDWSD-51.3* Plt ___
___ 09:57AM BLOOD WBC-13.0* RBC-2.47* Hgb-6.7* Hct-22.2*
MCV-90 MCH-27.1 MCHC-30.2* RDW-16.5* RDWSD-54.2* Plt ___
___ 05:00PM BLOOD WBC-13.8* RBC-2.22* Hgb-6.1* Hct-19.6*
MCV-88 MCH-27.5 MCHC-31.1* RDW-16.4* RDWSD-53.1* Plt ___
___ 07:25AM BLOOD WBC-16.3* RBC-2.81*# Hgb-7.6* Hct-25.2*#
MCV-90 MCH-27.0 MCHC-30.2* RDW-16.5* RDWSD-54.3* Plt ___
___ 06:35AM BLOOD WBC-19.5* RBC-2.93* Hgb-7.9* Hct-25.4*
MCV-87 MCH-27.0 MCHC-31.1* RDW-16.3* RDWSD-52.7* Plt ___
___ 09:51PM BLOOD Neuts-49 Bands-0 ___ Monos-11 Eos-4
Baso-0 Atyps-1* ___ Myelos-0 AbsNeut-2.79 AbsLymp-2.05
AbsMono-0.63 AbsEos-0.23 AbsBaso-0.00*
___ 09:00AM BLOOD Neuts-77.8* Lymphs-14.2* Monos-6.9
Eos-0.2* Baso-0.3 Im ___ AbsNeut-4.99 AbsLymp-0.91*
AbsMono-0.44 AbsEos-0.01* AbsBaso-0.02
___ 05:40AM BLOOD Neuts-85* Bands-2 Lymphs-10* Monos-1*
Eos-0 Baso-0 ___ Myelos-2* AbsNeut-7.48*
AbsLymp-0.86* AbsMono-0.09* AbsEos-0.00* AbsBaso-0.00*
___ 06:35AM BLOOD Neuts-87.3* Lymphs-2.5* Monos-9.1
Eos-0.0* Baso-0.2 NRBC-0.1* Im ___ AbsNeut-17.03*#
AbsLymp-0.48* AbsMono-1.77* AbsEos-0.00* AbsBaso-0.03
___ 09:51PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-2+
Macrocy-1+ Microcy-NORMAL Polychr-NORMAL Ovalocy-1+ Tear
___ Fragmen-OCCASIONAL
___ 09:57AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+
Macrocy-NORMAL Microcy-NORMAL Polychr-1+ Ovalocy-1+ Schisto-1+
Burr-1+ Fragmen-OCCASIONAL
___ 09:51PM BLOOD ___ PTT-35.2 ___
___ 06:35AM BLOOD ___ PTT-28.7 ___
___ 08:36AM BLOOD Ret Aut-1.1 Abs Ret-0.03
___ 09:51PM BLOOD Glucose-105* UreaN-26* Creat-1.2* Na-137
K-5.5* Cl-99 HCO3-23 AnGap-21*
___ 07:32AM BLOOD Glucose-139* UreaN-54* Creat-1.2* Na-145
K-3.7 Cl-112* HCO3-18* AnGap-19
___ 06:35AM BLOOD Glucose-136* UreaN-74* Creat-2.0* Na-148*
K-4.5 Cl-112* HCO3-18* AnGap-23*
___ 09:51PM BLOOD ALT-26 AST-38 AlkPhos-101 TotBili-0.2
___ 09:57AM BLOOD ALT-9 AST-17 AlkPhos-75 TotBili-<0.2
___ 01:20PM BLOOD cTropnT-0.11*
___ 08:25AM BLOOD cTropnT-0.09*
___ 03:25PM BLOOD cTropnT-0.09*
___ 09:57AM BLOOD cTropnT-0.04*
___ 09:51PM BLOOD Albumin-4.3 Calcium-9.1 Phos-4.2 Mg-1.9
___ 06:50AM BLOOD Calcium-8.8 Phos-3.2 Mg-1.8 Cholest-139
___ 06:15AM BLOOD Calcium-7.9* Phos-3.3 Mg-1.8
___ 09:00AM BLOOD Calcium-7.7* Phos-4.9* Mg-2.1
___ 05:40AM BLOOD Calcium-8.0* Phos-3.9 Mg-2.5
___ 06:15AM BLOOD Albumin-2.6* Calcium-7.7* Phos-4.3 Mg-2.5
___ 05:00PM BLOOD Calcium-7.5* Phos-4.9* Mg-2.5
___ 08:36AM BLOOD calTIBC-181* Ferritn-155* TRF-139*
___ 06:50AM BLOOD Triglyc-81 HDL-73 CHOL/HD-1.9 LDLcalc-50
___ 06:50AM BLOOD TSH-2.3
___ 06:05AM BLOOD Vanco-6.8*
___ 12:40PM BLOOD Valproa-56
___ 07:32AM BLOOD Valproa-35*
___ 05:40AM BLOOD Valproa-60
___ 09:51PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 05:11PM BLOOD pH-7.45
___ 10:49AM BLOOD Type-ART pO2-248* pCO2-30* pH-7.44
calTCO2-21 Base XS--1 Comment-GREEN TOP
___ 10:13AM BLOOD ___ pO2-207* pCO2-33* pH-7.42
calTCO2-22 Base XS--1 Comment-GREEN TOP
___ 09:58AM BLOOD Type-ART pO2-88 pCO2-27* pH-7.55*
calTCO2-24 Base XS-2
___ 11:16PM URINE Blood-NEG Nitrite-POS Protein-300
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-SM
___ 03:30PM URINE Blood-NEG Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM
___ 09:52AM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 11:16PM URINE RBC-2 WBC-14* Bacteri-FEW Yeast-NONE
Epi-1
___ 03:30PM URINE RBC-1 WBC-10* Bacteri-FEW Yeast-NONE
Epi-<1
___ 09:52AM URINE RBC-7* WBC-111* Bacteri-FEW Yeast-RARE
Epi-<1 TransE-1
=======
IMAGING
=======
-___ CTA HEAD & NECK
IMPRESSION:
1. Small focus of hyperdensity in the paracentral portion of the
cingulate
gyrus may represent subarachnoid hemorrhage.
2. Large chronic infarction in the left anterior cerebral artery
territory, moderate-sized chronic infarction in the
inferolateral left frontal lobe in the left middle cerebral
artery territory, and multiple small chronic infarctions in the
right basal ganglia and deep white matter. No CT evidence for
an acute major vascular territorial infarction.
3. Right parietal/occipital subgaleal hematoma and right
inferior frontal
subgaleal hematoma extending into the periorbital region,
without evidence for fractures or postseptal intraorbital
extension.
4. At least mild stenosis of the proximal right subclavian
artery. Moderate to severe stenosis of the right vertebral
artery origin, with patency of the right vertebral artery distal
to its origin. Calcified plaque causing high-grade stenosis of
the proximal right V4 segment.
5. Apparent greater than 50% stenosis of the proximal and mid
left subclavian artery, not adequately quantified on this exam.
Occlusion of the left vertebral artery from its origin to the
C4-C5 level, with diffusely irregular, small-caliber
reconstitution from C4-C5 to the basilar artery.
6. Diffusely narrowed and irregular basilar artery. Bilateral
___, AICA, and superior cerebellar arteries appear patent.
Posterior cerebral arteries receive greater contributions from
the posterior communicating arteries than from the basilar
artery.
7. Calcified plaque causing greater than 90% stenosis of the
proximal right internal carotid artery by NASCET criteria.
8. High-grade stenosis of the M1 segment of the left middle
cerebral artery. Mild stenosis at the junction of M1/M2
segments of the right middle cerebral artery. Diffusely
irregular A2 segments of the anterior cerebral arteries. These
findings are presumably atherosclerotic.
9. 2 mm laterally projecting infundibulum versus aneurysm of the
proximal A2 segment of the right anterior cerebral artery.
10. No evidence for a cervical spine fracture on technically
limited
evaluation. Mild retrolisthesis at C3-C4, C4-C5, C5-C6, and
C6-C7 is almost certainly degenerative, though there are no
comparison exams to confirm chronicity.
11. Thyroid nodules measuring up to 1 cm. The ___ College
of Radiology guidelines suggest that in the absence of risk
factors for thyroid cancer, no further evaluation is
recommended.
12. 4 mm pulmonary nodule in the right upper lobe.
-___ CT HEAD
1. Acute hemorrhage partially filling the right lateral
ventricle as well as a small amount layering in the occipital
horn of the left lateral ventricle, which are both new compared
to the prior CT dated ___. No evidence of
hydrocephalus.
2. Persistent right frontal scalp hematoma without evidence of
underlying
fracture.
3. Chronic encephalomalacia within the inferior left frontal
lobe and along the left ACA distribution, likely due to prior
infarct.
-___ CT HEAD
Stable intraventricular hemorrhage and ventricle size. No new
intracranial hemorrhage.
-___ CT HEAD
1. Intraventricular blood products is similar to ___
at 04:15 but decreased compared to ___. No new
hemorrhage.
2. No CT evidence for an acute major vascular territorial
infarction.
Multiple chronic infarctions are again demonstrated.
-___ MRI HEAD
1. Late acute/early subacute right cerebral hemisphere infarcts
involving the right ACA/MCA/PCA watershed zones as described
above, although the infarcts to extend to the cortical surface
in the right frontal parietal lobes. A single punctate focus of
acute/subacute infarct is also present in the left posterior
parietal lobe.
2. Suggestion of mild attenuation of normal right M1
bifurcation flow void, which may be artifactual versus
potentially thrombus. Although the infarcts are in a
predominately watershed distribution (although right hemispheric
predominant), MRA could be performed for further evaluation.
3. Small intraventricular hemorrhages, similar to the prior CT.
4. Cystic encephalomalacia from chronic infarcts in the
superior paramedian and inferolateral left frontal lobe.
-___ CXR
Moderate bilateral pleural effusions and moderate bibasilar
atelectasis
unchanged from ___ study.
Brief Hospital Course:
___ woman with CAD s/p stents, HTN, HLD, DM2, and old ischemic
strokes presents after a fall with a period of unresponsiveness
and difficulty speaking. Initially, speech returned to baseline.
CT scans showed small SDH. Subsequent agitated delirium and
uncontrolled HTN (refusing meds due to agitation), then new
right-sided IVH. Also NSTEMI ___. New left arm plegia
___, left hand focal motor seizure ___ -> loaded with
valproate, then diminished responsiveness c/f complex partial
seizure -> loaded with Keppra.
Repeat CT showed reduction in IVH. Seizure ceased evening of
___. Slow to regain consciousness ___, presumed due to
post-ictal state and AEDs in setting of advanced age. Likely
underlying cause new right-sided strokes leading to left arm
plegia and focal seizures which later generalized to complex
seizure. On ___, Hgb drop to 7.5 (from 8.9), worsening BUN and
Cr, also diarrhea overnight. Cdiff was positive so PO vancomycin
was started, later changed to IV metronidazole due to lack of PO
access. EEG looked worse, so EEG was halted and MRI done which
confirmed multiple acute to subacute right-hemispheric infarcts.
There would not ever be a return of consciousness during her
admission.
On the morning of ___ there was acute desaturation,
tachypnea, and worsening of respiratory status. Elevated WBC,
started empiric antibiotics out of concern for HCAP. Other
studies (CXR, troponin, EKG, ABG, chemistries) were essentially
normal. Stopped tube feeds due to climbing phosphorus,
potassium, and worsening renal function. Hemoglobin also
continued to fall during this time, down to a nadir of 6.7.
Patient is Jehova's witness, so we limited blood draws as much
as possible. As of ___, WBC continued to climb despite
broad-spectrum antibiotics. Renal function also continued to
worsen. On ___ family agreed to comfort measures only.
# COMFORT MEASURES: Confirmed with son/HCP, ___, on
___.
- Glycopyrrolate PRN
- Morphine 20mg/ml Q2H PO PRN shortness-of-breath, pain
- Morphine ___ Q15MIN IV PRN pain or respiratory distress
- Lorazepam 0.5-2mg Q2H PRN anxiety/distress
- Zofran PRN
- CONTINUE Valproate and Levetiracetam for seizure control.
- DISCONTINUE all other meds, fingersticks, pneumoboots, vitals
checks, labs.
Medications on Admission:
ALBUTEROL SULFATE [PROAIR HFA] - ProAir HFA 90 mcg/actuation
aerosol inhaler. 2 puffs inhaled four times a day - (Not Taking
as Prescribed: Not needing)
ALLOPURINOL - allopurinol ___ mg tablet. 1 Tablet(s) by mouth
once a day
AMLODIPINE - amlodipine 10 mg tablet. 1 (One) Tablet(s) by mouth
once a day
ATORVASTATIN - atorvastatin 40 mg tablet. 1 tablet(s) by mouth
Daily
CLOPIDOGREL - clopidogrel 75 mg tablet. 1 tablet(s) by mouth
Daily
CYANOCOBALAMIN (VITAMIN B-12) - cyanocobalamin (vit B-12) 1,000
mcg/mL injection solution. 1000 mcg IM each month
DIABETIC EXTRA DEPTH SHOES PLUS INSOLES - Diabetic Extra Depth
Shoes plus Insoles . Use as directed
DIABETIC SHOES DX DIABETES - Diabetic shoes Dx Diabetes . use
every day as directed 1 pair
FOLIC ACID - folic acid 1 mg tablet. 1 Tablet(s) by mouth once a
day
GLUCOMETER - Glucometer . use as directed once a day Dx Type II
DM
ISOSORBIDE MONONITRATE - isosorbide mononitrate ER 60 mg
tablet,extended release 24 hr. 1 tablet(s) by mouth once a day.
Take with 120mg tablet. Total daily dose is 180mg.
ISOSORBIDE MONONITRATE - isosorbide mononitrate ER 120 mg
tablet,extended release 24 hr. 1 (One) tablet(s) by mouth once a
day Take with isosorbide mononitrate ER 60mg for total daily
dose
of 180mg
METOPROLOL TARTRATE - metoprolol tartrate 50 mg tablet. 1 tablet
by mouth three times a day
NITROGLYCERIN - nitroglycerin 0.3 mg sublingual tablet. 1
Tablet(s) sublingually every 5 minutes as needed (call doctor if
not better after 3 doses)
PREDNISONE - prednisone 2.5 mg tablet. 1 tablet(s) by mouth
daily
- (On Hold from ___ to unknown for not needed)
R FOOT BRACE FOR FOOT DROP - R foot brace for Foot drop . s/p
CVA
ROLLING WALKER WITH 2 WHEELS - rolling walker with 2 wheels .
use as directed daily Diagnosis of Osteoporosis, unsteady gait
and history of falls
TOLTERODINE [DETROL LA] - Detrol LA 4 mg capsule,extended
release. 1 capsule(s) by mouth once a day at night
Medications - OTC
ACETAMINOPHEN - acetaminophen 325 mg tablet. 2 tablet(s) by
mouth
every six (6) hours as needed for pain do not exceed 8 tabs per
day
ASPIRIN - aspirin 325 mg tablet. 1 tablet(s) by mouth daily
BLOOD SUGAR DIAGNOSTIC [FREESTYLE LITE STRIPS] - FreeStyle Lite
Strips. use as directed once a day Dx Type II DM; pls give
strips
for Freestyle Freedom Lite Strips
BLOOD SUGAR DIAGNOSTIC [ONETOUCH ULTRA TEST] - OneTouch Ultra
Test strips. use to test your blood sugar once a day ICD: 250.0
CALCIUM CARBONATE-VITAMIN D3 [OYSTER SHELL CALCIUM-VIT D3] -
Oyster Shell Calcium-Vitamin D3 500 mg (1,250 mg)-200 unit
tablet. TAKE ONE (1) TABLET(S) TWO (2) TIMES A DAY
CHOLECALCIFEROL (VITAMIN D3) - cholecalciferol (vitamin D3)
2,000
unit tablet. 1 tablet(s) by mouth daily
DIAPER,BRIEF,ADULT,DISPOSABLE - diaper,brief,adult,disposable.
size small-medium use as directed ___ times per day Dx: urinary
incontinence
MENTHOL [BIOFREEZE (MENTHOL)] - Biofreeze (menthol) 4 % topical
gel. Topically at bedtime as needed for cramping
NUT.TX.GLUC.INTOL,LAC-FREE,SOY [GLUCERNA] - Glucerna oral
liquid.
1 can by mouth twice a day
OXYQUINOLINE-NA LAURYL SULFATE [TRIMO-SAN JELLY] - Trimo-San
Jelly 0.025 %-0.01 % vaginal. apply intravaginal prn - (Not
Taking as Prescribed)
TROLAMINE SALICYLATE - trolamine salicylate 10 % topical cream.
Topically daily as needed for cramping
Discharge Medications:
1. Acetaminophen 650 mg PR Q6H:PRN Fever, Pain
RX *acetaminophen 650 mg 1 suppository(s) rectally every 6 hours
Disp #*12 Suppository Refills:*1
2. Glycopyrrolate 0.1 mg IV Q6H:PRN excess secretions
RX *glycopyrrolate 0.4 mg/2 mL (0.2 mg/mL) 0.1 mg IV every 6
hours Disp #*20 Syringe Refills:*1
3. LevETIRAcetam 500 mg IV BID
RX *levetiracetam 500 mg/5 mL 500 mg IV twice a day Disp #*60
Vial Refills:*1
4. LORazepam 0.5-1 mg IV Q4H:PRN continuous jerking of arm > 5
minutes
RX *lorazepam 2 mg/mL 0.5-1 mg IV every 2 hours Disp #*10 Vial
Refills:*1
5. LORazepam 0.5-2 mg IV Q2H:PRN anxiety/distress
RX *lorazepam 2 mg/mL 0.5-2 mg IV every 2 hours Disp #*10 Vial
Refills:*1
6. Morphine Sulfate (Concentrated Oral Solution) 20 mg/mL ___
mg PO Q2H:PRN SOB or pain
RX *morphine concentrate 100 mg/5 mL (20 mg/mL) ___ mg by mouth
Q4H:PRN Refills:*0
7. Morphine Sulfate ___ mg IM Q15MIN:PRN Pain or Respiratory
Distress
RX *morphine 2 mg/mL ___ mg IV Q15MIN:PRN Disp #*20 Syringe
Refills:*0
8. Morphine Sulfate ___ mg IV Q15MIN:PRN Pain or respiratory
distress
9. Ondansetron ___ mg IV Q6H:PRN nausea/vomiting
RX *ondansetron HCl 2 mg/mL 4 mg IV every 8 hours Disp #*10 Vial
Refills:*1
10. Valproate Sodium 150 mg IV Q6H
RX *valproate sodium 500 mg/5 mL (100 mg/mL) 150 mg IV every 6
hours Disp #*50 Vial Refills:*1
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Subdural hemorrhage, Intraventricular Hemorrhage, NSTEMI,
Multifocal Right Hemisphere Ischemic Stroke, Focal motor
seizures, Complex partial seizures, Coma, C.diff infection,
HCAP, GI blood loss, and renal failure.
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Ms. ___ was admitted after a fall and found to have a
subdural hemorrhage. She subsequently became agitated, developed
an intraventricular hemorrhage, NSTEMI, right-sided stroke,
seizures, coma, C.diff infection, pneumonia, GI blood loss, and
renal failure.
She was transitioned to comfort care measures on ___ and is
being transferred to a hospice facility. While there, she will
be maintained on anti-seizure medications, and otherwise only
medications to keep her comfortable.
- Your ___ Neurology Team
Followup Instructions:
___
|
19599923-DS-12
| 19,599,923 | 21,366,926 |
DS
| 12 |
2125-06-15 00:00:00
|
2125-06-15 17:46:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
OxyContin
Attending: ___.
Chief Complaint:
seizure
Major Surgical or Invasive Procedure:
Intubation ___
History of Present Illness:
The pt is a ___ year-old woman with a hx of R MCA stroke in ___
who presented to ___ from home for unresponsiveness. The
history is obtained from the patient's husband and paperwork as
the patient is intubated. Per husband, Mrs. ___ was at home,
sitting on her shower chair, bathing with the help of a home
health aid. Suddenly she lost consciousness and slumped to the
right. The aid caught her and she did not fall to the ground.
EMS
was called. She continued to be unresponsive by time they
arrived, a few minutes later. Her O2 sat was noted to be 96 %.
Her SBPs were 200s. She was brought to ___. Per her
husband, she awoke, started talking, was confused about her
location but otherwise appeared at baseline. On her way back
from
radiology, she had shaking of both arms and legs, concerning
___ staff for seizure. Her husband reports neither any
seizure history nor any episodes of loss of
consciousness/confusion in the past.
At BI-N, she was given ativan 2mg, then ___ 500mg IV x 1. The
decision was made to intubate, which was difficult and required
2
inductions. She was given versed 2mg and maintained on a versed
gtt for some length of time before being transferred here on
propofol and fentanyl.
ROS: unobtainable
Past Medical History:
PMH:
-hx of R MCA stroke in ___ - thought to be due to emboli thru
patent PFO. Treated initially with warfarin, then switched to
aggrenox, then Plavix, which she continues on. Has resultant
left
hemiparesis, affecting arm > leg. Follows with Dr. ___ in
stroke clinic.
- HTN
- ___ edema, left > right
Social History:
___
Family History:
___
Physical Exam:
Admission Exam
**********
Physical Exam:
Vitals: T: 37.7 P:80 BP: 157/71 RR: 18 SaO2: 100% intubated
General: intubated, sedated, NAD.
HEENT: NC/AT, no scleral icterus, MMM, intubated
Neck: Supple, no nuchal rigidity. No carotid bruits
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G
Abdomen: soft, NT/ND, normoactive bowel sounds
Extremities: trace edema in b/l ___. Left UE and ___ cooler
than right
Skin: no rashes or lesions
Neurologic: 10 min off propofol:
-Mental Status: eyes closed, opens eyes to voice. Gaze
conjugate.
Follows "squeeze" and "let go" in right hand, does not follow
any
other commands. Closes eyes immediately without stimulation.
-Cranial Nerves:
Pupils reactive 4 to 3mm b/l. Corneals present b/l. OCR intact.
Face obscured by tube. Gag present.
-Motor: Increased tone in b/l ___ and ___ arm (with
contractures). Atrophy of left UE. To noxious, withdraws
antigravity in RUE and RLE. Withdraws on LUE in plane of bed.
LLE
triple flexes.
-Sensory: Localizes to noxious in b/l UEs and right ___. Triple
flexes to noxious in LLE.
-DTRs:
Bi Tri ___ Pat Ach
L 2+ 2 2+ 0 0
R 2+ 2 2+ 0 0
Plantar response was majestically up bilaterally.
DISCHARGE EXAM
Mental status unremarkable save slight disorientation to place
on the day of discharge (on other days fully oriented). Mild
left neglect.
CN with left facial weakness.
Limb examination reveals left ARM>LEG hemiparesis. Good power on
the right side. Extensor plantar on the left>right.
Pertinent Results:
Admission labs:
___ 06:18PM BLOOD WBC-9.4 RBC-4.75 Hgb-15.0 Hct-45.5 MCV-96
MCH-31.5 MCHC-32.9 RDW-12.2 Plt ___
___ 06:18PM BLOOD Neuts-80.7* Lymphs-12.1* Monos-5.6
Eos-1.0 Baso-0.7
___ 05:59AM BLOOD ___ PTT-31.4 ___
___ 05:59AM BLOOD Glucose-117* UreaN-19 Creat-0.7 Na-146*
K-3.5 Cl-109* HCO3-25 AnGap-16
___ 06:18PM BLOOD ALT-26 AST-36 AlkPhos-70 TotBili-0.8
___ 06:18PM BLOOD Lipase-94*
___ 06:18PM BLOOD Albumin-4.3 Calcium-8.8 Phos-3.4 Mg-2.2
.
Discharge labs:
___ 05:40AM BLOOD WBC-8.5 RBC-4.21 Hgb-13.4 Hct-39.2 MCV-93
MCH-31.9 MCHC-34.2 RDW-12.1 Plt ___
___ 12:36PM BLOOD Glucose-104* UreaN-7 Creat-0.6 Na-147*
K-4.0 Cl-109* HCO3-25 AnGap-17
___ 05:40AM BLOOD Calcium-9.0 Phos-2.7 Mg-1.8
.
K trend:
___ 05:59AM BLOOD Glucose-117* UreaN-19 Creat-0.7 Na-146*
K-3.5 Cl-109* HCO3-25 AnGap-16
___ 05:10AM BLOOD Glucose-75 UreaN-11 Creat-0.6 Na-144
K-2.5* Cl-108 HCO3-27 AnGap-12
___ 08:35AM BLOOD Glucose-78 UreaN-10 Creat-0.5 Na-145
K-2.4* Cl-106 HCO3-28 AnGap-13
___ 04:35AM BLOOD Glucose-99 UreaN-10 Creat-0.5 Na-142
K-3.0* Cl-105 HCO3-26 AnGap-14
___ 06:05PM BLOOD Na-146* K-3.3 Cl-109*
___ 05:40AM BLOOD Glucose-108* UreaN-8 Creat-0.7 Na-143
K-3.1* Cl-105 HCO3-26 AnGap-15
___ 12:36PM BLOOD Glucose-104* UreaN-7 Creat-0.6 Na-147*
K-4.0 Cl-109* HCO3-25 AnGap-17
.
Other pertinent labs:
___ 04:00PM BLOOD CK(CPK)-266*
___ 05:10AM BLOOD ALT-20 AST-36 LD(LDH)-299* AlkPhos-56
TotBili-0.7
___ 11:12PM BLOOD CK-MB-4 cTropnT-<0.01
___ 05:59AM BLOOD CK-MB-5 cTropnT-<0.01
___ 04:00PM BLOOD CK-MB-6 cTropnT-<0.01
___ 06:18PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 08:10PM BLOOD Type-ART Rates-/___ Tidal V-400 PEEP-5
FiO2-100 pO2-211* pCO2-52* pH-7.33* calTCO2-29 Base XS-0
AADO2-445 REQ O2-77 -ASSIST/CON Intubat-INTUBATED\
.
.
Urine:
___ 06:15PM URINE Color-Straw Appear-Hazy Sp ___
___ 06:15PM URINE Blood-SM Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-NEG pH-5.5 Leuks-SM
___ 06:15PM URINE RBC-7* WBC-7* Bacteri-NONE Yeast-NONE
Epi-0
___ 06:15PM URINE CastHy-4*
___ 06:15PM URINE Uric AX-RARE
___ 06:15PM URINE Mucous-MANY
___ 06:15PM URINE bnzodzp-POS barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
___ 10:14AM URINE Color-Straw Appear-Clear Sp ___
___ 10:14AM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
___ 10:14AM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE Epi-0
.
.
Microbiology:
___ 6:15 pm URINE TRAUMA.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
.
___ 1:06 pm SPUTUM Source: Endotracheal.
**FINAL REPORT ___
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final ___:
SPARSE GROWTH Commensal Respiratory Flora.
GRAM NEGATIVE ROD(S). SPARSE GROWTH.
.
.
Radiology:
CHEST (PORTABLE AP) Study Date of ___ 5:45 ___
FINDINGS: An endotracheal tube is seen, terminating
approximately 1 cm above
the level of the carina. Recommend withdrawal by approximately
2 cm for more
optimal positioning. An enteric tube is seen coursing below the
level of the
diaphragm; however, the side port appears to be in the level of
the distal
esophagus. Distal aspect of the feeding tube is in the expected
location of
the proximal stomach. Recommend advancement so that it is well
within the
stomach. Left base retrocardiac opacity is seen, which may be
due to a
combination of atelectasis, consolidation, possibly from
aspiration or
infection. Right basilar opacity is seen to a lesser extent,
which may be due
to atelectasis. Trace pleural effusions are difficult to
exclude. Overall,
there are low lung volumes, which accentuate the bronchovascular
markings.
There is prominence of the hila which may relate to pulmonary
vascular
engorgement and which are likely somewhat accentuated by low
lung volumes.
.
CHEST (PORTABLE AP) Study Date of ___ 4:18 AM
IMPRESSION:
1. ETT cuff exceeds tracheal diameter. Correlate clinically to
avoid tracheal
damage.
2. Left retrocardiac opacity is likely atelectasis, but
underlying pneumonia
cannot be excluded.
.
MR HEAD W/O CONTRAST Study Date of ___ 10:24 AM
IMPRESSION: No acute infarction or other acute intracranial
abnormalities.
Stable appearance of chronic right middle cerebral artery
territory infarction
with evidence of prior hemorrhagic transformation.
.
.
Cardiology:
Portable TTE (Complete) Done ___ at 9:12:15 AM
Conclusions
The left atrium is normal in size. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). The estimated cardiac index is normal
(>=2.5L/min/m2). Doppler parameters are indeterminate for left
ventricular diastolic function. The right ventricle is not well
seen but in limited views is probably normal in size and overall
systolic function. 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. There is no mitral valve prolapse. Physiologic mitral
regurgitation is seen (within normal limits). The tricuspid
valve leaflets are mildly thickened. There is mild pulmonary
artery systolic hypertension. The pulmonic valve leaflets are
thickened. There is a trivial/physiologic pericardial effusion.
IMPRESSION: Suboptimal image quality. Normal left ventricular
cavity sizes with preserved global and regional systolic
function. Right ventricle not well seen. Mild pulmonary
hypertension.
.
.
Neurophysiology:
EEG Study Date of ___
IMPRESSION: This telemetry captured no pushbutton activations.
It showed a
slow, encephalopathic background throughout. Medications,
metabolic
disturbances, and infection are among the most common causes. In
addition,
there was right frontal slowing likely related to the history of
a stroke.
There were also multifocal sharp waves. These appeared more
likely to be part
of the encephalopathies and particularly epileptiform. There
were no spike or
sharp and slow wave complexes, and there were no electrographic
seizures.
.
EEG Study Date of ___
IMPRESSION: This is an abnormal video EEG monitoring session
because of
frequent multifocal spike and wave or sharp and slow wave
discharges seen in
the left parasagittal region, more diffusely over the left
hemisphere, and
also over the right temporal region. In addition, generalized
epileptiform
discharges are also seen. These findings indicate multifocal and
generalized
cortical irritability. The discharges decrease significantly in
frequency
during the second half of the recording. The background activity
is slow and
disorganized, typically in the ___ Hz range with bursts of
generalized delta
frequency slowing, consistent with a moderate encephalopathy.
However, the
background improves during the second half of the recording.
Additional nearly
continuous slowing is seen in the right frontal temporal region
suggestive of
a structural lesion causing focal cerebral dysfunction. There
are no clear
electrographic seizures. The study is much improved in the
second half of the
recording due to a slightly faster background activity and a
significant
decrease in interictal epileptiform discharges.
Brief Hospital Course:
___ with a PMH of HTN and right MCA stroke in ___ with chronic
left arm>leg hemiparesis who presented after focal and latterly
secondarily generalised seizures on ___ as a transfer from
___. She was admitted to the ICU and started on ___
and EEG showed multifocal epileptiform discharges but no
seizures and these improved on uptitration of her
anti-convulsant. The cause of her seizures was felt to be due to
her underlying abnormal substrate given prior stroke in the
setting of an infection with pneumonia found on CXR and treated
with antibiotics. She also had hypokalaemia which was repleted
in ___. She was seen by ___ and deemed appropriate for rehab
and discharged to rehab on ___. She has outpatient
neurology follow-up.
# Neurology:
The patient initially presented to ___ after a first
time seizure with initial left sided focal motor seizures and
secondarily generalising. She was initially treated with ___
500mg IV x2 and lorazepam 2mg and intubated
with 2mg midazolam before transfer to ___ ED. She was thence
transferred to the neuro ICU. In the ICU she not had further
seizures. She has not had any evidence of further seizure
either clinically or on EEG although there was evidence of
multifocal sharp waves throughout both hemispheres. Her ___
was increased to 750 bid. An MRI head on ___ revealed only
chronic changes of her old right MCA stroke with
encephalomalacia and evidence of past hemorrhagic transformation
but no acute infarct or bleed to account for her seizures. LP
was deferred. EEG monitoring revealed epileptiform discharges
but no further seizures. She was successfully extubated on
___ and was transferred to the floor. The patient
continued to do well on the floor where she was monitored on LTM
and saw improvement of the multifocal epileptiform discharges
after increasing ___ to 1000mg bid. EEG monitoring revealed
no electrographic seizures during her hospitalisation. She was
felt to have a likely pneumonia with gram negative rods growing
from her sputum and a retrocardiac opacity on CXR that was
suspicious for pneumonia. We treated her with
ceftriaxone/azithromycin with a plan for 7 days total treatment
and she had no further signs of persistent infection. We
continued clopidogrel as her home medication. Due to her
prolonged hospital course she had some generalized weakness and
physical therapy felt she would benefit from rehab. She was
discharged on ___ with plan to follow up in Neurology
Clinic with Dr ___ on ___.
# Cardiology: The patient was monitored on telemetry and there
was no evidence of AF. We initially held the patient's home dose
of amlodipine although this was increased back to the home dose
of 10mg daily given hypertension in the 170s.
# ID: On admission the patient had a leukocytosis with WBC 11.5.
UA was negative and CXR suggested possible pneumonia. She was
treated with a 7 day course of ceftriaxone to finish on
___ and 5 days of azithromycin to finish on ___.
# Metabolic: Patient had hypokalaemia requiring multiple doses
of KCl repletion. K on discharge was 4.0. This should be trended
until stable at rehab and repleted as necessary.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 5 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Citalopram 40 mg PO DAILY
4. Pantoprazole 40 mg PO Q24H
5. Multivitamins 1 TAB PO DAILY
6. Calcium Carbonate 500 mg PO DAILY
7. Vitamin D 800 UNIT PO DAILY
8. Acetaminophen 650 mg PO Q6H:PRN pain
Discharge Medications:
1. Azithromycin 250 mg PO Q24H Duration: 4 Days
STOP on ___
2. CeftriaXONE 1 gm IV Q24H Duration: 7 Days
STOP on ___
3. Clopidogrel 75 mg PO DAILY
4. Heparin 5000 UNIT SC TID
5. LeVETiracetam 1000 mg PO BID
6. Docusate Sodium 100 mg PO BID:PRN bm
7. Amlodipine 10 mg PO DAILY
8. Acetaminophen 325-650 mg PO Q6H:PRN pain/fever
9. Pantoprazole 40 mg PO Q24H
10. Calcium Carbonate 500 mg PO DAILY
11. Citalopram 40 mg PO DAILY
12. Multivitamins 1 TAB PO DAILY
13. Vitamin D 800 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
1. Focal and secondarily generalised seizures with seizure
threshold lowered in the setting of infection
2. Pneumonia
3. Hypokalaemia requiring treatment.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge examination:
Mental status unremarkable save slight duisorientation to place
on the day of discharge. Mild left neglect.
CN with left facial weakness.
Limb examination reveals left ARM>LEG hemiparesis. Good power on
the right side. Extensor plantar on the left>right.
Discharge Instructions:
It was a pleasure taking care of you during your stay at the
___.
You presented on ___ with seizures resulting in anti-seizure
and sedative medications given and you were admitted to the
nuerology ICU. You were briefly monitored in the Neurology ICU
while your seizures improved and the breathing tube was removed
on ___. We found evidence that you likely had a pneumonia and
treated you with antibiotics for 7 days. The cause of your
seizures was likely due to the abnormal brain on the right side
in the area of your stroke and with your seizure treshold
lowered in the setting of infection. EEG to assess brain waves
showed multiple discharges that suggested some increased risk of
seizures but no actual seizures and on increasing
anti-convulsant medication, these improved greatly by ___. To
treat your seizures, a new medication named ___ was started,
and you had no evidence of side effects of this. You had a low
potassium level in the hospital and you were given
supplementation. Physical therapy felt you were appropriate for
discharge to rehab on ___.
Followup Instructions:
___
|
19600190-DS-18
| 19,600,190 | 26,638,244 |
DS
| 18 |
2162-08-21 00:00:00
|
2162-08-21 11:38:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
raw clams
Attending: ___.
Chief Complaint:
Right hip pain
Major Surgical or Invasive Procedure:
N/A at this admission
___ s/p right total hip replacement
History of Present Illness:
___ s/p R THA ___. Discharged to ___ ___ on
___ and re-admitted 24hrs later for poor pain control and Tmax
101.6po x 1.
Past Medical History:
- hepC
- h/o heroine abuse
- psoriasis
Social History:
___
Family History:
per outpatient notes:
mother died at age ___ from lung cancer
father with MI
Physical Exam:
Well appearing in no acute distress
Afebrile with stable vital signs
Pain well-controlled
Respiratory: CTAB
Cardiovascular: RRR
Gastrointestinal: NT/ND
Genitourinary: Voiding independently
Neurologic: Intact with no focal deficits
Psychiatric: Pleasant, A&O x3
Musculoskeletal Lower Extremity:
* Incision healing well with staples
* Serous drainage from drain site
* +ecchymosis
* Thigh full but soft
* No calf tenderness
* ___ strength
* SILT, NVI distally
* Toes warm
Pertinent Results:
___ 08:45AM BLOOD WBC-5.8 RBC-2.47* Hgb-7.2* Hct-22.8*
MCV-93 MCH-29.2 MCHC-31.5 RDW-15.9* Plt ___
___ 09:15PM BLOOD WBC-10.6# RBC-2.61* Hgb-7.5* Hct-23.1*
MCV-89 MCH-28.5 MCHC-32.3 RDW-15.6* Plt ___
___ 07:10AM BLOOD WBC-6.6 RBC-2.64* Hgb-7.8* Hct-23.7*
MCV-90 MCH-29.7 MCHC-33.1 RDW-15.3 Plt ___
___ 06:57AM BLOOD WBC-5.0 RBC-2.39* Hgb-7.1* Hct-21.3*
MCV-89 MCH-29.6 MCHC-33.3 RDW-15.4 Plt ___
___ 09:15PM BLOOD Neuts-80.7* Lymphs-12.7* Monos-6.0
Eos-0.2 Baso-0.4
___ 09:15PM BLOOD ___ PTT-30.7 ___
___ 09:15PM BLOOD Glucose-99 UreaN-12 Creat-0.8 Na-138
K-4.6 Cl-101 HCO3-25 AnGap-17
___ 09:26PM BLOOD Lactate-2.3*
Brief Hospital Course:
The patient was re-admitted to the orthopedic surgery service
for poor pain control and Tmax 101.6po x 1.
Admission was remarkable for the following:
- Pain regimen - Unchanged from original discharge on ___.
Patient demonstrated ambulation and transfers without issue.
- Infection workup - Full fever workup initiated upon arrival.
CXR and UA were negative. Patient was afebrile for entire
admission. Blood cx NGTD at time of discharge.
- RLE US - negative for DVT. Patient refusing TEDs -> bilateral
ACE wraps instead. Continue Lovenox 40mg SC daily until ___
for DVT prophylaxis.
Otherwise, the patient was seen daily by physical therapy. Labs
were checked throughout the hospital course and repleted
accordingly. At the time of discharge the patient was tolerating
a regular diet and feeling well. The patient was afebrile with
stable vital signs. The patient's hematocrit was acceptable and
pain was adequately controlled on an oral regimen. The operative
extremity was neurovascularly intact and the wound was benign.
The patient's weight-bearing status is weight bearing as
tolerated on the operative extremity with posterior precautions.
Mr. ___ is discharged to ___ Rehab in stable
condition.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Methadone 30 mg PO BID
2. Gabapentin 1200 mg PO TID
3. Naproxen 220 mg PO Q12H:PRN pain
4. Citalopram 20 mg PO DAILY
Discharge Medications:
1. Citalopram 20 mg PO DAILY
2. Gabapentin 1200 mg PO TID
3. Methadone 40 mg PO BID
4. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
5. Docusate Sodium 100 mg PO BID
6. Enoxaparin Sodium 40 mg SC DAILY Duration: 4 Weeks *Last dose
___
7. Ferrous Sulfate 325 mg PO DAILY *Last dose ___
8. Lidocaine 5% Patch 1 PTCH TD QAM
9. Lorazepam 0.5 mg PO Q8H:PRN Anxiety
10. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN Pain
11. Senna 8.6 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
s/p R total hip replacement ___ c/b uncontrolled pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
1. Please return to the emergency department or notify your
physician if you experience any of the following: severe pain
not relieved by medication, increased swelling, decreased
sensation, difficulty with movement, fevers greater than 101.5,
shaking chills, increasing redness or drainage from the incision
site, chest pain, shortness of breath or any other concerns.
2. Please follow up with your primary physician regarding this
admission and any new medications and refills.
3. Resume your home medications unless otherwise instructed.
4. You have been given medications for pain control. Please do
not drive, operate heavy machinery, or drink alcohol while
taking these medications. As your pain decreases, take fewer
tablets and increase the time between doses. This medication can
cause constipation, so you should drink plenty of water daily
and take a stool softener (such as Colace) as needed to prevent
this side effect. Call your surgeons office 3 days before you
are out of medication so that it can be refilled. These
medications cannot be called into your pharmacy and must be
picked up in the clinic or mailed to your house. Please allow
an extra 2 days if you would like your medication mailed to your
home.
5. You may not drive a car until cleared to do so by your
surgeon.
6. Please call your surgeon's office to schedule or confirm your
follow-up appointment.
7. SWELLING: Ice the operative joint 20 minutes at a time,
especially after activity or physical therapy. Do not place ice
directly on the skin. Please DO NOT take any non-steroidal
anti-inflammatory medications (NSAIDs such as Celebrex,
ibuprofen, Advil, Aleve, Motrin, naproxen etc).
8. ANTICOAGULATION: Please continue your Lovenox for four (4)
weeks to help prevent deep vein thrombosis (blood clots). If
you were taking aspirin prior to your surgery, it is OK to
continue at your previous dose while taking this medication.
___ STOCKINGS x 6 WEEKS.
9. WOUND CARE: Please keep your incision clean and dry. It is
okay to shower five days after surgery but no tub baths,
swimming, or submerging your incision until after your four (4)
week checkup. Please place a dry sterile dressing on the wound
each day if there is drainage, otherwise leave it open to air.
Check wound regularly for signs of infection such as redness or
thick yellow drainage. Staples will be removed by the visiting
nurse or rehab facility in two (2) weeks.
10. ___ (once at home): Home ___, dressing changes as
instructed, wound checks, and staple removal at two weeks after
surgery.
11. ACTIVITY: Weight bearing as tolerated on the operative
extremity. Posterior precautions. No strenuous exercise or heavy
lifting until follow up appointment. Mobilize frequently.
Physical Therapy:
WBAT
Posterior hip precautions
Mobilize
Treatment Frequency:
DSD daily prn drainage
Wound checks
Ice
TEDs
Staple removal POD17 (___), replace with steris
Followup Instructions:
___
|
19600236-DS-5
| 19,600,236 | 25,798,521 |
DS
| 5 |
2165-04-30 00:00:00
|
2165-04-30 17:53:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Lexapro / gabapentin
Attending: ___
Chief Complaint:
right facial droop, code stroke
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ man with past medical history of
diabetes, aphasia concerning for stroke status post ___ ___ in
___ who presents with an acute right facial droop.
The patient was in his usual state of health the day prior to
presentation, went to work at ___ where he is ___.
The
day of presentation he woke up and noticed that his eye was
bloodshot. However, he felt well, there were no problems with
his vision and he went to work. While he was at work, his
coworkers thought that during the day his conjunctival
hemorrhage
was getting worse which made him concerned. Towards the end of
the day he began to experience some numbness in his right hand,
followed by pain in his right elbow to his right shoulder. His
coworkers noticed that he also had a right facial droop, this
was
around 6:30 ___. In retrospect, the patient is not sure if his
symptoms started acutely, or progressed slowly. He called his
insurance company to see where he could be evaluated since his
insurance is from ___, and a nurse she spoke to at the
company called him an ambulance to bring him to the hospital for
evaluation.
In the ED, the patient had progression of his right shoulder
pain, and was extremely uncomfortable. His on ___ stroke scale
on arrival was 1 for right facial droop. He did endorse
decreased sensation on the right hemibody including the face to
pinprick. CT scan of the head showed no acute bleed, CTA showed
clean vessels, and CT perfusion showed no decreased areas of
perfusion.
___ describes the stroke he had a year ago. He said that he
was at home, and started speaking "nonsense". He was
stuttering,
and his wife brought him to the doctor, and by the time he was
at
his primary care doctor's office he could not speak at all. He
was brought to the emergency department, where he was given the
option to receive TPA, which he elected for. He was then
admitted to the hospital to be watched, and was told that they
never found a stroke in his brain, so they presumed that the TPA
must have broken up the stroke and not cause any damage. He was
never told about a cause of the stroke such as abnormal heart
rhythm or high cholesterol.
Currently, he denies headache, visual loss, blurry vision or
diplopia. Denies any difficulty with his speech including
dysarthria, trouble producing recurrent branding speech,
dysphagia, vertigo. No difficulty with gait. No bowel or
bladder symptoms. He does endorse the numbness in his right
hand. He elaborates that he regularly experiences tingling in
his fingertips, but the numbness and tingling he is experiencing
in his right hand right now is different from that. He denies
any history of migraine, although he does say that he gets
"regular" headaches from time to time. He describes these as
whole head squeezing type headaches, with no associated
neurologic symptoms, no photo or phonophobia, no flashing lights
or scotoma. He does endorse flashing lights in his visual
fields
regularly, he had a retinal detachment in the 1990s, and is
experience the symptoms since that time.
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. He says that the right arm pain that he is currently
experiencing has been on and off for the past week.
Past Medical History:
Obstructive Sleep Apnea
Restless Leg Syndrome
Depression / Anxiety
Social History:
___
Family History:
Brother with a stroke at ___
Physical Exam:
ADMISSION PHYSICAL EXAM
==========================
Vitals: T: afebrile 104 BP 160/90 RR 17 SaO2 95% RA
General: Awake, cooperative, extremely uncomfortable appearing.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Normal work of breathing
Cardiac: RRR, warm, well-perfused
Abdomen: soft, non-distended
Extremities: No ___ edema. Peripheral pulses palpated
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. There was no
evidence of neglect.
-Cranial Nerves:
II, III, IV, VI: Right conjunctival hemorrhage. PERRL 2
millimeters and minimally reactive, postsurgical. EOMI without
nystagmus, no pain with eye movement. Normal saccades. VFF to
confrontation.
V: Decreased sensation to pinprick on right face, intact to
light
touch.
VII: Right facial droop. Strong eye closure bilaterally,
forehead raise intact.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline with good excursions.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FE IP Quad Ham TA ___ ___
L 5 ___ 5 5 5 ___ 5
R 5 ___ ___ ___ 5
Extreme pain with movement of right deltoid, but patient able to
give full strength with encouragement.
-Sensory: Decreased sensation to pinprick on the right hemibody
80% compared to 100% on the left. This included the right side
of the face, the right chest (increased sensation just before
midline on the right), the right arm and the right leg.
Proprioception intact bilateral great toes. Cold sensation
vibratory sense intact.
-DTRs:
Bi Tri ___ Pat Ach
L 1 1 1 2 1
R 1 1 1 2 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor. Normal finger-tap
bilaterally. No dysmetria on FNF bilaterally.
-Gait: deferred
DISCHARGE PHYSICAL EXAM
=========================
General: no acute distress, pleasant and conversant
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Normal work of breathing
Cardiac: RRR, warm, well-perfused
Abdomen: soft, non-distended
Extremities: No ___ edema. Peripheral pulses palpated
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. There was no
evidence of neglect.
-Cranial Nerves:
II, III, IV, VI: Right conjunctival hemorrhage. PERRL 2
millimeters and minimally reactive, postsurgical. EOMI without
nystagmus, no pain with eye movement. Normal saccades. VFF to
confrontation.
V: Decreased sensation to pinprick on right face, intact to
light
touch (inconsistent, fluctuates).
VII: Right facial droop. Strong eye closure bilaterally,
forehead raise intact.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline with good excursions.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FE IP Quad Ham TA ___ ___
L 5 ___ 5 5 5 ___ 5
R 5 ___ ___ ___ 5
-Sensory: inconsistent changes to sensation in right face, arms,
and legs, reported some intermittent diminished pinprick, cold
temperature, and vibration sensation (right 50% compared to
left)
-DTRs:
Bi Tri ___ Pat Ach
L 1 1 1 2 1
R 1 1 1 2 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor. Normal finger-tap
bilaterally. No dysmetria on FNF bilaterally.
-Gait: narrow based, normal
DISCHARGE VISUAL EXAM
======================
Visual Acuity;
OD (sc): ___
OS (sc): ___
Mental status: Alert and oriented x 3
Pupils (mm)
Relative afferent pupillary defect: [x ] none [ ] present
OD: +
OS: +
Extraocular motility: Full ___
Visual fields by confrontation: Full to counting fingers ___
Intraocular pressure (mm Hg):
OD: 11
OS: 13
External Exam: [ x] NL
No V1 or V2 hypesthesia
Anterior Segment (Penlight or portable slitlamp)
Lids/Lashes/Lacrimal:
OD: Normal
OS: Normal
Conjunctiva:
OD: SCH from 3 to 9
OS: White and quiet
Cornea:
OD: Clear, no epithelial defects
OS: Clear, no epithelial defects
Anterior Chamber:
OD: Deep and quiet
OS: Deep and quiet
___:
OD: Flat
OS: Flat
Lens:
OD: Clear
OS: Clear
Pertinent Results:
ADMISSION LABS
===============
___ 08:20PM BLOOD WBC-11.3* RBC-4.89 Hgb-13.2* Hct-40.8
MCV-83 MCH-27.0 MCHC-32.4 RDW-14.7 RDWSD-44.4 Plt ___
___ 08:20PM BLOOD Neuts-63.3 ___ Monos-5.3 Eos-3.1
Baso-0.5 Im ___ AbsNeut-7.18* AbsLymp-3.11 AbsMono-0.60
AbsEos-0.35 AbsBaso-0.06
___ 08:20PM BLOOD ___ PTT-33.9 ___
___ 08:20PM BLOOD Plt ___
___ 08:20PM BLOOD Creat-1.6*
___ 08:20PM BLOOD UreaN-24*
___ 08:20PM BLOOD ALT-24 AST-42* AlkPhos-66 TotBili-0.3
___ 08:20PM BLOOD cTropnT-<0.01
___ 08:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 08:30PM BLOOD Glucose-101 Na-145 K-4.6 Cl-107
calHCO3-25
DISCHARGE LABS
================
___ 09:00AM BLOOD WBC-7.4 RBC-4.56* Hgb-12.6* Hct-38.6*
MCV-85 MCH-27.6 MCHC-32.6 RDW-14.6 RDWSD-45.2 Plt ___
___ 09:00AM BLOOD Plt ___
___ 09:00AM BLOOD ___ PTT-35.5 ___
___ 09:00AM BLOOD Glucose-123* UreaN-21* Creat-1.2 Na-145
K-4.2 Cl-106 HCO3-25 AnGap-14
___ 09:00AM BLOOD ALT-21 AST-20 LD(___)-174 AlkPhos-69
TotBili-0.4
___ 09:00AM BLOOD Albumin-4.2 Calcium-9.0 Phos-4.3 Mg-2.1
Cholest-PND
___ 09:00AM BLOOD %HbA1c-6.3* eAG-134*
IMAGING
========
CTA HEAD AND CTA NECK Study Date of ___
Noncontrast CT head:
No acute intracranial hemorrhage or territorial infarction.
CTA head and neck:
There is no high-grade stenosis, occlusion, or aneurysmal
dilatation of the major vessels of the head and neck.
Imaged lung apices show no concerning parenchymal opacification
or nodularity. The thyroid gland is without dominant nodule.
GLENO-HUMERAL SHOULDER (W/ Y VIEW) RIGHT Study Date of
___
FINDINGS:
Three views of the right shoulder were provided. No acute
fracture or
dislocation is seen. There is a tiny calcific density abutting
the greater tuberosity of the right proximal humerus which could
reflect calcific tendinopathy in the correct clinical setting.
No significant degenerative joint disease. The imaged right
upper ribs appear intact.
ELBOW (AP, LAT & OBLIQUE) RIGHT Study Date of ___
FINDINGS:
AP, lateral, oblique views of the right elbow were provided. No
acute
fracture or dislocation. No evidence of joint effusion. A well
corticated ossific density abutting the medial epicondyle of the
distal humerus likely reflects old injury. Soft tissues are
grossly unremarkable.
IMPRESSION:
No acute fracture or dislocation.
MRI ___
FINDINGS:
Study is mildly degraded by motion.
There is no evidence of hemorrhage, edema, masses, mass effect,
midline shift or infarction. The ventricles and sulci are normal
in caliber and
configuration. A couple small periventricular and subcortical T2
and FLAIR
hyperintensities are noted which may represent small vessel
ischemic changes. There are postsurgical changes of bilateral
lens replacement. There is mild mucosal thickening of the
ethmoid sinuses. The mastoid air cells are clear. The major
intracranial arterial flow voids are preserved.
IMPRESSION:
1. Study is mildly degraded by motion.
2. No evidence of acute intracranial hemorrhage, infarction, or
mass lesion.
Brief Hospital Course:
Mr. ___ is a ___ year old man with a past medical history of
diabetes, hyperlipidemia, unspecified previous stroke (aphasia
s/p tPA, ___ who presented with acute right facial droop and
right eye subconjunctival hemorrhage.
#Right facial droop:
Presented with acute onset of right facial droop noted by
coworkers. Also experienced ___ in right hand, as well
as right shoulder and elbow pain. Presented to ED where code
stroke was called. NIHSS was 1 for facial palsy. CT with no
acute bleed, CTA with clean vessels, MRI with no evidence of
stroke, FLAIR also notable for no evidence of prior stroke. His
neurologic exam was notable mild facial asymmetry with right
facial droop that changed with position, as well as an
inconsistent patchy sensory exam that was difficult to
interpret. He most likely has a stroke mimic. One may also
consider a viral etiology causing facial nerve inflammation,
especially in the setting of his eye conjunctival hemorrhage and
a new cough following admission. TIA is unlikely, as his
symptoms persisted >24 hours, and MRI was negative while
symptoms were present. Lymes is also a consideration, although
no clear forehead involvement, study was pending at discharge.
Initiated aspirin 81 mg daily for primary prevention given
multiple risk factors. Continued home atorvastatin 80 mg daily.
Was able to ambulate independently, was at his functional
baseline, ___ and OT consults were deferred.
#Right eye subconjunctival hemorrhage:
Developed day of admission. No eye pain or visual symptoms
including decreased vision, visual field deficits, or diplopia.
Visual acuity in ___ ___. Evaluated by ophthalmology who
recommended artificial tears, tylenol, and outpatient ___.
___ have been exacerbated by coughing, or scratching
unknowingly.
#Right shoulder pain
#Right elbow pain:
Developed one week prior to admission, pain is intermittent, no
history of trauma, no evidence of infection on exam. Xray of
both shoulder and elbow unremarkable with no evidence of
fracture. Etiology unclear, most likely musculoskeletal.
Improved with tylenol.
#T2DM:
Held home Januvia, glipizide, resumed at discharge. Sliding
scale in-house.
#Restless leg syndrome:
Continued home ropinirole, duloxetine.
#?seizure disorder:
History unclear. Continued home lamotrigine.
TRANSITIONAL ISSUES:
=====================
[] f/u lymes studies and urine culture, pending at discharge
[] initiated aspirin 81 mg daily for stroke prevention
[] please perform dilated eye examination in next ___ days
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. GlipiZIDE 5 mg PO BID
2. Januvia (SITagliptin) 100 mg oral DAILY
3. LamoTRIgine 100 mg PO DAILY
4. DULoxetine 60 mg PO DAILY
5. rOPINIRole 8 mg oral QHS
6. Atorvastatin 80 mg PO QPM
Discharge Medications:
1. Artificial Tears ___ DROP BOTH EYES PRN eye irritation
RX *artificial tears(hypromellose) [EQ Gentle] 0.3 % 2 drops in
each eye Q1H Disp #*1 Package Refills:*0
2. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Atorvastatin 80 mg PO QPM
4. DULoxetine 60 mg PO DAILY
5. GlipiZIDE 5 mg PO BID
6. Januvia (SITagliptin) 100 mg oral DAILY
7. LamoTRIgine 100 mg PO DAILY
8. rOPINIRole 8 mg oral QHS
Discharge Disposition:
Home
Discharge Diagnosis:
#right facial droop
#right eye conjuctival hemorrhage
#Right shoulder pain
#Right elbow pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure to care for you at the ___
___.
You came to the hospital because you developed facial droop.
This symptom is concerning for a stroke. We performed blood
tests and imaging of your brain, including an MRI, and found
that you did NOT have a stroke. Since you have risk factors for
strokes (diabetes, high cholesterol, concern for a previous
stroke in the past), we started you on a medication called
"aspirin" which keeps your blood thin and helps prevent future
strokes.
You also developed redness in your eye. You were evaluated by an
eye doctor. We believe the redness is caused by a ruptured blood
vessel. This does not cause you any harm. You were prescribed
artificial tear eye drops to use as needed.
Please continue to take your medications as prescribed and
___ with your doctors as ___.
We wish you all the best,
Your ___ care team
Followup Instructions:
___
|
19600417-DS-21
| 19,600,417 | 22,292,376 |
DS
| 21 |
2187-07-26 00:00:00
|
2187-07-26 13:09:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / vancomycin
Attending: ___.
Chief Complaint:
Probable endocarditis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old female from ___ for urgent spine evaluation
after presenting with concern for cord compression in the
setting of polysustance use with concern for epidural abscess.
The patient states she last used IV drugs ___ years prior to
admission, but is actively using cocaine along with alcohol. She
presented with right sided lumbar back pain with perineal and
bilateral leg parasthesias, urinary and fecal incontinence,
along with fever and chills for a week prior to admission.
In the ___ ED her initial vitals signs were 98, 142/97, 94,
14, 98%. She was given methadone 30mg, started on a diazepam
taper for CIWA receiving a total of 40mg, Tylenol and underwent
an evaluation by spine and orthopedics. Of note she has a broken
needle in her right forearm, so a removal was attempted prior to
MRI scanning, which was unsuccessful, but patient was OKed for
MRI by the surgeons. She underwent MRI as below.
Past Medical History:
PNC:
- ___ ___ by ___
- Labs Rh pos/Abs neg/Rub I/RPR NR/HBsAg neg/HIV neg/GBS PND
(sent here today)
- Screening: LR ERA
- FFS: wnl
- GLT: 97
- U/S ___: EFW 1951g, 64th%, vtx
- Issues:
*) Hepatitis C - diagnosed initially in ___. She has not yet
seen a GI specialist and plans to see one in the postpartum
period. Her LFTs are elevated with AST 86 and ALT 113. Viral
load
is 10,080. FSEs should be avoided.
*) History of seizure disorder - Described as partial seizures.
Reports having ___ in her lifetime, but none in pats year since
she has been on Klonopin.
*) Tobacco use - has smoked ___ throughout pregnancy.
*) Methadone use - takes 135mg/day of methadone, which she
receives from Habit Opco in ___ for history of heroin
and
Percocet abuse. She has had a NICU consult this pregnancy. Utoxs
this pregnancy only positive for methadone.
*) Anxiety - being treated on Klonopin. Also has a history of
IPV
but reports feeling safe now. FOB died of drug overdose earlier
this year (___).
*) LGSIL diagnosed this pregnancy with ___ colposcopy
*) Itching - negative bile acids
OBHx:
- G1 - ectopic pregnancy, did not require medication or surgery
(passed on its own)
- G2 - current
GynHx:
- Abnormal pap as above. No GYN surgeries. No STIs.
PMH: As listed above.
PSH: None
Social History:
___
Family History:
Mother: Died of COlon Ca, also with Ovarian CA
Father: healthy
Physical ___:
ROS:
GEN: - fevers, - Chills, - Weight Loss
EYES: - Photophobia, - Visual Changes
HEENT: - Oral/Gum bleeding
CARDIAC: - Chest Pain, - Palpitations, - Edema
GI: - Nausea, - Vomitting, - Diarhea, - Abdominal Pain, -
Constipation, - Hematochezia
PULM: - Dyspnea, - Cough, - Hemoptysis
HEME: - Bleeding, - Lymphadenopathy
GU: - Dysuria, - hematuria, - Incontinence
SKIN: - Rash
ENDO: - Heat/Cold Intolerance
MSK: - Myalgia, - Arthralgia, - Back Pain
NEURO: - Numbness, - Weakness, - Vertigo, - Headache
PHYSICAL EXAM:
VSS: 98, 140/74, 76, 16, 98%
GEN: NAD
Pain: ___
HEENT: EOMI, MMM, - OP Lesions
PUL: CTA B/L
COR: RRR, S1/S2, II/VI HSM MRG at base, non-displaced PMI
ABD: NT/ND, +BS, - CVAT
EXT: - CCE,
Fingers: - ___ Nodes, - Splinter hemorrhages
NEURO: CAOx3, Non-Focal
Pertinent Results:
___ 05:33AM BLOOD WBC-6.2 RBC-3.74* Hgb-9.1* Hct-29.4*
MCV-79* MCH-24.3* MCHC-31.0* RDW-18.5* RDWSD-52.7* Plt ___
___ 05:33AM BLOOD Neuts-68.1 ___ Monos-8.7 Eos-2.9
Baso-0.6 Im ___ AbsNeut-4.21 AbsLymp-1.20 AbsMono-0.54
AbsEos-0.18 AbsBaso-0.04
___ 05:33AM BLOOD ___ PTT-27.6 ___
___ 05:33AM BLOOD Glucose-103* UreaN-6 Creat-1.1 Na-144
K-4.1 Cl-106 HCO3-22 AnGap-16
___ 05:33AM BLOOD ALT-92* AST-88* AlkPhos-137* TotBili-0.4
___ 05:33AM BLOOD Lipase-49
___ 05:33AM BLOOD cTropnT-<0.01
___ 05:33AM BLOOD Albumin-4.1 Calcium-8.9 Phos-3.4 Mg-1.4*
___ 05:33AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 06:12AM BLOOD Lactate-1.5
___ 08:04AM URINE Color-Yellow Appear-Hazy* Sp ___
___ 08:04AM URINE Blood-NEG Nitrite-NEG Protein-30*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-SM*
___ 08:04AM URINE RBC-3* WBC-17* Bacteri-FEW* Yeast-NONE
Epi-13
___ 08:04AM URINE CastHy-4*
___ 08:04AM URINE UCG-NEGATIVE
___ 08:04AM URINE bnzodzp-POS* barbitr-POS* opiates-NEG
cocaine-POS* amphetm-NEG oxycodn-NEG mthdone-POS*
ECG Study Date of ___ 4:51:44 AM
Intervals Axes
Rate PR QRS QT QTc (___) P QRS T
92 132 89 ___ 21 36 38
HUMERUS (AP & LAT) RIGHT Study Date of ___ 6:12 AM
FOREARM (AP & LAT) RIGHT Study Date of ___ 6:11 AM
IMPRESSION:
No fracture. Linear metallic object in the soft tissues
overlying the volar distal humerus may reflect a needle
fragment.
MR ___ W/O CONTRAST Study Date of ___ 12:19 ___
T-SPINE W &W/O CONTRAST; MR ___ & W/O CONTRAST Clip #
___
IMPRESSION:
1. No evidence of discitis osteomyelitis. No epidural
collection. No
prevertebral edema. No paraspinal soft tissue abnormality.
2. No spinal canal or neural foraminal narrowing. There is no
signal
abnormality or enhancement of the spinal cord or cauda equina.
3. Prominent cervical lymph nodes measuring up to 1.7 cm in long
axis at the right level 2A. Nonspecific and likely reactive in
nature. Clinical
correlation is recommended.
4. The marrow signal is T1 isointense to the disc, without focal
suspicious lesion. This likely represents marrow reconversion
in setting chronic anemia. Correlation with CBC value is
recommended.
___ BLOOD CULTURE Blood Culture,
Routine-PENDING INPATIENT
___ BLOOD CULTURE Blood Culture,
Routine-PENDING INPATIENT
___ BLOOD CULTURE Blood Culture,
Routine-PENDING EMERGENCY WARD
___ URINE URINE CULTURE-FINAL EMERGENCY WARD
___ BLOOD CULTURE Blood Culture,
Routine-PENDING EMERGENCY WARD
___ BLOOD CULTURE Blood Culture,
Routine-PENDING EMERGENCY WARD
Brief Hospital Course:
ASSESSMENT AND PLAN: Pt is a ___ y.o woman with h.o polysubstance
drug abuse including ETOH with methadone maintainence who
presented with fever, back and neck pain.
#fever
#back pain
#neck pain
#viral infection
#CERVICAL LYMPHADENOPATHY
Given h.o drug use, would be concerned about possible
endocarditis given fever, though none during admission and thus
far 5 sets of BCX NGTD. Despite back pain, MRI spine without
concern for osteo or infection. No current leukocytosis or fever
during admission. Given generalized aches, symptoms and LAD
could be c/w viral infection, denied sore throat, odynophagia,
dysphagia but does have some cervical LAD on the L.side.
*****d/w pt the importance of PCP ___ for her LAD and potential
need
for further w/u. She expressed understanding*****
#Chronic Hepatitis C-outpt ___
#Anemia of Chronic Disease-remained stable during admission. NO
signs of active bleeding or unstable hemodynamics during
admission.
#Chronic Alcohol Dependence
Patient with history of severe disease, including withdrawal
seizure
#polysubstance drug abuse
Pt was placed on Thiamine, Folate, MVI continued. CIWA
empirically ordered with diazepam. She was treated for ETOH
withdrawal, but on the day of DC no longer showed signs of
withdrawal and requested to be discharged. The addictions
consult service evaluated the patient during admission to help
provide her with resources for ongoing sobriety. Naloxone nasal
provided on DC.
#Opioid Dependence
On methadone: 30mg Center: ___ ___ (confirmed in ED). Pt given last dose
letter on ___.
#prolonged QTC noted on EKG-would recommend repeat EKG at PCP
___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. HydrOXYzine 50 mg PO Q6H:PRN anxiety
2. QUEtiapine Fumarate 50 mg PO QHS
3. FoLIC Acid 1 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Methadone 30 mg PO DAILY
6. CloNIDine 0.1 mg PO TID
Discharge Medications:
1. Naloxone 0.4 mg Subcut ONCE Duration: 1 Dose
RX *naloxone [Narcan] 4 mg/actuation 1 spray by nose prn
overdose Disp #*2 Spray Refills:*0
2. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth daily
Disp #*30 Tablet Refills:*0
3. Acamprosate 333 mg PO TID
4. CloNIDine 0.1 mg PO TID
5. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
6. HydrOXYzine 50 mg PO Q6H:PRN anxiety
7. Methadone 30 mg PO DAILY
Consider prescribing naloxone at discharge
8. Multivitamins 1 TAB PO DAILY
9. QUEtiapine Fumarate 50 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
back and neck pain
alcohol withdrawal
methadone dependence
lymphadenopathy in the neck
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were evaluated for symptoms of fever with neck and back
pain. For this, you had an infectious work up including a few
blood cultures that are still PENDING but have had no growth at
the time of discharge. In addition, you had an MRI of your spine
that did not show evidence of infection. Fortunately, your
symptoms improved.
You were seen by the addictions and social work team for
assistance with resources for ongoing drug/alcohol use. It is
important to maintain sobriety as taking other sedating
medications with your methadone such as alcohol and
benzodiazepines can cause death or overdose or organ injury and
failure. We would recommend avoidance of all non prescribed
substances at this time.
You have some lymph nodes in your neck that were swollen and
could have been due to a viral infection. However, it is very
important that you be sure to follow up with your regular
primary care doctor within ___ week to ensure that these lymph
nodes have gone away. If not, you will need further work up and
potentially a biopsy.
We wish you the best!
Followup Instructions:
___
|
19601105-DS-2
| 19,601,105 | 28,264,603 |
DS
| 2 |
2125-05-24 00:00:00
|
2125-05-24 13:44:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics) / Bactrim
Attending: ___.
Chief Complaint:
LLE calf ulceration
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with uncontrolled pain secondary to acutely infected venous
stasis ulceration. She has been followed in clinic for another
ulcer by Dr. ___ had recommended adaptic and leg
elevation.
___ nurse called yesterday stated that there is a new ulcer (pt
last seen ___ on the left medial calf measuring 3x3cm that
was a dark red with yellow drainage. The nurse cleaned the area
with saline, applied Adaptic, and a 4x4 gauze and wrapped with
kerlix. She has been ambulating throughout the house and has not
been elevating her foot. She is taking tramadol and oxycodone
without relief and is sent from clinic for admission.
Past Medical History:
PMH:
- Hypertension
- Peripheral arterial disease
- Chronic venous insufficiency
- Mild cognitive impairment
- CAD s/p negative stress test w EF 72%
- COPD
- Osteoporosis with chronic low back pain
- Atrial fibrillation on coumadin
PSH:
- Right hip replacement
- Lap chole
Social History:
___
Family History:
NC
Physical Exam:
On admission:
VS: 98 68 174/80 20 95%
Gen - NAD, AO x 3
Heart - irregular rhythm, rate wnl
Lungs - CTAB
Abd - soft, NT, ND
Extrem - warm, multiple varicosities of b/l LEs, 2x3 shallow
ulceration on anterior shin with surrounding cellulitis and
edema extending down to ankle and up to below knee, exquisite
TTP in that area
Pulses - R p/d/p/d; L p/d/d/d
Neuro - motor and sensory equal bilaterally
On discharge:
VS: 98.1, 59, 162/82, 20, 95% RA
Gen: NAD, AAOx3, pleasant
Neuro: CN II-XII grossly intact
CV: RRR no m/r/g
Pulm: CTAB no w/r/r
Abd: Soft, NT/ND
L shin ulcer: stable L shin ulcer, moist, no drainage or
erythema
Extremities: WWP
Fem Pop DP ___
Left: p d d d
Right: p d p d
Pertinent Results:
___ 04:46PM BLOOD WBC-7.0 RBC-4.53 Hgb-15.5 Hct-48.0
MCV-106* MCH-34.1* MCHC-32.2 RDW-13.4 Plt ___
___ 05:40AM BLOOD WBC-7.3 RBC-4.51 Hgb-15.6 Hct-46.7
MCV-104* MCH-34.7* MCHC-33.5 RDW-12.7 Plt ___
___ 05:40AM BLOOD WBC-6.3 RBC-4.66 Hgb-15.6 Hct-49.1*
MCV-105* MCH-33.4* MCHC-31.8 RDW-13.4 Plt ___
___ 05:40AM BLOOD ___ PTT-38.0* ___
___ 05:40AM BLOOD ___
___ 04:46PM BLOOD Glucose-87 UreaN-14 Creat-0.9 Na-139
K-4.3 Cl-99 HCO3-31 AnGap-13
___ 05:40AM BLOOD Glucose-84 UreaN-12 Creat-0.9 Na-141
K-3.8 Cl-100 HCO3-32 AnGap-13
___ 05:40AM BLOOD Glucose-104* UreaN-13 Creat-0.9 Na-137
K-3.9 Cl-100 HCO3-30 AnGap-11
Brief Hospital Course:
Ms. ___ was admitted to the Vascular Surgery service with HPI
as stated above and started on intravenous
vancomycin/cipro/flagyl. Pain control was initialed with PO
agents with IV meds for breakthrough pain. Intensive wound care
was started with adaptec in dry dressings as well as LLE
elevation. It was decided that she would go for LLE LENIs and
non-invasives as soon as they could be tolerated.
On ___ her ABIs from ___ were noted to show an ABI ___
with monophasic waveforms of the popliteal and below. LENIs
revealed no evidence of DVT. She was continued on IV
antibiotics of vanc/cipro/flagyl; white blood cell count was 7.3
and she was afebrile. Despite having voided the previous night,
she was unable to void in the afternoon and was bladder-scanned
for 900cc and then straight-cathed. INR was 1.9 and she
received her home dose of 1mg of warfarin.
Overnight into ___ she had difficulty voiding with large
volumes on bladder scan and so a foley was replaced, which was
discontinued after starting flomax in the morning, and she
successfully voided. Her ambulation status was made
weight-bearing-as-tolerated. She received her daily coumadin
dosing. Physical therapy worked with her and recommended rehab.
Finally, she was started on a daily aspirin.
On ___, it was decided that she was appropriate for
discharge. Hospital antibiotics are discontinued prior to
discharge and she will be sent to rehab with 10-day course of
Augmentin; Bactrim was not an option due to sulfa allergy. She
is discharged to rehab on ___ with appropriate
information, warnings, prescriptions, and plans to follow up.
Medications on Admission:
donepezil 10 mg tablet, synthroid 75 mcg tablet, losartan 100 mg
tablet, Spiriva 1 INH daily, coumadin 1 mg ___ and 1.5
___, diltiazem 120 daily
Discharge Medications:
1. Donepezil 10 mg PO HS
2. Levothyroxine Sodium 75 mcg PO DAILY
3. Losartan Potassium 100 mg PO DAILY
4. Warfarin 1 mg PO 5X/WEEK (___)
5. Warfarin 1.5 mg PO 2X/WEEK (___)
6. Tiotropium Bromide 1 CAP IH DAILY
7. Tamsulosin 0.4 mg PO HS
Take for 1 week, then you may stop
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth at bedtime Disp #*7
Capsule Refills:*0
8. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
9. Diltiazem Extended-Release 120 mg PO QHS
10. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*14 Capsule Refills:*0
11. OxycoDONE (Immediate Release) 5 mg PO Q3H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
12. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 650 mg 1 tablet(s) by mouth every six (6)
hours Disp #*30 Tablet Refills:*0
13. Amoxicillin-Clavulanic Acid ___ mg PO Q24H
RX *amoxicillin-pot clavulanate 500 mg-125 mg 1 tablet by mouth
once a day Disp #*10 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Infected venous stasis ulcer, cellulitis of left lower extremity
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were seen for a wound on your left shin. You received
powerful antibiotics in the hospital and will be discharged on
oral antibiotics to finish a full course. Please call us if you
experience fevers, chills, or increased redness/swelling or pain
of your leg.
Followup Instructions:
___
|
19601656-DS-10
| 19,601,656 | 26,400,308 |
DS
| 10 |
2140-02-22 00:00:00
|
2140-03-02 16:46:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Cipro / Penicillins / Levaquin / Sulfa(Sulfonamide Antibiotics)
/ Gentamicin / Cephalosporins / Haldol
Attending: ___.
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
___ placement
History of Present Illness:
HPI:
___ with h/o recurrent UTIs, bipolar disorder presenting after
told by urologist over phone that urine + for infection from
last wed. Per family she has been increasingly confused since
last ___. Family says she normally becomes this way with
UTIs. Uctx recently e coli. Last adm ___ for UTI treated with
Tigecycline. Patient refuses to further discuss condition on
arrival to floor. She states she does not want to be here and
does not know why family sent her.
.
Ammendum ___: Clarified course with daughter. Patient became
symptomatic over last week and saw urologist Dr. ___ in ___
office where he sent a UC showing Pseudomonas.
Past Medical History:
bipolar disorder
frequent UTIs
s/p bladder suspension
hyperlipidemia
hypothyroidism
glaucoma
aortic stenosis
Social History:
___
Family History:
non-contributory
Physical Exam:
Admission:
VS: T:98 BP:152/70 P:75 R:18 100% RA
GENERAL: NAD, appears confused, patient says she doesnt want to
talk
HEENT: MMM. no LAD. no JVD. neck supple.
HEART: RRR S1/S2 heard. no murmurs/gallops/rubs.
LUNGS: CTAB no crackles or wheezes, non labored
ABDOMEN: soft, nontender, nondistended. no guarding or rebound,
neg HSM. neg ___ sign.
EXT: wwp, no edema. DPs, PTs 2+.
LYMPH: no cervical, axillary, or inguinal LAD
SKIN: dry, no rash
NEURO/PSYCH: CNs II-XII grossly intact.
Discharge:
VS: T:98.5 BP:140/70 P:70 R:18 100% RA
GENERAL: NAD, sitting in ___ chair at nursing station
HEENT: MMM. no LAD. no JVD. neck supple.
HEART: RRR S1/S2 heard. no murmurs/gallops/rubs.
LUNGS: CTAB no crackles or wheezes, non labored
ABDOMEN: soft, nontender, nondistended. no guarding or rebound,
neg HSM. neg ___ sign.
EXT: wwp, no edema. DPs, PTs 2+.
LYMPH: no cervical, axillary, or inguinal LAD
SKIN: dry, no rash
NEURO/PSYCH: CNs II-XII grossly intact.
Pertinent Results:
___ 12:30PM BLOOD WBC-10.5# RBC-4.36 Hgb-13.5 Hct-40.4
MCV-93 MCH-30.9 MCHC-33.3 RDW-12.7 Plt ___
___ 06:25AM BLOOD TSH-0.81
___ 12:10PM URINE RBC-2 WBC-27* Bacteri-MANY Yeast-NONE
Epi-1 TransE-1
___ 12:30PM BLOOD Glucose-101* UreaN-12 Creat-0.7 Na-134
K-4.3 Cl-94* HCO3-26 AnGap-18
___ 12:30PM BLOOD Valproa-39*
Discharge:
___ 08:00AM BLOOD Glucose-117* UreaN-16 Creat-0.7 Na-138
K-4.7 Cl-103 HCO3-24 AnGap-16
___ 08:00AM BLOOD WBC-8.1 RBC-4.33 Hgb-13.4 Hct-40.9 MCV-95
MCH-31.0 MCHC-32.8 RDW-13.0 Plt ___
___ 05:30AM BLOOD VitB12-787
___ 11:00AM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-7.0 Leuks-NEG
URINE CULTURE (Final ___: NO GROWTH.
Renal US:
IMPRESSION: No hydronephrosis and no perinephric fluid
collection identified.
Tiny left renal cyst noted.
Brief Hospital Course:
___ yo F with bipolar disorder, frequent UTIs, presenting with
altered mental status for the past week per family
# Delirium: Patient was brought in by her family after becoming
agitated and confused at home and for treatment of UTI. Patient
had seen her urologist Dr. ___ earlier in the week and culture
has shown Pseudomonas. On presentation the patient was very
confused and agitated, refusing to work with medical staff.
Delirium was most likely secondary to UTI given history of
confusion with previous UTIs and know positive UC. A depakote
level, TSH, and RPR were negative. She was started on Meropenem
as patient has many known drug allergies. Olanzipine was used
PRN for agitation and she received several doses. Delirium
failed to resolve with antibiotics and patient continued to be
agitated. She pulled out several IVs and a PICC line. Psych was
consulted for refractory delirium and recommended haldol .___.
A qt interval was normal. 3 days following treatment with
haldol, the patient developed a tremor in all 4 extremities
thought to be from EPS. Delirium moderately improved and family
expressed wish to bring her home. Medical staff felt it was in
patient's best interest to be in a more familiar environment. A
head CT was not ordered as the patient had a similar admission
this ___ at which time a head CT was unremarkable. The
family was instructed with clear instructions to bring the
patient back to the hospital if her mental status did not
improve in the next ___ hours upon returning to home.
# Recurrent Urinary tract infections: UCx was positive for
pseudomonas as an outpatient but she required meropenem due to
many drug allergies. Pt had been put on Tigecycline on previous
admission this ___ after failing nitrofuritonin. A repeat UA
and culture at admission was positive and culture grew E.Coli
sensitive to meropenem. The treatment was complicated by
delirium which resulted in the patient not receiving several
doses. She completed a ___t which time a UA was
negative and a UC showed no growth. She will continue
methenamine as an outpatient. Her urologist was informed of
admission and did not believe additional work up was warranted.
# Hypothyroidism: Patient has normal TSH. Continued with home
synthroid dose.
.
# Glaucoma: Continued Combigan, daily to right eye.
.
# Bipolar disorder: Psych saw patient but could not confirm
this diagnosis. She as kept on her home dose of depakote
.
#HTN: Patient did not come with diagnosis but was persistently
hypertensive throughout stay. She was started on lisinopril and
responded well. Cr was normal at initiation and repeat labs
showed no increase. She will follow up with PCP.
.
# Hyperlipidemia: Continued simvastatin.
.
Transitions of Care:
1.Patient will continue UTI ppx with methenamine and follow up
with urologist
2.Patient will go home with family at their request
3.Patient will follow up with PCP to check BP following
initiation of lisinopril
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Family/Caregiver.
1. Levothyroxine Sodium 112 mcg PO DAILY
2. Combigan *NF* (brimonidine-timolol) 0.2-0.5 % ___ daily
1 drop BID to right eye
3. travoprost *NF* 0.004 % ___ daily
1 drop daily to right eye
4. Ascorbic Acid ___ mg PO BID
5. valproic acid (as sodium salt) *NF* 500mg Oral qhs
6. methenamine hippurate *NF* 1 gram Oral daily
Discharge Medications:
1. travoprost *NF* 0.004 % ___ daily
1 drop daily to right eye
2. valproic acid (as sodium salt) *NF* 500mg Oral qhs
3. Ascorbic Acid ___ mg PO BID
4. Combigan *NF* (brimonidine-timolol) 0.2-0.5 % ___ daily
1 drop BID to right eye
5. Levothyroxine Sodium 112 mcg PO DAILY
6. methenamine hippurate *NF* 1 gram Oral daily
RX *methenamine hippurate 1 gram 1 tablet(s) by mouth daily Disp
#*28 Tablet Refills:*0
7. Lisinopril 5 mg PO DAILY
hold for sbp <100
RX *lisinopril 5 mg 1 tablet(s) by mouth daily Disp #*28 Tablet
Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
___:
Urinary Tract Infection with secondary delirium
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. ___,
It was a pleasure taking care of you during your stay at ___.
You came in due to a urinary tract infection and confusion. We
treated you with antibiotics for your infection and your
infection improved. We also gave you some medication to help
reduce your confusion.
Though your confusion has not totally resolved, we discussed
with your family that being at home would be a more stable
environment for you as you get better.
Followup Instructions:
___
|
19601805-DS-12
| 19,601,805 | 28,192,403 |
DS
| 12 |
2141-07-04 00:00:00
|
2141-07-05 14:52:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Percocet / Lasix
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old female with hypertension,
multinodular goiter with subclinical hyperthyroidism and
thrombocytosis/leukocystosis. She was doing well until this
morning. She recently had cataract surgery and has been having
cold cuts and pickels to celebrate her recovery. She noticed
acute shortness of breath this morning without associated chest
pressure/palpatations/nausea/headache/double vision/nausea or
pleurtic chest pain. She checked her BP which was around 200.
She called ___. EMS gave her IV lasix 40 mg and placed her on
CPAP enroute to ___ ED.
In the ED, initial vitals were Today 01:20 ___ 30 94%
CPAP. CXR was consistent with pulmonary edema. Labs notable for
WBC of 36.6, HCT of 55.4, Plt of 1254, BNP of 4455 and normal
UA. Troponins were 0.02 and 0.16 respectively. ECG concerning
for LVH though without regional ischemic changes. She was
started on nitro gtt and transferred to cardiology service for
futher evaluation.
On the floor, she reports feeling well.
Past Medical History:
Hypertension
Multinodular goiter
hx of thrombocytosis/leukocytosis
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
Admission Exam
VS: 98.3 55 160/95 96%2LnC
GENERAL: Elderly female in no acute distress
HEENT: NC. NT. Anicteric. Moist mucous membranes. JVP ~10cm
CARDIAC: RRR. Soft s3. No murmurs noted
LUNGS: Diffuse inspiratory crackles all the way upto top of her
lungs. No wheezing noted
ABDOMEN: Soft, NT and ND. NABS
EXTREMITIES: No edema. No rash
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
Discharge Exam
VS: 98.9 65 130/75 96%RA (at rest and with ambulation)
GENERAL: Elderly female in no acute distress
HEENT: NC. NT. Anicteric. Moist mucous membranes.
CARDIAC: RRR. II/XI systolic murmur
LUNGS: Scant bibasilar crackles; no overlying wheeze; good
aeration, no accessory muscle use.
ABDOMEN: Soft, NT and ND. NABS
EXTREMITIES: WWP, No edema. No rash
Pertinent Results:
Admission Labs
___ 01:24AM BLOOD WBC-36.6* RBC-6.29* Hgb-18.2* Hct-55.4*
MCV-88 MCH-29.0 MCHC-32.9 RDW-15.7* Plt ___
___ 06:20AM BLOOD Neuts-76.9* Lymphs-13.9* Monos-6.3
Eos-2.3 Baso-0.7
___ 01:24AM BLOOD UreaN-39* Creat-1.1
___ 06:20AM BLOOD ALT-20 AST-22 LD(LDH)-258* AlkPhos-49
TotBili-1.3
___ 01:24AM BLOOD cTropnT-0.02*
___ 01:24AM BLOOD CK-MB-4 proBNP-4455*
___ 01:24AM BLOOD ___
___ 07:50AM BLOOD cTropnT-0.16*
___ 03:46PM BLOOD CK-MB-4 cTropnT-0.08*
___ 06:20AM BLOOD Albumin-3.3* Calcium-9.1 Phos-4.0 Mg-1.6
UricAcd-9.2*
___ 01:24AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Discharge Labs
___ 07:50AM BLOOD WBC-16.1* RBC-5.55* Hgb-16.0 Hct-47.8
MCV-86 MCH-28.9 MCHC-33.5 RDW-15.0 Plt ___
___ 07:50AM BLOOD Glucose-89 UreaN-38* Creat-1.1 Na-143
K-4.6 Cl-98 HCO3-30 AnGap-20
___ 06:20AM BLOOD ALT-20 AST-22 LD(LDH)-258* AlkPhos-49
TotBili-1.3
___ 07:50AM BLOOD Calcium-9.1 Phos-4.3 Mg-1.5*
JAK2 V617F - DETECTED
BCR-ABL - NOT DETECTED
TTE (___)
The left atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. Overall left ventricular systolic function is normal
(LVEF 60%). Right ventricular chamber size and free wall motion
are normal. The aortic valve is not well seen. There is no
aortic valve stenosis. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
A diastolic transmitral Doppler L-wave is present. This finding
is associated with impaired/delayed diastolic relaxation.
CXR (___)
Consolidation and volume loss are pronounced in the right upper
lobe, less so in the right infrahilar lung. Diffuse
interstitial abnormality could be due moderate pulmonary edema,
but its nodularity suggests carcinomatosis. Pleural effusions
are small. Mass-like consolidation occupies the right
suprahilar and left mid lung zones. The aorta is generally
large, heart probably not.
EKG: NSR. NA. NI. Normal P wave morphology. LVH by voltage
criteria. No regional ischemic changes noted. Lateral TWI
likely due to LVH with strain
TTE ___
The left atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. Overall left ventricular systolic function is normal
(LVEF 60%). Right ventricular chamber size and free wall motion
are normal. The aortic valve is not well seen. There is no
aortic valve stenosis. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
A diastolic transmitral Doppler L-wave is present. This finding
is associated with impaired/delayed diastolic relaxationhest
(___)
CT Chest ___
IMPRESSION:
1. Bilateral small non hemorrhagic pleural effusion with
adjacent compressive atelectasis. The lungs are otherwise
clear.
2. Multinodular thyroid.
3. Multiple thoracic vertebral compression fractures, age
indeterminate
Brief Hospital Course:
Ms. ___ is a ___ year old female with hypertension,
multinodular goiter who presented with hypertensive emergency
and pulmonary edema with inpatient labs notable for
thrombocytosis/leukocystosis.
# Hypertensive emergency/pulmonary edema. On admission patients
blood pressure elevated to >200/90 with CXR consistent with
pulmonary edema. Hypertension thought secondary to dietary
indiscrepancy as patient acknowledged high salt load in days
prior to presentation (deli meats, pickles, etc). She was
initially started on a nitro gtt and CPAP with improvement in
symptoms. In house, TTE demonstrated diastolic dysfunction;
normal LVEF. She was continued on her home atenolol and
lisinopril. In house, lisinopril increased from 20mg daily to
40mg. Her HCTZ was switched to ethacrynic acid 25 mg twice daily
(sulfa allergy). Prior to discharge patient was counseled on low
sodium diet and medication changes/adherance. She was saturating
well on RA at rest and on ambulation, BPs: 120s-130s/60-70s,
HRs: 60-80s. Creatinine 1.1.
OUTPATIENT ISSUES:
[] Trend daily weight
[] Trend chemistry panel in the setting of started ethacrynic
acid
#. Leukocytosis/thrombocytosis/elevated HCT: HemOnc was
consulted who recommended sending out JAK2 and BCR-ABL. JAK2 was
detected. BCR-ABL was not detected. As counts were downtrending
in house, decision made to hold initiation of hydroxyurea.
OUTPATIENT:
[] Heme-onc follow-up at ___
# Back pain/compression fracture. Patient reported acute on
chronic back pain similar in character to previous pain. Neuro
exam non-focal. CT without evidence of new fracture; only old,
known thoracic fractures. Patient placed on standing tylenol.
Evaluated by physical therapy who deemed her safe to return
home.
#. RUL mass/infiltrate: Visualized on admission CXR. Improved
with diuresis. CT was obtained to ensure no evidence of mass or
lymphadenopathy. CT demonstrated mild bilateral pleural
effusions but was otherwise unremarkable without evidence of
mass, LAD.
#. Hyperthyrodism. Continued home methamizole without signs or
hyperthyroidism.
#. Seasonal allergies. Allerga as needed continued.
#. S/p cataract surgery: Continued on home eye drops
Transitional issues
1. Follow up with PCP for electrolyte check and BP check after
change in her blood pressure medications
2. Follow up with outpatient HemOnc provider
___ on ___:
The Preadmission Medication list is accurate and complete.
1. Ecotrin 325 mg PO DAILY
2. Methimazole 2.5 mg PO QAM
3. Atenolol 100 mg PO DAILY
4. Lisinopril 20 mg PO DAILY
5. Hydrochlorothiazide 50 mg PO DAILY
6. Fexofenadine 180 mg PO DAILY
7. Lorazepam 0.5 mg PO Q4H:PRN anxiety
8. Centrum Silver *NF* (multivitamin-minerals-lutein;<br>mv with
min-lycopene-lutein;<br>mv-min-folic acid-lutein) 0.4-300-250
mg-mcg-mcg Oral daily
9. Nevanac *NF* (nepafenac) 0.1 % ___
10. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES ___
11. Vigamox *NF* (moxifloxacin) 0.5 % ___
Discharge Medications:
1. Atenolol 100 mg PO DAILY
2. Ecotrin 325 mg PO DAILY
3. Fexofenadine 180 mg PO DAILY
4. Methimazole 2.5 mg PO QAM
5. Nevanac *NF* (nepafenac) 0.1 % ___
6. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES ___
7. Centrum Silver *NF* (multivitamin-minerals-lutein;<br>mv with
min-lycopene-lutein;<br>mv-min-folic acid-lutein) 0.4-300-250
mg-mcg-mcg Oral daily
8. Lorazepam 0.5 mg PO Q4H:PRN anxiety
9. Vigamox *NF* (moxifloxacin) 0.5 % ___
10. gatifloxacin *NF* 0.5 % OD ___
11. Acetaminophen 650 mg PO TID pain
12. Ethacrynic Acid 25 mg PO BID
RX *ethacrynic acid [Edecrin] 25 mg 1 tablet(s) by mouth twice a
day Disp #*60 Tablet Refills:*3
13. Lisinopril 40 mg PO DAILY
Please take two of your 20mg lisinopril tablets in the morning
(for a total of 40mg)
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
1. Hypertensive emergency
2. Pulmonary edema
3. Myelodysplastic 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.
You were admitted to the hospital with in the setting of high
blood pressure and fluid in your lung likely due to too much
salt intake. Your blood pressure and breathing improved with
change in your blood pressure medication and water pill. You
were noted to have abnormal blood counts for which hematology
doctors were ___ and recommended following up with
outpatient hematologist at ___ which Dr ___
will arrange.
FOLLOWING CHANGES WERE MADE TO YOUR OUTPATIENT REGIMEN
STOP HCTZ 50 MG BY MOUTH DAILY
START ETHACRYNIC ACID 25 MG BY MOUTH TWICE A DAY
INCREASE LISINOPRIL TO 40 MG BY MOUTH DAILY
CONTINUE TO TAKE TYLENOL AT HOME IN TREATMENT OF YOUR BACK PAIN
Please see an attached list of your medications below
Followup Instructions:
___
|
19602520-DS-8
| 19,602,520 | 26,356,034 |
DS
| 8 |
2151-04-04 00:00:00
|
2151-04-04 14:50:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Allergies/ADRs on File
Attending: ___.
Chief Complaint:
Hypoexmia
Major Surgical or Invasive Procedure:
Intubation ___
Extubation ___
History of Present Illness:
___ male with emphysema, HTN who presents as a transfer
from ___ for respiratory distress. Reportedly patient
came into ED with shortness of breath, was found by EMS to be
tripoding and tachypneic to the ___ with O2 sats ___ the ___. He
was placed on CPAP ___ the field, however, still ___ respiratory
distress.
___ ___, he was then placed on BiPAP but ultimately
intubated. At the time he was noted to have frothy secretions
and elevated JVP. The concern at the time was for flash
pulmonary edema ___ the setting of renal failure, hypertension.
However, given a normal BNP of 155, the diagnosis of volume
overload was called into question. He was placed on nitro drip
after receiving multiple sublingual nitro for hypertension and
volume overload; this was discontinued once BP improved. He
received 40 mg IV Lasix. Finally, he received Solu-Medrol x1
for ? COPD exacerbation; however, this too was questioned at OSH
given VBG did not show hypercarbia. At OSH, he had a bedside
TTE ___ the ED that showed no pericardial effusion. Given lack
of ICU beds at OSH, he was transferred to twice daily MC.
Ultimately, per ED at ___, the etiology of his dyspnea
was felt to be rather unclear: CHF versus PE but unable to
obtain CTA chest
___ ED initial VS: T 97.5 HR 81 BP 97/57 respiratory rate 18, 90%
on ATC ___ FiO2/5 PEEP
Exam: Intubated
Labs significant for: Creatinine 6.7, K+ 6.1 -> 5.6, VBG 7.15/___
-> 7.___, lactate 1.2
Patient was given:
Propofol drip, insulin 10 units IV regular, sodium bicarb ___ MeQ
X1 Lasix 100 mg IV X1 albuterol nebs X2
Imaging notable for:
CXR: Intubated, bilateral basilar opacities concerning for
atelectasis versus infiltrate, mild pulmonary edema
Bedside portable echo: No signs of right heart strain, R:L ratio
0.7, TAPSE 22 mm, no effusion, bilateral numerous B-lines. 2+
pitting edema bilaterally, and soft abdomen, brown stool, guaiac
negative
Consults:
Renal:
Please obtain records regarding baseline kidney function, send
serum of some toxic alcohol, U tox, his urine autism, renal
ultrasound. Agree with bicarbonate diuretics for hyperkalemia.
Agree with diuretics with high dose Lasix if less than 200 cc
urine ___ ___ hours would recommend Lasix drip, formal echo
T 97.5 VS prior to transfer: Heart rate 86 BP 132/70 RR 20 97%
intubated
On arrival to the MICU, noted to have significant autoPEEP (13)
w wheeze, gave albuterol nebs. Added ceftriaxone, azithromycin.
Sent respiratory viral screen and flu swabs
REVIEW OF SYSTEMS: unable to obtain
Upon further collateral from family, patient generally did not
see doctors until about ___ years ago after his dyspnea progressed
substantially. He has never been intubated before and never
required hospitalization for respiratory distress. Not on home
O2. Uses albuterol IH PRN only, no other inhalers.
Past Medical History:
Emphysema
HTN
Social History:
___
Family History:
father - died of emphysema ___
Physical Exam:
Admission exam;
VITALS: T afebrile heart rate 82 BP 108/70 CMV 500/22/40% PEEP
5
GENERAL: intubated, sedated
HEENT: Sclera anicteric, MMM
NECK: supple, JVP approx. clavicle, difficult to appreciate, no
LAD
LUNGS: poor air flow, wheeze, no rales, rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, 1+ edema bilaterally
SKIN: no rash
NEURO: no clonus
Pertinent Results:
Admission and notable labs:
___ 12:00AM BLOOD WBC-5.4 RBC-4.10* Hgb-9.7* Hct-31.6*
MCV-77* MCH-23.7* MCHC-30.7* RDW-17.7* RDWSD-49.3* Plt ___
___ 12:00AM BLOOD Neuts-79* Bands-3 Lymphs-5* Monos-13
Eos-0 Baso-0 ___ Myelos-0 AbsNeut-4.43 AbsLymp-0.27*
AbsMono-0.70 AbsEos-0.00* AbsBaso-0.00*
___ 12:00AM BLOOD ___ PTT-29.2 ___
___ 12:00AM BLOOD Glucose-94 UreaN-63* Creat-6.7* Na-132*
K-6.1* Cl-91* HCO3-18* AnGap-23*
___ 12:00AM BLOOD ALT-18 AST-21 CK(CPK)-198 AlkPhos-103
TotBili-0.5
___ 12:00AM BLOOD CK-MB-10 MB Indx-5.1 cTropnT-<0.01
___ 04:02AM BLOOD CK-MB-9 cTropnT-<0.01 proBNP-2341*
___ 12:00AM BLOOD Albumin-3.3* Calcium-8.4 Phos-8.1* Mg-1.7
___ 12:00AM BLOOD TSH-0.67
___ 04:02AM BLOOD Ethanol-NEG
___ 12:16AM BLOOD ___ pO2-58* pCO2-66* pH-7.15*
calTCO2-24 Base XS--7 Intubat-INTUBATED
___ 12:41AM BLOOD Lactate-1.2 K-5.6*
___ 08:44PM BLOOD Glucose-147* Lactate-0.9 Na-134 K-5.7*
Cl-95*
___ 04:31AM BLOOD freeCa-1.06*
___ 12:02AM URINE Blood-MOD* Nitrite-NEG Protein-300*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 12:02AM URINE RBC-33* WBC-1 Bacteri-FEW* Yeast-NONE
Epi-0
___ 12:02AM URINE Color-Yellow Appear-Cloudy* Sp ___
___ 07:24AM URINE Hours-RANDOM Creat-85 TotProt-36
Prot/Cr-0.4*
___ 12:02AM URINE Hours-RANDOM UreaN-303 Creat-137 Na-39
K-19 Cl-<20
___ 05:50PM URINE Osmolal-286
___ 12:02AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
MICROBIOLOGY:
___ 03:58AM OTHER BODY FLUID FluAPCR-POSITIVE*
FluBPCR-NEGATIVE
___ 4:02 am URINE Source: Catheter.
**FINAL REPORT ___
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
A negative result does not rule out infection due to other
L.
pneumophila serogroups or other Legionella species.
Furthermore, ___
infected patients the excretion of antigen ___ urine may
vary.
___ 3:58 am Rapid Respiratory Viral Screen & Culture
Source: Nasopharyngeal swab.
**FINAL REPORT ___
Respiratory Viral Culture (Final ___:
TEST CANCELLED, PATIENT CREDITED.
Refer to Influenza PCR (results listed under "OTHER" tab)
for further
information..
Respiratory Viral Antigen Screen (Final ___:
TEST CANCELLED, PATIENT CREDITED.
Refer to Influenza PCR (results listed under "OTHER" tab)
for further
information..
___ 5:56 am SPUTUM Site: ENDOTRACHEAL
**FINAL REPORT ___
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS.
2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
RESPIRATORY CULTURE (Final ___:
MODERATE GROWTH Commensal Respiratory Flora.
ACHROMOBACTER SP.. MODERATE GROWTH.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
ACHROMOBACTER SP.
|
AMIKACIN-------------- =>64 R
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- 16 I
CEFTAZIDIME----------- 4 S
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- 2 I
GENTAMICIN------------ =>16 R
LEVOFLOXACIN---------- 2 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- <=1 S
___ 2:10 pm CSF;SPINAL FLUID Source: LP #3.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final ___: NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST CULTURE (Preliminary):
The sensitivity of an AFB smear on CSF is very low..
If present, AFB may take ___ weeks to grow..
___ 2:10 pm CSF;SPINAL FLUID Source: LP.
**FINAL REPORT ___
CRYPTOCOCCAL ANTIGEN (Final ___:
CRYPTOCOCCAL ANTIGEN NOT DETECTED.
(Reference Range-Negative).
Test performed by Lateral Flow Assay.
Results should be evaluated ___ light of culture results
and clinical
presentation.
___ 5:23 am SPUTUM Source: Endotracheal.
**FINAL REPORT ___
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CHAINS.
2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final ___:
SPARSE GROWTH Commensal Respiratory Flora.
STREPTOCOCCUS PNEUMONIAE. MODERATE GROWTH.
PRESUMPTIVELY PENICILLIN SENSITIVE BY OXACILLIN SCREEN.
MORAXELLA CATARRHALIS. MODERATE GROWTH.
NEISSERIA MENINGITIDIS. MODERATE GROWTH.
HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE NEGATIVE.
MODERATE GROWTH.
Beta-lactamse negative: presumptively sensitive to
ampicillin.
Confirmation should be requested ___ cases of treatment
failure ___
life-threatening infections..
IMAGING
MR HEAD WITHOUT CONTRAST:
1. No acute infarcts.
2. Opacified paranasal sinuses, mastoids, nasopharynx, likely
from intubation.
RENAL US 1. 4 cm left simple renal cyst.
2. Otherwise normal appearing right and left kidneys without
hydronephrosis.
TTE
The left atrium is normal ___ size. 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%). Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). Right ventricular
chamber size and free wall motion are normal. The aortic root is
mildly dilated at the sinus level. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Trivial
mitral regurgitation is seen. There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Normal left ventricular wall thickness, cavity
size, and regional/global systolic function. Increased PCWP. No
definite pathologic valvular flow identified. Mild pulmonary
artery systolic hypertension.
Brief Hospital Course:
___ man with history of COPD, hypertension who
presented from ___ with respiratory failure secondary
to influenza and polymicrobial bacterial infection.
# Hypoxemic hypercarbic respiratory failure: Intubated prior to
arrival. Likely precipitated ___ setting of flu and pneumonia on
underlying severe COPD. Found to be flu positive and growing
strep pneumo, Neisseria meningitides, H. flu, and Moraxella ___
sputum culture (see below for more details). Patient was
successfully extubated on ___ and transitioned to room air
prior to discharge.
# Influenza A
# Community Acquired Pneumonia:
Presented with respiratory failure, found to be influenza A
positive, and sputum culture grew strep pneumo, Neisseria
meningitidus, H. flu, and Moraxella. Treated with 5 days
prednisone, ceftriaxone, azithromycin, and Tamiflu. Also found
to have Achromobacter ___ sputum and started on levofloxacin for
___ncephalopathy: Despite treatment for infection remained
significantly encephalopathic. He was either very agitated or
very sedated. Precedex and antipsychotics were trialed without
significant benefit. CT head and LP were unremarkable, and EEG
had no evidence of seizure. MRI was ordered which showed no
acute infarcts. He was continued on quetiapine 50 mg TID and
mental status improved slowly and he was eventually weaned off
Seroquel completely. On floor, he continued to have some mild
sundowning but was redirectable and able to be re-oriented.
Continued to have improving mental status throughout floor
stay.
# Acute kidney injury: Unknown baseline creatinine, previously
without renal disease. Presented with creatinine 6.7 on
admission and low urine output ___ ED, with hyaline casts ___
urine sediment and per renal consult ___ was felt to be
pre-renal ___ which developed into ATN. He received IVF with
slow improvement ___ Cr. Felt to be prerenal ___ setting of
infectious presentation. He was diuresed during ICU stay but
did not require further diuresis on transfer to the floor.
# CAD primary prevention: continued atorvastatin
# HTN: Restarted home metoprolol XL 50 prior to discharge
TRANSITIONAL ISSUES:
- Started on tiotropium inhaler prior to discharge. Monitor for
COPD symptoms and increase controller inhalers as needed. Will
probably need PFTs if has not had recent ones.
- Last day Levofloxacin = ___
- Renal U/S showed 4 cm left simple renal cyst. Follow up as
outpatient.
- Patient had lower ankle and foot edema bilaterally at
discharge. No signs of CHF and no hx of CHF so not started on
diuretics. Started compression stockings. Please assess volume
status and edema for improvement.
- Can consider TTE as outpatient to work up causes of lower
extremity edema if not improved.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 20 mg PO QPM
2. Metoprolol Succinate XL 50 mg PO DAILY
3. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze
Discharge Medications:
1. Levofloxacin 750 mg PO Q24H
2. Tiotropium Bromide 1 CAP IH DAILY
RX *tiotropium bromide [Spiriva Respimat] 1.25 mcg/actuation 1
cap inh daily Disp #*1 Inhaler Refills:*0
3. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze
4. Atorvastatin 20 mg PO QPM
5. Metoprolol Succinate XL 50 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Hypercarbic and Hypoxic Respiratory Failure
Influenza Infection
Polymicrobial Bacterial Infection
COPD exacerbation
Acute Tubular Necrosis
Toxic-Metabolic Encephalopathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It has been a pleasure taking care of you at ___.
Why was I here?
- You were admitted with trouble breathing.
What was done for me here?
- You had a breathing tube placed to help you breathe ___ the
intensive care unit (ICU).
- You were found to have influenza and pneumonia and you were
treated with antibiotics and antivirals.
- You had kidney injury which recovered during your hospital
stay.
- You were started on new inhalers for your COPD.
What should I do when I go home?
- You need to take your new inhaler every day and only use your
albuterol inhaler as needed for breathing problems.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19602712-DS-11
| 19,602,712 | 23,899,670 |
DS
| 11 |
2120-01-11 00:00:00
|
2120-02-12 16:15:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
foot pain
Major Surgical or Invasive Procedure:
___ I&D
History of Present Illness:
___ is a ___ man with a history of Charcot
neuropathy (reportedly idiopathic, not related to diabetes) to
bilateral feet, status post LEFT foot surgical correction
followed by orthopedics. Patient was previously on antibiotics,
was supposed to be wearing a hard cast boot is presenting with a
left foot swelling with purulent drainage. Seen by primary care
provider, referred to the emergency department for further
evaluation. Patient denies fever, chills, numbness, tingling or
weakness. Foot is painful and warm.
He was recently here for a right foot ulcer which he stated he
had since ___, fine until ___. He saw podiatry
outpatient who gave him oral antibiotics. He was admitted for a
right strayer procedure (gastrocnemius release), ___ MT head
resection, and plantar heel ulcer debridement.
In the ED, initial VS were T 98.7 HR 100 BP 147/80 RR 22 O2 99%
RA.
Exam notable for LEFT foot that is warm and painful to touch.
Labs showed:
- Lactate 1.4
- WBC 10.8
Imaging showed:
- ___ FOOT AP,LAT & OBL **LEFT**:
1. Charcot deformity of the left foot, unchanged in
appearance.
2. No radiographic evidence of osteomyelitis.
Received:
- 1L NS
- Vancomycin 1,000 mg
- Zosyn 4.5 g
Transfer VS were T 97.5 HR 88 BP 156/86 RR 18 O2 100% RA
Ortho was consulted and noted plantar left foot ulcer with
drainage that appeared purulent to them. Culture swab was done
at
bedside. They recommended admission to medicine for IV
antibiotics, as well as MRI of the foot for osteomyelitis
evaluation.
The decision was made to admit to medicine for further
management.
On arrival to the floor, patient reports that his left foot
started to hurt him between 2 and 3 weeks ago. He did not injure
it, but thinks that it became infected from dry skin. He has had
trouble standing on it for two weeks now. He went to bed last
night and it was a normal size, and he woke up this morning to
it
throbbing and significantly more swollen than before.
REVIEW OF SYSTEMS:
(+) As noted above, +nocturnal urinary frequency
(-) 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:
- Ankylosing spondylitis
- Hypertension
- Hyperlipidemia
- Obstructive sleep apnea
- Ocular hypertension/glaucoma suspect
- Partial retinal detachment ___, repaired with vitrectomy)
- H/O prostate cancer (dx ___, ___ ___ with
radiation and hormone therapy)
- Bilateral idiopathic neuropathy of the feet
- Bilateral Charcot deformity
- ___: R ___ procedure, ___ MT head resection, and
plantar ulcer debridement
Social History:
___
Family History:
- Mother died of stroke
- Father died of "heart damage"
- Two brothers alive and in good health
Physical Exam:
ADMISSION:
VS: T 99.3 BP 121/68 HR 81 RR 24 O2 95% RA
GENERAL: NAD, appears stated age
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: Non-tender supple neck, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: Right foot with healed ulcer, scars from previous
surgeries on the posterior lower leg and over the ___
metatarsal.
Left foot is very swollen, hot, tender with Charcot deformity
and
a 2 cm circular well-circumscribed ulceration on the plantar
surface with purulent drainage.
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: Warm and well perfused. No lesions other than noted above.
DISCHARGE:
VS: 98.1, 163/99, 72, 18, 97% on RA
GENERAL: NAD, appears stated age
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: Non-tender supple neck, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: Right foot with healed ulcer, scars from previous
surgeries on the posterior lower leg and over the ___
metatarsal.
L foot in soft boot.
PULSES: 2+ DP pulses bilaterally
NEURO: AOx3, grossly nonfocal
SKIN: Warm and well perfused. No lesions other than noted above.
Pertinent Results:
ADMISSION:
___ 09:40PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 09:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-NEG
___ 02:01PM LACTATE-1.4
___ 01:55PM GLUCOSE-98 UREA N-14 CREAT-1.0 SODIUM-134
POTASSIUM-4.3 CHLORIDE-99 TOTAL CO2-24 ANION GAP-15
___ 01:55PM CRP-277.6*
___ 01:55PM WBC-10.8* RBC-4.92 HGB-15.0 HCT-44.9 MCV-91
MCH-30.5 MCHC-33.4 RDW-14.6 RDWSD-49.5*
___ 01:55PM NEUTS-77.8* LYMPHS-11.0* MONOS-10.0 EOS-0.3*
BASOS-0.3 IM ___ AbsNeut-8.39* AbsLymp-1.18* AbsMono-1.08*
AbsEos-0.03* AbsBaso-0.03
___ 01:55PM PLT COUNT-185
___ 01:55PM ___ PTT-30.7 ___
IMAGING:
___ FOOT AP,LAT & OBL **LEFT**:
1. Charcot deformity of the left foot, unchanged in appearance.
2. No radiographic evidence of osteomyelitis.
___ MRI L FOOT
1. Background Charcot arthropathy and postoperative changes as
above.
2. The generalized subcutaneous edema about the forefoot and
midfoot is
compatible with cellulitis. More localized skin thickening and
subcutaneous edema in the plantar soft tissues extends
posteriorly beyond the field view and evaluation is further
limited without contrast. Within this limitation, no obvious
fluid collection or mass is detected. No bone marrow signal
convincing for osteomyelitis is seen.
3. Additional contrast-enhanced imaging with centering in the
midfoot could be performed, as an adjunct to the current
examination, if clinically indicated.
MICRO:
___ BCx x 2 pending
___ UCx negative
___ 3:16 pm SWAB LEFT FOOT # 1.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final ___:
MIXED BACTERIAL FLORA.
This culture contains mixed bacterial types (>=3) so an
abbreviated workup is performed. Any growth of
P.aeruginosa,
S.aureus and beta hemolytic streptococci will be
reported. IF
THESE BACTERIA ARE NOT REPORTED, THEY ARE NOT PRESENT
in this
culture.
STAPH AUREUS COAG +. RARE 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
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
A swab is not the optimal specimen for recovery of
mycobacteria or
filamentous fungi. A negative result should be
interpreted with
caution. Whenever possible tissue biopsy or aspirated
fluid should
be submitted.
FUNGAL CULTURE (Preliminary):
NO FUNGUS ISOLATED.
A swab is not the optimal specimen for recovery of
mycobacteria or
filamentous fungi. A negative result should be
interpreted with
caution. Whenever possible tissue biopsy or aspirated
fluid should
be submitted.
BONE BIOPSY PATHOLOGY (___) pending
DISCHARGE LABS:
___ 12:46PM BLOOD WBC-6.5 RBC-4.66 Hgb-14.5 Hct-42.2 MCV-91
MCH-31.1 MCHC-34.4 RDW-14.6 RDWSD-48.6* Plt ___
___ 12:46PM BLOOD Plt ___
Brief Hospital Course:
___ is a ___ year old man with a history of idiopathic
peripheral neuropathy, ankylosing spondylitis, chronic plantar
ulcers (s/p debridement of the right foot in ___, admitted
with L foot swelling/pain.
#L foot cellulitis
Patient presented with pain, erythema and purulent drainage from
a L foot wound. He failed outpatient oral antibiotics (Keflex)
and was transitioned to IV vancomycin during this admission. He
is now s/p I&D in the OR per Ortho on ___ wound cultures and
bone biopsy with NGTD. He has no evidence of osteomyelitis on
MRI and given likely adequate source control with debridement,
and was ultimately transitioned to levofloxacin for Staph
coverage (likely failed Keflex b/c inadequate Staph coverage as
outpatient). Wound swab cultures show scarce coag + Staph.
Patient discharged to complete total 10 day course of
levofloxacin (d10 on ___.
#ANKYLOSING SPONDYLITIS: Not currently on any immunosuppression
#HYPERTENSION: Continued home lisinopril
#HYPERLIPIDEMIA: Continued home simvastatin
#RESTLESS LEG SYNDROME: Continued home pramipexole
#GERD: Continued home omeprazole
***TRANSITIONAL ISSUES***
- Bone biopsy pending
- Last day of levofloxacin on ___
- Full Code (confirmed)
- Contact: ___ (girlfriend) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 40 mg PO DAILY
2. Simvastatin 40 mg PO QPM
3. Omeprazole 40 mg PO DAILY
4. Pramipexole 0.375 mg PO QHS:PRN restless legs
5. Sildenafil ___ mg PO ONE HOUR BEFORE SEX
6. imiquimod 1 packet topical 1X/WEEK
7. Cyanocobalamin 1000 mcg PO DAILY
8. Ferrous Sulfate 325 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Benzonatate 100 mg PO TID
RX *benzonatate 100 mg 1 capsule(s) by mouth three times a day
Disp #*21 Capsule Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*30 Capsule Refills:*0
3. Guaifenesin-Dextromethorphan 5 mL PO Q6H:PRN cough
RX *dextromethorphan-guaifenesin 100 mg-10 mg/5 mL 5 ml by mouth
every six (6) hours Refills:*0
4. Levofloxacin 500 mg PO Q24H
Last day on ___
RX *levofloxacin 500 mg 1 tablet(s) by mouth daily Disp #*3
Tablet Refills:*0
5. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *oxycodone 5 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*15 Tablet Refills:*0
6. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram/dose 17 gm by mouth daily
Refills:*0
7. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 tab by mouth twice a day Disp
#*30 Tablet Refills:*0
8. Cyanocobalamin 1000 mcg PO DAILY
9. Ferrous Sulfate 325 mg PO DAILY
10. imiquimod 1 packet topical 1X/WEEK
11. Lisinopril 40 mg PO DAILY
12. Multivitamins 1 TAB PO DAILY
13. Omeprazole 40 mg PO DAILY
14. Pramipexole 0.375 mg PO QHS:PRN restless legs
15. Sildenafil ___ mg PO ONE HOUR BEFORE SEX
___. Simvastatin 40 mg PO QPM
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
L foot cellulitis
Charcot foot
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at ___
___. You were admitted to the hospital for
cellulitis (skin infection) and infection of your soft tissue
related to a left foot wound. You were initially treated with
IV antibiotics and you underwent surgical debridement of your
wound by the Orthopedic Surgery team. You underwent an MRI of
your left foot which fortunately showed extension of the
infection to your bony tissues (osteomyelitis). You were
successfully transitioned to oral antibiotics and will complete
a total 10 day course, last dose on ___.
Please follow-up with your outpatient providers as instructed
below. Please make sure you do not bear any weight on your left
foot.
Thank you for allowing us to participate in your care. All best
wishes for your health.
Sincerely,
Your ___ medical team
Followup Instructions:
___
|
19602712-DS-14
| 19,602,712 | 25,977,622 |
DS
| 14 |
2121-12-27 00:00:00
|
2121-12-27 11:48:00
|
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 foot pain
Major Surgical or Invasive Procedure:
Irrigation and debridement of left foot
History of Present Illness:
This is a ___ male with a history of a left Charcot foot
deformity who presents today with concerns for possible
infection. Orthopedics is consulted with a question of need for
debridement. The patient has a known chronic left plantar foot
wound. He is undergone multiple debridements for this. He
previously grew out MRSA and was on IV antibiotics. His recent
history includes being off IV daptomycin since ___. He was
followed by the wound clinic and having dressing changes every
other day. He was cleared by the wound clinic approximately ___
weeks ago. He states over the last ___ days he has had
increasing pain in the bottom of his foot. Today it was worse
to the point that he was unable to bear weight on it. He does
have severe neuropathy. He denies any fevers or chills, nausea
or vomiting, or any other systemic symptoms. He has not eaten
anything today. He states that he took a photo of the bottom of
his foot and noticed that he "had a golf ball" growing on it.
Past Medical History:
- Ankylosing spondylitis
- Hypertension
- Hyperlipidemia
- Obstructive sleep apnea
- Ocular hypertension/glaucoma suspect
- Partial retinal detachment ___, repaired with vitrectomy)
- H/O prostate cancer (dx ___, ___ ___ with
radiation and hormone therapy)
- Bilateral idiopathic neuropathy of the feet
- Bilateral Charcot deformity
- ___: R ___ procedure, ___ MT head resection, and
plantar ulcer debridement
Social History:
___
Family History:
- Mother died of stroke
- Father died of "heart damage"
- Two brothers alive and in good health
Physical Exam:
General: Well-appearing, NAD
Resp: Normal WOB, symmetric chest rise
CV: Extremities WWP
MSK:
Charcot deformity, with rocker-bottom foot.
WTD dressing c/d/i
No sensation in except for slightly diminished sensation lateral
foot c/w baseline exam
___, FHL, ___, TA
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 foot abscess and was admitted to the orthopedic
surgery service. The patient was taken to the operating room on
___ for irrigation and debridement, 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 ___ for daily
wet-to-dry dressing changes was appropriate. Infectious disease
was consulted and is recommending flagyl, vanc, cipro. the
___ hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
nonweightbearing in the left lower extremity, and will be
discharged on aspirin for DVT prophylaxis. The patient will
follow up with Dr. ___ routine. A thorough discussion
was had with the patient regarding the diagnosis and expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient was also given written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient expressed readiness for discharge.
Medications on Admission:
See PAML
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
3. Aspirin 325 mg PO DAILY
RX *aspirin 325 mg 1 tablet(s) by mouth once a day Disp #*28
Tablet Refills:*0
4. Docusate Sodium 100 mg PO BID
5. Ferrous Sulfate 325 mg PO DAILY
6. Montelukast 10 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Omeprazole 20 mg PO DAILY
9. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain
RX *oxycodone 5 mg 1 tablet(s) by mouth q4 hours Disp #*20
Tablet Refills:*0
10. Pramipexole 0.125 mg PO QHS:PRN prn restless leg syndrome
11. Sertraline 50 mg PO DAILY
12. Simvastatin 40 mg PO QPM
13. Zolpidem Tartrate 5 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Left foot abscess
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.
-You will require home ___, with recommended twice daily
wet-to-dry dressing changes for your wound.
-You are followed by infectious disease while you are inpatient,
interest strictly adhere to their antibiotic regimen. Please
see discharge summary for follow-up information.
ACTIVITY AND WEIGHT BEARING:
-Nonweightbearing left lower extremity
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 ASA 325 daily for 4 weeks
WOUND CARE:
- Daily wet to dry dressing changes by ___ until wound closes.
Small gauze should be inserted into the open wound.
ANTIBIOTICS:
Vancomycin 1g IV every 8 hours
Ciprofloxacin 500 mg PO every 12 hours
Flagyl 500mg PO three times daily
PICC CARE: Per protocol
WEEKLY LABS: draw on ___ and send result weekly to ID RNs
at: ___ R.N.s at ___.
- CBC/DIFF
- BUN
- Cr
- Vancomycin trough
Please also draw AST, ALT, Total Bili, Alk phos ONCE 7 days post
discharge (___).
**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.**
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:
NWB LLE
Treatments Frequency:
Daily dressing changes by ___ to left foot wound. Wet to dry
gauze in the open wound until it closes.
Followup Instructions:
___
|
19602745-DS-6
| 19,602,745 | 22,567,701 |
DS
| 6 |
2193-12-17 00:00:00
|
2193-12-17 13:55:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
diarrhea, weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ yo F w/ hx depression and hypothyroidism who was brought to
the ED by SW from ___ for evaluation for ongoing diarrhea and
psych assessment as the patient has been living in ___ and
her house has been condemned.
Pt reports that she has had diarrhea for 10 days that is watery
and occuring several times/day, though this has started to
improve over the last couple of days. She states the stool will
sometimes "ooze" out of her. She took Milk of Magnesia on
___ as she was feeling constipated. However, other
interviewers document that the original onset of the diarrhea
was after the feeling of constipation, for which she took the
Milk of Magnesia. She denies any sick contacts, recent travel,
or new foods. She had no associated abd pain, nausea/vomiting
and no changes to her appetite. However, she has been feeling
feeble since ___ and notes times that she collapses out on
the street becasue she can't carry the weight of her body. She
denies fevers/chills, cough/sore throat.
Per the psychiatry note, her home was condemned by the Dept ___
___ Health and she was removed by the ___ Police and
Fire and sent to the ___. A week ago, she reportedly
collapsed in front of ther home and police were called. When
they brought her into her home it was found to be filthy,
cluttered, with a strong odor and no heat or running water.
Though she was asked to leave, she refused as she she did not
feel there was a problem. Subsequently ___ condemned her home,
she was removed by the police, and ___ put
her up in the ___.
In the ED, initial VS were: 99.2 104 135/84 18 96%. Physical
exam notable for generally disheveled and very gaunt appearance,
RRR borderline tachy. She was given 1L NS. She was seen by
psychiatry, who felt that she did not meet ___ criteria
and would not benefit from voluntary psych hospitalization at
this time. The pt would like to return to ___
temporarily, follow with ___ Social work, and eventually
move to rooming house, and psych felt there was no
capacity/competency contraindications to this discharge plan.
She was also evaluated by physical therapy who felt the pt was
not safe to go anywhere but rehab.
Of note, pt states hx of facial fractures in 1980s after being
punched in face by burglar with 5 surgeries to reconstruct these
including a repair of her retro-orbital floor and confirms that
surgeons did indeed take bone from another part of her
calvarium. CT head was done in the ED, which showed areas of
white matter hypodensity and opacification of the right frontal
sinus.
VS on transfer 98.6 96 122/72 16 98%. On the floor, pt felt
fine, but tired. She had no acute complaints and felt that it
was nice and quiet here, almost like a respite.
Past Medical History:
Depression
Hypothyroidism
Social History:
___
Family History:
Mother with depression
Father - lung cancer, died in ___
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 97.7 BP 125/67 P ___ R ___, Wt 38.5kg
GENERAL: cachectic, chronically ill-appearing
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM
NECK: supple, no LAD
LUNGS: CTAB, no r/rh/wh
HEART: Tachycardic, but regular rhythm, no MRG, nl S1-S2
ABDOMEN: normal bowel sounds, soft, non-tender, non-distended
EXTREMITIES: no edema, excorations near the knees
DISCHARGE PHYSICAL EXAM:
VS: T97.8, BP 120/73 (SBP 112-128), HR 96 (96-197), RR 18, 97%
RA
Gen: cachectic woman in NAD, A&Ox3
HEENT: MM dry, OP clear
CV: irregular, no MRG
Resp: clear to ausculation bilaterally
Abd: +BS, soft, non-tender, non-distended
ext: thin, warm, no edema
Neuro: L pupil>R (chronic), L leg weaker than R (chronic), R
corner of mouth with subtle droop improved, speech clear.
Pertinent Results:
ADMISSION:
___ 01:20PM BLOOD WBC-9.7 RBC-4.72 Hgb-14.0 Hct-43.0 MCV-91
MCH-29.7 MCHC-32.6 RDW-13.5 Plt ___
___ 01:20PM BLOOD Neuts-80.7* Lymphs-12.6* Monos-5.4
Eos-1.1 Baso-0.3
___ 01:20PM BLOOD Plt ___
___ 01:20PM BLOOD Glucose-87 UreaN-15 Creat-0.6 Na-139
K-3.9 Cl-100 HCO3-27 AnGap-16
___ 01:20PM BLOOD Albumin-4.7 Calcium-9.5 Phos-3.0 Mg-2.7*
PERTINENT LABS:
___ 01:20PM BLOOD TSH-4.7*
___ 01:20PM BLOOD T4-10.5
___ 06:35AM BLOOD Free T4-1.2
___ 06:55AM BLOOD HIV Ab-NEGATIVE
___ 02:30PM BLOOD calTIBC-329 VitB12-169* Folate-10.1
Ferritn-42 TRF-253
___ 07:00AM BLOOD 25VitD-13*
DISCHARGE:
___ 07:20AM BLOOD WBC-3.6* RBC-4.18* Hgb-13.2 Hct-38.9
MCV-93 MCH-31.5 MCHC-33.9 RDW-14.1 Plt ___
___ 07:10AM BLOOD Glucose-119* UreaN-13 Creat-0.5 Na-140
K-3.8 Cl-101 HCO3-28 AnGap-15
___ 07:10AM BLOOD Calcium-8.6 Phos-4.4 Mg-1.8
MICRO:
___ 6:00 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool. **FINAL REPORT ___
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
___ 8:52 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool. **FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
___ Blood Culture, Routine-NEGATIVE
___ Blood Culture, Routine-NEGATIVE
IMAGING:
IMPRESSION:
1. No evidence of acute intracranial process.
2. Post-surgical changes involving the right frontal and facial
bones.
Correlation with surgical history is recommended as well as with
prior
imaging, if available.
3. Areas of white matter hypodensity, highly nonspecific,
although most often are seen with chronic small vessel ischemic
disease. If the patient has a history of malignancy, however,
then it may be appropriate to consider contrast-enhanced CT or
MR to investigate further.
4. Opacification of the right frontal sinus with hyperdense
context which
suggests either hemorrhage or infection, possibly with a fungal
organism,
which could be seen with hyperdense material.
2-view CXR ___ :
IMPRESSION: PA and lateral chest reviewed in the absence of
prior chest
radiographs: On the lateral view, a small region of
bronchiectasis may be present in one of the lower lungs
projected over the posterior cardiac silhouette. Lungs are
hyperexpanded due to emphysema, but clear of any other focal
abnormality. Cardiomediastinal and hilar silhouettes and
pleural surfaces are normal. There is no evidence of
intrathoracic malignancy or infection. Cardiomediastinal and
hilar silhouettes and pleural surfaces are normal.
pCXR ___
The patient has hyperinflated lungs. There is new bilateral
lower lobe
bronchial wall thickening consistent with bronchial infection.
Subtle right upper lobe subcentimeter nodular opacity adjacent
to ___ anterior rib is new. There is no pleural effusion or
pneumothorax. Mediastinal and cardiac contours are normal.
CONCLUSION:
1. New bronchial wall thickening mostly in the lower lobes is
concerning foracute bronchitis.
2. New right upper lobe small nodular opacity is likely
infectious or
inflammatory, but a follow up standard PA and lateral chest
x-ray before
discharge is suggested.
Brief Hospital Course:
___ yo F w/ hx depression and hypothyroidism who was brought to
the ED by SW from ___ for evaluation for diarrhea and psych
assessment, found to have persistent mild sinus tachycardia,
deconditioning, malnutrition and multiple vitamin deficiencies.
# Vitamin B12 deficiency: Patient presented with paresthesias in
bilateral hands and feet, as well as difficulty with ambulation.
Work up revealed B12 level of 169, most likely from poor PO
intake. Her hemaglobin was normal but macrocytic. Received
1000mcg IM ___, discharged on 1000mcg PO daily. If
paresthesias persist could benefit from outpatient neurology
referral. B12 level should be rechecked ___ weeks after
discharge.
# Acute diarrhea: On admission patient reported diarrhea but
history revealed that she had been constipated and diarrhea may
have been caused by laxatives. However, later in hospital course
she developed nausea, vomiting, and water diarrhea ___ bowel
movements a day). Stool for c. diff was negative. She was felt
to have infectious gastroenteritis as her hospital roommate had
similar symptoms. She had one isolated fever but no other red
flag symptoms to suggest inflammatory or invasive infectious
diarrhea. She was treated with supportive care and symptoms
gradually resolved.
# Deconditioning/malnutrition - Patient cachectic, likely from
malnutrition, though albumin was within normal range. Accurate
calorie counts proved difficult but rough calculation was about
400-500 kcal/day. Nutrition was consulted, patient was offered
several nutritional supplements a day and weight increased over
course of the admission by about 4kg (from 38.5kg to 42.8kg).
Nutrition recommended tube feedings to meet caloric needs but
patient declined this intervention after discussion of risks of
malnutrition. Outpatient work up for malignancy could be
considered if increased PO intake does not continue to result in
appropriate weight gain. Also gave an empiric 1 week course of
thiamine repletion 100mg PO daily x7d. ___ recommended continued
outpatient ___, was able to transfer on her own, one problem
identified was frequent poor problem-solving ability. Patient
observed to be able to walk but with small shuffling steps and
slight limp on L leg.
# Vit D deficiency: Vit D level found to be 13. Started on
50,000U vitamin D every ___ starting ___.
# Inability to care for herself - Per report, patient was living
in squalid conditions, not understanding the severity of the
situation as she had refused to leave when asked given the
living conditions. CT head performed to evaluate for chronic SDH
or tumor and found areas of white matter hypodensity, highly
nonspecific, although most often seen with chronic small vessel
ischemic disease. Psychiatry was consulted and agreed that
patient was competent to make her healthcare decisions. She did
at times show splitting of the staff but had no suicidal
ideation or evidence of psychosis.
TRANSITIONAL ISSUES:
- 12 week course of 50,000u once a week started ___
- Consider outpatient malignancy work up given cachexia and
smoking hisotry
- Patient may have well-compensated COPD given smoking history
and hyperinflated lungs on CXR
- Further outpatient work up of tachycardia may be warranted if
persists
- If parethesias do not improve with B12 replacement, consider
neurology referral
- Recheck B12 level as outpatient, consider further work up if
no improvement
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Equipment
16 inch wheelchair
2. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Mirtazapine 7.5-15 mg PO HS
RX *mirtazapine 7.5 mg ___ tablet(s) by mouth at bedtime Disp
#*30 Tablet Refills:*0
4. Vitamin D 50,000 UNIT PO 1X/WEEK (WE)
Once a week for 12 weeks (started ___
RX *ergocalciferol (vitamin D2) 50,000 unit 1 capsule(s) by
mouth Every ___ Disp #*11 Capsule Refills:*0
5. Cyanocobalamin 1000 mcg PO DAILY
RX *cyanocobalamin (vitamin B-12) 1,000 mcg 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary: Deconditioning, Vitamin B12 deficiency, Vitamin D
deficiency, malnutrition, viral gastroenteritis organism not
specified
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 ___ for evaluation of weakness and for
diarrhea. On your arrival your diarrhea had resolved, and we
believe your weakness was from malnutrition and vitamin B12
deficiency. You declined tube feedings but continued to take
dietary supplements to add to your caloric intake. You were
treated with B12 replacement. You were also treated with
thiamine and vitamin D replacement. You were evaluated and
treated by our physical therapists who recommend continued
physical therapy after discharge.
While you were in the hospital, you had new nausea, vomiting,
and diarrhea, most likely viral gastroenteritis. You were
treated with IV fluids and electrolyte replacement. While your
electrolytes were up and down from the diarrhea, you developed
an irregular heart rate with frequent premature ventricular
beats, or PVCs, most likely from low levels of potassium and
magnesium. As your diarrhea improved, so did your heart rate.
Followup Instructions:
___
|
19602823-DS-19
| 19,602,823 | 25,005,980 |
DS
| 19 |
2142-11-08 00:00:00
|
2142-11-09 08:41:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Fosamax / Pollen,Micronized
Attending: ___.
Chief Complaint:
Abd pain, N/V/D, dehydration
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ with a history of chronic back pain, uterine prolapse with
pessary who presents with nausea, NBNB brown vomiting and
nonbloody brown diarrhea x4 days. She had difficulty eating
things normally and felt dehydrated. She denied fevers, chills,
sick contacts, recent travel, or any antibiotic use. She has
been tolerating fluids.
She initially presented to PCP 3 days ago and was given Zofran
and BRAT diet. This helped her vomiting but diarrhea persisted.
Today returned to ___ with complaints of continued diarrhea and
was referred to ___ ED for concerns for diarrhea and worsening
of her abdominal exam, now with guarding.
In the ED, initial vitals were: 98.2 93 ___ 98% RA
Exam notable for: "abd with epig ttp, +guarding, +bs"
Labs notable for: WBC 21.9 (88%N), Na 126, BUN 46/1.5 -> 41/1.3
with IVF, UA large leuk/pos nitrates
Imaging notable for: CT abd/pelvis: "1. Heterogeneous
enhancement pattern of the left upper pole renal cortex raises
question of pyelonephritis. Correlate with urinalysis."
Patient was given:
___ 19:05 IVF 1000 mL NS 1000 mL
___ 21:04 IV CeftriaXONE 1 gm
___ 22:45 IVF 1000 mL NS 1000 mL
___ 23:15 IVF 1000 mL NS 1000 mL
On the floor, she denies current nausea/abdominal pain, but
continues to endorse epigastric tenderness to palpation
secondary to frequent emesis. She is feeling slightly better
with the intravenous fluids, but still very tired with low
energy. She denies dysuria, urinary frequency, suprapubic
discomfort, or flank pain. She tried to eat in ED, however, was
nauseated and had to stop.
Past Medical History:
BACK PAIN
COMPRESSION FRACTURES
MENOPAUSE
OSTEOPOROSIS
RECLAST
TOBACCO ABUSE
VARICOSE VEINS
PERIPHERAL NEUROPATHY
LUMBAR RADICULOPATHY
HYPERTENSION
Uterine prolapse with pessary in place currently
Cystocele
Large umbilical hernia s/p surgical reduction in ___
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vital Signs: 97.7 PO 161 / 78 R Lying 90 18 99 RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, mild TTP epigastrium without rebound.
non-distended, bowel sounds present, no organomegaly
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, gait deferred.
DISCHARGE PHYSICAL EXAM:
VS - 98.4 147/60, 91, 18, 97% r.a.
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, 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 in all quadrants, no rebound/guarding,
non-distended, bowel sounds present, no organomegaly
GU: Deferred
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Grossly intact, somewhat odd affect / circuitous way of
speaking, but insight/judgment appears to be intact and she is
able to teach back the details of her hospitalization
Pertinent Results:
ADMISSION LABS:
___ 06:50PM BLOOD WBC-21.6*# RBC-4.58 Hgb-14.6 Hct-40.9
MCV-89 MCH-31.9 MCHC-35.7 RDW-13.2 RDWSD-43.4 Plt ___
___ 06:50PM BLOOD Neuts-87.0* Lymphs-6.8* Monos-4.4*
Eos-0.1* Baso-0.5 Im ___ AbsNeut-18.82* AbsLymp-1.47
AbsMono-0.96* AbsEos-0.03* AbsBaso-0.10*
___ 11:00PM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-1+
Macrocy-1+ Microcy-NORMAL Polychr-NORMAL Burr-1+
___ 06:50PM BLOOD Plt ___
___ 06:50PM BLOOD Glucose-88 UreaN-46* Creat-1.5* Na-126*
K-4.1 Cl-88* HCO3-18* AnGap-24*
___ 06:50PM BLOOD ALT-34 AST-39 AlkPhos-145* TotBili-0.3
___ 08:20AM BLOOD Calcium-8.1* Phos-1.9* Mg-2.3
___ 06:50PM BLOOD Albumin-3.4*
___ 11:00PM BLOOD Osmolal-280
___ 12:42AM BLOOD Lactate-1.0
MICRO: ___ Urine culture
___ 6:45 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 CFU/mL.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
___ 11:36 am STOOL CONSISTENCY: FORMED Source:
Stool.
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Pending):
IMAGING:
___ CT ABD/PELVIS:
1. Heterogeneous enhancement pattern of the left upper pole
renal cortex raises question of pyelonephritis. Correlate with
urinalysis.
2. Right adrenal nodule and thickening of the left adrenal gland
are likely bilateral adenomas although remain incompletely
characterized. Nonemergent dedicated adrenal imaging can be
performed for further evaluation.
3. Sigmoid diverticular disease is mild without evidence of
diverticulitis.
4. Prominent ovarian vessels bilaterally may reflect pelvic
congestion syndrome. Uterine pessary is noted.
5. Numerous compression and wedge deformities involving the
visualized thoracolumbar spine. New since MR dated ___,
there is a compression deformity of T12 vertebral body which
appears chronic. Clinically correlate.
DISCHARGE LABS:
___ 08:37AM BLOOD WBC-17.3* RBC-4.20 Hgb-13.1 Hct-39.1
MCV-93 MCH-31.2 MCHC-33.5 RDW-14.0 RDWSD-47.7* Plt ___
___ 08:37AM BLOOD Plt ___
___ 08:37AM BLOOD Glucose-104* UreaN-19 Creat-0.8 Na-137
K-3.4 Cl-100 HCO3-20* AnGap-20
___ 08:37AM BLOOD Calcium-8.9 Phos-3.0 Mg-2.2
Brief Hospital Course:
The patient is a ___ year-old female with a history of chronic
back pain, uterine prolapse with pessary who presents with
several days nausea/emesis/diarrhea and was found to have
pyelonephritis as well as hyponatremia, acute kidney injury and
hypokalemia. Her hyponatremia and acute kidney injury improved
with IV fluid administration. Her potassium was repleted. Her
pyelonephritis was initially treated with ceftriaxone and she
was switched to ciprofloxacin for a 14-day course (end of
therapy: ___. She was discharged in stable condition.
ACTIVE ISSUES:
#Pyelonephritis (E coli) with leukocytosis:
The patient presented with abdominal pain, nausea, vomiting and
found to have WBC 21, acute renal failure, electrolyte
abnormalities, and was found to have positive urinalysis,
culture with > 100,000 E. coli, pansensitive, and CT scan
suggestive of pyelonephritis. She was treated with ceftriaxone
on admission which was subsequently transitioned to oral
ciprofloxacin (___). Her leukocytosis downtrended
appropriately. Urine cultures from ___ were pan-sensitive E.
coli. She should continue oral ciprofloxacin until ___ for a
14-day course for pyelonephritis.
It is possible that her pessary may put her at increased risk of
urinary tract infection - she was counseled to follow up with
gynecology to ensure well-fitted pessary.
#Abdominal pain, Nausea/emesis/diarrhea
The patient presented with intermittent nausea, vomiting, and
diarrhea, suspect due to pyelonephritis with possible
superimposed gastroenteritis and antibiotic associated diarrhea.
CT abdomen showed pyelonephritis as well as diverticulosis
without diverticulitis or other apparent intra-abdominal
disease. Her abdominal exam remained benign. She was tolerating
a regular diet on discharge. She should follow up in the clinic
to ensure resolution of these symptoms and to ensure adequate
oral intake. A C. Diff study was pending at the time of
discharge and should be followed up in the outpatient setting.
#Acute Kidney Injury:
The patient presented with an elevated creatinine which
normalized after IV fluid administration. This was most likely
pre-renal from GI losses.
#Anion gap metabolic acidosis:
The patient presented with an anion gap acidosis without lactic
acidosis which improved after IV fluid administration.
#Hyponatremia:
The patient presented with asymptomatic hyponatremia which
resolved after IV fluid administration. This was likely
hypovolemic hyponatremia in the setting of GI losses.
#Hypokalemia:
The patient had hypokalemia on presentation which was attributed
to GI losses. This was repleted during hospitalization. She
should follow up in the clinic for repeat electrolytes.
CHRONIC ISSUES:
#Hypertension: Lisinopril held during hospitalization, restarted
on discharge.
#Chronic alcohol use: The patient reports no history of alcohol
withdrawal. She was kept on a CIWA scale during hospitalization.
She should follow up in the clinic about her alcohol use for
evaluation of its effect on her health and lifestyle.
TRANSITIONAL ISSUES:
#Pyelonephritis with leukocytosis: Urine cultures from ___ were
pan-sensitive E. coli. She should continue oral ciprofloxacin
until ___ for a 14-day course for pyelonephritis.
#Abdominal pain, Nausea/emesis/diarrhea: She should follow up in
the clinic to ensure resolution of these symptoms and to ensure
adequate oral intake. A C. Diff study was pending at the time of
discharge and should be followed up in the outpatient setting.
#Chronic alcohol use: She should follow up in the clinic about
her alcohol use for evaluation of its effect on her health and
lifestyle.
#Incidental findings: The patient had a CT scan with right
adrenal nodule and thickening of the left adrenal gland that
should be followed up with nonemergent dedicated adrenal
imagaing (likely adenoma). Patient was counseled, PCP was
notified.
# CODE: Full, confirmed, but patient would not like to be kept
alive if in a vegetative state/on ventilator for prolonged
# CONTACT: Son ___ ___
30 minutes on discharge activities
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 20 mg PO DAILY
2. Vitamin D ___ UNIT PO DAILY
3. Ibuprofen 800 mg PO Q8H:PRN Pain - Moderate
4. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*25 Tablet Refills:*0
2. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild
3. Ibuprofen 800 mg PO Q8H:PRN Pain - Moderate
4. Lisinopril 20 mg PO DAILY
5. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Pyelonephritis, Gastroenteritis, Acute Kidney Injury,
Hyponatremia, Hypokalemia
Secondary: Hypertension, Alcohol abuse
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 ___ ___ ___
because you were having nausea, vomiting, and diarrhea. While
you were here, we found that you have a urinary tract infection
and we treated this with antibiotics.
You should take ciprofloxacin 500mg twice daily x14 days (last
day ___
When you go home, please remember to take all of your
medications as directed. Please follow up with your primary
doctor. It will be very important to continue eating and
drinking enough. If you find that you are unable to keep food
and water down, please return to the emergency department
immediately.
Thank you for allowing us to care for you here,
Your ___ care team
Followup Instructions:
___
|
19603090-DS-7
| 19,603,090 | 25,251,500 |
DS
| 7 |
2145-05-27 00:00:00
|
2145-05-27 15:02:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left ankle fracture
Major Surgical or Invasive Procedure:
Left ankle ORIF
History of Present Illness:
___ female with a h/o HTN who was struck by a motorcycle
while crossing the street in ___ ___. She went to the
hospital there and was told it was not broken but only
dislocated. It was reduced and splinted. She also had burns on
the left foot. The splint was later taken down by an herbal
healer to treat the burns with a yellow powder. She arrived back
in the ___ ___ and presented to ___ for further care. She
reports pain in the left ankle, worse with ambulation.
Past Medical History:
1. GERD.
2. Hypertension.
3. Heart murmur.
4. Allergic rhinitis.
5. Obesity.
6. Headaches.
7. Hyperthyroidism.
8. Pulmonary embolus following a cesarean section.
9. Obstructive sleep apnea.
10. Major depressive disorder.
11. Peptic ulcer disease.
12. Osteoarthritis, status post left knee replacement.
Social History:
___
Family History:
son with schizophrenia, daughter with bipolar
disorder, older son with "mental health problems:
Physical Exam:
Gen: middle-age female in no acute distress
Neuro: alert and interactive
CV: palpable DP pulse
Pulm: no respiratory distress on room air
LLE: in splint, toes WWP, SILT: MP/LP/SP/DP, fires ___
Pertinent Results:
None
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 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 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
non-weight-bearing 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 ___ care.
The patient expressed readiness for discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 10 mg PO DAILY
2. Gabapentin 300 mg PO BID
3. Omeprazole 20 mg PO DAILY
4. Gabapentin 600 mg PO QHS
5. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
6. Diclofenac Sodium ___ 100 mg PO Q6H:PRN pain
7. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 500
mg(1,250mg) -125 unit oral DAILY
8. Cyanocobalamin 1000 mcg PO DAILY
9. Ferrous Sulfate 325 mg PO DAILY
10. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. Enoxaparin Sodium 40 mg SC Q24H
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 40 mg/0.4 mL 40 mg subcutaneous daily Disp #*14
Syringe Refills:*0
3. OxyCODONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours as
needed for pain Disp #*40 Tablet Refills:*0
4. Senna 17.2 mg PO QHS
5. Acetaminophen 650 mg PO TID
6. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 500
mg(1,250mg) -125 unit oral DAILY
7. Cyanocobalamin 1000 mcg PO DAILY
8. Ferrous Sulfate 325 mg PO DAILY
9. Gabapentin 300 mg PO BID
10. Gabapentin 600 mg PO QHS
11. Lisinopril 10 mg PO DAILY
12. Multivitamins 1 TAB PO DAILY
13. Omeprazole 20 mg PO DAILY
14. HELD- Diclofenac Sodium ___ 100 mg PO Q6H:PRN pain This
medication was held. Do not restart Diclofenac Sodium ___ ___
___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left ankle fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- non-weight-bearing 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 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.
- Please remain in your dressing and do not change unless it is
visibly soaked or falling off.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
Physical Therapy:
Non-weight-bearing left lower extremity in splint
Treatments Frequency:
Please keep splint on until ___
Followup Instructions:
___
|
19603912-DS-23
| 19,603,912 | 23,317,228 |
DS
| 23 |
2127-05-24 00:00:00
|
2127-05-24 15:57:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
IV Dye, Iodine Containing Contrast Media
Attending: ___
Chief Complaint:
Word finding difficulties
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr ___ is a ___ year old right-handed man with AF on
warfarin, HTN, CAD and MI s/p cardiac arrest (___), CABG and
multiple stents, recent cholelithiasis and cholecystitis s/p
stenting and cholecystectomy off AC ~15 days presenting with one
week of word finding difficulties.
Patient with abdominal pain, jaundice, one day of fever,
admitted to ___ x 2 weeks with cholecystitis and
cholelithiasis s/p stenting and cholecystectomy, discharged on
___. During that admission he was off anticoagulation given
the surgery. He saw his PCP and restarted warfarin on ___.
The next evening ___ he was on the phone and feeling fine.
Went in to the bedroom to see his dog, reports feeling an
unusual sensation in his head (has difficulty describing it,
reports was unpleasant but unclear if pain or dizziness or
what). Reports he went to turn on the light and had significant
difficulty, was fumbling around and could not seem to figure out
how to turn on the light. Then went in and was watching TV with
his wife, trying to talk to his wife and had difficulty finding
his words. Over the following days had ongoing difficulty with
word finding, some effortful speech and at times using the wrong
words but with effort able to eventually find words. Reports
this has improved bit by bit but continued somewhat.
On ___ around 10:30 ___ was watching TV when he reports the TV
seemed to get "dim," like someone turned down the lights,
possibly blurry. Reports this was the whole TV in the middle of
his vision, no particular part of his vision. Felt a bit
lightheaded at the same time. Went to the other room to try to
change scenery and after about twenty minutes this resolved.
Daughter (who is a ___) and son-in-law just returned from a
trip and heard his symptoms and had him come in to the ER. Had
his sutures removed from his surgery and then came in. Reports
he has an appointment with his cardiologist at ___ at 1PM
today.
Endorses some hoarseness to his voice since surgery, no further
changes in his voice. Denies dysphagia. Denies vertigo. Reports
his vision is now at baseline. Denies weakness, numbness,
confusion. Was able to assemble a garden set without difficulty.
Denies fevers, cough, URI symptoms, rashes, chest pain, SOB.
Reports with his recent hospitalization had significant edema,
was up to 220 lbs, now down to 188 with Lasix. Had jaundice,
abdominal pain, one day of fever with recent cholelithiasis, now
improved s/p intervention.
Past Medical History:
CAD (s/p anterolateral MI ___ treated with TPA; CABG ___
LIMA-LAD and SVG-OM)
cholelithiasis and cholecystitis s/p stenting and
cholecystectomy
Atrial Fibrillation (on warfarin)
Atrial Flutter ___ s/p spontaneous conversion
SSS/prolonged PR and Mobitz type I/bradycardia s/p dual chamber
PPM
History of NSVT
GERD
Hypercholesterolemia
HTN
Onychomycosis
Macular Degeneration
Cataract
Urinary Urgency
Social History:
Lives with his wife (second wife of ___ years) in senior housing
in ___. Quit smoking about ___ years ago, stopped drinking
alcohol in ___. Previously divorced (___), has 5 children (3
daughters, 2 sons).
- Modified Rankin Scale: 0
[x] 0: No symptoms
[] 1: No significant disability - able to carry out all usual
activities despite some symptoms
[] 2: Slight disability: able to look after own affairs without
assistance but unable to carry out all previous activities
[] 3: Moderate disability: requires some help but able to walk
unassisted
[] 4: Moderately severe disability: unable to attend to own
bodily needs without assistance and unable to walk unassisted
[] 5: Severe disability: requires constant nursing care and
attention, bedridden, incontinent
[] 6: Dead
Family History:
No family history of early MI, early strokes, blood clots.
Mother had stroke. Father and paternal grandmother has MI.
Family history of cancer and CAD.
Multiple family members with various cancers. Father deceased
of colon CA. Mother deceased of unspecified CA.
Physical Exam:
Admission Physical Exam:
=========================
Vitals: T: 97.5 HR: 70 BP: 135/76 RR: 17 SaO2: 100% RA
General: NAD
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: RRR, no M/R/G; regular, palpable radial pulse
Pulmonary: CTAB, no crackles or wheezes
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema
Neurologic Examination:
- Mental status: Awake, alert, oriented x 3. Able to relate
history without difficulty. Attentive, able to name ___ backward
without difficulty. Speech is subtly effortful with a few pauses
but otherwise fluent with full sentences, intact repetition, and
intact verbal comprehension. Naming intact. No paraphasias. No
dysarthria. Normal prosody. No apraxia. No evidence of
hemineglect. No left-right confusion. Able to follow both
midline and appendicular commands.
- Cranial Nerves: Pupils 2.5 and minimally reactive
bilaterally. VF full to confrontation. EOMI, few beats end gaze
nystagmus which extinguishes. V1-V3 without deficits to light
touch bilaterally. No facial movement asymmetry. Hearing intact
to finger rub bilaterally. Palate elevation symmetric.
SCM/Trapezius strength ___ bilaterally. Tongue midline.
- Motor: Normal bulk and tone. No drift. No tremor or
asterixis.
[___]
L 5 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5 5
- Reflexes:
[Bic] [___] [Quad] [Gastroc]
L 1+ 1+ 1+ 1
R 1+ 1+ 1+ 1
Plantar response flexor bilaterally
- Sensory: No deficits to light touch or cold sensation
bilaterally. No extinction to DSS.
- Coordination: No dysmetria with finger to nose testing
bilaterally.
- Gait: Deferred.
Discharge Physical Exam:
=============================
Vitals: Temp98.0 BP 133 / 74 HR68 RR20 O2 Sat97 RA
General: NAD, interactive, sitting in chair comfortably
Neurologic Examination:
- Mental status: Awake, alert, oriented x 3. Able to relate
history without difficulty. Attentive. Speech is subtly
effortful with a few pauses but otherwise fluent with full
sentences, intact repetition, and intact verbal comprehension.
Able to read. Naming intact. No paraphasias. No dysarthria.
Normal prosody. No apraxia. No evidence of hemineglect. No
left-right confusion. Able to follow both midline and
appendicular commands. Able to follow complex commands.
- Cranial Nerves: VF full to confrontation. No facial movement
asymmetry.
- Motor: Normal bulk and tone, symmetric bilaterally. No
pronator drift.
- Reflexes:
[Bic] [___] [Quad] [Gastroc]
L 1+ 1+ 1+ 1
R 1+ 1+ 1+ 1
Plantar response flexor bilaterally
- Gait: normal based with normal arm swing. Able to walk
tandem. Romberg negative.
Pertinent Results:
Admission Labs:
====================
___ 10:24AM BLOOD WBC-7.6 RBC-4.05* Hgb-12.5* Hct-37.7*
MCV-93 MCH-30.9 MCHC-33.2 RDW-12.9 RDWSD-43.8 Plt ___
___ 10:24AM BLOOD Neuts-62.0 ___ Monos-9.5 Eos-1.4
Baso-0.5 Im ___ AbsNeut-4.72 AbsLymp-1.97 AbsMono-0.72
AbsEos-0.11 AbsBaso-0.04
___ 10:24AM BLOOD Plt ___
___ 10:24AM BLOOD ___ PTT-29.7 ___
___ 10:24AM BLOOD Glucose-98 UreaN-25* Creat-1.0 Na-137
K-4.0 Cl-98 HCO3-27 AnGap-16
___ 10:24AM BLOOD ALT-22 AST-26 AlkPhos-57 TotBili-0.9
___ 05:35PM BLOOD GGT-48
___ 10:24AM BLOOD cTropnT-<0.01
___ 05:35PM BLOOD TotProt-6.6 Albumin-3.9 Globuln-2.7
Cholest-119
___ 05:35PM BLOOD %HbA1c-5.4 eAG-108
___ 05:35PM BLOOD Triglyc-148 HDL-27 CHOL/HD-4.4 LDLcalc-62
___ 05:35PM BLOOD TSH-3.4
___ 05:35PM BLOOD CRP-1.4
___ 10:24AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 12:47PM URINE Color-Yellow Appear-Clear Sp ___
___ 12:47PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
Imaging:
========================
Carotid Series ___
1. Approximately 40-50% right carotid artery stenosis with mild
heterogeneous plaque.
2. No evidence of hemodynamically significant left carotid
artery stenosis.
CTA Head and Neck ___
CT HEAD WITHOUT CONTRAST:
There is no evidence of no evidence of infarction, hemorrhage,
edema, or mass.
The ventricles and sulci are normal in size and configuration.
CTA HEAD:
The vessels of the circle of ___ and their principal
intracranial branches appear normal without stenosis, occlusion,
or aneurysm formation. The dural venous sinuses are patent.
CTA NECK:
The vertebral arteries and their major branches appear normal
with no evidence of stenosis or occlusion. Extensive
atherosclerotic calcifications and plaque are seen at the
carotid bifurcations. There is approximately 70% stenosis of the
right and left ICA per NASCET criteria.
Final read pending 3D reformations.
CT Head w/o contrast ___
No acute intracranial process.
Chest PA and Lat ___
No acute cardiopulmonary process. No significant change from
the prior study.
Discharge Labs:
========================
___ 09:05AM BLOOD ___ PTT-69.9* ___
___ 12:40AM BLOOD PTT-58.4*
Brief Hospital Course:
Mr. ___ is ___ year old right-handed man with AF on
warfarin, HTN, CAD and MI s/p cardiac arrest (___), CABG and
multiple stents, recent cholelithiasis and cholecystitis s/p
stenting and cholecystectomy off AC ~15 days who is admitted to
the Neurology stroke service with word-finging difficulties
secondary to an acute ischemic stroke. His stroke was most
likely secondary to being off anticoagulation for 15 days with
subtherapeutic INR 1.6 at time of admission. Patient had CT
head without contrast (___) which showed no evidence of
hemorrhage or infarction. CTA of head and neck (___) was
signficant for 70% stenosis of right and left ICA. Carotid US
(___) confirmed 40-50% right carotid artery stenosis. Patient
did not receive an MRI due to incompatible pacemaker. He was
treated with a heparin drip until his INR became therapeutic, as
it was later that day. His speech deficits improved throughout
this hospital stay. At the time of discharge, the only notable
deficit was subtly effortful with a few pauses but otherwise
fluent with full sentences. NIHSS = 0. Patient was continued on
his home medications.
His stroke risk factors include the following:
1) Approximately 40-50% right carotid artery stenosis with mild
heterogeneous
plaque.
2) Hyperlipidemia: well controlled on Simvastatin 40mg with LDL
62
3) Atrial Fibrillation (on Warfarin)
4) HTN, well controlled on Lisinopril 5mg, Metoprolol Succinate
XL 50mg DAILY, and Metoprolol Succinate XL 25mg QHS
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No
4. LDL documented? (x) Yes (LDL = 62) - () 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:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[x] LDL-c less than 70 mg/dL
6. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No
9. Discharged on statin therapy? (x) Yes - () No [if LDL >70,
reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
10. Discharged on antithrombotic therapy? (x) Yes [Type: (x)
Antiplatelet - (x) Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? (x) Yes - () No - () N/A
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 5 mg PO DAILY
2. Metoprolol Succinate XL 50 mg PO BREAKFAST
3. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
4. Pantoprazole 40 mg PO Q12H
5. Ranitidine 150 mg PO BID
6. Simvastatin 40 mg PO QPM
7. Tolterodine 2 mg PO DAILY
8. Isosorbide Mononitrate 60 mg PO DAILY:PRN chest pain
9. Gabapentin 300 mg PO BID
10. Docusate Sodium 100 mg PO BID
11. Fluticasone Propionate NASAL 2 SPRY NU DAILY:PRN Allergic
rhinitis
12. Aspirin 81 mg PO DAILY
13. Warfarin 3 mg PO DAILY16
14. Metoprolol Succinate XL 25 mg PO QHS
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. Fluticasone Propionate NASAL 2 SPRY NU DAILY:PRN Allergic
rhinitis
4. Gabapentin 300 mg PO BID
5. Isosorbide Mononitrate 60 mg PO DAILY:PRN chest pain
6. Metoprolol Succinate XL 50 mg PO BREAKFAST
7. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
8. Pantoprazole 40 mg PO Q12H
9. Ranitidine 150 mg PO BID
10. Simvastatin 40 mg PO QPM
11. Tolterodine 2 mg PO DAILY
12. Warfarin 3 mg PO DAILY16
Discharge Disposition:
Home
Discharge Diagnosis:
Acute Ischemic Stroke
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were hospitalized due to symptoms of difficulty with
word-finding for one week and one episode of blurry vision
resulting from an ACUTE ISCHEMIC STROKE, a condition where a
blood vessel providing oxygen and nutrients to the brain is
blocked by a clot. The brain is the part of your body that
controls and directs all the other parts of your body, so damage
to the brain from being deprived of its blood supply can result
in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
1) Coronary Artery Disease
2) High Cholesterol
3) Atrial Fibrillation
4) High Blood Pressure
Please take your other medications as prescribed.
Please call your primary care physician for referral to
Neurology.
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:
___
|
19604550-DS-2
| 19,604,550 | 29,345,495 |
DS
| 2 |
2127-09-08 00:00:00
|
2127-09-18 13:42:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
HTN
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ h/o Charcot ___ who was referred from PCP with HA
and
elevated BP with SBP 190s.
Pt recently moved to area and established primary care at ___
___. Previously she had not seen doctor in ___ years. 2 weeks
ago at her initial PCP visit, she was noted to be hypertensive
160/100. Workup for secondary hypertension was sent at that
visit
including renin, aldosterone and metanephrines all of which were
normal. Cr 1.3. At PCP follow up ___, she reported home BP
readings of 170s-200s/110s-130s, with visit BP recorded as
142/80. She was started on amlodipine 5mg, later increased to
10mg. Pt also complaining of whole body pruritus during this
time, treated empirically with permethrin. She was seen in ___
clinic on day of presentation for mild HA, at which point BP was
elevated, and she was referred to ED.
In the ED:
Initial vital signs were notable for: 99.2, ___, 18,
100% RA
Labs were notable for:
140 ___ AGap=11
-------------<
4.3 26 1.3
9.9 11.8 311
>-----<
37.6
- UA: sm leuk, mod bld, neg nitrite, prot 600, RBC 49, WBC 31,
few bacteria, 7 epi
Studies performed include:
- RENAL U.S. Doppler: No definite Doppler evidence of renal
artery stenosis.
- EKG: LVH
Patient was given: PO/NG Lisinopril 10 mg
Consults:
- Renal: Urinalysis with red cells/acanthocytes, white
cells and lipid-laden casts concerning for an active glomerular
process. Urine with nephrotic range proteinuria, however there
is
no clinical edema/anasarca... Presentation of elevated blood
pressure, renal dysfunction and hematuria/acanthocytes
concerning
for nephritic process... recommend admission to medicine for BP
control and further workup to evaluate for glomerulonephritis
Vitals on transfer: 98.7, ___, 16, 98% RA
Upon arrival to the floor, patient feels well. She reports she
has at baseline once weekly HA that is located on top of her
head, no vision changes or N/V or focal deficits. the HA she
noted to PCP was consistent with her typical HA. No f/c, CP,
SOB,
cough, N/V, abd pain, ___, dysuria, diarrhea, constipation,
melena, hematochezia. she reports having a mild "head cold" last
weekend. she has itching that has been migratory over body, now
in lower abdomen. she thinks this is bc she scratches it too
much
and it irritates the skin further.
REVIEW OF SYSTEMS:
Complete ROS obtained and is otherwise negative.
Past Medical History:
URINARY INCONTINENCE
ANXIETY
HEADACHE
___
Social History:
___
Family History:
Mother with hypertension, diabetes, thyroid problems.
Sister with charcot ___ tooth and thyroid problems.
No family history of kidney disease or relatives on dialysis
Physical Exam:
ADMISSION PHYSICAL EXAM:
=========================
VITALS: 98.4PO, 130 / 84L Lying, 78, 18, 96 Ra
GENERAL: Alert and interactive. In no acute distress.
HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without
injection.
MMM.
NECK: supple
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. lower abdomen skin with
excoriation marks.
EXTREMITIES: No clubbing, cyanosis, or edema
SKIN: Warm. Cap refill <2s. excoriations on lower abdomen
NEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal
sensation. AOx3.
DISCHARGE PHYSICAL EXAM:
========================
Vitals: 24 HR Data (last updated ___ @ 1025)
Temp: 97.9 (Tm 98.4), BP: 132/94 (130-145/84-94), HR: 75
(74-78), RR: 16 (___), O2 sat: 97% (96-97), O2 delivery: Ra,
Wt: 220.68 lb/100.1 kg
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Face grossly symmetric. Moving all limbs with purpose
against gravity. Not dysarthric.
Pertinent Results:
ADMISSION LABS:
===============
___ 12:15PM BLOOD WBC-9.9 RBC-4.49 Hgb-11.8 Hct-37.6 MCV-84
MCH-26.3 MCHC-31.4* RDW-14.6 RDWSD-44.8 Plt ___
___ 12:15PM BLOOD Neuts-74.3* Lymphs-17.6* Monos-4.3*
Eos-2.7 Baso-0.8 Im ___ AbsNeut-7.35* AbsLymp-1.74
AbsMono-0.43 AbsEos-0.27 AbsBaso-0.08
___ 12:15PM BLOOD Plt ___
___ 12:15PM BLOOD Glucose-128* UreaN-20 Creat-1.3* Na-140
K-4.3 Cl-103 HCO3-26 AnGap-11
___ 12:15PM BLOOD Albumin-3.9 Cholest-179
___ 12:15PM BLOOD Triglyc-120 HDL-44 CHOL/HD-4.1
LDLcalc-111
___ 12:15PM BLOOD HBsAg-NEG HBsAb-POS HBcAb-NEG HAV Ab-NEG
IgM HAV-PND
___ 12:15PM BLOOD C3-153 C4-34
___ 11:35AM URINE Color-Yellow Appear-Hazy* Sp ___
___ 11:35AM URINE Blood-MOD* Nitrite-NEG Protein-600*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM*
___ 11:35AM URINE RBC-49* WBC-31* Bacteri-FEW* Yeast-NONE
Epi-7
___ 11:35AM URINE CastGr-1*
___ 11:35AM URINE Mucous-RARE*
___ 11:35AM URINE UCG-NEGATIVE
DISCHARGE LABS:
===============
___ 05:23AM BLOOD WBC-9.0 RBC-4.40 Hgb-11.4 Hct-37.0 MCV-84
MCH-25.9* MCHC-30.8* RDW-14.9 RDWSD-45.3 Plt ___
___ 05:23AM BLOOD Plt ___
___ 05:23AM BLOOD ___ PTT-33.2 ___
___ 05:23AM BLOOD Glucose-89 UreaN-25* Creat-1.5* Na-144
K-4.3 Cl-105 HCO3-24 AnGap-15
___ 05:23AM BLOOD ALT-10 AST-10 AlkPhos-61 TotBili-0.2
___ 10:05AM BLOOD CK-MB-1 cTropnT-<0.01
___ 05:23AM BLOOD Calcium-8.5 Phos-3.7 Mg-2.2
IMAGING:
========
___ Renal Ultrasound:
There is no hydronephrosis, stones, or masses bilaterally.
Normal cortical
echogenicity and corticomedullary differentiation are seen
bilaterally.
Right kidney: 10.1 cm
Left kidney: 10.7 cm
Renal Doppler: Intrarenal arteries show slightly dampened
systolic upstrokes
but continuous antegrade diastolic flow. The resistive indices
of the right
intra renal arteries range from 0.51-0.59. The resistive
indices on the left
range from 0.53-0.57. Bilaterally, the main renal arteries are
patent with
normal waveforms. The peak systolic velocity on the right is
43.1
centimeters/second. The peak systolic velocity on the left is
36.6
centimeters/second. Main renal veins are patent bilaterally with
normal
waveforms.
The bladder is moderately well distended and normal in
appearance.
IMPRESSION:
No definite Doppler evidence of renal artery stenosis.
Brief Hospital Course:
___ h/o Charcot ___ who was referred from PCP with
hypertensive urgency, found to have active urine sediment
concerning for glomerulonephritis.
ACUTE ISSUES:
====================
# Active urine sediment c/f glomerulonephritis
___
Urinalysis in ED showed red cells/microscopy w/ acanthocytes,
white cells and lipid-laden casts concerning for an active
glomerular process. Overall clinical picture felt to be
consistent with glomerulonephritis given presenting HTN, though
she was also found to have nephrotic range proteinuria without
edema on exam. Differential is broad including IgA nephropathy,
postinfectious, lupus, hypertensive nephropathy, interstitial
nephritis, less likely pauci-immune GN/anti-GBM. Renal was
consulted who felt that given patient was stable she would be
able to have kidney biopsy as an outpatient. While in house lab
testing revealed normal complement levels, negative Hepatitis
A/B/C serologies, negative HIV, unrevealing lipid panel, and an
albumin of 3.9. Her pending labs on discharge for
glomerulonephritis include ANCA, ___, dsDNA, anti-Sm,
anti-Scl-70.
# HTN
Found at primary care clinic to have severe HTN unusual for
young patient. Intial work up for secondary causes of HTN
showing normal serum metanephrines andrenin/aldosterone. Renal
US in ED without evidence of renal artery stenosis on Doppler.
Given active urine sediment, HTN was felt to be most likely a
manifestation of her glomerulonephritis. In addition to
continuing her home amlodipine 10mg daily she was also started
on lisinopril 10mg daily with improvement in her blood
pressures.
#HA
Patient reporting mild chronic HA (top of head, lasts a few
hours, once a weekly, sometimes takes 1 ibuprofen); HA noted on
presentation to PCP seems consistent with this. Headache not
present on admission but returned morning on ___ with BP
140s/90s. Resolved with Tylenol.
CHRONIC ISSUES:
# Charcot ___
Patient is new to ___, plans to establish care with a CMT
specialist soon. She reports having some new urinary
incontinence
as the only manifestation of her disease currently.
TRANSITIONAL ISSUES:
=====================
[] Patient will need CBC and CMP drawn early this coming week
and faxed to her PCP ___ @ ___
[] Will need follow up in ___ clinic and renal biopsy
[] Cr. 1.4 at discharge
[] Pending at discharge: ANCA, ___, dsDNA, anti-Sm, anti-Scl-70,
HAV IgM, Urine Culture
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY
Discharge Medications:
1. Lisinopril 10 mg PO DAILY
RX *lisinopril 10 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
2. amLODIPine 10 mg PO DAILY
3.Outpatient Lab Work
Please draw Complete Blood Count, Complete Metabolic Panel
Fax results to: ___ Attn: Dr. ___
Discharge Disposition:
Home
Discharge Diagnosis:
#Hypertensive urgency
#Glomerulonephritis
#Headache
#Charcot ___ Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure to care for you at the ___
___.
Why did you come to the hospital?
- You were admitted to the hospital because your blood pressure
was dangerously high despite being on blood pressure medications
at home
What happened in the hospital?
- A test of your urine found that you likely have an illness in
your kidneys
- We tested your blood for many of the common causes of illness
like yours
- We had our kidney specialists evaluate you and help us with
your treatment
- You were started on a second blood pressure medication called
Lisinopril
- We monitored your blood pressure and lab values until we felt
that you were safe to discharge from the hospital
What should you do once you leave the hospital?
- Please continue to take all your medications as prescribed
- Please have your blood tests drawn and schedule an appointment
to follow up with your PCP early this coming week
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
19605073-DS-3
| 19,605,073 | 24,654,970 |
DS
| 3 |
2184-07-20 00:00:00
|
2184-07-20 13:17:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right sided neck pain, headache, and vertigo
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ year old woman with no past medical
history who presented to the ED with two weeks right sided neck
pain and headache, and two episodes of vertigo over the past 4
days.
Patient reports that about two weeks prior to presentation, she
began to have right sided neck pain. This was followed by a
right sided headache, located at the front of her head. The
beginning of this pain was fairly indolent, and she doesn't
recall precisely when it started. The pain was near constant,
and she
was taking ibuprofen very frequently which would somewhat
alleviate the headache. She was able to continue working, but
was bothered by the headache frequently while in the OR. She
describes the right sided headache as a pulsating pain at the
front of her head on the right.
On ___, she was walking into work and just before
turning a corner to go into her office she felt acute onset
vertigo with room spinning so severe she could not maintain her
balance and fell to the ground. She crawled to her office, where
she vomited. The symptoms persisted for about 30 minutes, then
slowly started to improve. A similar, less severe episode
happened on ___ evening, with acute onset room spinning,
but was not associated with nausea. She noted that putting her
head down between her legs helped the symptoms very minimally.
There was no provocation with head movement or positional
change. On
___ and ___, she was not bothered much by vertigo, but
she did experience some nausea. On ___ the day of
presentation, she was going to catch the T to come to work, and
she took a couple faster running steps to make her train, and
after she got in the train on the T, she felt acute onset of
vertigo again, which was so severe she had to lie on the ground
of the T. This was associated with nausea and vomiting. She
noted she had some lightheadedness, like presyncope, but no loss
of consciousness. An ambulance was called, and she was brought
to the ED for evaluation.
In the ED, she had a CTA that showed a diminutive right
vertebral artery. It appeared patent on CTA, but given history
MRI of the neck with fat sat was ordered to evaluate for
dissection. Neurology was consulted, and we recommended MRI
given history, despite lack of physical exam findings. MRI of
the brain showed several right cerebellar strokes. MRI of the
neck with fat sat
showed vertebral artery dissection. This dissection did not
extend intracranially. We discussed with patient that there is
no definitive recommendation regarding treatment of dissection.
Both antiplatelets and anticoagulants have been studied, but the
efficacy of one over the other is not clear. However, given that
she has had ___ episodes of acute vertigo which all likely
represent acute strokes, it seems that the dissection is leading
to clot formation and embolus. We would therefore favor
anticoagulation with heparin gtt followed by oral
anticoagulation for a to be specified period of time, with
repeat imaging in the future. We discussed the risks of
anticoagulation, including bleeding. Patient was understanding
of risks and benefits of anticoagulation and decided to pursue
AC.
In terms of risk factors for dissection, patient denies any
trauma, neck manipulation, yoga or heavy lifting, heavy
exercise, vomiting. No family history of recurrent pregnancy
loss, hypermobile joints.
Past Medical History:
None
Social History:
___
Family History:
Father with migraines. No family history of stroke or connective
tissue disease.
Physical Exam:
ADMISSION EXAM:
===============
Vitals: T: 35 P: 72 BP: 125/79 RR: 14 SaO2: 100% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, pain with palpation of right side
Pulmonary: Normal work of breathing
Cardiac: RRR, warm, well-perfused
Abdomen: soft, non-distended
Extremities: No ___ edema.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented, attentive. Language is fluent
with intact repetition and comprehension. Normal prosody. There
were no paraphasic errors. 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.
CN
I: not tested
II,III: VFF to confrontation, pupils 4mm->2mm bilaterally
III,IV,VI: EOMI, no ptosis. No nystagmus in any direction of
gaze. There is no vertical skew. There is a slight left
esophoria
on cover uncover.
V: sensation intact V1-V3 to LT and pinprick
VII: Facial strength intact/symmetrical, symm forehead wrinkling
VIII: intact to conversation
IX,X: palate elevates symmetrically, uvula midline
XI: SCM/trapezeii ___ bilaterally
XII: tongue protrudes midline, no dysarthria
On HINTS exam, there was no corrective saccade with head impulse
testing. There was no nystagmus or skew deviation.
With ___, there was no nystagmus with head turn in
either direction. Notably, patient was not experiencing room
spinning vertigo when this test was done.
Motor: Normal bulk and tone, no rigidity; no asterixis or
myoclonus. No pronator drift.
Delt Bi Tri WE FE Grip
C5 C6 C7 C6 C7 C8/T1
L 5 ___ 5 5
R 5 ___ 5 5
IP Quad Hamst DF PF
L2 L3 L4-S1 L4 S1/S2
L 5 5 5 5 5
R 5 5 5 5 5
Reflex: No clonus
Bi Tri Bra Pat An Plantar
C5 C7 C6 L4 S1 CST
L 2+ 2+ 2+ 2+ ___ Flexor
R 2+ 2+ 2+ 2+ ___ Flexor
No pathological reflexes bilaterally.
-Sensory: No deficits to light touch or pinprick throughout. No
extinction to DSS.
-Coordination: No intention tremor, dysdiadochokinesia noted. No
dysmetria on FNF bilaterally. No pass pointing. She was able to
sit up without obvious truncal ataxia. Sitting up makes her feel
uncomfortable, but does not precipitate vertigo.
-Gait: deferred due to discomfort.
DISCHARGE EXAM:
===============
VS:
Tmax: 36.8 °C (98.3 °F)
Tcurrent: 36.7 °C (98.1 °F)
HR: 82 (69 - 95) bpm
BP: 122/81(105) {110/44(0) - 125/81(0)} mmHg
RR: 20 (16 - 20) insp/min
SpO2: 96%
Exam:
General: Awake and cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, pain with palpation of right side
Pulmonary: Normal work of breathing
Cardiac: RRR, warm, well-perfused
Abdomen: soft, non-distended
Extremities: No ___ edema.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented, attentive. Language is fluent
with intact repetition and comprehension. Normal prosody. There
were no paraphasic errors. There was no evidence of apraxia or
neglect.
-CN
I: not tested
II,III: VFF to confrontation, pupils 4mm->2mm bilaterally
III,IV,VI: EOMI, no ptosis. No nystagmus in any direction of
gaze. There is no vertical skew.
V: sensation intact V1-V3 to LT and pinprick
VII: Facial strength intact/symmetrical, symm forehead wrinkling
VIII: intact to conversation
IX,X: palate elevates symmetrically, uvula midline
XI: SCM/trapezeii ___ bilaterally
XII: tongue protrudes midline, no dysarthria
-Motor: Normal bulk and tone, no rigidity; no asterixis or
myoclonus. No pronator drift. Full strength throughout.
-Sensory: No sensory deficits throughout.
-Coordination: No intention tremor, dysdiadochokinesia noted. No
dysmetria on FNF bilaterally. No pass pointing. She was able to
sit up without obvious truncal ataxia.
-Gait: Slightly unsteady but narrow stance.
Pertinent Results:
ADMISSION LABS:
===============
___ 04:56PM LACTATE-0.7
___ 09:54AM URINE HOURS-RANDOM
___ 09:54AM URINE UCG-NEGATIVE
___ 09:54AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 09:54AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-70* KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 08:50AM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
___ 08:50AM ___ COMMENTS-GREEN TOP
___ 08:50AM LACTATE-2.6*
___ 08:27AM GLUCOSE-236* UREA N-13 CREAT-0.9 SODIUM-141
POTASSIUM-4.2 CHLORIDE-106 TOTAL CO2-20* ANION GAP-15
___ 08:27AM estGFR-Using this
___ 08:27AM ALT(SGPT)-11 AST(SGOT)-16 ALK PHOS-45 TOT
BILI-0.5
___ 08:27AM LIPASE-35
___ 08:27AM ALBUMIN-4.4 CALCIUM-9.3 PHOSPHATE-1.9*
MAGNESIUM-1.5*
___ 08:27AM HCG-<5
___ 08:27AM WBC-8.7 RBC-4.21 HGB-13.3 HCT-37.9 MCV-90
MCH-31.6 MCHC-35.1 RDW-11.5 RDWSD-37.5
___ 08:27AM NEUTS-48.9 ___ MONOS-6.8 EOS-2.1
BASOS-0.8 IM ___ AbsNeut-4.26 AbsLymp-3.55 AbsMono-0.59
AbsEos-0.18 AbsBaso-0.07
___ 08:27AM PLT COUNT-252
DISCHARGE LABS:
===============
IMAGING:
========
CTA HEAD/NECK ___:
1. No significant intracranial abnormality. No evidence of
acute infarction, hemorrhage or mass. If there is persistent
clinical concern related with acute/subacute ischemic event,
correlation with MRI/MRA of the head is recommended.
2. The right vertebral artery appears diminutive throughout its
course with intermittent visualization and near complete
occlusion at the V2/V3 segment, suggestive of dissection,
correlation with MRA of the neck is recommended.
3. Both PICAs are visualized. The Long segment dissection right
___ likely fills from retrograde supply from the contralateral
left vertebral artery.
RECOMMENDATION(S): The right vertebral artery appears
diminutive throughout its course with intermittent visualization
and near complete occlusion at the V2/V3 segment, suggestive of
dissection, correlation with MRA of the neck is recommended.
MRI/MRA BRAIN ___:
1. Multiple foci of acute/subacute infarct within the inferior
right
cerebellum and cerebellar tonsils, ___ distribution. No
evidence of
hemorrhage.
2. Diminutive right vertebral artery throughout its course with
areas of
irregularity and near occlusion of the V2 and V3 segments.
Circumferential
intrinsic T1 hyperintensity throughout the length of the right
vertebral
artery, compatible with long segment dissection.
CT HEAD ___:
Expected evolution of a right ___ territory cerebellar infarct,
which is not significantly changed in size compared to prior
MRI. No evidence of
hemorrhagic conversion.
Brief Hospital Course:
PATIENT SUMMARY:
================
This is a ___ year old woman with no significant medical history
who presented with acute onset vertigo/nausea/disequilibrium
after having 2 weeks of posterior neck pain/headache and another
transient episode of vertigo/dysequilibrium ___ days ago.
Her imaging studies revealed small right cerebellar and vermian
acute ischemic strokes and an acute right vertebral artery
dissection of the V2 segment. The dissection appears to be
spontaneous with the information we have thus far.
She was started on heparin gtt in house and transitioned to
warfarin with goal INR ___.
The patient's symptoms of dizziness/vertigo were improved with
low dose Ativan, acetaminophen, Compazine, and Benadryl.
TRANSITIONAL ISSUES:
====================
# Re-image with CTA or MR ___ sat in 3 months (Late ___ -
Early ___.
# Continue warfarin with goal INR ___.
# Patient scheduled to establish care with HCA and ___
___ with planned intake on ___.
# Please consider outpatient workup for connective tissue
disease given atraumatic vertebral dissection.
# Home ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. LORazepam 0.5 mg PO Q8H:PRN Dizziness/nausea
RX *lorazepam 0.5 mg 1 tablet by mouth Every 8 hours Disp #*21
Tablet Refills:*0
2. Warfarin 10 mg PO/NG ONCE Duration: 1 Dose
Next INR should be drawn on ___
RX *warfarin 2.5 mg ___ tablet(s) by mouth Every day Disp #*90
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Vertebral artery dissection
Acute ischemic stroke
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Dr. ___,
___ were hospitalized due to symptoms of neck pain, vertigo,
and headache resulting from an ACUTE ISCHEMIC STROKE, a
condition where a blood vessel providing oxygen and nutrients to
the brain is blocked by a clot. The brain is the part of your
body that controls and directs all the other parts of your body,
so damage to the brain from being deprived of its blood supply
can result in a variety of symptoms.
Stroke can have many different causes, so we assessed ___ for
medical conditions that might raise your risk of having stroke.
___ were found to have a vertebral artery dissection. In order
to prevent future strokes, we plan to modify those risk factors.
Your risk factors are:
- Vertebral artery dissection
We are changing your medications as follows:
- Started warfarin with goal INR ___
Please take your other medications as prescribed.
Please follow up with Neurology and your primary care physician
as listed below.
If ___ 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
___
- 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:
___
|
19605111-DS-8
| 19,605,111 | 27,977,609 |
DS
| 8 |
2178-02-04 00:00:00
|
2178-02-04 14:39:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
dirt bike accident
Major Surgical or Invasive Procedure:
___ Right craniotomy for evacuation epidural hematoma
History of Present Illness:
___ who was found near a railroad track next to an overturned
dirt bike around 12:30am. He was subdued (extremly agitated on
the field, walking) and dropped of at ___ around 1am.
CTH there (around 1:45am) showed 4mm right sided epidural. Per
ED
to ED report, the patient's pupils were equal on presentation.
Sometime during transport, he blew his right pupil. He was
immediately transferred to ___ by EMS. Per EMS, he has a
history of drinking.
Past Medical History:
none
Social History:
___
Family History:
none
Physical Exam:
On Admission:
Patient intubated with multiple contusions over skull, blood
pooled under his head, bilateral orbital edema/hematomas. After
propofol bolus, patient's right eye 6mm non-reactive, left eye
2mm sluggish. Patient moved all four to noxious stimuli.
On Discharge:
Oriented x person, ___, hospital. Left facial droop,
sensation intact throughout (V1-V3). Vision intact. Right
pupil 6mm, non-reactive. Left pupil 5->4, brisk.
MAE with full strength. No drift.
Pertinent Results:
___ Trauma Chest xray: No acute cardiopulmonary process. ET
tube in appropriate position. Enteric tube ends in the distal
esophagus and should be advanced.
___ CT head noncontrast: The right epidural hematoma overlying
the right temporal, frontal and parietal lobes is increasing in
size, now measuring 15 mm in thickness, previously measuring 5
mm in thickness. There is also increase in midline shift to the
left, now measuring 6 mm, previously 3 mm. There is right uncal
herniation.
Again seen is pneumocephalus. No hydrocephalus.
There is a fracture of the right temporal bone which extends
superiorly into the right parietal bone to the vertex and
inferiorly to involve the mastoid air cells, foramen magnum,
jugular foramen, extends to the right carotid canal. The
right-sided ossicles are likely disrupted. There is a fracture
through the sphenoid sinus and pterygoid plates bilaterally.
There is a fracture of the lateral wall of the right maxillary
sinus and medial walls of both maxillary sinuses. Bilateral
nasal bone fractures. Air is seen in the right and left orbits.
Globes appear normal in shape. No retrobulbar hematoma. Blood
is seen in the maxillary sinuses bilaterally and sphenoid
sinuses. There is a large right subgaleal hematoma. In the
temporal bone fracture may have involved labyrinth.
___ CT Chest/Abd/Pelvis:
IMPRESSION:
No intrathoracic or intra-abdominal injury. No fracture.
Enteric tube ends in the distal esophagus and should be
advanced.
___ CT Cervical spine: IMPRESSION: No evidence of acute fracture
or traumatic malalignment in the cervical spine.
___ CT maxillofacial/sinus/mandible
Multiple facial bone fractures as detailed below.
There is opacification of the right mastoid air cells with a
comminuted right temporal bone fracture extending through the
jugular foramen and into the carotid canal. The right sided
ossicles appear disrupted. There is blood within the middle ear
cavity.
There is fracture through the sphenoid sinus and pterygoid
plates bilaterally. There is a depressed fracture through the
lateral wall of the right maxillary sinus. An additional
fracture is noted through the medial wall of the right maxillary
sinus. There is no definite left maxillary sinus fracture
identified however, there is blood within both maxillary
sinuses.
Bilateral mildly comminuted bilateral nasal bone fractures are
noted. A
nondisplaced fracture of the posterior right the zygomatic arch
is also seen. The left zygomatic arch appears intact.
There is a nondisplaced fracture through the lateral right
orbital wall
extending through the posterior superior orbital wall (02:22).
There is
minimal subperiosteal soft tissue density adjacent to the
lateral orbital wall in the region of the fracture, which likely
with represents a small amount of extraconal blood. Air is
noted within both orbits. The globes
appear intact. There is preorbital swelling and hematomas right
greater than left.
___ CTA head and neck:
1. Interval postoperative changes of a right temporal craniotomy
with
evacuation of epidural hematoma and marked improvement of
overall midline
shift and subarachnoid hemorrhage.
2. Mild asymmetric effacement of sulci within right cerebral
hemisphere which is compatible with cerebral edema.
3. Lack of contrast opacification within the distal right
transverse and
sigmoid sinus, in the region of the associated temporal bone
fracture,
suggesting a compression from traumatic hematoma or thrombus.
4. Suboptimal evaluation of internal carotid arteries secondary
to slightly delayed contrast timing which limits evaluation in
the region of the fracture.
5. Hyperdense material within the foramen magnum and upper
cervical spine, the appearance of which may be largely due to
venous enhancement, given slightly delayed timing.
___ CXR
As compared to the previous image, the previously malpositioned
subclavian catheter on the left has been repositioned. The
course of the catheter is now normal, the tip projects over the
mid SVC. There is no complications such as pneumothorax.
Unchanged position of the nasogastric tube and the endotracheal
tube.
___ CXR
The patient has received the new left internal jugular vein
catheter. The
course of the catheter is unremarkable, the tip of the catheter
projects over the mid SVC. No evidence of complications,
notably no pneumothorax.
___ MRV HEAD W/O CONTRAST; MRA NECK W&W/O CONTRAST; MR HEAD W/O
CONTRAST
1. Changes secondary to recent trauma in the right temporal
and inferior frontal contusions.
2. Lack of flow related enhancement with suggestion of T1
hyperintensity
within the right transverse and sigmoid sinus likely indicate
focal
posttraumatic thrombosis.
3. No evidence of infarct.
___ CT Temporal bone:
1. Comminuted complex fracture through the squamous in petrous
portions of the right temporal bone, with longitudinal and axial
components with respect to the petrous temporal bone, disrupting
the tegmen tympani. Dislocation and rotation of the malleus and
incus. The stapes is not well seen and may also be damaged.
Disruption of the region of the oval window. Disruption of the
horizontal semicircular canal, as well as of the horizontal and
mastoid portions of the facial nerve.
2. Nondisplaced longitudinal fracture through the left temporal
bone
disrupting the mastoid air cells, which appears to extend to the
tegmen
tympani without a clear defect. Left middle and inner ear
structures appear intact.
Brief Hospital Course:
Mr. ___ was taken directly to the operating room for
emergent right craniotomy for evacuation of expanding SDH.
Postoperatively he was admitted to the Trauma ICU where a
central line was placed and 3% hypertonic saline was initiated
for a goal Na of 150 in an effort to reduce cerebral edema.
Postoperative head CT showed good evacuation of blood products.
Pt was moving all extremities purposefully with good strength.
Right pupil remained dilated at 8mm and nonreactive. CTA head
and neck was performed for concern for vascular injury in the
setting of skull base fractures and demonstrated a defect in the
sigmoid sinus on the right, concerning for thrombosis.
ENT was consulted for temporal bone fracture and Right otorrhea,
consistent with blood and CSF. A wic was place in right otic
canal and ciprodex drops were started. Ophthalmology was
consulted for right eye mydriasis, edema and subconjunctival
hemorrhage. Right eye pressures found to be slightly elevated
compared to left but not significant. At this time they were
able to evaluate the retina on the right as it was dilated
however they will defer bilateral dilated exam until the patient
is communicative and able to participate in vision testing.
Lacrilube was started bilaterally. Plastic surgery was
consulted for facial fractures which are nonsurgical and they
recommend sinus precautions x 1 week: no using straws, sneeze
with mouth open, no sniffing, no smoking, keep head of bed
elevated.
MRI/V overnight demonstrated a lack of flow related enhancement
with suggestion of T1 hyperintensity within the right transverse
and sigmoid sinus likely indicative of focal posttraumatic
thrombosis.
On ___ his neurological exam was improving and he was
consistently following commands in all extremities with good
strength, showing 2 fingers, sticking out his tongue. Two
additional head lacerations were closed with staples. Sedation
was weaned and transitioned to precedex with a goal for
extubation the following day.
Neurology was consulted for right transverse and sigmoid sinus
thrombus.
On ___, the patient self-extubated, he became hypertensive and
tachycardic so he was started on lopressor BID and a nicardipine
drip. Hypertonic saline was stopped. He underwent an angiogram
to assess for a carotid cavernous malformation and was started
on aspirin 325mg daily for a sigmoid sinus thrombus.
On ___, he was stable and transferred to the floor. He was seen
by ENT, and was started on dexamethasone 10mg q8h x10 days for
facial nerve injury and a right face droop that became apparent
as he was extubated and his mental status improved.
On ___, he was seen by speech and swallow, and passed a bedside
speech and swallow evaluation, after which he was advanced to a
soft diet before being cleared to a regular diet with continued
sinus precautions. ENT reviewed his scans, which appear to have
a temporal bone fracture through the facial nerve canal, so he
was scheduled for an audiogram ___ to evaluate his hearing.
ON ___ Central line was discontinued. Peripheral IV placed.
Continues on Dexamethasone for facial nerve injury. Underwent
audiogram with ENT, results are unavailable at this time. Being
screened for rehab.
On ___ the day of discharge he is tolerating a soft diet,
ambulating with assistance, afebrile with stable vital signs.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
3. Aspirin 325 mg PO DAILY
4. Bisacodyl 10 mg PO/PR DAILY
5. Ciprofloxacin 0.3% Ophth Soln 4 DROPS BOTH EARS TID Duration:
10 Days
Stop date: ___. Dexamethasone Ophthalmic Soln 0.1% 2 DROP BOTH EARS TID
Duration: 10 Days
stop date ___. Docusate Sodium 100 mg PO BID
8. Heparin 5000 UNIT SC TID
9. LeVETiracetam 500 mg PO BID
10. Metoprolol Tartrate 12.5 mg PO BID
Hold for SBP < 110, HR < 60
11. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
12. Senna 8.6 mg PO BID
13. Dexamethasone 10 mg PO Q8H Duration: 7 Days
7 days then taper to off.
Tapered dose - DOWN
14. Dexamethasone 6 mg PO Q8H Duration: 6 Doses
Start: Future Date - ___, First Dose: First Routine
Administration Time
Start taper following 7 days of 10mg TID
15. Dexamethasone 3 mg PO Q8H Duration: 6 Doses
Start: After 6 mg tapered dose
Start taper following 7 days of 10mg TID
16. Dexamethasone 2 mg PO Q12H Duration: 4 Doses
Start: After 3 mg tapered dose
Start taper following 7 days of 10mg TID
17. Dexamethasone 2 mg PO DAILY Duration: 2 Doses
Start: After 2 mg tapered dose
Start taper following 7 days of 10mg TID
18. Omeprazole 20 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right Temporal Epidural Hematoma
Right temporal bone fracture extending superiorly to the right
parietal bone inferiorly to foramen magnum
Bilateral nasal bone fractures, minimally displaced.
Bilateral non-displaced medial wall maxillary sinus fractures
Minimally displaced Right maxillary sinus lateral wall fracture
Bilateral ptyergoid plate fractures.
Non-displaced Right zygomatic arch fracture.
Right Facial nerve injury with facial droop
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid
Discharge Instructions:
Craniotomy for Hemorrhage
Have a friend/family member check your incision daily for
signs of infection.
Take your pain medicine as prescribed.
Exercise should be limited to walking; no lifting, straining,
or excessive bending.
Your wound was closed with staples. You may wash your hair
only after staples have been removed.
You may shower before this time using a shower cap to cover
your head.
Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
You have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
Clearance to drive and return to work will be addressed at
your post-operative office visit.
Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
- Sinus Precautions: soft foods, NO straws, Sneeze with open
mouth, NO nose blowing
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:
___
|
19605459-DS-4
| 19,605,459 | 23,078,692 |
DS
| 4 |
2132-10-20 00:00:00
|
2132-10-20 08:13:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Compazine
Attending: ___.
Chief Complaint:
Right subtrochanteric femur fracture
Major Surgical or Invasive Procedure:
Right long TFN (___)
History of Present Illness:
___ is a ___ female with hx of COPD (no baseline O2
requirement),diabetes who presents with right hip pain after
mechanical fall. She tripped on nonsteroidal outside falling
directly onto her right hip with immediate pain and inability to
bear weight. She denies head strike or loss of consciousness
though she does endorse headache today which she believes is
secondary to her not having eaten recently. She is brought to
outside hospital where initial imaging demonstrate her right
subtrochanteric hip fracture with significant shortening. She
was transferred to ___ for
further evaluation.
Past Medical History:
COPD
Diabetes
Social History:
___
Family History:
N/C
Physical Exam:
General: Uncomfortable appearing female reclined in bed,
answering questions appropriately in ___.
Resp: Normal respiratory effort on 3 L nasal cannula.
CV: Regular rate and rhythm by peripheral palpation.
RLE:
Dressing clean, dry, and intact. Dressing changed with
underlying
incision c/d/i with no erythema or purulence.
Motor intact to ankle plantarflexion/dorsiflexion, ___.
Sensation intact light touch and S/S/SP/DP/T distributions.
Palpable pedal pulses. Foot warm and well-perfused.
Pertinent Results:
___ 10:14AM BLOOD WBC-8.3 RBC-3.78* Hgb-9.5* Hct-31.5*
MCV-83 MCH-25.1* MCHC-30.2* RDW-16.6* RDWSD-50.4* 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 a right subtrochanteric femur fracture and was admitted
to the orthopedic surgery service. The patient was taken to the
operating room on ___ for R long 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 remarkable for
urinary retention and multiple failed voiding trails. As such, a
foley catheter was placed on ___ and will remain in place until
the morning of ___ for full bladder rest.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was moving bowels spontaneously. The patient is WBAT in
the RLE, and will be discharged on Lovenox 40 mg nightly 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:
Omeprazole, Reglan, albuterol, Prozac, Keppra, metformin,
gabapentin, Flomax
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
3. Enoxaparin Sodium 40 mg SC QHS
RX *enoxaparin 40 mg/0.4 mL 40 mg Nightly Disp #*30 Syringe
Refills:*0
4. Insulin SC
Sliding Scale
Fingerstick QACHS, HS
Insulin SC Sliding Scale using REG Insulin
5. Nicotine Patch 14 mg TD DAILY
6. Ondansetron 4 mg IV Q8H:PRN nausea/vomiting
7. OxyCODONE (Immediate Release) ___ mg PO Q3H:PRN Pain
RX *oxycodone 5 mg 1 to 2 tablet(s) by mouth every four (4)
hours Disp #*30 Tablet Refills:*0
8. Senna 8.6 mg PO BID
9. Ipratropium-Albuterol Neb 1 NEB NEB BID PRN
symptomatic/wheezing
10. LevETIRAcetam 500 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right subtrochanteric femur 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 right lower extremity
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is
an over the counter medication.
2) Add oxycodone ___ mg every four hours 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 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 40 mg nightly for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
THIS PATIENT IS EXPECTED TO REQUIRE <30 DAYS OF REHAB
Physical Therapy:
WBAT RLE. Evaluate and treat.
Treatments Frequency:
Dry gauze/tegaderm dressing changes as needed.
Followup Instructions:
___
|
19605487-DS-42
| 19,605,487 | 21,583,948 |
DS
| 42 |
2135-07-16 00:00:00
|
2135-07-16 10:40:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
___ Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
paracentesis (10L removed)
History of Present Illness:
This is a ___ year old male with a history of end-stage renal
disease (on HD), cirrhosis secondary to alcohol with multiple
complications (see below) and insulin dependant diabetes who
presents with abdominal pain and malaise. For the past couple
days, his wife noted that he was increasingly lethargic and that
he was complaining of abdominal pain. 4 days prior to
presentation, he had been tapped therapeutically and 12 L of
fluid was drained; he does get weekly paracenteses for recurrent
ascites following a failed TIPS. He was initiated on HD in
___ for hepatorenal syndrome, the hemodialysis being
a bridge until he gets a transplant. Initially he was getting
tapped twice a week; the frequency of his taps has decreased to
once a week. In the emergency department, diagnostic
paracentesis revealed > 4000 WBCs in para fluid suggestive of
spontaneous bacterial peritonitis. Vancomycin and zosyn were
administered. Nephrology and hepatology were consulted.
Lactate was noted to be 6. At time of transfer to the MICU,
vitals were: 98.2 ___.
Past Medical History:
-Alcohol-related cirrhosis complicated by esophageal varices,
encephalopathy, refractory ascites s/p TIPS which is likely no
longer patent, h/o hepato-renal syndrome requiring admission to
___ from ___ to ___, and h/o SBP on Cipro ppx. Sober
since ___. On transplant list for combined liver-kidney.
-IDDM
-Hypothyroid
-Pituitary mass
-h/o nephrolithiasis
-h/o +PPD
-ESRD on HD MWF, initiated ___
Social History:
___
Family History:
Mother deceased, age ___, CVA. Father deceased, age ___, stomach
problems. One brother living and in good health. Two sisters,
both living and in good health.
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: SBP 93/55, HR 99, SpO2 99% RA, temp 98, RR 12
Gen: ___ male, dark-skinned, drowsy, but
otherwise arousable and oriented, in no apparent distress
Cardiac: Nl s1/s2 RRR, no murmurs appreciable
Pulm: clear bilaterally, no accessory muscle use
Abd: grossly distended with dullness to percussion throughout
consistent with significant ascites
Ext: 1+ edema bilaterally, warm
DISCHARGE PHYSICAL EXAM
General Appearance: Thin, with protuberant abdomen. Moaning.
Eyes / Conjunctiva: scleral icterus
Head, Ears, Nose, Throat: Normocephalic, NG tube
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Crackles : bibasilar)
Abdominal: Bowel sounds present, extremely Distended,
Tender-diffusely
Extremities: Right lower extremity edema: 2+, Left lower
extremity edema: 2+
Musculoskeletal: Muscle wasting
Skin: Warm
Neurologic: Attentive, Follows simple commands, Responds to:
Verbal stimuli, Oriented (to): self, place, year, month not
date, Movement: Purposeful, Tone: Normal
Pertinent Results:
ADMISSION LABS
___ 03:15PM BLOOD WBC-7.4 RBC-3.12* Hgb-8.7* Hct-28.1*
MCV-90 MCH-28.0 MCHC-31.1 RDW-17.0* Plt ___
___ 03:15PM BLOOD Neuts-92.5* Lymphs-3.7* Monos-3.3 Eos-0.3
Baso-0.2
___ 03:15PM BLOOD ___ PTT-25.7 ___
___ 03:50PM BLOOD Glucose-294* UreaN-75* Creat-6.1*#
Na-125* K-4.6 Cl-86* HCO3-17* AnGap-27*
___ 03:50PM BLOOD ALT-17 AST-32 CK(CPK)-48 AlkPhos-231*
TotBili-0.9
___ 03:50PM BLOOD Lipase-42
___ 03:50PM BLOOD CK-MB-6 cTropnT-0.28*
___ 03:50PM BLOOD Albumin-2.9* Calcium-8.2* Phos-7.7*#
Mg-2.9*
___ 03:34PM BLOOD Glucose-294* Lactate-6.4* Na-126* K-4.4
Cl-89* calHCO3-16*
CXR ___ Portable AP upright chest radiograph obtained. A left
IJ tunneled dialysis catheter is again noted with its tip
residing in the expected location of the right atrium. Lung
volumes are low. Previously noted right PICC line has been
removed. Given the low lung volumes, evaluation of the lung
bases is limited. There is linear opacity in the left
retrocardiac space, likely representing atelectasis. No definite
signs of pneumonia or CHF. No pleural effusion or pneumothorax.
The heart size cannot be readily assessed. Mediastinal contour
appears stable with atherosclerotic calcifications along the
aortic knob. Bony structures are intact. IMPRESSION: Basilar
atelectasis without definite signs of pneumonia.
CT ABD/PELVIS ___ 1. No evidence of perforation, abscess
formation or hemorrhage.
2. Severe liver cirrhosis with splenomegaly and large amount of
ascites.
3. Filling defect is seen in the distal SMV, at the portal
confluence, the
proximal portal vein, and the TIPS stent, representing
thrombosis or flow
artifact. Evaluation is limited due to lack of multiphase
imaging.
Further workup with Doppler liver vascular ultrasound should be
considered.
TIPS ___ 1. Occluded TIPS shunt. This is a change from the
ultrasound of ___. The portal veins and hepatic veins are patent.
2. Massive ascites.
3. Cirrhotic appearing liver with splenomegaly.
PORTABLE ABDOMEN ___
1. Technically limited study, demonstrating diffuse gaseous
distention of the large and small bowel, most consistent with
ileus.
2. Apparent nasogastric tube should be advanced for optimal
positioning.
CXR ___
The patient is severely rotated, distorting anatomical
landmarks. The
examination was performed at near expiration, which crowds and
dilates
pulmonary vasculature and is responsible for severe left lower
lobe
atelectasis. The upper lungs are probably clear. Cardiac size
cannot be
assessed. Left subclavian dialysis catheter ends in the right
atrium.
Nasogastric tube passes to the lower esophagus and out of view.
There is no pneumothorax.
PERITONEAL FLUID ___ AND ___
ESCHERICHIA COLI
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- R
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- =>16 R
Brief Hospital Course:
___ year old male with a history of EtOh-cirrhosis, on transplant
list, complicated by hepato-renal syndrome on HD, presenting
with worsening abdominal pain and fatigue.
.
# Transition to Comfort Care: the patient's TIPS was found to be
not patent and the patient was not considered a transplant
candidate in the near future. The family opted to focus on
comfort. He was transitioned to CMO and passed away at 6:30 am
on ___.
.
# Sepsis - Abdominal pain is present on review of systems;
diagnostic paracentesis reveals a WBC count of >4000 with >90%
polys consistent with either SBP or secondary bacterial
peritonitis (given repeated taps), but no perforation or abscess
seen on CT abdomen. Lipase and LFTs are within normal limits
making other abdominal sources unlikely. Alkaline phosphatase
is elevated which could be secondary to TIPS. There is concern
that a clot in the TIPS could be infected. He was treated
empirically initially with vanc and zosyn, the vancomycin was
changed to daptomycin for VRE given hx of VRE in peritoneal
fluid in ___ and chronic thrombocytopenia (so avoid linezolid).
The fluid culture revealed GNRs. He did receive albumin for SBP
despite already having HRS and being on HD. The fluid culture
grew e.coli which was resistant to zosyn, which he had been
treated with, and he was transitioned to ceftriaxone, which the
e.coli was sensitive to.
.
# Hypotension: blood pressure was in the range of SBP ___ at
night; then increased during the day to the 100s. He was started
on midodrine but was unable to take this secondary to his ileus,
which was causing him not to absorb PO medications. At time of
transition to CMO, the patient's blood pressure was 60/40.
.
# Ileus: the patient developed a severe ileus, which was thought
to be ___ his peritonitis and his ascites. An NGT was placed
with relief of nausea and vomiting, and he was discharged with
this tube to hospice for intermittent suctioning. At time of
discharge, less than 500cc per day was being aspirated, which
was mostly the food that he was eating for comfort. He did stool
very small amounts even with lactulose.
.
# Anemia: the patient has had an acute hematocrit drop from 28
to 21. The patient has baseline anemia, likely secondary to
kidney disease and liver disease; prior iron studies consistent
with anemia of chronic disease. In the setting of acute
hematocrit drop, concern for bleed; no signs of acute bleeding
despite history of varices. No signs of hemorrhage on CT abd.
.
# Cirrhosis - Secondary to EtOH. He is no longer drinking.
Listed for transplant. Complicated by esophageal varices,
hepatic encephalopathy, and refractory ascites s/p TIPS that is
no longer patent. Continued lactulose and rifaximin. On
prophylactic bactrim for SBP, which was held during his
treatment of SBP. He did receive a therapeutic paracentesis with
removal of 10L of fluid on ___. After that point, although he
was in pain with his distension, the patient could not have
another paracentesis as his hypotension was preventative.
.
# End stage renal disease - Hemodialysis for hepatorenal
syndrome in setting of cirrhosis. The patient missed HD on day
of admission (___) so recieved an extra session on ___,
in which 1L was removed. Sevelamer and calcium acetate were
continued.
.
#IDDM - continue home lantus and sliding scale.
.
#. Ventral Hernia: Per records this is not reducible but not
changed from prior. No evidence of incarceration/strangulation.
This has been one of the patient's most significant sources of
discomfort and embarassment for several years however he has
been told that he is not a candidate for surgical repair until
after he has a liver transplant.
.
#. Hypothyroidism: Chronic. Continue Levothyroxine at home dose.
.
# CONTACT: WIFE : ___ sister
___
Medications on Admission:
1. calcium acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
2. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
7. lactulose 10 gram/15 mL Syrup Sig: One (1) ML PO three times
a day: take as needed to maintain ___ Bowel Movements per day.
8. insulin glargine 100 unit/mL Solution Sig: Forty (40) units
Subcutaneous at bedtime: please follow your sugars closely, you
may need this dose to be increased if your sugars are high.
9. insulin lispro 100 unit/mL Solution Sig: please see below
units Subcutaneous four times a day: as directed 4 times a day
per sliding scale sliding scale: (<70) no insulin. (71-100)8
units before meals.(101-150)10 units before meals.(151-200) 12
units before meals.(201-250)14 units before meals, 2 at
HS.(251-300)16 units before meals, 3 units @HS. (301-350)18
units before meals, 4 units @HS. (351-400)20 units before
meals,5 units @HS. (>401) give 22 units before meals, 6 units
@HS and call MD. .
10. VITAMIN D2 Sig: 50,000 units once a week.
11. B-complex with vitamin C Tablet Sig: One (1) Tablet PO
once a day.
12. CALCIUM CARBONATE [TUMS] - (OTC) - 200 mg calcium (500 mg)
Sig: One (1) tablet once a day.
13. CLOTRIMAZOLE Sig: Ten (10) troche PO dissolve in mouth
5x/day.
Discharge Medications:
1. fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
Disp:*10 Patch 72 hr(s)* Refills:*0*
2. morphine concentrate 100 mg/5 mL (20 mg/mL) Solution Sig: One
(1) bottle PO Q1H (every hour) as needed for pain: Use for
breakthrough pain. Hold for sedation. Hold for respiratory rate
less than 12.
Disp:*2 bottle* Refills:*0*
Discharge Disposition:
Home with Service
Discharge Diagnosis:
patient expired
Primary Diagnosis:
alcoholic cirrhosis
hepatorenal syndrome on hemodialysis
hepatic encephalopathy
Secondary diagnosis:
hypothyroidism
insulin dependent diabetes
Discharge Condition:
patient expired.
Discharge Instructions:
patient expired
Dear Mr. ___,
You were admitted to the hospital for your liver and kidney
disease. We wish you all the best. It was a pleasure taking care
of you.
Please note to stop taking all of your medications except the
following:
- Morphine by mouth ___ every one hour as needed for pain.
- Fentanyl patch every 72 hours.
You will have a nurse to help you with your general care at home
as well as the following:
- Suction your nasogastric tube as needed.
Followup Instructions:
___
|
19605554-DS-17
| 19,605,554 | 26,536,576 |
DS
| 17 |
2170-02-28 00:00:00
|
2170-03-01 22:03:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
cough
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HISTORY OF PRESENT ILLNESS:
___ with PMHx AAA s/p repair, colon cancer s/p resection, HTN,
non-obstructive CAD, CKD (baseline Cr 2.0), non-Hodgkin's
lymphoma s/p tx ___, pulmonary fibrosis, who presents with 2
weeks of productive cough and DOE, s/p 3 days of Augmentin.
Patient is a poor historian, history obtained from son who
states
patient has had productive cough of yellow sputum for 2 weeks,
worse over the past several days. Also with sob and increased
wob, subjective f/c. Went to urgent care and prescribed
Augmentin
___. Went to PCP for ___ CXR after 3 days of abx and showed
worsened PNA, was also found to be hypoxic 91% on RA, placed on
2L NC.
Of note, had CT Chest ___ for persistent cough which revealed
severe multi lobar pulmonary fibrosis with extensive
honeycombing
as well as multiple nonpathologically enlarged mediastinal lymph
nodes.
Past Medical History:
Colonic adenoma
Vitamin D deficiency
PAD (peripheral artery disease)
Chronic Kidney Disease, Stage III (Moderate)
ESOPHAGEAL ULCER W BLEED
DERMATITIS - UNKNOWN ETIOLOGY
ANEURYSM - ABDOMINAL AORTIC
CANCER - COLON, UNSPEC SITE
HISTORY OF HERNIA - INGUINAL
HYPERTENSION, ESSENTIAL
HYPERCHOLESTEROLEMIA
CORONARY ARTERY DISEASE
HEARING LOSS
Social History:
___
Family History:
Both parents healthy to his knowledge, Father lived to ___,
Mother lived to ___. No h/o cancer or dermatologic disorders.
Physical Exam:
ADMISSION PHYSICAL EXAM
===========================
VITALS: T98.3, BP 179/89, HR 78, RR 18, O2 94% on RA
GENERAL: Alert and interactive. In no acute distress.
HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without
injection.
MMM.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops. No JVD.
RESP: Bl mild crackles throughout, moderate crackles in the
right
base. No wheezes or rhonchi. No increased work of breathing on
RA.
ABDOMEN: Normal bowels sounds, soft, non-distended, non-tender
to
deep palpation in all four quadrants.
MSK: No spinous process tenderness. No CVA tenderness. No
clubbing, cyanosis, or edema. Pulses DP 2+ bilaterally.
SKIN: Warm. No rash.
NEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal
sensation to light touch. AOx2 to name and location, doesn't
know
name of hospital, not oriented to date or year, thinks its ___.
PSYCH: appropriate mood and affect
DISCHARGE PHYSICAL EXAM
========================
24 HR Data (last updated ___ @ 822)
Temp: 98.2 (Tm 98.7), BP: 146/84 (146-179/84-89), HR: 77
(77-79), RR: 18 (___), O2 sat: 92% (92-94), O2 delivery: Ra
GENERAL: Alert and interactive. In no acute distress.
HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without
injection.
MMM.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops. No JVD.
RESP: decreased breath sounds on R lung fields. No wheezes or
rhonchi. No increased work of breathing on RA.
ABDOMEN: Normal bowels sounds, soft, non-distended, non-tender
to
deep palpation in all four quadrants.
MSK: No spinous process tenderness. No CVA tenderness. No
clubbing, cyanosis, or edema. Pulses DP 2+ bilaterally.
SKIN: Warm. No rash.
NEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal
sensation to light touch. alert, oriented to self but not place
or time (believes it is ___, not sure of the year).
PSYCH: appropriate mood and affect
Pertinent Results:
ADMISSION LABS
===============
___ 11:15AM BLOOD WBC-8.0 RBC-4.04* Hgb-11.9* Hct-38.7*
MCV-96 MCH-29.5 MCHC-30.7* RDW-17.5* RDWSD-60.5* Plt ___
___ 11:15AM BLOOD Glucose-93 UreaN-15 Creat-1.9* Na-139
K-6.5* Cl-109* HCO3-17* AnGap-13
___ 12:47PM BLOOD ALT-8 AST-23 LD(LDH)-553* AlkPhos-78
TotBili-0.3
___ 12:47PM BLOOD Albumin-3.1* Calcium-8.6 Phos-3.1 Mg-1.7
UricAcd-6.5 Iron-22*
___ 12:47PM BLOOD calTIBC-216* Ferritn-165 TRF-166*
DISCHARGE LABS
================
___ 12:00AM BLOOD WBC-7.6 RBC-3.76* Hgb-11.0* Hct-34.7*
MCV-92 MCH-29.3 MCHC-31.7* RDW-17.0* RDWSD-57.3* Plt ___
___ 12:00AM BLOOD Glucose-81 UreaN-12 Creat-1.9* Na-143
K-4.2 Cl-109* HCO3-22 AnGap-12
IMAGING
==========
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___ ___ ___
Radiology ReportCHEST (PA & LAT)Study Date of ___ 1:04
___
___ ___ 1:04 ___
CHEST (PA & LAT) Clip # ___
Reason: eval PNA
UNDERLYING MEDICAL CONDITION:
History: ___ with coughing
REASON FOR THIS EXAMINATION:
eval PNA
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Wet Read by ___ on ___ 12:12 AM
Large posterior right lower lobe opacity which on the frontal
view appears
round and measures approximately 9.5 x 8.7 cm. While findings
could be due to
a large pneumonia, underlying mas/neoplasm is of concern.
Diffuse prominence
of interstitial markings bilaterally, differential diagnosis
would include
carcinomatosis, chronic lung disease new since ___ versus
interstitial edema.
*** ED URGENT ATTENTION ***
Final Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with coughing// eval PNA
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: ___
FINDINGS:
There is a large posterior right lower lobe opacity which on the
frontal view
appears relatively round and measures approximately 9.5 x 8.7
cm. While
findings could be due to a large pneumonia, underlying mass is
in the
differential diagnosis and of concern. There is diffuse
increased
interstitial markings bilaterally, differential diagnosis of
chronic lung
disease, interstitial edema, carcinomatosis. No pleural
effusion is seen.
The cardiac silhouette size is borderline to mildly enlarged.
The aorta is
tortuous.
IMPRESSION:
Large posterior right lower lobe opacity which on the frontal
view appears
round and measures approximately 9.5 x 8.7 cm. While findings
could be due to
a large pneumonia, underlying mass/neoplasm is of concern.
Diffuse prominence
of interstitial markings bilaterally, differential diagnosis
would include
carcinomatosis, chronic lung disease new since ___ versus
interstitial edema.
___, MD electronically signed on SUN ___
12:12 AM
Imaging Lab
Report History
___ 12:12 AM
by INFORMATION,SYSTEMSView Close
CT
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___ ___ ___
Radiology ReportCT CHEST W/O CONTRASTStudy Date of ___
8:58 AM
___ 8:___HEST W/O CONTRAST Clip # ___
Reason: evaluate right lobe opacity
UNDERLYING MEDICAL CONDITION:
___ year old man with pulmonary fibrosis, presenting with 2
weeks productive
cough and sob, right lobe opacity on CXR - PNA v underlying
malignancy
REASON FOR THIS EXAMINATION:
evaluate right lobe opacity
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Final Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ year old man with pulmonary fibrosis, presenting
with 2 weeks
productive cough and sob, right lobe opacity on CXR- PNA v
underlying
malignancy// evaluate right lobe opacity
TECHNIQUE: Contiguous axial images were obtained through the
chest without
intravenous contrast. Coronal and sagittal reformats were
obtained.
COMPARISON: Chest radiograph of ___. Atrius CT
examination
from ___.
FINDINGS:
HEART AND VASCULATURE: The thoracic aorta is mildly tortuous,
otherwise
normal in caliber. Mild atherosclerotic calcifications are seen
at the
origins of the right innominate and left subclavian arteries.
Coronary
arterial calcifications are also present. The heart is mildly
enlarged.
There is no pericardial effusion.
AXILLA, HILA, AND MEDIASTINUM: Multiple prominent and borderline
enlarged
lymph nodes are noted within the mediastinum and hilar regions.
No
mediastinal masses identified given limitations of noncontrast
enhanced
examination. A small hiatal hernia is present. There is no
axillary
lymphadenopathy.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: There is severe honeycombing throughout the
lungs. Extensive
associated traction bronchiectasis and bronchial thickening are
present. A
large area of consolidation is identified in apical segment of
the right lower
lobe, corresponding to chest radiograph findings. This was not
present on the
prior chest CT examination from ___. There is dependent
atelectasis
within the right upper lobe. Minimal scattered air bronchogram
is noted
within the consolidation. No consolidative changes are apparent
in the left
lung. There is biapical scarring. No definite discrete
pulmonary nodule is
identified.
BASE OF NECK: Visualized portions of the base of the neck show
no abnormality.
ABDOMEN: The included upper abdomen demonstrates cholelithiasis
without
findings to suggest acute cholecystitis. An 8 mm calcific
density is noted
within the herniating portion of the gastric fundus at the level
of the
diaphragm. This may relate to ingested material, however
appears to be
embedded within the posterior mucosal wall. Several prominent
crural lymph
nodes are identified, measuring up to 0.9 cm in short axis.
BONES: No suspicious osseous abnormality is seen.? There is no
acute fracture.
IMPRESSION:
1. Large consolidation within the apical segment of the right
lower lobe,
favoring pneumonia given clinical symptoms of infection.
2. Extensive interstitial fibrosis throughout bilateral lungs.
3. Small hiatal hernia with coarse calcification within the
posterior mucosal
wall, of uncertain significance. Several prominent and enlarged
crural lymph
nodes are present. Nonurgent endoscopy can be considered if
clinically
indicated.
RECOMMENDATION(S): Followup chest CT should be obtained
following treatment
of presumed pneumonia to exclude an underlying mass.
BY ELECTRONICALLY SIGNING THIS REPORT, I THE ATTENDING PHYSICIAN
ATTEST THAT ___ HAVE REVIEWED THE ABOVE IMAGES FOR THE ABOVE
EXAMINATION(S) AND AGREE WITH THE FINDINGS AS DOCUMENTED ABOVE.
___, MD
___, MD, PhD electronically signed on SAT ___
2:34 ___
Imaging Lab
Report History
SAT ___ 2:34 ___
by INFORMATION,SYSTEMSView Close
Brief Hospital Course:
BRIEF HOPSITAL COURSE:
======================
___ with PMHx AAA s/p repair, colon cancer s/p resection, HTN,
non-obstructive CAD, CKD (baseline Cr 2.0), non-Hodgkin's
lymphoma s/p tx ___, pulmonary fibrosis, who presents with 2
weeks of productive cough and DOE. His CXR revealed a RLL
opacity, a chest CT was obtained to investigate presence of
malignancy given acute on chronic symptoms and smoking history,
which was only significant for a large right lower lobe
consolidation consistent with pneumonia. He was able to maintain
his oxygen sats to 94% on room air, lowest ambulatory O2
recording was 91%, and he remained hemodynamically stable
without increased work of breathing. He received
vanc/ceftriaxone/flagyl in the ED and was transitioned back to
oral Augmentin on day of discharge; he finished a total 5 day
antibiotic course for CAP.
TRANSITIONAL ISSUES:
====================
[ ] monitor resolution of respiratory symptoms and oxygen
saturation in setting of PNA (finished 5 day abx course while in
hospital), may repeat CXR in ___ weeks to monitor for resolution
[ ] CT imaging showed incidental finding of small hiatal hernia
with coarse calcification within the posterior mucosal wall, of
uncertain significance. Several prominent and enlarged crural
lymph nodes are present. Endoscopy can be considered if
clinically indicated.
#CODE: Full Code, confirmed with patient
#CONTACT: ___ (son): ___, Daughter/HCP: ___
ACUTE ISSUES:
=============
# Productive Cough
# RLL CAP
Mr ___ recently developed a productive cough per his son
(has chronic dry cough), and was admitted due to concern for
satting 90% on RA at clinic, with a PSI score showing moderate
risk given comorbidities. He had been on Augmentin as an
outpatient since ___. His CXR revealed a RLL opacity, and a
chest CT was obtained to investigate presence of malignancy
given acute on chronic symptoms and smoking history, which was
only significant for a large right lower lobe consolidation
consistent with pneumonia. He was able to maintain his oxygen
sats to 94% on room air, lowest ambulatory O2 recording was 91%,
and he remained hemodynamically stable without increased work of
breathing. He received vanc/ceftriaxone/flagyl in the ED and was
transitioned back to oral Augmentin on day of discharge; he
finished a total 5 day antibiotic course for CAP.
CHRONIC ISSUES:
===============
# Chronic anemia
Hx warm agglutinin hemolytic anemia, stable ___. Recent hx GI
bleed ___ esophageal ulcer early ___. Baseline Hgb ___ over
past several months. Hgb was 11.9 on admission, near baseline
with no
signs of active bleeding. continued home omeprazole 40mg BID
#CKD
Came with Cr of 1.9 on admission, appears baseline per Atrius
records. Nephrotoxic medications were avoided during
hospitalization.
# Pulmonary Fibrosis
We continued home Umeclidinium-vilanterol inhaler
# HTN, now Orthostatic Hypotension
We continued home Fludrocortisone 0.1 mg daily
# Mild dementia
Possible Alzheimer's per OSH notes, impaired short term memory
and executive dysfunction, functional impairments. Pt unable to
provide history, however is alert and interactive, answering
questions appropriately, he was alert and oriented to self/place
but not time.
We continued home mirtazapine and donepezil
# HLD
Continued home rosuvastatin
# Vit D deficiency
Continued home vit D 1000 IU daily
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Anoro Ellipta (umeclidinium-vilanterol) 62.5-25 mcg/actuation
inhalation DAILY
2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
3. Vitamin D 1000 UNIT PO DAILY
4. Donepezil 5 mg PO QHS
5. Fludrocortisone Acetate 0.1 mg PO DAILY
6. FoLIC Acid 1 mg PO DAILY
7. Mirtazapine 3.75 mg PO QHS
8. Omeprazole 40 mg PO BID
9. Rosuvastatin Calcium 40 mg PO QPM
Discharge Medications:
1. Anoro Ellipta (umeclidinium-vilanterol) 62.5-25
mcg/actuation inhalation DAILY
2. Donepezil 5 mg PO QHS
3. Fludrocortisone Acetate 0.1 mg PO DAILY
4. FoLIC Acid 1 mg PO DAILY
5. Mirtazapine 3.75 mg PO QHS
6. Omeprazole 40 mg PO BID
7. Rosuvastatin Calcium 40 mg PO QPM
8. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
right lower lobe community acquired pneumonia
SECONDARY DIAGNOSIS
pulmonary fibrosis
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 here at ___!
Why was I admitted to the hospital?
- You were admitted for cough and were found to have pneumonia
What was done for me while I was in the hospital?
- You received antibiotics to treat your pneumonia
- You had a CT scan of your chest that confirmed a pneumonia
(infection) in your right lung, and did not show any signs of
lung cancer
What should I do when I leave the hospital?
-You should got o your appointments as listed below
-You should continued to take your medications as prescribed
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19605554-DS-18
| 19,605,554 | 23,209,316 |
DS
| 18 |
2170-03-21 00:00:00
|
2170-03-22 16:25:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
heparin
Attending: ___.
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
ADMISSION LABS:
___ 11:19AM BLOOD WBC-7.0 RBC-3.80* Hgb-11.1* Hct-35.6*
MCV-94 MCH-29.2 MCHC-31.2* RDW-16.6* RDWSD-55.6* Plt ___
___ 11:19AM BLOOD Neuts-52.2 ___ Monos-8.1 Eos-5.0
Baso-0.9 Im ___ AbsNeut-3.66 AbsLymp-2.34 AbsMono-0.57
AbsEos-0.35 AbsBaso-0.06
___ 11:19AM BLOOD ___ PTT-27.6 ___
___ 11:19AM BLOOD Glucose-91 UreaN-17 Creat-1.9* Na-144
K-6.3* Cl-109* HCO3-21* AnGap-14
___ 11:19AM BLOOD cTropnT-<0.01
___ 11:27AM BLOOD Lactate-1.9 K-4.0
DISCHARGE LABS:
___ 05:59AM BLOOD WBC-7.2 RBC-4.33* Hgb-12.7* Hct-43.6
MCV-101* MCH-29.3 MCHC-29.1* RDW-17.0* RDWSD-62.4* Plt ___
___ 06:21AM BLOOD Glucose-86 UreaN-17 Creat-1.5* Na-145
K-4.1 Cl-105 HCO3-21* AnGap-19*
___ 07:55AM BLOOD Calcium-9.1 Phos-3.3 Mg-2.0 Iron-28*
___ 07:55AM BLOOD calTIBC-203* Ferritn-316 TRF-156*
___
FINDINGS:
PA and lateral views of the chest provided. Extensive fibrosis
is again noted
with persistent hazy rounded mass measuring approximately 9.3 x
9.1 cm
projecting over the right posterior lower lung. Given
persistence despite
treatment, the possibility of neoplasm must be considered.
Cardiomediastinal
silhouette is stable. Bony structures are intact.
IMPRESSION:
Interstitial lung disease with round mass projecting over the
right lower lung
as on prior, concerning for neoplasm.
___ CT Chest w/o contrast
FINDINGS:
HEART AND VASCULATURE: Heart is mildly enlarged. There is
redemonstration of
atherosclerotic calcification involving the coronary arteries
and thoracic
aorta. The main pulmonary artery is mildly dilated measuring
3.1 cm
suggestive of pulmonary hypertension. There is decreased
attenuation of the
great vessel lumen consistent with anemia.
AXILLA, HILA, AND MEDIASTINUM: There are multiple enlarged
mediastinum lymph
nodes measuring up to 2.8 cm in short axis in the subcarinal
region (series 2,
image 29). There are bilateral axillary subcentimeter lymph
nodes.
LUNGS/AIRWAYS: The airways are patent to the level of the
segmental bronchi
bilaterally. There is redemonstration of bilateral lung diffuse
honeycombing,
traction bronchiectasis and peribronchial wall thickening
consistent with
pulmonary fibrosis. There is redemonstration of right lower
lobe apical
segment consolidation interval worsening from previous study.
There is
interval increased right small pleural effusion with associated
atelectasis.
ABDOMEN: There is a small hiatal hernia. The partially
visualized liver,
spleen, pancreas, adrenal glands, bilateral renal upper pole
grossly
unremarkable. There is cholelithiasis in the partially
visualized
gallbladder.
BONES: No suspicious osseous abnormality is seen.? There is no
acute fracture.
There is mild multilevel degenerative changes of the thoracic
spine.
IMPRESSION:
1. Similar to slightly increased in size of right lower lobe
consolidation
with possible slight increase in size of right small pleural
effusion. Again
findings may represent pneumonia, but underlying neoplastic
process is not
excluded.
2. Grossly similar mediastinum lymphadenopathy measuring up to
2.8 cm in short
axis at the subcarinal region.
3. Other chronic/incidental findings described as in above.
MRSA SCREEN ___
MRSA SCREEN (Final ___: No MRSA isolated.
Brief Hospital Course:
BRIEF HOSPITAL COURSE
=======================
___ with PMHx pulmonary fibrosis, AAA s/p repair, colon cancer
s/p resection, non-obstructive CAD, CKD (baseline Cr 1.85-2.0),
non-Hodgkin's lymphoma s/p tx ___, dementia, recently
discharged on ___ following treatment for RLL pneumonia, now
presenting with generalized weakness, decreased p.o. intake, and
worsening
cough, CT and CXR concerning for malignancy. A ___ discussion
was had and it was determined to be most in line with the
patient's goals of care to discharge home with hospice and focus
aggressively on comfort
TRANSITIONAL ISSUES
=====================
[] Patient was discharged to home hospice, MOLST completed with
___ (HCP) was for DNR/DNI, no transfer to the hospital
[] Would consider further deprescribed of antipsychotics and PPI
based on patient's comfort
[] Pt has appointment with PCP which he can attend if wanted
ACUTE ISSUES:
=============
#Acute hypoxenic respiratory failure
#Right Lobe Opacity c/f malignancy
Patient initially presented with worsening dry cough and
shortness of breath since recent discharge on ___. He has
completed a course of augmentin for CAP at the time without
recovering in his respiratory status. On admission, required 3L
O2 requirement (not on O2 at baseline). In the setting of weight
loss and loss of appetite with no recent fevers or chills and no
leukocytosis, malignancy was suspected. Review of imaging from
___ outside records is suggestive of possible malignancy in
RLL in that area that wasn't present in ___ imaging.
Pulmonary was consulted who helped to review the case, who
agreed with the most likely suspicion for underlying lung
malignancy. A ___ discussion was had with the family, including
HCP ___ and ___ and it was determined it would be most in line
with his goals of care to not pursue further worse up of the
mass and to discharge home with hospice to focus on comfort
measures only.
#Failure to thrive
Patient's son reports increasing fatigue and weakness, as well
as decreased appetite and weight loss, unknown amount. Suspected
to be in the setting of malignancy. He was given ensure while in
house
#?H/o HIT
Documented history of HIT in ___ admission note, however no
prior records available to clarify. Did not received heparin
while in house
# Chronic normocytic anemia
Remained around 11 while in house. No signs of bleeding. Suspect
___ to iron deficiency and chronic disease. Iron therapy was
deferred to focus medication regimen on those which bring
comfort
CHRONIC/STABLE ISSUES:
=======================
# HTN, now Orthostatic Hypotension
Baseline SBPs ranging from 150s-180s. Continued on home
Fludrocortisone 0.1 mg daily
# HLD
- Continued home rosuvastatin while in house, d/c on discharge
# Vit D deficiency
- Continued home vit D 1000 IU daily while in house, d/c on
discharge
# Pulmonary Fibrosis
- Duonebs for hospitalization, return to Umeclidinium-vilanterol
inhaler on discharge as non-formulary.
# Mild dementia
Patient unable to provide history, however is alert and
interactive, answering questions appropriately. Alert and
oriented to self, recognized he was in a hospital, not oriented
to time. Per son, currently at baseline. Atrius notes suggest
possible AD and VD contribution. Was continue home mirtazapine
and donepezil.
#CKD
Came with Cr of 1.9 on admission, appears baseline per Atrius
records (Cr 1.85-2).
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Donepezil 5 mg PO QHS
2. Fludrocortisone Acetate 0.1 mg PO DAILY
3. FoLIC Acid 1 mg PO DAILY
4. Mirtazapine 3.75 mg PO QHS
5. Omeprazole 40 mg PO BID
6. Rosuvastatin Calcium 40 mg PO QPM
7. Vitamin D 1000 UNIT PO DAILY
8. Anoro Ellipta (umeclidinium-vilanterol) 62.5-25 mcg/actuation
inhalation DAILY
Discharge Medications:
1. Anoro Ellipta (umeclidinium-vilanterol) 62.5-25
mcg/actuation inhalation DAILY
2. Donepezil 5 mg PO QHS
3. Fludrocortisone Acetate 0.1 mg PO DAILY
4. Mirtazapine 3.75 mg PO QHS
5. Omeprazole 40 mg PO BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary
============
Right lobe mass/consolidation concerning for malignancy
Acute hypoxic respiratory failure
Secondary
=============
Pulmonary fibrosis
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 Mr. ___,
It was a pleasure taking care of you at ___!
You were here because you were short of breath. While you were
here, you had a x-ray and CT (a special time of x-ray) which
showed concerned that you may have cancer. We discussed this
information with you and your family and decided it would be
most in line with your goals of care to discharge you home where
you will be comfortable.
When you leave, it is important you let your Hospice team know
if you are uncomfortable or if there is anything you need. There
goal is to make sure you are comfortable!
We wish you the best of luck!
Your ___ Care Team
Followup Instructions:
___
|
19606425-DS-20
| 19,606,425 | 28,130,824 |
DS
| 20 |
2126-10-30 00:00:00
|
2126-10-30 12:50:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
SOB, cough
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ yoM with PHMx of HTN, HLD, possible CAD and possible COPD
who presents with SOB. He states that his symptoms started 5
days ago with mild shortness of breath and productive cough.
Cough productive of white sputum. He symptoms worsened and
patient presented to ___ yesterday. He was diagnosed
with pna and discharged on azithromycin. However, his symptoms
continued to worsen, prompting his presented to ___ today.
Overnight, his SOB progressed to to the point where he felt that
he was "gasping' for air. He also endorses lightheadedness and
right sided chest pain. The chest pain is worse with coughing.
Over the last ___ days, he has also had sweats/chills, but he
has not checked his temperature. No abdominal pain,
constipation/diarrhea, or urinary symptoms. No rash.
Of note, admitted ___ for wheezing and chest pressure. He
underwent cardiac catheterization which showed no stenosis. He
also completed 5d course of oral steroids for COPD exacerbation
and was also started on advair and spiriva. He was also
continued on cipro/flagyl that was started at OSH for
osteomyelitis of L thumb(end date: ___. He has no known
diagnosis of COPD and was encouraged to have PFTs performed
after last admission. These have not been done yet. The patient
states that his current symptoms feel very similar with the
addition of feeling feverish this time.
In the ED, initial vitals: 99.5 94 140/79 20 99% 4L
Non-Rebreather
- Exam notable for: tachycardic, with normal S1, S2. right lung
crackles and rhonchi. Intermittent wet cough.
- Labs notable for: WBC 10.5 with 79.5 PMNs
- Imaging notable for: CXR showed mild central peribronchial
cuffing likely representing bronchitis in the setting of
infectious symptoms.
- Pt given:
___ 05:58 IV Azithromycin 500 mg ___
___ 05:58 IV CeftriaXONE 1 gm ___
___ 05:58 IH Albuterol 0.083% Neb Soln 1 NEB ___
___ 06:09 IH Albuterol 0.083% Neb Soln 1 NEB ___
___ 07:54 PO Ibuprofen 600 mg ___
- Vitals prior to transfer: 99.4 95 133/72 20 96% Non-Rebreather
On arrival to the floor, pt reports that his breathing has
improved with nebulizer treatement in the ED.
Past Medical History:
HTN
HLD
CAD per recent stress test though cath ___ showed no
significant obstruction
Remote history PNA
left thumb osteomyeltitis (___)
___
Social History:
___
Family History:
Mother: died of old age
Father: died of ___ disease
Physical Exam:
ADMISSION PHYSICAL EXAM:
============================
Vitals: 98.1, 142/78, 50, 22, 94/RA
General: +diaphoretic, coughing during exam
HEENT: MMM, PERRL, OP clear
Neck: no lymphadenopathy
Lungs: diffuse wheezing throughout lung fields, greatest in R
lung base
CV: distant heart sounds, RRR, no m/r/g
Abdomen: mild TTP in RUQ, +BS, non-distended
GU: no foley
Ext: warm, well perfused, no edema
Neuro: AOx3, no gross deficits
DISCHARGE PHYSICAL EXAM:
============================
Vitals: 98, 142/85, 77, 18, 97/RA at rest, 96/RA with ambulation
General: well appearing male in NAD
HEENT: MMM, PERRL, OP clear
Neck: no lymphadenopathy
Lungs: mild wheezing at R lung base and mild rhonchi at L lung
base
CV: distant heart sounds, RRR, no m/r/g
Abdomen: non-tender, non-distended
GU: no foley
Ext: warm, well perfused, no edema
Neuro: AOx3, no gross deficits
Pertinent Results:
ADMISSION LABS:
===============
___ 05:08AM BLOOD WBC-10.5* RBC-4.26* Hgb-12.9* Hct-37.7*
MCV-89 MCH-30.3 MCHC-34.2 RDW-13.3 RDWSD-43.3 Plt ___
___ 05:08AM BLOOD Neuts-79.5* Lymphs-12.6* Monos-5.3
Eos-1.7 Baso-0.5 Im ___ AbsNeut-8.38* AbsLymp-1.33
AbsMono-0.56 AbsEos-0.18 AbsBaso-0.05
___ 05:08AM BLOOD Glucose-103* UreaN-17 Creat-0.9 Na-142
K-3.3 Cl-102 HCO3-28 AnGap-15
___ 05:08AM BLOOD ALT-9 AST-20 AlkPhos-75 TotBili-0.8
IMAGING/STUDIES:
===================
___ CXR: Mild central peribronchial cuffing likely
representing bronchitis in the setting of infectious symptoms.
DISCHARGE LABS:
================
___ 08:07AM BLOOD WBC-7.1# RBC-3.93* Hgb-11.9* Hct-34.9*
MCV-89 MCH-30.3 MCHC-34.1 RDW-13.2 RDWSD-43.2 Plt ___
___ 08:07AM BLOOD Glucose-92 UreaN-13 Creat-0.8 Na-140
K-3.4 Cl-102 HCO3-27 AnGap-14
___ 08:07AM BLOOD Calcium-9.2 Phos-2.8 Mg-2.0
Brief Hospital Course:
Patient is a ___ with a PMHx of HTN, HLD, and possible COPD
who presented with SOB, cough, pleuritic chest pain and
subjective fevers. Presentation felt to be consistent with
pneumonia with likely COPD exacerbation. Patient was started on
ceftriaxone and azithromycin for CAP along with prednisone for
COPD exacerbation with standing albuterol nebulizers. His
symptoms improved significantly by time of discharge.
#community acquired pneumonia complicated by likely COPD
exacerbation: Patient presented with subjective fevers,
leukocystosis, cough, SOB, wheezing and increased sputum
production. CXR did not ___ clear consolidation. Presentation
was felt to be consistent with community acquired pneumonia that
was complicated by likley COPD exacerbation. His symptoms felt
very similar to recent presentation during which time he was
treated for COPD flare, though he has not had PFTs and carries
no formal diagnosis for COPD (however, patient has singificant
smoking exposure history). Patient improved significantly with
ceftriaxone and azithromycin for CAP therapy, along with
tiotropium IH, albuterol nebds, and prednisone for COPD flare.
Patient met clinical criteria for HCAP, but clinical suspicion
was low given well-appearance and low CURB-65 score. He was
monitored closely and improved withouth HCAP coverage. Patient
was transitioned to cefpodoxime and discharged on
azithromycin/cefpodoxime/prednisone to complete 5 day course. He
was encouraged to have PFTs as outpatient.
# Hx GERD: CTA ___ showed hiatal hernia. Continued on home
omeprazole and discontinued home famotidine.
#HLD: continued home simvastatin
#BPH: continued home tamsulosin
#home meds: continued home ASA
TRANSITIONAL ISSUES:
======================
- continue cefpodoxine twice daily, last day ___
- continue azithromycin 250mg daily, last day ___
- continue prednisone 40mg daily, last day ___
- continue tiotropium daily and albuterol inhaler PRN
- follow up with PCP for ___ testing
- follow up chest CT in ___. CTA from ___ in ___
showed: "3 mm RUL nodule. Rec F/U CT thorax in 12 months for
nodule."
# EMERGENCY CONTACT: ___, wife: ___
# CODE STATUS: Full, confirmed
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Docusate Sodium 100 mg PO TID
2. Tamsulosin 0.4 mg PO QHS
3. Aspirin 81 mg PO DAILY
4. Albuterol Inhaler ___ PUFF IH Q4H:PRN sob
5. Tiotropium Bromide 1 CAP IH DAILY
6. Famotidine 40 mg PO DAILY
7. Ibuprofen 600 mg PO Q8H:PRN pain
8. Omeprazole 40 mg PO BID
9. Simvastatin 40 mg PO QPM
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Docusate Sodium 100 mg PO TID
3. Omeprazole 40 mg PO BID
4. Simvastatin 40 mg PO QPM
5. Tamsulosin 0.4 mg PO QHS
6. Tiotropium Bromide 1 CAP IH DAILY
RX *tiotropium bromide [Spiriva with HandiHaler] 18 mcg 1 cap IH
daily Disp #*30 Capsule Refills:*0
7. Azithromycin 250 mg PO Q24H
RX *azithromycin 250 mg 1 tablet(s) by mouth daily Disp #*2
Tablet Refills:*0
8. Benzonatate 100 mg PO TID
RX *benzonatate 100 mg 1 capsule(s) by mouth three times a day
Disp #*20 Capsule Refills:*0
9. Cefpodoxime Proxetil 400 mg PO Q12H
RX *cefpodoxime 200 mg 2 tablet(s) by mouth twice daily Disp
#*10 Tablet Refills:*0
10. PredniSONE 40 mg PO DAILY Duration: 5 Doses
RX *prednisone 20 mg 2 tablet(s) by mouth daily Disp #*4 Tablet
Refills:*0
11. Albuterol Inhaler ___ PUFF IH Q4H:PRN sob
RX *albuterol sulfate 90 mcg ___ puff IH every 4 to 6 hours Disp
#*1 Inhaler Refills:*0
12. Ibuprofen 600 mg PO Q8H:PRN pain
13. Guaifenesin ___ mL PO Q6H:PRN cough
RX *guaifenesin 100 mg/5 mL ___ mL by mouth every 6 hours
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
community acquired pneumonia
possible COPD exacerbation
Secondary:
possible COPD
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 ___ with shortness of breath. Your
symptoms were felt to be due to pneumonia and a possible COPD
flare. Your breathing improved with antibiotics, steroids, and
breathing treatments. You will need to continue these
antibiotics and steroids. Your last day will be ___. Please
continue to use your inhalers as directed in this paperwork and
in your prescriptions. Please follow up with your doctors as
directed. It is also important that you talk to your primary
care doctor about getting lung function tests done to see if you
have COPD.
It has been a pleasure taking care of you and we wish you all
the best,
Your ___ Care Team
Followup Instructions:
___
|
19606590-DS-7
| 19,606,590 | 27,033,426 |
DS
| 7 |
2142-07-07 00:00:00
|
2142-07-07 18:46:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Lumbar stenosis; weakness
Major Surgical or Invasive Procedure:
Lumbar laminectomy decompression L4-5 and L5-S1
History of Present Illness:
___ L4-5, L5-S1 Lumbar Stenosis with right sciatica pain.
Basically, the pain
has been going on for about a week and a bit almost two weeks
starting in from ___ when she has always had a kind of a
history of chronic back pain and sort of walking intolerance
that has acutely got worse approximately two weeks ago by ___
evening. Previously, she has been self-treating with naproxen
and has not really been limited by her walking too much other
than ___ evening. Her low back pain got limiting to a point
where she was really limited and then inability to walk. She has
no sensory changes and some weakness sort of on the right leg,
but has full strength on the left. She is still able to ambulate
a few steps and get herself in and out of a chair, but she has
been borrowing a friend's wheelchair since last ___. She has
seen her primary care doctor, ___ prescribed her
Percocet and diazepam, which has been helping her pain and
allowing her to manage. With any type of activity, it is ___.
However, at rest, it is only 3 or 4. Most of the pain is running
down the back of her leg and shoots into the top of her right
foot. Previously, she was quite immobile.
Intermittent Course: Patient was noted to have history of atrial
fibrillation, but On ___ she was transferred to the medical
service for further management given asymptomatic episodes of
atrial fibrillation/flutter with rates in 150s. Pt asymptomatic
with regards to palpitations, chest pain, dyspnea, pre-syncope,
surgical site pain.
Past Medical History:
Afib
HTN
HLD
PreDiabetes
Post polio
right shoulder DJD
history of uterine cancer status post hysterectomy.
Social History:
___
Family History:
Significant for cancer, diabetes and heart disease in her
sister, mother and father respectively.
Physical Exam:
ADMISSION PHYSICAL EXAM
VITAL SIGNS: 98.7 133/93 92 16 97% RA
GENERAL: pleasant, NAD
HEENT: anicteric sclera, MMM
CARDIAC: irregular rhythm, regular rate, no m/r/g
LUNGS: CTAB without adventitious sounds
ABDOMEN: NT/ND + BS
EXTREMITIES: WWP, no edema
SKIN:. No rash
NEURO: upper extremity motor function intact, lower extremity
exam limited by pain at hips, knees and ankles, ___ strength at
toes
PSYCH: normal affect
DISCHARGE PHYSICAL EXAM:
VS: 98.8 BP 109-134/57-62 HR 58-68, RR 18 94% RA
GENERAL: WDWN woman in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple with JVP of 6-8 cm.
CARDIAC: Regular rate and rhythm, normal S1, S2.
LUNGS: +kyphosis. Resp were unlabored, no accessory muscle use.
CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: R>L swelling, with distal erythema (chronic per
patient), not warm to touch, ___ pitting edema below knees b/l
Pertinent Results:
==ADMISSION LABS:==
___ 04:35PM ___ PTT-29.8 ___
___ 04:35PM PLT COUNT-173
___ 04:35PM NEUTS-61.5 ___ MONOS-6.2 EOS-1.4
BASOS-0.7 IM ___ AbsNeut-5.30 AbsLymp-2.59 AbsMono-0.53
AbsEos-0.12 AbsBaso-0.06
___ 04:35PM WBC-8.6 RBC-5.62* HGB-16.5* HCT-49.1* MCV-87
MCH-29.4 MCHC-33.6 RDW-13.0 RDWSD-41.3
___ 04:35PM estGFR-Using this
___ 04:35PM GLUCOSE-104* UREA N-13 CREAT-0.6 SODIUM-142
POTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-27 ANION GAP-17
___ 05:31PM URINE MUCOUS-RARE
___ 05:31PM URINE RBC-2 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-<1
___ 05:31PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-NEG
___ 05:31PM URINE COLOR-Straw APPEAR-Clear SP ___
==DISCHARGE LABS:==
___ 06:50AM BLOOD WBC-6.4 RBC-4.34 Hgb-12.8 Hct-39.6 MCV-91
MCH-29.5 MCHC-32.3 RDW-12.8 RDWSD-42.8 Plt ___
___ 06:50AM BLOOD Calcium-9.4 Phos-4.1 Mg-2.0
==IMAGING==
CHEST X RAY ___:
No acute intrathoracic process.
CHEST X RAY ___:
Heart size and mediastinum are stable. No appreciable pleural
effusion is
present. Left basal opacity is new and is concerning for
aspiration. Right
lung is clear.
LUMBAR SINGLE VIEW IN OR ___:
There is a posterior probe at what appears to be the L5
vertebral body.
Further information can be gathered from the operative report.
EKG ___:
Artifact is present. The rhythm is initially sinus followed by
atrial
tachycardia and then resumption of sinus rhythm. There are Q
waves in the
inferior leads consistent with myocardial infarction. There is a
late
transition with tiny R waves in the anterior leads consistent
with possible
myocardial infarction. Non-specific ST-T wave changes. Compared
to the
previous tracing of ___ the rhythm has changed and small R
waves in the
anterior leads are new.
EKG ___:
The rhythm is initially atrial tachycardia with variable block
followed by
sinus rhythm and then an ectopic atrial beat. There are Q waves
in the
inferior leads consistent with myocardial infarction. There is a
late
transition with small R waves in the anterior leads consistent
with possible
myocardial infarction. Non-specific ST-T wave changes. Compared
to the
previous tracing of ___ there is no significant change.
EKG ___:
Artifact is present. Atrial flutter with a rapid ventricular
response.
Non-specific ST-T wave changes. Compared to the previous tracing
of ___
the rhythm has changed.
TTE ___:
The left atrium is mildly dilated. The estimated right atrial
pressure is ___ mmHg. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is low normal (LVEF 50-55%). There
is no ventricular septal defect. Right ventricular chamber size
and free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
aortic valve is not well seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Mild (1+)
mitral regurgitation is seen. There is borderline pulmonary
artery systolic hypertension. There is an anterior space which
most likely represents a prominent fat pad.
Brief Hospital Course:
___ with h/o atrial fibrillation, HTN, HLD who is s/p L5-S1
laminectomy and far lateral L4-L5 decompression found to have
atrial fibrillation with RVR, self converted to sinus rhythm,
with some intermittent premature atrial contractions noted on
telemetry monitoring.
# Atrial fibrillation: Patient had noted to have remote history
of atrial fibrillation, last noted couple of years ago, without
any anticoagulation treatment. Her Chads2Vasc score was 3, which
would recommend anticoagulation.When the patient was transferred
to the medicine service her heart rate was already controlled to
___. We continued her on metoprolol tartate 12.5 TID and
monitored her on telemetry. Her heart rate remained in sinus
rhythm between 60-70. The pt was transferred to the MICU for
persistent afib with RVR and sinus pauses up to 4.5 seconds. She
was started on a heparin drip. She continued to be tachy to the
150s and had sinus pauses up to 5 seconds--due to these pauses
her metoprolol was d/c'ed. Cardioversion with TEE was discussed
and planned for ___ however, the pt spontaneously converted
to sinus. She was started on flecainide and bridged to coumadin.
The pt expressed reluctance to take coumadin but agreed to the
planthe plan to put her on coumadin for 2 weeks in the post-op
period and then transition her to rivaroxaban. Patient's PCP was
informed of the plan.
# L5-S1 laminectomy and far lateral L4-L5 decompression-
(written by ortho spine)
Patient was admitted to the ___ Spine Surgery Service from
clinic urgently due to progressive weakness and dsyfunction in
ADLs. She was seen preopoepratively and thus taken to the
Operating Room for the above procedure. Refer to the dictated
operative note for further details. The surgery was without
complication and the patient was transferred to the PACU in a
stable condition. TEDs/pnemoboots were used for postoperative
DVT prophylaxis. Intravenous antibiotics were continued for
24hrs postop per standard protocol. Initial postop pain was
controlled with a PCA. Diet was advanced as tolerated. The
patient was transitioned to oral pain medication when tolerating
PO diet. Foley was removed on POD#1. Physical therapy was
consulted for mobilization OOB to ambulate. Hospital course was
otherwise unremarkable. Patient was noted to continue be limited
by post-op pain and also has decreased awareness of
post-operative activity guidelines including spine precautions.
As pt had limited support and continues to require
assist for all mobility, ___ recommended discharge to rehab. On
the day of discharge the patient was afebrile with stable vital
signs, comfortable on oral pain control and tolerating a regular
diet. Patient was discharged with oxycodone 5 mg for pain
control.
#Wheezing: Patient noted to have wheezing on physical exams,
with no known history of COPD or asthma. She was symptomatically
managed with ipratropium nebs as needed, avoided albuterol given
possible worsening of tachycardia as above.
#Home medications: We continued gabapentin, diazepam, vitamin D,
cyanocobalamin and pyridoxine.
TRANSITIONAL ISSUES:
====================
- Pt. would likely benefit from repeat sleep study and
initiation of CPAP overnight.
- Ortho says needs to be on REVERSIBLE anticoag x 2 weeks. cards
prefer her to be on rivarox 20 mg once daily, so may switch to
this after
- Tentative plan for 2wks of Coumadin then transition to
rivaroxaban as long as ortho approves
- New medications: Flecainide Acetate 100 mg PO Q12H and Stopped
Home metoprolol
Full Code
- INR 3.7 at time of discharge after one dose 5mg Coumadin;
Coumadin held at discharge, with plan to trend INR daily at
rehab
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Vitamin D 5000 UNIT PO DAILY
2. Clobetasol Propionate 0.05% Cream 1 Appl TP DAILY as needed
to scalp
3. Cyanocobalamin 500 mcg PO DAILY
4. Gabapentin 600 mg PO BID
5. Metoprolol Succinate XL 25 mg PO DAILY
6. Pyridoxine 50 mg PO DAILY
7. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4-6H prn pain
8. Diazepam 3.5 mg PO Q6H:PRN anxiety
Discharge Medications:
1. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 capsule(s) by mouth by mouth every 6 hours
as needed for pain Disp #*35 Capsule Refills:*0
2. Clobetasol Propionate 0.05% Cream 1 Appl TP DAILY as needed
to scalp
3. Cyanocobalamin 500 mcg PO DAILY
4. Gabapentin 600 mg PO BID
5. Pyridoxine 50 mg PO DAILY
6. Vitamin D 5000 UNIT PO DAILY
7. Diazepam 3.5 mg PO Q6H:PRN anxiety
RX *diazepam 2 mg 1 tab by mouth ___ tabs by mouth every 6 hours
Disp #*20 Tablet Refills:*0
8. Flecainide Acetate 100 mg PO Q12H
RX *flecainide 100 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*60 Tablet Refills:*0
9. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine [Lidoderm] 5 % (700 mg/patch) Apply to back once a
day Disp #*20 Patch Refills:*0
10. Warfarin 2 mg PO DAILY16
On hold while INR > 3.0; restart when INR < 3.0
RX *warfarin 5 mg 1 tablet(s) by mouth once a day Disp #*60
Tablet Refills:*0
11. Outpatient Lab Work
Please draw ___, INR
Fax Results to:
___
___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Lumbar Spinal Stenosis
Paroxysmal atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You have undergone the following operation: Lumbar Decompression
Without Fusion by the ortho spine service.
You have a history of atrial fibrillation and you were found to
have recurrent atrial fibrillation while in the hospital. You
were seen by the cardiologists who recommended the medication
Flecainide. Having this condition even if the abnormal rhythm
occurs sometimes puts you at increased risk for stroke so we
highly recommended you start a blood thinner to prevent you from
having a stroke in the future. Because you have had a recent
surgery you will need to continue Coumadin and lovenox shots.
You can stop your lovenox shots once your Coumadin is in
therapeutic range as determined by your primary doctor. After 2
weeks you may decide to switch your blood thinner to a
medication that requires less monitoring as guided by your
primary doctor.
It was a pleasure taking care of you,
Your ___ Team
Immediately after the operation:
Activity: You should not lift anything greater
than 10 lbs for 2 weeks. You will be more comfortable if you do
not sit or stand more than ~45 minutes without moving around.
Rehabilitation/ Physical Therapy:
___ ___ times a day you should go for a walk
for ___ minutes as part of your recovery. You can walk as
much as you can tolerate.
___ Limit any kind of lifting.
Diet: Eat a normal healthy diet. You may have
some constipation after surgery. You have been given medication
to help with this issue.
Brace: You may have been given a brace. This
brace is to be worn when you are walking. You may take it off
when sitting in a chair or lying in bed.
Wound Care: Remove the dressing in 2 days. If
the incision is draining cover it with a new sterile dressing.
If it is dry then you can leave the incision open to the air.
Once the incision is completely dry (usually ___ days after the
operation) you may take a shower. Do not soak the incision in a
bath or pool. If the incision starts draining at anytime after
surgery, do not get the incision wet. Cover it with a sterile
dressing and call the office.
You should resume taking your normal home
medications.
You have also been given Additional Medications
to control your pain. Please allow 72 hours for refill of
narcotic prescriptions, so please plan ahead. You can either
have them mailed to your home or pick them up at the clinic
located on ___. We are not allowed to call in or fax
narcotic prescriptions (oxycontin, oxycodone, percocet) to your
pharmacy. In addition, we are only allowed to write for pain
medications for 90 days from the date of surgery.
Follow up: You have been scheduled to see
your spine surgeon 2 weeks after discharge.
We will then see you at 6 weeks from the day of the
operation and at that time release you to full activity.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
Followup Instructions:
___
|
19606653-DS-2
| 19,606,653 | 29,521,589 |
DS
| 2 |
2185-12-08 00:00:00
|
2185-12-22 10:52:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
sulfamethizole / codeine
Attending: ___.
Chief Complaint:
Right olecranon fracture with radial head dislocation, right
ulnar shaft fracture
Major Surgical or Invasive Procedure:
ORIF right elbow Monteggia fracture and right ulnar shaft
fracture ___, Dr. ___
History of Present Illness:
This is a ___ ___ COPD, asthma, osteoporosis who presents as
transfer from OSH with R olecranon fracture, midshaft ulna
fracture, and radial head dislocation. Patient was unrestrained
driver in ___ at approximately 25mph. Rear ended vehicle. Unsure
of exact mechanism of injury but immediate pain to R arm. Seen
at OSH and radial head was dislocated. Reduced and placed in
splint and sent for further care.
Past Medical History:
COPD
Asthma
Osteoporosis
Reflux
Social History:
___
Family History:
Non-contributory
Physical Exam:
Vitals: 98.5 93 121/87 16 96% Nasal cannula
Right upper extremity:
- Skin intact
- Deformity at elbow with soft tissue swelling and minor
ecchymosis along medial AC fossa
- Elbow tender to palpation and PROM
- Humerus and wrist nontender to palpation
- EPL/FPL/DIO (index) fire
- SILT axillary/radial/median/ulnar nerve distributions
- 2+ radial pulse
Pertinent Results:
- CT RUE: There is a moderately displaced, comminuted fracture
at the base of the right olecranon with radial displacement of
the body of the ulna. Scattered free bony fragments are present
at the fracture site. There is no extension of the fracture line
into the articular joint.The humeroulnar joint appears well
aligned, as is the humeroradial joint. There is extensive soft
tissue swelling at the elbow joint
- X-ray RUE: Olecranon fracture, radial head dislocation, ulnar
shaft fracture
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 olecranon and ulna fractures and was admitted to
the orthopedic surgery service. The patient was taken to the
operating room on ___ for ORIF R olecranon and ulnar shaft
fractures, 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. Her hematocrit was 21.9 on POD#1 and she was
given 2 units of PRBC. Her hematocrit rose to 30.1 on POD#2 and
remained stable on POD#3. The patient worked with ___ and OT 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
non-weightbearing on the right upper extremity. The patient will
follow up with Dr. ___ routine. A thorough discussion
was had with the patient regarding the diagnosis and expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient was also given written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient expressed readiness for discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Tiotropium Bromide 1 CAP IH DAILY
2. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
3. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing
4. Omeprazole 20 mg PO DAILY
5. TraZODone 150 mg PO QHS:PRN insomnia
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing
2. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
3. Omeprazole 20 mg PO DAILY
4. Tiotropium Bromide 1 CAP IH DAILY
5. TraZODone 150 mg PO QHS:PRN insomnia
6. Acetaminophen 650 mg PO TID
7. Docusate Sodium 100 mg PO BID
8. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Right olecranon fracture with radial head dislocation, right
ulnar shaft fracture.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Non-weightbearing on right upper extremity in splint
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
Physical Therapy:
Non-weightbearing right upper extremity in splint
Treatments Frequency:
Splint to stay in place until follow up in ___ days
Followup Instructions:
___
|
19606882-DS-5
| 19,606,882 | 26,731,723 |
DS
| 5 |
2161-04-21 00:00:00
|
2161-04-22 19:03:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
shrimp / contrast dye
Attending: ___
Chief Complaint:
Fevers, diarrhea, rash
Major Surgical or Invasive Procedure:
Skin biopsy - ___
History of Present Illness:
Mr. ___ is a ___ yo M with hx of Fabry's dz s/p living
unrelated renal transplant ___ presents with fever, nausea,
diarrhea and rash. Pt was in his usual state of health until
___, when he went to a raw ___ bar and ate raw shell fish.
within a few days he developed GI distress with diarrhea. He was
seen at his ___ and was diagnosed with
cryptosporidium and was started on nitazoxanide. After starting
this medication he was admitted to local hospital (___) with
fever, headache, and rash. The nitazoxanide was held. He had
fever and a new intense headache, for which he underwent a
lumbar punture. He was discharged on doxycycline for presumed
tick borne illness and had improvement in his symptoms over the
next few days. He was discharged on ___.
His diarrhea has been ongoing throughout. Yesterday he spiked a
fever to 102. His rash returned. He endorses feeling fatigued,
nauseous, and dizzy, with chills and sweats. He denies CP, SOB,
palpitations, sick contacts, recent travel. He spends a lot of
time outdoors in rural areas that are lyme endemic.
He presented today to outpatient infectious disease clinic and
it was decided that he should be admitted for further workup.
In the ED, initial vitals were:
101.2 64 ___ 100% RA blood cultures were sent. Labs were
significant for a ALT 116, AST 94, AP 167, Tbili .4 alb 3.2. CBC
WNL and chem 7 was significant for a bicarb of 19. CXR with no
acute proccess. US of tranplanted kidney showed no acute
changed.
Past Medical History:
Fabry's Disease
ESRD s/p Living Unrelated Renal Transplant (___)
HTN
Neuropathy
Social History:
___
Family History:
Family history of fabry's. Otherwise non-contributory.
Physical Exam:
========================
Admission Physical Exam
========================
VS: Tm:99.0 BP:111/62 P:67 R:20 O2:97RA
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: Macular papular rash on arms, abdomen, and groin. Rash
spares hands. No rash below knee.
NEURO: Alert and oreinted. EOMI, PERRL, CNII-XII intact.
Strenght intact throughout.
========================
Discharge Physical Exam
========================
VS: Tmax 101 BP 107/68 - 117/63 HR ___ RR20 O2 96%ra
GENERAL: Alert and oriented, no acute distress, pleasant
HEENT: Sclera anicteric, MMM
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, II/VI systolic
crescendo-decrescendo murmur at apex
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: stable macular rash on groin
NEURO: Alert and oriented. No focal neurological deficits
Pertinent Results:
====================================
ADMISSION LABS
====================================
___ 02:15PM BLOOD WBC-4.8 RBC-5.18 Hgb-14.1 Hct-40.8
MCV-79* MCH-27.2 MCHC-34.6 RDW-13.4 RDWSD-38.3 Plt ___
___ 02:15PM BLOOD Neuts-74.0* Lymphs-11.8* Monos-9.3
Eos-4.1 Baso-0.2 Im ___ AbsNeut-3.58 AbsLymp-0.57*
AbsMono-0.45 AbsEos-0.20 AbsBaso-0.01
___ 02:15PM BLOOD Glucose-97 UreaN-15 Creat-1.2 Na-136
K-4.0 Cl-102 HCO3-19* AnGap-19
___ 02:15PM BLOOD ALT-116* AST-94* AlkPhos-167* TotBili-0.4
___ 02:15PM BLOOD cTropnT-0.02*
====================================
PERTINENT LABS
====================================
___ 07:15AM BLOOD CRP-181.0*
___ 02:45PM BLOOD Lactate-1.6
====================================
DISCHARGE LABS
====================================
___ 06:01AM BLOOD WBC-4.5 RBC-3.79* Hgb-10.1* Hct-31.8*
MCV-84 MCH-26.6 MCHC-31.8* RDW-13.9 RDWSD-42.5 Plt ___
___ 06:01AM BLOOD Plt ___
___ 06:01AM BLOOD Glucose-92 UreaN-7 Creat-0.9 Na-142 K-4.6
Cl-106 HCO3-27 AnGap-14
___ 06:01AM BLOOD Albumin-2.4* Calcium-8.4 Phos-4.1 Mg-2.1
====================================
STUDIES
====================================
___ Renal transplant US: Normal renal transplant ultrasound.
___ EKG
Baseline artifact. Sinus rhythm. Consider incomplete right
bundle-branch
block. Left ventricular hypertrophy. Non-specific ST-T wave
abnormalities
could be from left ventricular hypertrophy. Compared to the
previous tracing of ___ incomplete right bundle-branch block
and ST-T wave abnormalities are new. Bradycardia is absent.
___ CXR: No acute cardiopulmonary process, no focal
consolidation.
___ Biopsy: Micro negative.
Skin, left upper arm, biopsy:
Scant superficial perivascular lymphocytic inflammation with
rare neutrophils, see note.
Note: The findings are not specific and mild. The focal finding
of neutrophils suggests the possibility of urticaria, however,
the changes are not definitive. No inflammation is observed in
the deep dermis
and subcutis. Special stains (Gram, PAS, and GMS) are negative
for organisms. This case was discussed with Dr. ___ on
___.
___ abd US
1. Unremarkable appearance the liver with no biliary dilatation
and no
perihepatic collection.
2. No hydronephrosis of the transplant kidney. No
peritransplant collection.
3. Mild splenomegaly.
___ CT abd w/ PO contrast:
IMPRESSION:
1. Circumferential wall thickening of multiple loops of
proximal jejunum is consistent with enteritis, which may be
infectious, inflammatory, or less likely ischemic. Small bowel
(jejunal) diverticula.
2. Few prominent regional mesenteric lymph nodes are likely
reactive.
3. Unremarkable unenhanced appearance of the right iliac fossa
renal
transplant. Atrophic native kidneys.
====================================
MICROBIOLOGY
====================================
-uCMV VL-Negative
-Hepatitis A serologies-IGG pos, IgM neg. Not likely acute
infection
-Parasite smear x 3 negative x2
-Stool norovirus PCR-Negative for GI and GII
-HIV negative
-Parasite smear negative x3
-Toxoplasmosis serologies neg
-Ova and Parasites neg
-Cryptosporidium/Giardia (DFA) negative
-Cyclospora negative
-Microsporidium negative
-Stool culture - E.coli 0157:H7 negative
-Stool culture - Vibrio negative
-Stool culture - Yersinia negative
UA/UC, CXR negative
-sent Stool bacterial culture (includes Campylobacter,
Salmonella, Shigella) negative
-C. difficile DNA amplification assay negative
-Lyme IgM/IgG negative
-RPR negative
-Stool rotavirus antigen- Negative
-Serum HHV-6 PCR negative
====================================
PENDING RESULTS
====================================
- Hep B, Hep C serologies
- Autoimmune hepatitis panel
- Ceruplasmin
- Alpha-1 antitrypsin
- ___'s Disease PCR
- Yersinia Entercolitica IgG,IgA
- TB Quantiferon Gold
- Anaplasma antibody IgG, IgM
- EBV PCR
- Babesia antibodies IgG, IgM
- Arbovirus antibodies IgG, IgM
- Tissue fungal culture, acid fast culture
Brief Hospital Course:
Mr ___ is a ___ yo m with hx of Fabry's c/b ESRD s/p
living unrelated kidney transplant in ___, who presented with a
two week history of diarrhea, high fevers, abdominal pain, and
intermittent rash.
# Fever, rash and diarrhea: Pt presented with a two week history
of ongoing diarrhea and fevers and two episodes of diffuse rash.
Before admission, he had tested positive and was treated for
cryptosporidosis with nitazoxanide. Soon after, he developed a
rash which was attributed to a reaction to nitazoxanide. He was
admitted to OSH with fever and headache and had an LP that
showed aseptic pleocytosis, and so he was started on a course of
doxycycline, with limited improvement in his symptoms. 2 days
PTA, his rash returned, he was spiking fevers and his diarrhea
was ongoing. On admission he underwent a broad infectious
workup. Of note, cryptosporidium was negative. A CT
abdomen/pelvis with oral contrast showed enteritis. A biopsy was
done on his rash which showed non-specific inflammatory changes.
Throughout his admission he spiked fevers about twice a day,
once early in the morning and once in the afternoon or evening.
Blood cultures and an extensive infectious disease work-up have
been negative. Rheumatology was also consulted but work-up was
negative. He was eventually started on symptomatic therapy with
acetaminophen and loperamide, with some improvements in
symptoms. He was discharged with an emperic 7 day course of
ciprofloxacin and flagyl.
# Hypokalemia: Mr. ___ had frequent episodes of
hypokalemia during the hospitalization that required repletion.
This was likely ___ his ongoing diarrhea and improved once
loperamide was started.
# Transaminitis: Admission LFTs were notable for a mild
transaminitis. This improved but alkaline phosphatase trended
upward. Hepatology was consulted and work-up was performed for
infectious and non-infectious causes of his transaminitis. MRCP
was performed which was negative for biliary obstruction.
Multiple lab tests were pending at time of discharge.
# Chest paint: In the emergency department, patient reported
some chest pain. An ECG showed non-specific t-wave inversions
and initial troponins were mildly elevated at .02. Once he was
admitted his t-wave inversions resolved. Troponins were trended
x3 and never rose above .03.
Chronic Problems:
#Fabry's: Mr. ___ has Fabry's disease complicated by
ESRD. He takes fabeyzyme infusions at home twice a month but
tends to hold them when he is ill. On admission, he had been
overdue for fabryzyme by a week. It was decided to continue
holding his infusions while he was symptomatic and workup was
ongoing. Of note, his tunneled port that he uses for infusions
was partially clotted on admission requiring two treatments with
tPA, which resolved the occlusion.
# ESRD s/p transplant: His Cr had been stable throughout his
admission. He had a transplant US on admisision without acute
changes. His home doses of MMF and sirolimus were continued.
# HTN: Normotensive throughout admisison. Home metoprolol was
held in the setting of ongoing infection as it could mask
sepsis.
# HLD: His home statin was continued.
===============================
TRANSITIONAL ISSUES
===============================
- Patient needs repeat labs drawn at PCP. Please check CHEM 10,
LFTs, CBC.
- Discharged on 1 week of ciprofloxacin 500mg BID, metronidazole
500mg q8h (end date ___ for possible enteritis.
- Home metoprolol has been held in the setting of infection. He
was hemodynamically stable throughout admission. We recommended
re-starting metoprolol at discharge.
- Pt has not-received fabryzyme infusion during this admission
given acute illness. This should be re-started at the direction
of his outpatient provider.
- Extensive ID workup was completed and summarized below (please
see discharge summary or online record for comprehensive list).
- For pending labs, the inpatient primary attending physician
___ be notified of critical lab values. However, these results
must additionally be followed up by the patient's primary care
provider (Dr. ___.
PENDING
- Hep B, Hep C serologies
- Autoimmune hepatitis panel
- Ceruplasmin
- Alpha-1 antitrypsin
- Whipple's Disease PCR
- Yersinia Entercolitica IgG,IgA
- TB Quantiferon Gold
- Anaplasma antibody IgG, IgM
- EBV PCR
- Babesia antibodies IgG, IgM
- Arbovirus antibodies IgG, IgM
- Tissue fungal culture, acid fast culture
Full code (confirmed)
Contact ___ ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Mycophenolate Mofetil 500 mg PO BID
2. Sertraline 100 mg PO DAILY
3. Sirolimus 2 mg PO DAILY
4. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
5. Metoprolol Succinate XL 25 mg PO DAILY
6. Pravastatin 20 mg PO QPM
7. Calcium 600 with Vitamin D3 (calcium carbonate-vitamin D3)
600 mg(1,500mg) -200 unit oral BID
8. Fabrazyme (agalsidase beta) 90 injection INFUSION
9. ValACYclovir 500 mg PO Frequency is Unknown mouth sores
10. HYDROcodone-acetaminophen ___ mg oral Q8H:PRN pain
11. DiCYCLOmine 10 mg PO Frequency is Unknown
12. TraZODone 25 mg PO QHS:PRN sleep
13. Nystatin Oral Suspension 5 mL PO QID:PRN thrush
14. Ondansetron 8 mg PO Q8H:PRN nausea
15. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H:PRN headache
16. Doxycycline Hyclate 50 mg PO QID
Discharge Medications:
1. Mycophenolate Mofetil 500 mg PO BID
2. Pravastatin 20 mg PO QPM
3. Sertraline 100 mg PO DAILY
4. Sirolimus 2 mg PO DAILY
5. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
6. TraZODone 25 mg PO QHS:PRN sleep
7. Metoprolol Succinate XL 25 mg PO DAILY
8. Fabrazyme (agalsidase beta) 90 injection INFUSION
9. Ondansetron 8 mg PO Q8H:PRN nausea
10. Nystatin Oral Suspension 5 mL PO QID:PRN thrush
11. HYDROcodone-acetaminophen ___ mg oral Q8H:PRN pain
Do not take while taking oxycodone
12. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H:PRN headache
Hold while taking tylenol for fever control as can be damaging
to liver
13. Calcium 600 with Vitamin D3 (calcium carbonate-vitamin D3)
600 mg(1,500mg) -200 unit oral BID
14. DiCYCLOmine 10 mg PO PRN irritable stomach
15. ValACYclovir 500 mg PO PRN mouth sores
16. Ciprofloxacin HCl 500 mg PO Q12H Duration: 7 Days
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*14 Tablet Refills:*0
17. Lorazepam 0.5 mg PO Q6H:PRN nausea/anxiety
RX *lorazepam 0.5 mg 1 tablet by mouth every 6 hours Disp #*30
Tablet Refills:*0
18. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four hours Disp
#*60 Tablet Refills:*0
19. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H Duration: 7 Days
RX *metronidazole 500 mg 1 tablet(s) by mouth every 8 hours Disp
#*21 Tablet Refills:*0
20. Acetaminophen 500 mg PO Q6H:PRN fevers
21. Outpatient Lab Work
Lab: CBC, CHEM 10, LFTs
ICD 9: 276.___
Please send labs to: ___
___: ___
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
Enteritis
SECONDARY DIAGNOSIS
Fabry's Disease
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 diarrhea, rash, and fever. Your
diarrhea and rash improved during this hospitalization, but
fevers persisted. This prompted an extensive investigation for
an infection, but the tests we performed did not reveal any
obvious source. We also investigated non-infectious causes of
fever, such as autoimmune disorders, but this work-up was
unrevealing as well. Most likely, your symptoms were caused by a
transient virus. We continued the antibiotic you were started on
at ___ (doxycyline) for the full treatment duration,
and also treated your symptoms with acetaminophen. You were
discharged on one week of antibiotics to cover for the
gastroenteritis seen on CT scan of your abdomen. Please take
ciprofloxacin 500mg twice a day and metronidazole 500mg every 8
hours for a total of 7 days (___).
Please call your nephrologist or PCP if your rash worsens from
taking this medication.
Additionally, liver tests showed some mild abnormalities so an
MRI of your abdomen was obtained. It did not reveal a cause of
the abnormality such as a blockage of your gallbladder. Your
liver tests improved, and these abnormalities were thought best
explained as a side effect of the antibiotic you received
previously (doxycycline).
It is very important to measure your temperature regularly.
Though your fevers became less frequent and less severe during
the end of your hospitalization, they did not resolve
completely. You should continue taking acetaminophen (tylenol)
as needed, not to exceed 3 grams per day. Limit ibuprofen intake
to 400mg per day. Do not take other NSAIDs (e.g. naproxen). If
you continue to have persistent fevers ___ call your primary
physician ___.
VERY IMPORTANT: At the time of your discharge, some labwork was
still pending, and this must be followed up by your primary care
physician, infectious disease specialist, and nephrologist.
Please make sure to obtain updated records of lab work at each
clinic visit.
The stitches at your left arm biopsy site should be removed no
earlier on ___. You can get it removed from your PCP, or
your infusion nurse can remove it.
Thank you for allowing us to participate in your care.
Sincerely,
Your ___ team
Followup Instructions:
___
|
19606963-DS-23
| 19,606,963 | 28,508,405 |
DS
| 23 |
2132-06-16 00:00:00
|
2132-08-14 00:09:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Dicloxacillin / diltiazem
Attending: ___.
Chief Complaint:
cellulitis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ with a history of venous stasis, A fib on
coumadin, HTN, OSA, and gout who presents with swelling of the
left leg. He reports 2 days of swelling, however, worsening
erythema for 1 day. Painful with standing. Reports having a
'knot' on the outer portion of the leg which has since migrated
to his posterior thigh. Had one episode of chills 3 days ago, no
fevers. No h/o DVT or PE. Cellulitis in ___ with similar
presentation. Denies scratching, injuries to leg, has cats but
denies any recent scratches to skin. No recent travel, SOB,
cough, hemoptysis. Endorses dark urine for the past 2 days.
Denies dysuria, frequency, hesitancy, nocturia. No jaundice,
abdominal pain. 2 episode of diarrhea last night but has since
resolved. Was on vacation recently but did not travel, has not
been swimming. Has 2 cats at home; no scratches or bites.
In the ED, initial vital signs were T97.4 P 8 BP 118/78 R18 O2
sat 98%. Exam significant for erythema and swelling of L leg,
also palpable knot in thigh. Patient was given 1g vanc. ___
negative for DVT. Plain films of Tib/fib obtained to rule out
necrotizing fasciitis: no subq air.
Vitals on transfer 2 99.4 68 119/76 18 98% RA .
On the floor he has no pain, no complaints.
Review of Systems:
(+)
(-) fever, 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:
- Afib on coumadin
- HTN
- OSA
- chronic venous stasis
- obesity
- gout
- rosacea
Social History:
___
Family History:
Father ___ artery disease, colon cancer at age ___
No history of Inflammatory Bowel Disease
Physical Exam:
Vitals: 98.5 123/75 83 18 99% RA
GEN: NAD, ___: EOMI, sclera anicteric,
Neck: supple
CV: Irreg rhythm, regular rate, heart sounds distant ___
habitus, no m/r/g
Lungs: CTAB, no wheezes, rales or ronchi
Abdomen: obese, soft, NT/ND
Ext: Stable venous stasis ulcer. L leg with edema, erythema and
warmth extending from superior to ankle to thigh, erythema has
regressed from marked line, posterior thigh is more purple in
color rather than red. Overall improved erythema and warmth,
appears to be less tender upon palpation. There is minimal
induration and erythema around his upper/posterior left thigh
nodule, which seems to have also decreased in size
Lymph: no inguinal lymphadenopathy
Neuro: CN II-XII grossly intact, no focal deficits
Skin: blanching erythema of face and upper back, telangectasias
on cheeks and nose. Rhinophyma clearly evident
Pertinent Results:
___ 07:20PM PLT COUNT-225
___ 07:20PM NEUTS-78.2* LYMPHS-14.1* MONOS-6.6 EOS-0.7
BASOS-0.4
___ 07:20PM WBC-14.2* RBC-5.08 HGB-15.7 HCT-42.1 MCV-83
MCH-30.9 MCHC-37.2* RDW-13.5
___ 07:20PM estGFR-Using this
___ 07:20PM GLUCOSE-84 UREA N-25* CREAT-1.5* SODIUM-129*
POTASSIUM-4.1 CHLORIDE-94* TOTAL CO2-21* ANION GAP-18
___ 07:33PM LACTATE-1.4
LLE ultrasound:
IMPRESSION:
1.9 cm hypoechoic nodular lesion in the subcutaneous tissues of
the medial
inferior left thigh corresponding to the palpable abnormality.
The appearance
is non-specific but could be related to prior trauma or
potentially be
infectious and represent an area of phlegmon. There is no
discrete collection
to suggest abscess.
TECHNIQUE: Left tibia/ fibula, two views.
COMPARISON: ___.
FINDINGS: Mild soft tissue swelling involves much of the calf,
but there is
no subcutaneous emphysema. Superior enthesophyte of the patella
is more
apparent than on prior radiographs. There is no fracture or
dislocation.
There is no cortical breakthrough or periosteal reaction to
suggest
osteomyelitis.
IMPRESSION: Diffuse soft tissue swelling. No subcutaneous
emphysema.
left ___:
IMPRESSION: No evidence of deep vein thrombosis in the left
lower extremity,
although left peroneal veins were not visualized.
Brief Hospital Course:
PRIMARY:
left lower extremity cellulitis- portal of entry likely chronic
venous stasis ulcers. He was initially managed with
vancomycin, with slow improvement. Then added ceftriaxone for
enhanced Strep coverage, with more rapid resolution, although
still with significant posterior left leg cellulitis. An
ultrasound of the left medial thigh to eval for abscess, which
showed possible phlegmon. On day of discharge, it was
significantly improved, less tender, without erythema.
SECONDARY:
Atrial Fibrillation
Hypertension
Obstructive Sleep Apnea
Gout
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 20 mg PO DAILY
2. Allopurinol ___ mg PO DAILY
3. Metoprolol Tartrate 100 mg PO BID
4. Digoxin 0.125 mg PO DAILY
5. Warfarin 10 mg PO DAILY16
6. Spironolactone 25 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Hydrochlorothiazide 25 mg PO EVERY OTHER DAY
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Digoxin 0.125 mg PO DAILY
3. Hydrochlorothiazide 25 mg PO EVERY OTHER DAY
4. Lisinopril 20 mg PO DAILY
5. Metoprolol Tartrate 100 mg PO BID
6. Multivitamins 1 TAB PO DAILY
7. Spironolactone 25 mg PO DAILY
8. Warfarin 7.5 mg PO DAILY16
9. Sulfameth/Trimethoprim DS 2 TAB PO BID Duration: 5 Days
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1
tablet(s) by mouth twice a day Disp #*9 Tablet Refills:*0
10. Cephalexin 500 mg PO Q6H Duration: 5 Days
RX *cephalexin 500 mg 1 capsule(s) by mouth every six (6) hours
Disp #*18 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
left lower extremity cellulitis
SECONDARY:
Atrial Fibrillation
Hypertension
Obstructive Sleep Apnea
Gout
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 participating in your care while you were
inpatient at ___. You presented with an infection of the soft
tissue of your lower left leg. You were treated with two
antibiotics administered by an IV line: vancomycin and
ceftriaxone. Over the course of a few days, you showed signs of
clinical improvement. Given that you did not have a fever and
your leg improved significantly, you were discharged with close
follow-up. You will see Dr. ___ on ___. She
will not be your new primary care doctor, but it is important
that a physician evaluates your leg in a few days. We hope you
continue to feel better!
Followup Instructions:
___
|
19607228-DS-6
| 19,607,228 | 29,824,159 |
DS
| 6 |
2136-01-26 00:00:00
|
2136-01-27 21:05:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
___
Attending: ___.
Chief Complaint:
MVC: facial and neck lacerations, jaw fracture, soft tissue
injury to left arm
Major Surgical or Invasive Procedure:
___: repair of facial and neck lacerations, suturing left
arm laceration
History of Present Illness:
___ is a ___ year old male with PMHx of HLD who
presents via Med Flight to ___ s/p MVC earlier today. Patient
was a restrained driver when his pickup truck T-boned a tractor
trailer. Per report, airbags did not deploy and patient was able
to self-extricate. He arrived to the ED hemodynamically stable
with an injury burden that included extensive left facial soft
tissue lacerations, mandibular ramus fracture, and left
___ soft tissue injury. ___ surgery is consulted to
assist with management of the patient's LUE injury.
Past Medical History:
HLD
Social History:
___
Family History:
non-contributory
Physical Exam:
Physical Exam: upon admission: ___
Gen: A&Ox3, lying on stretcher. Neurologically intact and
emotionally handling situation well, calm and collected. Wife,
and employee/close family friend at bedside throughout and
supportive
CV: RRR
R: Breathing comfortably on room air. No wheezing.
HEENT: PERRL, EOMI. Visual acuity at baseline. No nasal septal
hematoma. Dentition grossly intact.
Sensation grossly intact and symmetric in V1, 2, 3
distributions.
VII function grossly intact and symmetric.
Numerous lacerations of nose, upper lip, lower lip, left cheek,
and neck secondary to glass shatter. Many of the lacerations
with
glass shards buried within laceration. Dried blood over majority
of face from eyes down.
Pertinent Results:
___ 06:20AM BLOOD WBC-7.5 RBC-3.93* Hgb-12.8* Hct-36.7*
MCV-93 MCH-32.6* MCHC-34.9 RDW-13.2 RDWSD-45.2 Plt ___
___ 01:05PM BLOOD Neuts-82.0* Lymphs-8.7* Monos-7.8
Eos-0.8* Baso-0.2 Im ___ AbsNeut-10.65* AbsLymp-1.13*
AbsMono-1.01* AbsEos-0.10 AbsBaso-0.02
___ 06:20AM BLOOD Plt ___
___ 01:05PM BLOOD ___ PTT-22.4* ___
___ 06:20AM BLOOD Glucose-121* UreaN-13 Creat-1.1 Na-140
K-3.9 Cl-105 HCO3-22 AnGap-13
___ 06:20AM BLOOD Calcium-8.9 Phos-2.8 Mg-2.0
___ 11:58AM BLOOD Glucose-111* Na-140 K-4.2 Cl-108
___ 11:58AM BLOOD Hgb-15.1 calcHCT-45
___: CT sinus:
1. Non-displaced fracture of the right mandibular ramus.
2. Left facial superficial injury with numerous radiopaque
foreign bodies as detailed.
___: CT chest:
Very minimal ground-glass opacity in the right upper lobe could
represent
subtle contusion. Otherwise, no acute sequelae of trauma.
___: left ___:
Skin debris versus foreign bodies within the soft tissues of the
left wrist and ___. Recommend repeat radiograph 1 superficial
debris has been removed 2 better assessed for retained foreign
bodies. No fracture.
___: left wrist:
Skin debris versus foreign bodies within the soft tissues of the
left wrist and ___. Recommend repeat radiograph 1 superficial
debris has been removed 2 better assessed for retained foreign
bodies. No fracture.
___: left elbow:
No fracture dislocation or joint effusion. Probable skin
debris or
superficial foreign bodies along the proximal forearm. Please
repeat imaging once surface debris has been removed to further
assess.
___: panorex mandible:
There is a minimally displaced fracture of the proximal ramus
of the right mandible, extending toward the coronoid process.
Brief Hospital Course:
___ year old male with PMHx of HLD who presents via Med Flight to
___ s/p MVC earlier today. Patient was a restrained driver
when his pickup truck T-boned a tractor trailer. Per report,
airbags did not deploy and patient was able to self-extricate.
He arrived to the ED hemodynamically stable and neurologically
intact, GCS 15, with no airway issues.
Thankfully, his CT scans were negative for acute intracranial
pathology or C-spine injuries. L ___ and elbow xrays
demonstrate glass fragments/foreign bodies but no fractures. CT
chest with mild pulmonary contusion. Injuries include R
mandibular ramus nondisplaced fracture (for which OMFS was
consulted), L ___ and forearm lacerations including complete
laceration of EDM, partial laceration of ECU, and a central slip
injury vs. EDC laceration of the L ___ finger, and extensive
lacerations and desquamation to his nose, lips, and neck
secondary to shattered glass. Both his ___ lacerations and
facial lacerations were severely burdened by shards of glass.
Plastic surgery was consulted for management of his facial
lacerations under Dr. ___ injuries under Dr.
___.
- Small 0.5 cm laceration on superior lip to the right of right
philtrum
- intra-oral horizontal 3-4cm laceration on inferior buccal
mucosa
- Vertically oriented, jagged laceration of inferior lip
- Desquamation of majority of nasal tip and left ala
- 4x4cm area of chunky desquamation on left cheek
- Numerous lacerations on anterior and left neck
His superficial upper lip laceration on right side through red
___ was re-approximated with ___ fast gut. His left lower
lip laceration through red vermilion border was re-approximated
with ___ fast to the mucosa and ___ nylon to the skin adjacent
to lip. Intra-oral lacerations x2 of the vestibule
without exposed muscle re-approximated with ___ chromic. Deeper
lacerations of over left mandible and mental region were
repaired with ___ monocryl deep and interrupted ___ nylon
sutures. Avulsed
lacerations x ___losed with ___ monocyl deep
and ___ nylon suture. Deep wound of right submental region
unable to be re-approximated without significant distortion of
surrounding
tissues so xeroform dressing placed. He will be followed up in
Plastic Surgery Clinic in 7 days for suture
removal.
___ surgery was consulted to assist with management of the
patient's LUE injury. He had full range of motion to FDP,FDS of
digits. Extensor lag noted at middle finger with equivocal
___ test secondary to
pain. They recommended follow up in ___ Surgery clinic, Dr.
___ one week to discuss need for possible tendon
repair.
___ was consulted to assist with management of his nondisplaced
R mandibular ramus fracture. They recommeded no surgical
intervention required and full liquid diet for two weeks.
Patient was evaluated by ___, which classified him as independent
to perform activities. Patient was safe to discharge home. At
time of discharge his pain was well controlled, patient was
independent in ambulation, GCS 15, tolerating full liquids.
Medications on Admission:
ASA 81, simvastatin, fenofibrate
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Docusate Sodium 100 mg PO BID
hold for diarrhea
3. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
may cause dizziness
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*8 Tablet Refills:*0
4. Aspirin 81 mg PO DAILY
begin ___. Fenofibrate 54 mg PO DAILY
6. Simvastatin 20 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
MVC: non-displaced mandibular fracture
facial and neck lacerations
soft tissue injury of left upper extremity
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital after you were involved in a
MVC in which you sustained facial and neck lacerations, a jaw
fracture, and a soft tissue injury to your right wrist. You
were evaluated by the Plastic surgery service who placed facial
sutures. The Orthopedic service placed your right arm in a
splint with recommended dressing changes. You did not require
surgery for your manbible fracture. Your pain has been
controlled with oral analgesia. You were evaluated by
Occupational therapy and cleared for discharge home with the
following instructions:
Instructions for facial lacerations:
- Bacitracin BID and PRN to abrasions & suture lines, with
xeroform over large exposed areas (change BID).
- Can rinse with water, pat dry, re-apply ointment. Keep face
injuries moist with ointment. ___ shower, and recommend
showering given diffuse glass shards
- Head of bed elevation to mitigate facial edema
Instructions from the ___ service:
Daily dressing changes with adaptic to abrasions, xeroform to
suture lines, WTD packing of dorsal wrist wound; wrap with kling
wrap and apply volar resting splint with ace. You will follow-up
in clinic on ___.
Other general instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following: The Acute care
clnic telephone number: ___
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Followup Instructions:
___
|
19607507-DS-23
| 19,607,507 | 29,980,558 |
DS
| 23 |
2149-11-08 00:00:00
|
2149-11-09 18:02:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Compazine
Attending: ___.
Chief Complaint:
N/V/D Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o M PMH significant to protein-losing enteropathy secondary
to Menetriere's disease s/p Total gastrectomy with Roux-en-Y
reconstruction and jejunostomy on ___, ATIII deficiency on
lovenox, hypogammaglobulinemia, recently discharged from
surgical service on ___ after total gastrectomy with Roux-en-Y
reconstruction and jejunostomy on ___ with his hospital
course complicated by Cdiff who presents to ED with N/V and
worsening diarrhea.
The following history was obtained with the assistance of a
phone interpreter. He reports that even when he was in the
hospital he was unable to tolerate po and had decreased
appetite. He would only drink small amounts of milk. When he
went home he was continuing on his tubefeeds, but reported that
he decreased po further given that he was consistently feeling
nauseated. Then two days prior to admission, he reported that
his nausea severely worsened with associated NBNB noncoffee
grounds emesis that he reports was mostly saliva. He also
reported that at night his generalized sharp abdominal pain was
___ for which he would take dilaudid which partially relieved
his pain. He reported that after he finished his course of
vancomycin, his diarrhea improved. However, he reported that he
was having worsening black diarrhea. He reports that the color
is approximately at his baseline. He denies any fevers, chills,
chest pain, SOB, DOE, CP, dysuria.
Vitals in the ED:98.3 104 132/85 21 100%
Labs notable for: Na 130 (baseline), Cr 0.4. WBC 12 and H&H
10.6/33.2 (approximately above his baseline), lactate 1.7. AST
85, ALT 47, AlkP159, Albumin 2.2. He underwent CXR that did not
show free air. CT abdomen/pelvis showed Thickening of the distal
esophagus and contrast within the distal esophageal lumen. He
was evaluated by Surgery (___ 3) who recommended admission to
medicine as there was no acute surgical intervention.
Patient given:1L NS, morphine total of 15mgIV. Zofran, total of
8mg, and metoclopramide. Blood cultures were obtained.
Vitals prior to transfer: 98.3 74 ___ 98% RA
On the floor, continues to have N/V/D.
Review of Systems:
(+) per HPI
Past Medical History:
Left deep femoral arterial thrombosis
Anti-thrombin III deficiency
Severe hypoalbuminemia
Protein-losing enteropathy secondary to Menetriere's disease s/p
Total gastrectomy with Roux-en-Y reconstruction and jejunostomy
on ___.
H. pylori gastritis, treated with subsequent negative stool
antigen
Positive Quantiferon Gold - Latent MTb
Thoracic duct bypass
Cdiff in ___
Social History:
___
Family History:
No history of GI malignancy, GI disease (specifically no
protein-losing enteropathies), inflammatory bowel disease, or
lymphoma.
Physical Exam:
ADMISSION PHYSICAL EXAM
====================================
Vitals - T:98.2 106/67 86 18 98%RA
GENERAL: NAD, AOx3
HEENT: AT/NC, EOMI, PERRL
White exudates on tongue, none visualized on buccal mucosa
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, No appreciable MRG
LUNG: CTAB, no wheezes, rales, rhonchi
ABDOMEN: Midline surgical scar without erythema tenderness or
drainage. Surgical staples in place
J tube in place with dressing C/D/I
NABS, generalized abdominal tenderness without rebound or
guarding
EXTREMITIES: Trace b/l ___ edema. moving all 4 extremities with
purpose
PULSES: 2+ DP pulses bilaterally
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM
====================================
Vitals - T:99.2 (T max 100.2) 113/73 109 18 96%RA ___
GENERAL: NAD, AOx3
HEENT: AT/NC, non-icteric sclera. Geographical tongue, buccal
mucosa without lesions. Mild periorbital edema.
NECK: nontender supple neck, no JVD
CARDIAC: RRR, S1/S2, No M/R/G
LUNG: CTAB, no wheezes, rales, rhonchi
ABDOMEN: Midline surgical scar without erythema tenderness or
drainage. Surgical staples removed. J tube in place with
dressing C/D/I. NABS, no tenderness to palpation, no rebound or
guarding
EXTREMITIES: No b/l ___ edema. moving all 4 extremities with
purpose
PULSES: 2+ DP pulses bilaterally
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS
======================
___ 01:05PM BLOOD WBC-12.0* RBC-4.53*# Hgb-10.6*#
Hct-33.2*# MCV-73* MCH-23.3* MCHC-31.8 RDW-18.5* Plt ___
___ 01:05PM BLOOD Neuts-64.6 ___ Monos-5.5 Eos-1.3
Baso-0.3
___ 01:05PM BLOOD Hypochr-3+ Anisocy-2+ Poiklo-2+
Macrocy-1+ Microcy-2+ Polychr-NORMAL Ovalocy-1+
___ 01:05PM BLOOD Glucose-113* UreaN-11 Creat-0.4* Na-130*
K-4.4 Cl-96 HCO3-25 AnGap-13
___ 01:05PM BLOOD ALT-85* AST-47* AlkPhos-159* TotBili-0.1
___ 01:05PM BLOOD Albumin-2.2* Calcium-7.7* Phos-4.2 Mg-1.9
___ 01:22PM BLOOD Lactate-1.7
PERTINENT LABS
======================
___ 07:35AM BLOOD ___
___ 07:15AM BLOOD ALT-87* AST-51* LD(LDH)-119 AlkPhos-226*
TotBili-0.1
___ 07:15AM BLOOD Albumin-1.7* Calcium-7.8* Phos-5.3*
Mg-1.7
___ 07:15AM BLOOD Hapto-217*
___ 07:35AM BLOOD IgG-991 IgA-155 IgM-155
___ 07:35AM BLOOD PREALBUMIN-14
DISCHARGE LABS
======================
___ 07:15AM BLOOD WBC-11.7* RBC-3.92* Hgb-8.9* Hct-28.6*
MCV-73* MCH-22.7* MCHC-31.0 RDW-18.6* Plt ___
___ 07:15AM BLOOD Glucose-102* UreaN-8 Creat-0.5 Na-130*
K-4.4 Cl-98 HCO3-25 AnGap-11
MICROBIOLOGY
======================
Blood cultures - NGTD at discharge
RADIOLOGY
======================
___ - PORTABLE CXR
FINDINGS:
No evidence of free air. Cardiomediastinal silhouette is normal.
There is no
focal lung consolidation. There is no pleural effusion or
pneumothorax.
Midline surgical staples are noted within the abdomen. Right
basilar
calcified granuloma again noted.
IMPRESSION:
No evidence of free air.
___- CT ABDOMEN WITH CONTRAST
FINDINGS:
There is a calcified granuloma at the right lung base. No
pleural or
pericardial effusion is seen.
LIVER: Geographic hypodensity along the left lobe may be related
to retractor
injury.There is no focal hepatic mass or intrahepatic biliary
duct dilation.
The portal vein is patent. The nondistended gallbladder is
within normal
limits, without wall thickening or pericholecystic fluid.
SPLEEN: The spleen is homogeneous and normal in size.
PANCREAS: The pancreas is without focal lesion or peripancreatic
stranding or
fluid collection.
ADRENALS: The adrenal glands are unremarkable.
KIDNEYS: The kidneys demonstrate symmetric nephrograms and
excrete contrast
promptly. There is no focal lesion or hydronephrosis.
GI:There is mild wall thickening of the distal esophagus
consistent with a
mild esophagitis, with contrast seen within the distal esophagus
likely
related to the patient's nausea/vomiting. The patient is status
post
gastrectomy and Roux-en-Y surgery, with the expected
postsurgical changes. A
small amount of non-organized free fluid adjacent to the
gastrectomy bed is
likely postsurgical. Percutaneous jejunostomy tube is noted,
unremarkable in
appearance. The small and large bowel demonstrate normal
caliber, without wall
thickening or evidence of obstruction. The large bowel is
fluid-filled.
RETROPERITONEUM: The aorta is normal in caliber, with no
atherosclerotic
calcifications.There is no retroperitoneal or mesenteric lymph
node
enlargement by CT size criteria. Hyperdense material within the
retroperitoneal and iliac lymphatics is noted, likely related to
prior
lymphangiogram
CT PELVIS: The urinary bladder appears normal.No pelvic wall or
inguinal lymph
node enlargement by CT size criteria is seen.There is no pelvic
free fluid.
OSSEOUS STRUCTURES:No focal lesion suspicious for malignancy
present. Midline
skin staples are seen within the anterior abdomen.
IMPRESSION:
1. Status post gastrectomy and Roux-en-Y surgery, with the
expected
postsurgical changes including a small amount of free fluid in
the gastrectomy
bed. No evidence of bowel obstruction or drainable fluid
collection.
2. Thickening of the distal esophagus and contrast within the
distal
esophageal lumen likely related to esophagitis and reflux, given
the patient's
nausea and vomiting.
3. Geographic hypodensity along the left lobe of the liver is
likely related
to retractor injury.
CARDIOLOGY
======================
Cardiovascular ReportECGStudy Date of ___ 1:36:52 ___
Sinus rhythm. Non-specific inferolateral T wave flattening.
Compared to the
previous tracing of ___ sinus tachycardia is absent. T wave
flattening is
new in leads V3-V6.
IntervalsAxes
___
___
PATHOLOGY/BLOOD BANK
======================
Difficult crossmatch and/or evaluation of irregular antibody (s)
CLINICAL/LAB DATA: Mr. ___ is a ___ year old man with a past
medical
history of severe protein loosing enteropathy s/p total
gastrectomy and
roux-en-y jejunostomy. A sample was sent for type and screen.
Laboratory Testing:
Patient ABO/Rh: Group O, Rh positive
Antibody Screen: Positive
Antibody Identity: Anti-E
DAT (Neo): Positive
Eluate: Positive with Anti-E specificity
Patient Phenotype: Could not be determined due to recent
transfusion
(2 units on ___ and ___
Phenotype of recently transfused red cell units: ___
positive,
patient is at risk for hemolysis (Dr. ___ notified on
___
Transfusion History:
Previous non-reactive red cell transfusions: 15
DIAGNOSIS, ASSESSMENT AND RECOMMENDATIONS: Mr. ___ has a new
diagnosis of Anti-E antibody in the setting of recent
transfusion of 2
units of electronically crossmatched, leukoreduced red blood
cells on
___ and ___. At that time, Mr. ___ screen
was
negative. After the identification of a new Anti-E antibody,
both units
were tested and found to be ___ positive. In addition, the
DAT is
positive and the eluate showed specificity for ___
confirming the
presence of an anti-E antibody. The transfused red cells may
remain in
circulation for up to 3 months puting Mr. ___ at risk for
hemolysis
in the setting of a developing Anti-E antibody. We recommend
serial
measurement of hemoglobin, LDH, bilirubin, and haptoglobin
levels and
red blood cell transfusion (with ___ negative RBCs) if
clinically
indicated for symptomatic anemia. This was communicated to Dr.
___ on ___.
___ is a member of the ___ blood group system. Anti-E
antibody is
clinically significant and capable of causing hemolytic
transfusion
reactions. In the future, Mr. ___ should receive ___
negative
products for all red cell transfusions. Approximately 71% of ABO
compatible blood will be ___ negative. A wallet card and a
letter
stating the above will be sent to the patient.
Brief Hospital Course:
___ y/o M PMH significant to protein-losing enteropathy secondary
to suspected Menetriere's disease s/p Total gastrectomy with
Roux-en-Y reconstruction and jejunostomy on ___, ATIII
deficiency on lovenox, hypogammaglobulinemia, recently
discharged from surgical service on ___ after total gastrectomy
with Roux-en-Y reconstruction and jejunostomy on ___ with
his hospital course complicated by Cdiff who presents to ED with
N/V and diarrhea.
# N/V/Abdominal pain/Diarrhea: His symptoms improved with IV
pain control, anti-nausea medications, and IVF. Overall his
clinical picture seems most consistent with a viral enteritis.
He was initially given an IV PPI (discontinued as he no longer
has gastric tissue) and PO vanc (discontinued after 24 hours
without a BM). Although he had recent c. diff diagnosed the
prior month and finished his PO vanco course 4 days prior to
admission, the fact that he stopped having bowel movements (and
repeat c. diff testing was unable to be sent due to lack of
specimen) was considered strong evidence this was not c. diff.
In addition to post surgical changes, CT scan revealed
thickening of distal esophagus, however he did not have
dysphasia or odynophagia. There was a thought that tube feeds
could be contributing (possibly due to high osmolality), however
they were resumed at their prescription and he did not
experience recurrence of diarrhea or N/V for 36 hours. GI was
consulted, and deferred intervention (EGD to evaluate
anastamosis site for ?stricture) as his symptoms improved. He
was tolerating PO medications and pizza/salad meals prior to
discharge.
# Recent Gastrectomy and Roux-en-Y reconstruction + jejunostomy:
Surgical scar appeared well healed and non-infected. Surgery
followed him during this admission, and staples were removed on
___.
# Protein-losing enteropathy secondary to Menetriere's disease
s/p Total gastrectomy with Roux-en-Y reconstruction and
jejunostomy on ___, complicated by hypoalbuminemia:
Immunoglobulins and prealbumin were checked given concern for
absorption with diarrhea and nausea/vomiting. Immunoglobulins
were WNL, however albumin and prealbumin were low, which
represented a decline from previous discharge values. However,
this was in the setting of an inflammatory state (indicated by
elevated platelets and haptoglobin), likely due to a viral
enteritis. He was given albumin influsion x 1 on ___,
however, after discussion with his outpatient
gastroenterologist, it was decided to avoid further albumin
transfusions.
# Pain control: He was continued on home fentanyl patch, PO
dilaudid, gabapentin, lidocaine patch, and amitriptyline.
Initially IV dilaudid was given to manage pain, which improved
and he was converted to oral dilaudid again prior to discharge.
# ATIII deficiency with Left deep femoral arterial thrombosis:
Continued previous anticoagulation with lovenox ___ BID.
===================================
Transitional issues:
===================================
-Needs surgery f/u and close GI f/u
-should continue home tube feeds
-It was explained to the patient and his wife that he will
likely continue to have nausea/abdominal pain at home, as these
are chronic issues, but that his acute exacerbation symptoms
(likely due to viral enteritis) have resolved.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amitriptyline 25 mg PO HS
2. Dronabinol 5 mg PO BID
3. gabapentin 300 mg/6 mL (6 mL) oral TID
4. Hydrocerin 1 Appl TP BID
5. Lidocaine 5% Patch 1 PTCH TD QPM
6. Simethicone 80 mg PO QID:PRN gas
7. Vitamin D 50,000 UNIT PO 1X/WEEK (FR)
8. Bisacodyl ___ID:PRN constipation
9. Cyanocobalamin 1000 mcg IM/SC QMONTH
10. Ondansetron 4 mg PO Q8H:PRN nausea
11. polyvinyl alcohol 2 drops ophthalmic q4h:prn
12. Calcium Carbonate 500 mg PO BID
13. Docusate Sodium 100 mg PO BID
14. HYDROmorphone (Dilaudid) 6 mg PO Q4H:PRN pain
15. Senna 8.6 mg PO DAILY
16. Enoxaparin Sodium 120 mg SC Q12H
Start: ___, First Dose: Next Routine Administration Time
17. Fentanyl Patch 200 mcg/h TD Q72H
18. Sodium Chloride 2 gm PO TID
19. Acetaminophen 1000 mg PO Q8H:PRN pain
20. Ursodiol 300 mg PO BID
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN pain
2. Amitriptyline 25 mg PO HS
3. Bisacodyl ___ID:PRN constipation
4. Calcium Carbonate 500 mg PO BID
5. Docusate Sodium 100 mg PO BID
6. Dronabinol 5 mg PO BID
RX *dronabinol 5 mg 1 capsule(s) by mouth twice daily Disp #*30
Capsule Refills:*0
7. Enoxaparin Sodium 120 mg SC Q12H
Start: ___, First Dose: Next Routine Administration Time
8. Fentanyl Patch 200 mcg/h TD Q72H
RX *fentanyl 100 mcg/hour ___ patches every 72 hours Disp #*20
Patch Refills:*0
9. gabapentin 300 mg/6 mL (6 mL) oral TID
10. Hydrocerin 1 Appl TP BID
11. HYDROmorphone (Dilaudid) 6 mg PO Q4H:PRN pain
RX *hydromorphone 2 mg 3 tablet(s) by mouth every 4 hours Disp
#*60 Tablet Refills:*0
12. Lidocaine 5% Patch 1 PTCH TD QPM
13. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth every 8 hours Disp
#*30 Tablet Refills:*0
14. Senna 8.6 mg PO DAILY
15. Simethicone 80 mg PO QID:PRN gas
16. Sodium Chloride 2 gm PO TID
17. Ursodiol 300 mg PO BID
18. Vitamin D 50,000 UNIT PO 1X/WEEK (FR)
19. Cyanocobalamin 1000 mcg IM/SC QMONTH
20. polyvinyl alcohol 2 drops ophthalmic q4h:prn
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: nausea/vomiting/diarrhea, abdominal pain, likely viral
gastroenteritis
Secondary: protein losing enteropathy, ATIII deficiency
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure to care for you at ___. You were admitted
with nausea/vomiting and abdominal pain. You were seen by
surgery, who did not think this was a surgical issue. We
temporarily held your tube feeds and your symptoms improved.
Your sympoms were likely due to a viral gastroenteritis. We are
discharging you home with close followup with GI and surgery.
Take care,
Your ___ medicine team
Followup Instructions:
___
|
19607628-DS-20
| 19,607,628 | 25,914,233 |
DS
| 20 |
2144-02-03 00:00:00
|
2144-02-03 22:39:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Dr. ___ is a ___ year old man ___ asthma presenting with 3
days of abdominal pain. He is currently staying in ___ for a
short period of time for a business trip, and lives in ___. His vague lower abdominal discomfort started on ___.
He
attributed his symptoms to constipation, and took over the
counter stool softeners and laxatives, which produced diarrhea.
His symptoms did not improve, and he presented to the ___ ED
for further care. A CT A/P was performed which showed scattered
free intraperitoneal air, diverticulosis, and inflamed sigmoid
colon consistent with perforated diverticulitis. ACS was
consulted, and on their exam was found to be peritoneal. He was
offered a ___ operation, which he declined due to the
requirement of an ostomy. Colorectal surgery was consulted for a
second opinion.
On initial assessment, Dr. ___ fever, chills, nausea,
vomiting, chest pain, shortness of breath, cough, or dysuria. He
had a colonoscopy ___ years ago that was reportedly normal. He
has never had an episode of diverticulitis.
Past Medical History:
asthma, HLD, anxiety
Social History:
___
Family History:
Noncontributory
Physical Exam:
Gen: [x] NAD, [x] AAOx3
CV: [x] RRR, [] murmur
Resp: [x] breaths unlabored, [] CTAB, [] wheezing, [] rales
Abdomen: [x] soft, [] distended, [] tender, [] rebound/guarding
Wound: [x] incisions clean, dry, intact
Ext: [x] warm, [] tender, [] edema
Pertinent Results:
___ 07:58AM BLOOD WBC-6.8 RBC-4.30* Hgb-13.3* Hct-41.0
MCV-95 MCH-30.9 MCHC-32.4 RDW-12.3 RDWSD-42.8 Plt ___
___ 06:40AM BLOOD WBC-8.2 RBC-4.15* Hgb-13.0* Hct-39.5*
MCV-95 MCH-31.3 MCHC-32.9 RDW-12.4 RDWSD-43.8 Plt ___
___ 05:10AM BLOOD WBC-12.9* RBC-4.53* Hgb-14.2 Hct-42.1
MCV-93 MCH-31.3 MCHC-33.7 RDW-12.6 RDWSD-43.1 Plt ___
___ 10:39PM BLOOD WBC-10.3* RBC-5.08 Hgb-16.0 Hct-47.7
MCV-94 MCH-31.5 MCHC-33.5 RDW-12.5 RDWSD-43.2 Plt ___
___ 10:39PM BLOOD WBC-10.3* RBC-5.08 Hgb-16.0 Hct-47.7
MCV-94 MCH-31.5 MCHC-33.5 RDW-12.5 RDWSD-43.2 Plt ___
___ 10:42PM BLOOD ___ PTT-31.3 ___
___ 07:58AM BLOOD Glucose-103* UreaN-9 Creat-0.9 Na-142
K-4.4 Cl-102 HCO3-29 AnGap-11
___ 06:40AM BLOOD Glucose-101* UreaN-10 Creat-0.9 Na-141
K-3.7 Cl-99 HCO3-30 AnGap-12
___ 05:10AM BLOOD Glucose-145* UreaN-13 Creat-1.0 Na-138
K-4.0 Cl-102 HCO3-23 AnGap-13
___ 10:39PM BLOOD Glucose-120* UreaN-16 Creat-1.2 Na-141
K-3.9 Cl-100 HCO3-___ AnGap-15
___ 07:58AM BLOOD Calcium-9.4 Phos-3.3 Mg-2.0
___ 06:40AM BLOOD Calcium-8.8 Phos-2.9 Mg-2.1
___ 05:10AM BLOOD Calcium-9.3 Phos-2.7 Mg-1.5*
___ 10:39PM BLOOD Albumin-4.8
Brief Hospital Course:
Mr. ___ presented to ___ ED on ___ due to abdominal
pain. He underwent a CT scan which demonstrated perferated
diverticulitis with free air ithe abdomen. ACS was consulted a
pouch surgery was offered. The patient refused, and CRS were
consulted next. CRS offered to to manage with conervative
efforts.
Neuro: Pain was well controlled on Tylenol and tramadol for
breakthrough pain.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulm: The patient remained stable from a pulmonary standpoint;
oxygen saturation was routinely monitored. He/She had good
pulmonary toileting, as early ambulation and incentive
spirometry were encouraged throughout hospitalization.
GI: The patient was initially kept NPO. The patient was advanced
to and tolerated a full liquid diet. Patient's intake and output
were closely monitored.
GU: At time of discharge, the patient was voiding without
difficulty. Urine output was monitored as indicated.
ID: The patient was closely monitored for signs and symptoms of
infection and fever, of which there was none. The patient was
initially given IV zosyn and ceftriaxone. Once tolerating PO was
discharged with augmentin to be taken for 10 days.
Heme: The patient received subcutaneous heparin and ___ dyne
boots during this stay. He was encouraged to get up and ambulate
as early as possible.
On ___, the patient was discharged to home. At discharge, he
was tolerating a full liquid diet, passing flatus, voiding, and
ambulating independently. He will follow up with his home PCP
and GI doctor when he returns to ___. On He was instructed to
advance to a regular low residue diet on the morning of ___.
This information was communicated to the patient directly prior
to discharge.
Post-Surgical Complications During Inpatient Admission:
[ ] Post-Operative Ileus resolving w/o NGT
[ ] Post-Operative Ileus requiring management with NGT
[ ] UTI
[ ] Wound Infection
[ ] Anastomotic Leak
[ ] Staple Line Bleed
[ ] Congestive Heart failure
[ ] ARF
[ ] Acute Urinary retention, failure to void after Foley D/C'd
[ ] Acute Urinary Retention requiring discharge with Foley
Catheter
[ ] DVT
[ ] Pneumonia
[ ] Abscess
[x] None
Social Issues Causing a Delay in Discharge:
[ ] Delay in organization of ___ services
[ ] Difficulty finding appropriate rehab hospital disposition.
[ ] Lack of insurance coverage for ___ services
[ ] Lack of insurance coverage for prescribed medications.
[ ] Family not agreeable to discharge plan.
[ ] Patient knowledge deficit related to ileostomy delaying
dispo
[x] No social factors contributing in delay of discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Dulera (mometasone-formoterol) 200-5 mcg/actuation inhalation
BID
2. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN dyspnea
3. Montelukast 10 mg PO DAILY
4. DULoxetine ___ 60 mg PO DAILY
5. Atorvastatin 20 mg PO QPM
6. Omeprazole 40 mg PO DAILY
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q24H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth twice a day Disp #*20 Tablet Refills:*0
2. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN
dyspnea
3. Atorvastatin 20 mg PO QPM
4. Dulera (mometasone-formoterol) 200-5 mcg/actuation
inhalation BID
5. DULoxetine ___ 60 mg PO DAILY
6. Montelukast 10 mg PO DAILY
7. Omeprazole 40 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Perforated Diverticulitis
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 perforated diverticulitis.
You were given bowel rest, intravenous fluids, and antibiotics.
Your pain has has subsequently resolved after conservative
management. You are tolerating a liquid diet,and your pain is
controlled with pain medications by mouth.
If you have any of the following symptoms, please call the
office 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. Please continue to take a
liquid diet until ___ morning. Eat processed, canned
liquids, nothing home made. You make switch to a low residue
diet On ___ morning.
Thank you for allowing us to participate in your care, we wish
you all the best!
Followup Instructions:
___
|
19608147-DS-12
| 19,608,147 | 26,279,337 |
DS
| 12 |
2145-01-29 00:00:00
|
2145-01-30 19:20:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
NSAIDS (Non-Steroidal Anti-Inflammatory Drug)
Attending: ___.
Chief Complaint:
Hematemesis
Major Surgical or Invasive Procedure:
Endoscopy
History of Present Illness:
___ with a history of HIV (last CD4 700 in ___, prior GI
bleed
in ___ from ulcerated mass treated w/ coil embolization c/b
necrosis of transverse colon and underwent ileostomy who
presents
with 4 episodes of hematemesis since 1 AM and lightheadedness.
Patient has been taking at least 500 mg two to three times daily
of ibuprofen for clavicular fracture since ___. On
___, patient was in his usual state of health. However, later
that night he felt nauseous and vomited about 1 cup of blood
total and subsequently came to the ED. States he had some dark
ostomy output a few days ago that cleared up. No blood in his
ostomy. No abdominal pain, chest pain, fevers, chills, shortness
of breath.
In the ED, initial VS were:
97.4 85 ___ 99% RA
Exam notable for:
Soft and nontender belly
Labs showed:
H/H 7.6/23.2
Consults: GI was consulted and will add on for EGD this AM.
Patient received: IV Esomeprazole sodium 40 mg
Transfer VS were:
88 107/63 20 98% RA
On arrival to the floor, patient endorses the above history. His
lightheadedness has resolved. Continues to deny chest pain,
dyspnea, abdominal pain, nausea.
Past Medical History:
-HIV - ___ CD4 700, VL 0
-Chronic non-healing PUD in the setting of high dose NSAIDs c/b
bleeding in ___ requiring exlap, LOA, partial gastrectomy c/b
ischemic bowel with perforation and fascial dehiscence s/p
right/transverse partial colectomies, end ileostomy, G-tube
placement
-Sigmoidectomy after traumatic injury.
-Chronic left shoulder and periscapular pain
following a traumatic event and fractures to the clavicle and
acromion.
-Depression
-Anxiety
Social History:
___
Family History:
No history of PUD; father died of brain aneurysm rupture at age
___.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: 98.4 80 100/65 18 100% RA
GENERAL: NAD
HEENT: MMM
HEART: RRR, S1/S2, no murmurs
LUNGS: CTAB, no wheezes, breathing comfortably without use of
accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding. Has ostomy bag with hard black stools in LLQ.
Large well-healed surgical midline scar.
EXTREMITIES: no cyanosis, clubbing, or edema. warm.
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
========================
VS: ___ 0710 Temp: 97.5 PO HR: 75 BP: 105/67 R Sitting RR:
18 O2 sat: 95% O2 delivery: ra
GENERAL: NAD
HEENT: MMM
HEART: RRR, S1/S2, no murmurs
LUNGS: CTAB, no wheezes, breathing comfortably without use of
accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding. Has ostomy bag with green/brown stool.
Large well-healed surgical midline scar.
EXTREMITIES: wwp, no edema.
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
Pertinent Results:
ADMISSION LABS:
==================
___ 02:03AM BLOOD WBC-13.5*# RBC-2.35* Hgb-7.6* Hct-23.2*
MCV-99*# MCH-32.3*# MCHC-32.8 RDW-13.8 RDWSD-48.7* Plt ___
___ 02:03AM BLOOD Neuts-71.9* Lymphs-16.0* Monos-8.2
Eos-2.9 Baso-0.3 Im ___ AbsNeut-9.67* AbsLymp-2.15
AbsMono-1.11* AbsEos-0.39 AbsBaso-0.04
___ 02:03AM BLOOD ___ PTT-25.7 ___
___ 09:50PM BLOOD ___
___ 06:30AM BLOOD ___ 02:03AM BLOOD Glucose-88 UreaN-48* Creat-1.1 Na-142
K-3.7 Cl-108 HCO3-24 AnGap-10
___ 02:03AM BLOOD Calcium-7.7* Phos-3.3 Mg-1.8
___ 02:09AM BLOOD Lactate-1.5
PERTINENT STUDIES
==================
RIGHT UPPER EXTREMITY DUPLEX US (___)
1. No evidence of deep vein thrombosis in the right upper
extremity.
2. Occlusive thrombus seen within a portion of the right basilic
vein in the
forearm. Note is made that the right basilic vein is a
superficial vein.
CTA ABD/PELVIS (___)
1. No evidence of active contrast extravasation. A 3.0 x 2.8 cm
cavity
posterior to the gastric fundus likely reflects that seen
postoperatively in
___, and appears to communicate with the stomach. This could
potentially
reflect the ulceration seen on recent endoscopy. Complete
evaluation of the
cavity is slightly limited due to the absence of oral contrast.
No free
intraperitoneal air.
2. Extensive postsurgical changes following partial
gastrectomy and extended
right hemicolectomy with right lower quadrant ileostomy. No
evidence of bowel
obstruction or anastomotic failure.
3. Status post splenic artery embolization with chronic
splenic infarct.
DISCHARGE LABS:
==================
___ 06:40AM BLOOD WBC-5.7 RBC-2.92* Hgb-9.3* Hct-28.6*
MCV-98 MCH-31.8 MCHC-32.5 RDW-15.9* RDWSD-56.6* Plt ___
___ 06:40AM BLOOD Plt ___
___ 06:40AM BLOOD Glucose-113* UreaN-11 Creat-1.0 Na-140
K-4.1 Cl-99 HCO3-29 AnGap-12
___ 06:40AM BLOOD Calcium-8.9 Phos-3.5 Mg-1.9
PERTINENT LABS:
==================
___ 06:40AM BLOOD WBC-5.7 RBC-2.92* Hgb-9.3* Hct-28.6*
MCV-98 MCH-31.8 MCHC-32.5 RDW-15.9* RDWSD-56.6* Plt ___
Brief Hospital Course:
Mr. ___ is a ___ year old man with a history of HIV on
treatment (CD4 count 700 ___, prior GI bleed in ___ gastric ulcer with course complicated by partial gastrectomy
and bowel ischema now s/p ileostomy who presented with massive
hematemesis found to have a deep 4.5cm ulcer with a visible
vessel in the fundus of the stomach.
ACTIVE ISSUES
-------------
#Gastric ulcer
#Upper GI Bleed:
EGD ___ showed a deep 4.5cm ulcer with a visible vessel in the
fundus of the stomach, likely secondary to NSAID use in the
setting of clavicular injury. GI was unable to intervene
endoscopically on initial EGD given the size of the ulcer.
General surgery was consulted, who noted he was a very high
surgical risk given his complicated surgical history and
post-operative anatomy. Specifically, he developed a non-healing
gasrtic ulcer in
___ from high dose NSAID use, requiring partial gastrectomy
with post-operative course complicated by ischemic bowel now
status post partial bowel resection and ileostomy. Patient
himself stated he would not want surgery given the associated
risk. Interventional radiology was also consulted, who noted his
risk of significant necrosis if embolization were pursued. Given
this, he was medically managed with sucralfate and IV
Esomeprazole, and transfusions. Repeat EGD on ___ demonstrated
an ulcer that was able to be cauterized and injected with
epinephrine. Post-procedurally he did not have recurrent
episodes of hemoptysis or evidence of GI bleeding. Diet was
advanced slowly to mechanical softs, which he will continue. Hgb
remained stable with no bloody ostomy output. Able to be
discharged with plan for lifetime PPI with plan for close GI
follow up.
#Acute kidney injury
Patient had uptrending Cr to 1.0, from baseline 0.6-0.7. This
was likely contrast induced nephropathy status post CTA on ___
v. pre-renal in the setting of being NPO.
CHRONIC ISSUES
--------------
#HIV: Continued home HIV medications.
#Depression/anxiety: Continued home medications.
TRANSITIONAL ISSUES
=============================
[] Discharged on soft mechanical diet
Medications:
[] STARTED sucralfate 1g TID.
[] STARTED pantoprazole 40mg BID
[] STOPPED Famotidine
Follow-up:
[] Patient needs follow up with his primary care doctor in ___
weeks.
[] Continue to counsel patient on avoidance of NSAID use.
Consider referral to pain management clinic for alternatives to
NSAIDs.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Desipramine 200 mg PO QHS
2. Dolutegravir 50 mg PO DAILY
3. darunavir-cobicistat 800-150 mg-mg PO DAILY
4. Emtricitabine-Tenofovir alafen (Descovy) 1 TAB PO DAILY
5. Ferrous Sulfate 325 mg PO DAILY
6. Vitamin D ___ UNIT PO DAILY
7. BuPROPion 100 mg PO TID
8. Famotidine 20 mg PO BID
9. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
Discharge Medications:
1. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
2. Sucralfate 1 gm PO TID
Do not take within 1 hour of Dolutegravir
RX *sucralfate [Carafate] 1 gram/10 mL 10 mL by mouth three
times a day Refills:*0
3. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
4. BuPROPion 100 mg PO TID
5. darunavir-cobicistat 800-150 mg-mg PO DAILY
6. Desipramine 200 mg PO QHS
7. Dolutegravir 50 mg PO DAILY
8. Emtricitabine-Tenofovir alafen (Descovy) 1 TAB PO DAILY
9. Ferrous Sulfate 325 mg PO DAILY
10. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
4.5cm gastric ulcer
Acute blood loss anemia
Secondary:
HIV
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking part in your care during your
hospitalization at ___. You
were admitted to the hospital because you were vomiting blood.
What happened while I was in the hospital?
- You had an a procedure called an endoscopy to look into your
stomach. Unfortunately you have a very large ulcer that was
found to be bleeding.
- We monitored your blood counts very closely and gave you blood
products when you needed them.
- You were evaluated by the surgeons. They felt the risks of
surgery were too high, and you also did not want surgery. You
were monitored, and improved without surgical intervention.
- You were evaluated by the interventional radiology team. They
also felt the risks of a procedure were very high and might
cause parts of the stomach to be permanently damaged.
- You had another endoscopy with the gastroenterologists, during
which one of the ulcers that was seen was injected with
medication to try and make it stop bleeding, and heat was
applied to also help it stop bleeding.
- You were started on a medicine called sucralfate and
pantoprazole which can help your ulcer heal.
What should I do when I go home?
- Please take all of your medicines as described in this
discharge paperwork.
- Please follow up with your primary care doctor and
gastroenterologist as described below.
- Please do NOT take any NSAID medications such as naproxen or
ibuprofen. Please continue to eat a soft diet until further
guidance from the gastroenterology team.
It was a pleasure to participate in your care. We wish you all
the best.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19608190-DS-14
| 19,608,190 | 27,290,704 |
DS
| 14 |
2131-04-16 00:00:00
|
2131-04-16 18:21:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
metformin
Attending: ___.
Chief Complaint:
hyponatremia and acute kidney injury
Major Surgical or Invasive Procedure:
Therapeutic/diagnostic paracentesis ___
Therapeutic/diagnostic paracentesis ___
History of Present Illness:
___ with decompensated cirrhosis (AIH vs. methotrexate/NASH)
complicated by esophageal varices status post banding,
hyponatremia, diuretic refractory ascites, malnutrition and HE
presenting with hyponatremia, ___, and worsening edema.
Patient requires q2week LVP for ascites management with 100 g of
albumin. He was instructed to come to the ED from his
paracentesis appointment with acute decompensation of his
cirrhosis with INR 2.2, sodium 123, creatinine 1.4 (from 0.8),
and worsening leg edema. Of note he did NOT have a paracentesis
performed on day of admission as they recommended he have be
evaluated prior to procedure.
His wife, his primary caretaker, reports that the patient seems
a little "slower" than usual but is otherwise well. The patient
has 6 bowel movements per day on lactulose, denies any bloody or
black stools. Patient denies fevers, nausea, vomiting, chest
pain, SOB, changes to urinary function.
Of note, he was recently seen by Dr. ___ in clinic with
hyponatremia and was instructed to hold his diuretics and
continue a two liter fluid restriction. Recently started on
nadolol.
Labs are notable for sodium of 126, creatinine 1.4, INR of 2.3.
Patient's baseline sodium is 120s to 140s. Base line creatinine
is 0.6 - 0.8.
Past Medical History:
Hypertension
Cirrhosis
Non-insulin dependent diabetes mellitus
Rheumatoid arthritis
Osteoporosis
History of gallstones s/p cholecystecomy
Peripheral neuropathy
Copper deficiency
Social History:
___
Family History:
Brother - cryptogenic cirrhosis
Brother - emphysema, smoker, diagnosed late in life
Mother - HTN, DM
Father - heart disease, DM
Grandfather - throat cancer, was a smoker
Children - bone cancer, osteoporosis, asthma
Grandson - osteogenesis ___
No family history of autoimmune disease
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS:
24 HR Data (last updated ___ @ 107)
Temp: 96.9 (Tm 96.9), BP: 107/62, HR: 109, RR: 16, O2 sat:
95%, O2 delivery: RA
GENERAL: Alert and interactive. In no acute distress.
HEENT: PERRL, EOMI. MMM.
CARDIAC: RRR no m/r/g
LUNGS: CTAB no r/r/w
ABDOMEN: Distended abdomen, NT, +BS
EXTREMITIES: 2+ edema bilaterally.
SKIN: Warm. No rashes.
NEUROLOGIC: No asterixis. A&Ox3
DISCHARGE PHYSICAL EXAM:
========================
VITALS: 24 HR Data (last updated ___ @ 313)
Temp: 99.6 (Tm 99.6), BP: 106/51 (96-109/50-71), HR: 92
(92-106), RR: 18 (___), O2 sat: 95% (94-96), O2 delivery: Ra,
Wt: 148.81 lb/67.5 kg
GENERAL: Cachectic appearing male in no acute distress.
HEENT: PERRL, anicteric.
CARDIAC: RRR, no m/r/g.
LUNGS: CTA in anterior fields; no r/r/w; posterior lobes
difficult to assess secondary to patient immobility in bed.
ABDOMEN: Distended, non-tender abdomen with positive fluid wave
and normal bowel sounds. Dry dressing over RLQ.
EXTREMITIES: No edema of lower extremities. No asterixis of UEs.
SKIN: Warm. No rashes. No jaundice, scattered bruises across
UEs.
NEURO: Alert and oriented x4. No gross sensory or motor
deficits.
Pertinent Results:
ADMISSION LABS
==============
___ 11:30AM WBC-6.2 RBC-4.58* HGB-11.5* HCT-36.5* MCV-80*
MCH-25.1* MCHC-31.5* RDW-19.7* RDWSD-55.3*
___ 11:30AM NEUTS-76.1* LYMPHS-10.2* MONOS-10.6 EOS-2.1
BASOS-0.2 NUC RBCS-0.3* IM ___ AbsNeut-4.72 AbsLymp-0.63*
AbsMono-0.66 AbsEos-0.13 AbsBaso-0.01
___ 09:10AM UREA N-45* CREAT-1.4* SODIUM-126*
POTASSIUM-4.3 CHLORIDE-100 TOTAL CO2-12* ANION GAP-14
___ 09:10AM ___
___ 11:30AM ALBUMIN-2.4* CALCIUM-8.3* PHOSPHATE-4.2
MAGNESIUM-2.0
___ 11:30AM ALT(SGPT)-22 AST(SGOT)-37 ALK PHOS-117 TOT
BILI-1.4
___ 11:48AM LACTATE-3.3*
___ 06:46PM ASCITES TNC-480* ___ POLYS-75*
LYMPHS-24* ___ MACROPHAG-1*
___ 08:45PM LACTATE-2.3*
PERTINENT LABS
==============
___ 01:04PM ASCITES ___-833* RBC-549* Polys-47* Lymphs-6*
___ Mesothe-3* Macroph-44*
DISCHARGE LABS
==============
___ 01:04PM ASCITES TNC-833* RBC-549* Polys-47* Lymphs-6*
___ Mesothe-3* Macroph-44*
___ 05:00AM BLOOD WBC-6.5 RBC-3.25* Hgb-8.1* Hct-25.9*
MCV-80* MCH-24.9* MCHC-31.3* RDW-19.9* RDWSD-55.5* Plt Ct-62*
___ 05:00AM BLOOD ___
___ 05:00AM BLOOD Glucose-164* UreaN-36* Creat-0.8 Na-132*
K-4.5 Cl-104 HCO3-17* AnGap-11
___ 05:14AM BLOOD ALT-20 AST-33 LD(LDH)-216 AlkPhos-102
TotBili-1.1
___ 05:00AM BLOOD Calcium-8.5 Phos-2.1* Mg-2.3
PERTINENT STUDIES
=================
CXR ___
- Low lung volumes with probable bibasilar atelectasis, though
infection or
aspiration is difficult to exclude in the correct clinical
setting. Possible trace left pleural effusion.
DUPLEX DOP ABD/PEL LIMITED; LIVER OR GALLBLADDER US ___
- Cirrhotic liver with splenomegaly and large volume ascites.
The portal venous system is patent.
Confirmatory CXR for Dobhoff placement - ___
- Enteric tube tip in the gastric body.
Brief Hospital Course:
TRANSITIONAL ISSUES:
=================================
[] Patient and family may benefit from further goals of care
discussions as an outpatient.
[] ___ choose to investigate whether PEG placement would be
beneficial given patient is severely malnourished and at risk
for continued decline and poor PO intake over many weeks.
[] FYI: patient discharged with Dobhoff tube in gastric antrum
with TF of 1.5 Glucerna at 65cc/hr.
[] Per nutrition: Replete Vitamin D w/ 50,000 units/week x8
weeks.
MEDICATIONS:
- New Meds: metoprolol, furosemide
- Stopped Meds: none
#CODE: Full Code presumed
#CONTACT:
___, wife, ___ HCP, ___
___
BRIEF HOSPITAL COURSE
=====================
___ male with past medical history of HTN, T2DM, RA on
chronic prednisone and cirrhosis thought to be secondary to
autoimmune hepatitis vs methotrexate induced liver disease vs
NAFLD decompensated by ascites, SBP, hepatic encephalopathy and
esophageal varices who presented from ___ clinic with
hyponatremia of 126 and ___. On presentation, patient was not
encephalopathic nor had any signs of bleeding. He received
albumin fluid resuscitation with subsequent improvement in his
serum sodium. Additionally he underwent diagnostic and
therapeutic paracentesis twice (4 days apart), with removal of
3.7 L and 7L of fluid, respectively. Diagnostic analysis of
ascitic fluid revealed elevated PMN count suggestive of
spontaneous bacterial peritonitis. Patient received ceftriaxone
for 5 days. Due to lack of p.o. intake and overall
malnourishment, Dobbhoff NG tube was placed, and patient was up
titrated to goal tube feeds of 65 cc/h of Glucerna 1.5. Patient
tolerated daily PO Lasix 20mg over the course of his stay with
resolution of his bilateral lower extremity swelling.
Arrangements were made for home ___, tube feeding education, and
a hospital bed to be used at home.
#Spontaneous bacterial peritonitis
Confirmed on diagnostic paracentesis on ___. Has history of
SBP, previously on cipro. Patient was treated with ceftriaxone
and continued on his ciprofloxacin prophylaxis after completion
of his 5-day ceftriaxone course. Ascitic cultures and blood
cultures showed no growth to date.
#Autoimmune hepatitis vs. methotrexate-induced vs. nonalcoholic
fatty liver disease
#Decompensated cirrhosis
On presentation, MELD 27 ___ C. Received scheduled
therapeutic paracenteses every 2 weeks. EGD on ___ showing 4
cords medium varices, 3 bands placed. No evidence of bleeding at
this time. Hgb stable around baseline throughout admission.
Presented with refractory ascites and asterixis on exam although
minimal signs of encephalopathy. Underwent diagnostic and
therapeutic paracentesis on ___ with removal of 3.7 L and
therapeutic paracentesis again on ___ (7L removed). Underwent
multiple albumin infusions with recovery of his blood sodium and
creatinine. Continued on metoprolol, lactulose, and rifaximin
with improvement in clinical status and stable bowel movements
at baseline (4-6/day).
#Severe protein calorie malnutrition
#Failure to thrive
#Lack of oral intake
Dobhoff tube placement ___ and continued on tubefeeds per
nutrition: Glucerna 1.5 @ 15cc/h advance 10cc q4h to goal of
65cc/hr. ___ consulted for post-pyloric placement but unable to
advance.
#___
Family would benefit from ___ discussion to discuss plans for
future treatment.
RESOLVED ISSUES:
================
#Hyponatremia
Patient presented with hyponatremia to 126 which had been
downtrending since ___. He was recently seen in clinic and
advised to stop his diuretics in the setting of his
hyponatremia. Improved with albumin infusions indicating likely
hypervolemic hyponatremia from intravascular volume depletion.
___
Creatinine 1.4 on admission from a baseline of 0.8. Likely in
setting of new nadolol medication. Improved to ___ s/p multiple
albumin infusions.
CHRONIC/STABLE ISSUES:
======================
# Type II DM
Continued on sliding scale, oral agents held.
# RA
Continued on prednisone 4 mg PO daily.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ciprofloxacin HCl 500 mg PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. Lactulose 30 mL PO TID
4. Multivitamins W/minerals 1 TAB PO DAILY
5. Nadolol 20 mg PO DAILY
6. PredniSONE 4 mg PO DAILY
7. rifAXIMin 550 mg PO BID
8. alogliptin 5 mg oral DAILY
9. copper gluconate 4 mg oral BID
10. Lactobacillus acidophilus 1 cap oral DAILY
11. Omeprazole 20 mg PO BID
12. Thiamine 100 mg PO DAILY
Discharge Medications:
1. Furosemide 20 mg PO DAILY
2. Lidocaine 5% Ointment 1 Appl TP ONCE Duration: 1 Dose
3. Vitamin D ___ UNIT PO 1X/WEEK (WE) Duration: 8 Weeks
4. alogliptin 5 mg oral DAILY
5. Ciprofloxacin HCl 500 mg PO DAILY
6. copper gluconate 4 mg oral BID
7. FoLIC Acid 1 mg PO DAILY
8. Lactobacillus acidophilus 1 cap oral DAILY
9. Lactulose 30 mL PO TID
10. Multivitamins W/minerals 1 TAB PO DAILY
11. Nadolol 20 mg PO DAILY
12. Omeprazole 20 mg PO BID
13. PredniSONE 4 mg PO DAILY
14. rifAXIMin 550 mg PO BID
15. Thiamine 100 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
Acute kidney injury
SECONDARY DIAGNOSES
===================
Hyponatremia
Decompensated cirrhosis
Non-insulin dependent diabetes mellitus
Rheumatoid arthritis
Osteoporosis
Gallstones status post cholecystectomy
Peripheral neuropathy
Copper deficiency secondary to zinc denture paste
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
Dear, Mr. ___,
It was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
- You were admitted for a decline in your kidney function and
low salt in your blood.
What was done for me while I was in the hospital?
- You underwent a two procedures to remove fluid from your
belly.
- You were given protein-rich fluids to help your kidneys and
improve the salt levels in your blood.
- You were started on feeding through a tube placed in your
stomach to help your body absorb nutrients.
- You were given antibiotics for an infection noted in your
belly.
What should I do when I leave the hospital?
- Please continue to take all your medications as prescribed.
- Please follow up with your physician appointments as listed in
your discharge paperwork.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19608211-DS-9
| 19,608,211 | 22,014,036 |
DS
| 9 |
2113-03-18 00:00:00
|
2113-03-18 10:37:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
RUG pain/biliary colic
Major Surgical or Invasive Procedure:
laparoscopic cholecystectomy
History of Present Illness:
Ms. ___ is a ___ female with history of gallstones and
biliary colic who presents to ___ ED today with complaint of
abdominal pain. She is followed for her cholelithiasis
complaints by Dr. ___ last saw her in clinic 4 days
prior to the present visit.
Per medical records, she has previously complained of
post-prandial abdominal pain and nausea and she states the
nausea
has been occurring after most meals since ___ but is
acutely worsening over the past month. She has also had 2
episodes of severe RUQ pain which were associated with large
meals, fevers, chills, and diaphoresis; she has not had these
symtoms today.
Her workup has previously included blood work and a RUQ U/S
which
revealed cholelithiasis and gallbladder wall thickening without
choledocholithiasis.
Today, she presents complaining of ~12 hours of RUQ pain similar
to prior episodes after a non-fatty dinner of vegetables with
pain beginning ___ hours after food intake. She did have
nausea,
no emesis. Pain and nausea have resolved in the ED over past
few
hours. Denies fevers/chills, denies any diarrhea/constipation.
This is patient's third episode of biliary colic in the past
month, episodes were previously about 1/month. Patient states
she is scheduled for elective cholecystectomy on ___ at
___ but would like to have gallbladder removed as early
as possible. She has been NPO for over 12 hours, has not taken
NSAIDs in over 2 weeks.
Past Medical History:
PMH:
- Nephrolithiasis
- Symptomatic cholelithiasis
PSH:
- Pediatric nose surgery, nature unknown
Social History:
___
Family History:
FamHx:
Father with cholelithiasis never had a cholecystectomy, Mother
and Sister are healthy
Physical Exam:
PE: vitals: T 98,1, HR 71, BP 94/60, RR 18, sat 100%/RA
Gen: NAD, A&O x3, looks comfortable
CV: RRR, no M/R/G
Pulm: CTA b/l
abs: port incision sites look good, no signs of
bleeding/hematoma/infection, dressings are in place, abdomen is
soft, NT, ND.
ext: no e/c/c, + pulse b/l
Pertinent Results:
___ 05:00AM URINE HOURS-RANDOM
___ 05:00AM URINE HOURS-RANDOM
___ 05:00AM URINE UCG-NEGATIVE
___ 05:00AM URINE GR HOLD-HOLD
___ 05:00AM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 05:00AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-SM
___ 05:00AM URINE RBC-10* WBC-6* BACTERIA-FEW YEAST-NONE
EPI-<1
___ 05:00AM URINE HYALINE-5*
___ 05:00AM URINE CA OXAL-FEW
___ 05:00AM URINE MUCOUS-MANY
___ 01:59AM ___ COMMENTS-GREEN
___ 01:59AM LACTATE-1.4
___ 01:50AM GLUCOSE-120* UREA N-9 CREAT-0.6 SODIUM-139
POTASSIUM-3.2* CHLORIDE-104 TOTAL CO2-24 ANION GAP-14
___ 01:50AM estGFR-Using this
___ 01:50AM ALT(SGPT)-25 AST(SGOT)-24 ALK PHOS-41 TOT
BILI-0.3
___ 01:50AM LIPASE-24
___ 01:50AM ALBUMIN-4.4
___ 01:50AM WBC-6.1 RBC-3.61* HGB-11.7* HCT-33.0* MCV-92
MCH-32.4* MCHC-35.3* RDW-12.0
___ 01:50AM NEUTS-73.5* ___ MONOS-3.8 EOS-0.5
BASOS-0.2
___ 01:50AM PLT COUNT-306
___ 01:50AM ___ PTT-32.1 ___
Brief Hospital Course:
The patient presented to pre-op on ___. Pt was
evaluated by anaesthesia and taken to the operating room for
laparoscopic cholecystectomy. There were no adverse events in
the operating room; please see the operative note for details.
Pt was extubated, taken to the PACU until stable, then
transferred to the ward for observation.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was initially managed with IV dilaudid and
then transferred to PO pain medications.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: The diet was advanced sequentially to a regular diet,
which was well tolerated. Patient's intake and output were
closely monitored.
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aviane (levonorgestrel-ethinyl estrad) 0.1-20 mg-mcg oral
DAILY
Discharge Medications:
1. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
do not drive or drink alcohol while taking this medication
RX *oxycodone 5 mg 1 to 2 tablet(s) by mouth every four (4)
hours Disp #*30 Tablet Refills:*0
2. Aviane (levonorgestrel-ethinyl estrad) 0.1-20 mg-mcg oral
DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
s/p laparoscopic cholecystectomy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
1.Leave the plastic dressing on for 48 hours. You can shower
(no bathing) with the dressing on for the first two days.
2.Remove dressing after 2 days and leave the paper tapes
(Steri-Strips) on the incision. You can shower (no bathing)
after removal of dressing and get the Steri-Strips wet. If you
prefer you can replace the dressing to keep your clothes from
being soiled or from the stitches catching on your clothes. If
you choose to replace dressing please do not use waterproof
plastic dressings and change dressing daily.
3.If the dressing has a little blood on it do not worry. You
can change the dressing if it is stained. Apply new dressing
with some mild pressure. You may notice some staining of the
Steri-Strips with bloody or yellowish discharge, this is normal.
In addition some swelling around the site of surgery is also
normal.
4.Please take first dose of pain medication before local
anesthetic wears off. Take pain medication regularly for the
first ___ hours and then as needed. Some patients can also
develop an ache/pain in their shoulder. Do not worry use warm
compress or pain medication for the ache in the shoulder.
5.The edges of Steri-Strips usually start curling at about
___ days. The paper strips should be removed at 14 days.
Rarely patients are sensitive to the glue on Steri-Strips in
which case please remove the strips and inform us as we may need
to use something else to keep the incision intact.
6.Avoid strenuous exercise after your surgery. Resume physical
activity when site of surgery does not hurt without pain
medication performing said activity.
7.You can perform all your activities of daily living. AVOID
lifting weights heavier than 30lbs for a total duration of 2
weeks after surgery. Please note chronic cough, chronic
constipation, excessive lifting of heavy weights and weight gain
predispose to development of hernia at the site of incisions
8.Avoid excessive fat in your diet for the first two weeks as
some patients may develop loose stool and some abdominal
discomfort while the body gets used to an absent gallbladder.
9. Call the office at ___ if you have any
of the following:
A.Persistent drainage of blood or pus from the incision
B.A fever higher than 101 degrees.
C.If the skin around the incision or incision is very red,
painful, swollen; looks infected
D.Jaundice ( yellowing of eyes, mucous membranes) or persistent
nausea and vomiting
Followup Instructions:
___
|
19608516-DS-20
| 19,608,516 | 27,992,252 |
DS
| 20 |
2145-03-12 00:00:00
|
2145-03-12 20:59:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Second degree atrioventricular block, Mobitz II
Major Surgical or Invasive Procedure:
Dual-chamber percutaneous pacemaker (___)
History of Present Illness:
CC: lightheadedness
___ with history of DM2, CAD s/p CABG, who presented on ___
with shortness of breath and lightheadedness.
Pt says that ___ days prior to admission, he had periodic
episodes of shortness of breath w/ exertion, lightheadedness,
and weakness. These episodes were not associated with chest
pain, palpitations, or syncope. Episodes lasted approximately 30
min and then resolved with rest. On the day of admission, he had
a similar episode that occurred at rest, which concerned him, so
he presented to ___. There, his HR was found to
be in the ___ but BPs were stable. He was given atropine and IV
fluids without effect. Initial plan was to admit there but given
lack of beds, he was transferred to ___ for further
management.
In the ED, initial vitals were: 98.4 47 159/79 18 98% on RA
Labs: Unremarkable. Trop neg. At OSH, BNP 492, TSH 7.17 w/ free
T4 1.25.
Consults: Cardiology reviewed EKGs and telemetry with EP
fellow. Patient had episodes of sinus pauses, blocked apc's and
second-degree Mobitz type 1 AV block.
Imaging: CXR performed at ___
Documentation from his cardiologist at ___ indicated that he
had symptomatic bradycardia in ___ so his Metoprolol was
stopped at that time, with improvement in symptoms. In ___ he developed atrial ectopy and runs of atrial tachycardia.
He was sent for Holter which showed a high burden of atrial
ectopy and runs of atrial tachycardia. He was started on
diltiazem for this in ___. He was last seen by his
cardiologist in ___ with plan for Holter to investigate
episode of shortness of breath. Pt states that he completed the
Holter but is not sure what the result was, and unfortunately we
did not have records of this.
Past Medical History:
-HTN
-HLD
-BPH
-DM2
-CAD s/p CABG (left internal mammary to LAD, saphenous vein
graft to ramus and saphenous vein graft to PDA) ___
-Atrial fibrillation (isolated episode related to CABG)
Social History:
___
Family History:
Father and brother had MIs.
Physical Exam:
Admission Physical Exam:
Vital Signs: 64.5kg, 98 136/96 61 18 100% on RA
General: pleasant well appearing elderly man in no distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple
CV: bradycardic. Audible pauses. ___ systolic murmur.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
gait deferred.
Discharge Physical Exam:
Vital Signs: 98.3 18x' 100% on RA Blood pressure-Heart rate
sitting 122/57mmHg and 76x'; Standing 111/53mmHg and 78x'
Wt: 64.2
General: pleasant well appearing elderly man in no distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple
CV: bradycardic. Audible pauses. soft, ___ systolic murmur.
Sternotomy scar well healed. Small ecchymosis peripheral to
pacemaker insertion site, dressing clean, dry and intact, no
erythema.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
gait normal.
0
Pertinent Results:
___ 06:22AM GLUCOSE-88 UREA N-16 CREAT-1.0 SODIUM-140
POTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-26 ANION GAP-16
___ 06:22AM CALCIUM-8.9 PHOSPHATE-3.3 MAGNESIUM-2.0
___ 06:22AM TSH-5.8*
___ 06:22AM T3-110 FREE T4-1.0
___ 06:22AM WBC-7.8 RBC-4.07* HGB-12.7* HCT-37.2* MCV-91
MCH-31.2 MCHC-34.1 RDW-12.5 RDWSD-41.3
___ 06:22AM PLT COUNT-188
___ 12:12AM GLUCOSE-106* UREA N-15 CREAT-0.9 SODIUM-139
POTASSIUM-4.2 CHLORIDE-102 TOTAL CO2-24 ANION GAP-17
___ 12:12AM estGFR-Using this
___ 12:12AM cTropnT-<0.01
___ 12:12AM CALCIUM-9.0 PHOSPHATE-3.0 MAGNESIUM-1.9
___ 12:12AM WBC-8.3 RBC-4.20* HGB-13.0* HCT-37.8* MCV-90
MCH-31.0 MCHC-34.4 RDW-12.4 RDWSD-40.4
___ 12:12AM NEUTS-69.5 ___ MONOS-9.3 EOS-1.2
BASOS-0.4 IM ___ AbsNeut-5.75 AbsLymp-1.61 AbsMono-0.77
AbsEos-0.10 AbsBaso-0.03
___ 12:12AM PLT COUNT-200
___ 12:12AM ___ PTT-31.9 ___
___ 11:31PM URINE HOURS-RANDOM
___ 11:31PM URINE UHOLD-HOLD
___ 11:31PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 11:31PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
TTE ___
Findings
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size.
Mildly depressed LVEF. TDI E/e' < 8, suggesting normal PCWP
(<12mmHg). No resting LVOT gradient.
RIGHT VENTRICLE: RV not well seen.
AORTA: Normal diameter of aorta at the sinus, ascending and arch
levels.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3).
Minimal AS. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular calcification. Mild thickening of mitral valve
chordae. ___ of the mitral chordae (normal variant). No resting
LVOT gradient. Calcified tips of papillary muscles. No MS.
___ MR. ___ (>250ms) transmitral E-wave decel time. LV
inflow pattern c/w impaired relaxation.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Normal
tricuspid valve supporting structures. No TS.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - poor apical views.
Suboptimal image quality - poor subcostal views.
Conclusions
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is mildly
depressed (LVEF = 45%) secondary to hypokinesis of the inferior,
posterior, and lateral walls. Tissue Doppler imaging suggests a
normal left ventricular filling pressure (PCWP<12mmHg). The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) are mildly thickened.
There is a minimally increased gradient consistent with minimal
aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. The left ventricular inflow pattern
suggests impaired relaxation. There is no pericardial effusion.
TTE ___ (focused study)
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is mildly depressed (LVEF= 45 %). There is
considerable beat-to-beat variability of the left ventricular
ejection fraction due to an irregular rhythm/premature beats.
There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Mildly depressed left
ventricular systolic function. No pericardial effusion.
Compared with the prior study (images reviewed) of ___,
the rhythm is irregular; overall echocardiogrphic findings are
similar.
Brief Hospital Course:
___ with history of DM2, CAD s/p CABG, who presents with
symptomatic bradycardia found to be second degree heart block
(Mobitz II).
#Bradycardia: He presented with symptomatic bradycardia, with HR
as low as ___ at OSH. He had associated lightheadedness and
shortness of breath at home, but maintained a normal blood
pressure. On telemetry he had multiple asymptomatic episodes of
bradycardia (___) w/second degree AV block (Mobitz II) on
___ and ___. His diltiazem was discontinued on admission.
He had a dual-chamber pacemaker (ventricular lead in para-Hisian
position) placed on ___ without complications. Post
procedure course was notable for 2 episodes of orthostatic
hypotension (likely associated with starting metoprolol) that
resolved with fluid administration. We discontinued his
Metoprolol treatment when he was discharged, but he would likely
benefit from a beta-blocker in the future.
#CAD s/p CABG ___ newly diagnosed RWMA and decreased EF on
TTE
(not present on ___ TTE from ___. He will need further
evaluation for this in the future.
Transitional issues:
-Had elevated TSH of 5.8 with normal Free T4(1) and T3 (110). He
will need follow-up TSH and consider starting treatment for
subclinical hypothyroidism.
-Needs further coronary evaluation due to finding of new
regional wall motion abnormalities and decrease in LVEF on TTE
-Metoprolol succinate 25mg PO daily was started during this
hospitalization but had to be stopped due to orthostatic
hypotension. He will be a good candidate for restarting
beta-blockers for his CAD as an outpatient by primary care
physician.
-Patient's home diltiazem was discontinued during this admission
-Surrogate/emergency contact: ___ (daughter)
___ (cell), ___ (home). ___ (daughter)
___
- Code Status during this admission full (confirmed)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Finasteride 5 mg PO DAILY
4. Diltiazem Extended-Release 120 mg PO DAILY
5. Losartan Potassium 12.5 mg PO DAILY
6. MetFORMIN (Glucophage) 850 mg PO DAILY
7. Cyanocobalamin 1000 mcg PO DAILY
Discharge Medications:
1. Cephalexin 250 mg PO Q6H
take for two days, take all doses
RX *cephalexin 250 mg 1 capsule(s) by mouth four times a day
Disp #*8 Capsule Refills:*0
2. Losartan Potassium 25 mg PO DAILY
RX *losartan 25 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. Cyanocobalamin 1000 mcg PO DAILY
6. Finasteride 5 mg PO DAILY
7. MetFORMIN (Glucophage) 850 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Second degree atrioventricular block, Mobitz II type
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___:
You were admitted to ___ because you felt fatigued, short of
breath, and lightheaded. We did some tests and we found that you
had a problem with your heart, called a "heart block". This
happens when electrical implulses cannot travel normally
throughout the heart muscle, and results in a low heart rate
which was likely the cause for your symptoms. You were seen by
an electrophysiology doctor. You had a pacemaker implanted on
___ without complications. We think that you may be
discharged and continue your recovery at home.
It is important that you attend your follow-up appointments at
the device clinic, and with your primary care Doctor.
___ you for letting us participate in your care.
Followup Instructions:
___
|
19608627-DS-11
| 19,608,627 | 27,483,682 |
DS
| 11 |
2164-09-05 00:00:00
|
2164-09-07 16:06:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bactrim
Attending: ___.
Chief Complaint:
Phrayngitis/Difficulty Swallowing.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ with CLL, CRI, DMII, who presents with progressive
difficulty swallowing. Ms ___ states that about 2 weeks
ago, she began having pain with swalloing. She was seen by her
Oncolgist and a viral pharyngitis was suspected. Viral panel and
strep cultures were negative. Over the past few days, the pain
with swallowing has been worsening and has limited diet. She has
had no aspiration, and has been able to get down her pills. She
has had recent coughing due to feeling irritation in pharynx but
has not had to expectorate her secretions. She has had a 5lb
weight loss in this time. She has also noted nasal discharge -
green and occasionally blood tinged at times.
.
With progressive pain with swallowing, she presented to the ED.
CT neck (wet read) showed "sinus dz w/ complete L max, partial
ethmoid opacification.
Scattered prominent cervical LN. Pharyngeal lymphoid tissue
slightly narrows airway. No obstructing lesions. Symmetric vocal
cords." CT Chest showed (wet read): "Patchy bilat pul opacities
suspicious for infection +/- intrapulmonary
lymphoma. New tracheal wall thickening, possibly lymphomatous
infiltration.
Small bilat pleural effusions, R pleural plaque. Bulky
mediastinal/hilar LN encasing tracheobronchial tree, w/
narrowing but no collapse. Massive splenomegaly." She was given
ceftriaxone and azithromycin for possible PNA, given CT findings
and transferred to the floor.
.
Currently, she feels ok, with persistent odynophagia. No chest
pain, no shortness of breath, no fevers, no chills, no joint
pain, no nausea, no vomiting, no abdominal pain, no rashes, no
edema.
Past Medical History:
Past Oncologic History:
Chronic Lymphocytic Leukemia
- Diagnosed in ___: Rai stage 0 in ___
- s/p 5 cycles of fludarabine ending in ___.
- recurrent anemia and advancing peripheral blood lymphocytosis
and lymphadenopathy, prompted 4 additional 3-day cycles of
fludarabine from ___ to ___.
.
Other Past Medical History:
- Macular degeneration (legally blind)
- Chronic renal failure: baseline creatinine 1.5
- Hypothyroidism secondary to hemithyroidectomy (___)
- Diabetes type II
- s/p hysterectomy at age ___
- s/p appendectomy
- s/p R thyroidectomy
- H1N1, ___
- Recurrent R-sided pleural effusion as above
- Chronic diastolic CHF with a preserved EF
Social History:
___
Family History:
Father - h/o esophageal cancer
Mother - h/o skin cancer
Sister - h/o breast cancer
Physical Exam:
ADMISSION EXAM:
99.9 147/80 86 21 94% on 2L
Gen: Elderly woman in no distress, raspy voice
SKIN: Warm, dry, without ecchymosis or petechiae; no urticarial
lesions visible.
HEENT: Sclerae anicteric, conjunctivae pink. Oropharynx dry,
white exudate on tongue and white plaques on posterior pharynx,
mold erythema, difficult to see tonsils. Multiple centimeter or
less nodes palpable in
posterior and anterior cervical, and supraclavicular R>L chains,
LUNGS: CTAB, no wheeze, no rhonchi
ABDOMEN: +BS, soft, nontender. Spleen tip is palpable ___ FBs
below the left costal margin.
EXTREMITIES: Symmetrical without edema
NEUROLOGIC: Speech and cognition intact; gait and stance
normal.
Pertinent Results:
ADMISSION LABS:
___ 12:57PM GLUCOSE-96 UREA N-39* CREAT-1.6* SODIUM-141
POTASSIUM-4.5 CHLORIDE-105 TOTAL CO2-26 ANION GAP-15
___ 12:57PM estGFR-Using this
___ 12:57PM WBC-89.2* RBC-3.60* HGB-10.4* HCT-32.6*
MCV-91 MCH-28.8 MCHC-31.8 RDW-15.6*
___ 12:57PM NEUTS-13* BANDS-0 LYMPHS-75* MONOS-8 EOS-0
BASOS-0 ATYPS-4* ___ MYELOS-0
___ 12:57PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-OCCASIONAL
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL OVALOCYT-OCCASIONAL
TEARDROP-OCCASIONAL
___ 12:57PM PLT SMR-NORMAL PLT COUNT-240
.
___ CT CHEST: IMPRESSION:
1. Slight increase in conglomerate supraclavicular, mediastinal,
and hilar adenopathy. Lymphadenopathy encases the
tracheobronchial airways but does not result in airway
obstruction.
2. New mild circumferential tracheal wall thickening could
represent
lymphomatous infiltration. Apparent tracheal narrowing at the
thoracic inlet may be present, though, this measurement is
likely imprecise as the images do not appear to be obtain at the
end-inspiratory phase of respiration. Consider CT trachea for
further evaluation.
3. Right upper lobe and bibasilar opacities are non-specific and
could represent inflammation,infection, or aspiration.
4. Stable pulmonary nodules.
5. New small left pleural effusion. Right pleurodesis.
6. Splenomegaly.
.
___ CT NECK: IMPRESSION:
1. Mild subglottic tracheal wall thickening could represent
lymphomatous infiltration.
2. Mild oropharyngeal narrowing and tracheobronchial encasement,
without obstructing lesions.
3. Diffuse cervical, supraclavicular, and mediastinal
adenopathy.
4. Paranasal sinus disease.
5. Mastoid opacification; please correlate clinically for
mastoiditis.
.
___ VIDEO SWALLOW: IMPRESSION:
1. Penetration with thin liquids, but no evidence of aspiration.
2. For complete report, please see speech and swallow note in
OMR.
.
___ CT TRACHEA: IMPRESSION:
1. As compared to ___, there is increase in the
conglomerate of supraclavicular, mediastinal and hilar
lymphadenopathy as described. There is currently encasement of
the tracheobronchial airways with decrease in the sagittal
diameters of the trachea and main bronchi, but no airway
obstruction.
2. No definitive evidence of tracheal inflammation is seen.
There is
potential for posterior tracheal wall invasion by
lymphadenopathy.
3. Mild tracheal wall thickening might reflect tracheal wall
infiltration by disease.
4. Multifocal opacities worrisome for multifocal infection some
of them are slightly increased since or new since study obtained
three days ago.
5. Interval increase in the lingular mass like consolidation.
6. New small left pleural effusion. Right pleurodesis with
minimal effusion.
7. Splenomegaly with subsequent compression of the stomach
between liver and massive spleen. The contrast material within
the esophagus demonstrates no evidence of obstruction or
specific esophageal wall thickening.
.
DISCHARGE LABS:
___ 12:50PM BLOOD WBC-65.0* RBC-3.04* Hgb-8.6* Hct-28.1*
MCV-92 MCH-28.4 MCHC-30.7* RDW-15.1 Plt ___
___ 07:25AM BLOOD ___ PTT-28.4 ___
___ 06:40AM BLOOD Ret Aut-2.1
___ 08:30AM BLOOD Glucose-91 UreaN-13 Creat-1.2* Na-143
K-4.2 Cl-109* HCO3-26 AnGap-12
___ 07:45AM BLOOD Albumin-4.3 Calcium-8.8 Phos-3.2 Mg-2.6
UricAcd-7.9*
___ 08:30AM BLOOD UricAcd-6.3*
___ 08:30AM BLOOD LD(LDH)-408*
___ 06:40AM BLOOD TSH-1.3
___ 06:40AM BLOOD IgG-761 IgA-89 IgM-37*
___ 07:45AM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN-PND
___ 07:45AM BLOOD B-GLUCAN-PND
Brief Hospital Course:
___ woman with CLL, DM, CKD, and CHF admitted for odynophagia
and pulmonary infiltrates.
.
# Sore throat, cough, hypoxia: Despite the CT findings,
improvement with antibiotics strongly favors an infectious
cause. Throat culture ___ and respiratory viral culture
___ negative. Monospot ___ negative. CT
neck/chest/trachea have shown increasing adenopathy, encasement
of the trachea with tracheal narrowing, and possible tracheal
infiltration. Interventional Pulmonary and ENT favored a
watch-and-wait approach as opposed to endoscopy. After
discussion with ID, ceftriaxone was changed to
ampicillin/sulbactam for better anaerobic coverage. O2 weaned
off. Changed ampicillin/sulbactam to amoxicillin/clavulanate
x2wks PO upon discharge. Last dose (Day #5) azithromycin
___. Plan to restart chemotherapy after the infection
clears. Guafenasin-dextromethorphan PRN cough. Albuterol PRN
for the wheeze and hypoxia. Oxymetazoline PRN for nasal
congestion. ENT to follow-up as outpatient.
- Follow-up blood cultures.
- Galactomannan and beta-glucan pending.
- F/U HSV throat swab.
.
# Odynophagia/dysphagia: Due to oral/esophageal candidiasis.
CLL infiltration of esophagus not seen on CT. Improving on
fluconazole. Video swallow negative. Continued fluconazole.
D/C clotrimazole. Started Maalox/diphenhydramine/viscous
lidocaine PRN. Changed meds to PO.
.
# Diarrhea: Resolved. Possibly medication-induced. C. diff
toxin negative.
.
# CLL: Last cycle given fludarabine ___. Although better
than ___, the lymphocytosis is significantly increased since
earlier in the year as is LDH. Adequate quantitative
immunoglobulins. Chemo planned for after antibiotic course.
Started allopurinol in preparation for impending chemo and
especially considering the high uric acid.
.
# Thrombocytopenia: Significant decline ___ was spurious.
Repeat back to baseline.
.
# Anemia: Stable. Likely due to CLL. Normal haptoglobin and
retic count ruled out hemolysis.
.
# Leukocytosis/Lymphocytosis: Due to CLL. Stable.
.
# CKD: Stable. Stopped IV fluids.
.
# DM: Covered with insulin sliding scale. Restarted metformin
upon discharge.
.
# Hypothyroidism: Continued outpatient levothyroxine. Normal
TSH.
.
# Pain: None.
.
# FEN: Regular diet. Video swallow negative.
.
# GI PPx: PPI and bowel regimen.
.
# DVT PPx: Pneumoboots.
.
# Precautions: None.
.
# Lines: Peripheral IV.
.
# CODE: FULL.
Medications on Admission:
ALLOPURINOL ___ mg PO once daily
DICYCLOMINE 10 mg PO once PRN abdominal bloating, nausea, and
loose stool.
LEVOTHYROXINE [SYNTHROID] 100 mcg PO daily - No Substitution
LIPASE-PROTEASE-AMYLASE [CREON] 24,000U-76,000U-120,000U Delayed
Release PO BID
METFORMIN 500 mg PO once a day
OMEPRAZOLE [PRILOSEC] 20 mg PO BID
TRAMADOL 50 mg PO daily as needed for leg pain
CETIRIZINE 10 mg Tablet - 2 Tablets PO twice on day 1, followed
by 2 tablets once on day 2, followed by 1 tablet once on day 3
PRN rash
ESSIAC (OTC) 3 capsules each day
VITAMIN A-VITAMIN C-VIT E-MIN [OCUVITE] 2 Tablet(s) PO daily
Discharge Medications:
1. allopurinol ___ mg PO DAILY.
2. dicyclomine 10 mg once a day PRN abdominal bloating, nausea,
and loose stool.
3. levothyroxine 100 mcg PO DAILY.
4. lipase-protease-amylase 24,000-76,000 -120,000U Delayed
Release(E.C.) PO BID.
5. metformin 500 mg PO once a day.
6. omeprazole 20 mg PO BID.
7. tramadol 50 mg PO Q6H PRN leg pain.
8. Augmentin 875-125 mg PO BID x10 days.
Disp:*20 Tablet(s)* Refills:*0*
9. azithromycin 250 mg PO once a day x10 days.
Disp:*10 Tablet(s)* Refills:*0*
10. fluconazole 200 mg PO Q24H x7 days.
Disp:*7 Tablet(s)* Refills:*0*
11. oxymetazoline 0.05 % Aerosol, Spray Sig: One (1) Spray Nasal
BID x3 days.
Disp:*1 Unit* Refills:*1*
12. dextromethorphan-guaifenesin ___ Sig: ___ MLs PO
Q6H PRN Cough.
Disp:*100 ML(s)* Refills:*0*
13. prochlorperazine maleate ___ PO Q6H PRN Nausea.
Disp:*20 Tablet(s)* Refills:*0*
14. docusate sodium 100 mg PO BID PRN Constipation.
15. senna 8.6 mg PO BID PRN Constipation.
Discharge Disposition:
Home
Discharge Diagnosis:
1. Cough.
2. Tracheitis/bronchitis (infection of the trachea and upper
airways).
3. Hypoxia (low oxygen).
4. Hoarse voice.
5. CLL (chronic lymphocytic leukemia).
6. Sinusitis.
7. Dysphagia (difficulty swallowing).
8. Throat pain.
9. Thrush and esophageal candidiasis (yeast/fungal infection of
mouth and esophagus).
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 a cough, hoarse voice,
pain and difficulty swallowing, and low oxygen level (hypoxia).
CT of the neck, trachea, and chest showed incresased lymph
nodes, lymph nodes surrounding the trachea, and possible
involvement of trachea. You were started on antibiotics and
seen by the Infectious Disease specialists, who felt that your
symptoms were mostly due to an infection. You did improve with
the antibiotics and will need to complete a course at home. If
your symptoms persist, you should contact one of your physicians
to extend the course. For the sinusitis, you were given a nasal
decongestant. You were also started on fluconazole, an
anti-fungal medication, for a yeast/fungal infection of the
mouth/esophagus, the likely cause of pain and difficulty
swallowing. A swallow study was normal. For the CLL (chronic
lymphocytic leukemia), you will likely be restarting
chemotherapy once the infection is cleared.
.
MEDICATION CHANGES:
1. Amoxicillin/clavulanate (Augmentin) 2x a day.
2. Azithromycin 250mg daily.
3. Fluconazole 200mg once daily.
4. Oxymetazoline (Afrin) one nasal spray 2x a day as needed for
nasal congestion.
5. Also for the nasal congestion/sinusitis, you can purchase a
Neti Pot over the counter at your local pharmacy to self
irrigate the nasal passages (Instructions have been provided).
ONLY USE STERILE DISTILLED WATER.
6. Continue allopurinol for an elevated uric acid and for kidney
protection with upcoming chemotherapy.
Followup Instructions:
___
|
19608627-DS-14
| 19,608,627 | 28,300,483 |
DS
| 14 |
2165-03-21 00:00:00
|
2165-03-23 17:02:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bactrim / acyclovir
Attending: ___.
Chief Complaint:
neutropenic fever
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with large B-cell transformation (Richter's transformation)
of chronic lymphocytic leukemia (CLL), being treated with
R-CHOP, last chemo ___ presents to the ER with fever. She
reported to the ER that she had chills, but later denies this on
the floor. She does complain of increased fatigue. She had a
right ureteral obstruction and came in for cysto, right stent
removal, right retrograde and right stent replacement on ___
which was uncomplicated. She states that she has urinary
frequency (___) since the procedure but no burning. She
denies any other localizing symptoms including chest pain,
shortness of breath, cough, rash, nausea, neck pain, vomiting,
abdominal pain, diarrhea, dysuria. She has had hematuria since
procedure. Had mild HA this afternooon, but that has since
resolved. Vitals in the ER: 101.5 78 143/42 18 99% RA. She
received Tylenol and Vancomycin.
.
Review of Systems:
(+) Per HPI
(-) Denies night sweats, blurry vision, diplopia, loss of
vision, photophobia. Denies headache, sinus tenderness,
rhinorrhea or congestion. Denies chest pain or tightness. Denies
cough, shortness of breath, or wheezes. Denies nausea, vomiting,
diarrhea, constipation, abdominal pain, melena, hematemesis,
hematochezia. Denies dysuria, stool or urine incontinence.
Denies arthralgias or myalgias. Denies rashes or skin breakdown.
No numbness/tingling in extremities. All other systems negative.
.
Past Medical History:
ONCOLOGY TREATMENT HISTORY:
-- Her CLL presented as Rai stage 0 in ___. Due to progressive
anemia, she received 5 cycles of fludarabine ending in ___.
-- With recurrent anemia and advancing peripheral blood
lymphocytosis and lymphadenopathy, she received 4 additional
3-day cycles of fludarabine from ___ to ___.
-- Hospitalized in ___ for multi-focal pneumonia;
during her evaluation pleural fluid analysis showed lymphocytes
in her effusion, c/w with her known CLL.
-- Hospitalized again ___ to ___ with increasing
shortness of breath d/t a large recurrent R-sided pleural
effusion.
Thoracentesis was performed, draining 3 liters fluid. CT of the
chest on ___ reported worsening RML and RUL opacities, and
LUL nodule. Bronchoscopy with BAL was done. Immunophenotyping of
bronchial lavage was consistent with CD5 positive B cell
lymphoproliferative disorder. Cytology of bronchial lavage
showed atypical cells; cytology of pleural fluid was consistent
with her CLL. Cultures were negative for legionella, PCP,
___, CMV, and AFB smear; AFB culture were negative.
-- On ___, CT of chest was repeated reporting interval
improvement since previous scan, an unchanged LUL opacity and
reaccumulation of R-sided effusion. Thoracentesis was again
performed on ___ 1500 cc cloudy fluid was removed, raising
the question whether effusion was chylous. Another bronchoscopy
with biopsy and BAL was performed on ___. Cytology and
culture results were consistent with previous results. Findings
of a biopsy of LUL were consistent with a reactive lymphoid
infiltrate.
-- Admitted to hospital ___ for pleuroscopy, talc
pleurodesis, pleurex catheter and chest tube placement after she
presented to ___ clinic with worsening dyspnea due to
reaccumulation of a R pleural effusion. 1.5 liters of turbid
fluid was drained. Pleural fluid cytology showed involvement by
CLL/SLL as did pleural biopsies. While in hospital, results of
BAL culture for AFB from ___ returned positive. She was
place in respiratory isolation. PCR for ___ and TB came back
negative. Definitive AFB culture grew MAC, thought to be due to
environmental contaminant.
-- In ___, readmitted to hospital for a second attempt at
talc pleurodesis. Pleurodesis was successful as output from her
Pleurex catheter declined to the point where the catheter could
be removed on ___.
-- On ___, she re-recommenced fludarabine IV on
days 1, 2 and 3 on a 28-day cycle.
-- On ___, she received cycle 2 fludarabine.
-- On ___, creatinine level elevated to 2.7 prompted
hospitalization for acute on chronic renal failure. Evaluation
disclosed bulky adenopathy in the right hemipelvis obstructing
the right ureter with hydronephrosis, a new left renal lesion,
and a new liver lesion compared with her ___ FDG-PET-CT
scan; spleen and other lymph nodes were smaller, c/w mixed
response of CLL to fludarabine. R ureter was stented. Core
needle biopsy of the new liver lesion on ___ showed findings
c/w large B-cell transformation with a MIB-staining approaching
100%.
- Ms. ___ had difficulty during her cycle 2 day 1 rituximab
infusion on ___ with back pain, treated with
famotidine and dexamethasone, followed by abdominal discomfort,
nausea and rigors that subsided with IV meperidine and IV
ondansetron. She subsequently received the remainder of the
rituximab infusion and chemotherapy without incident. She
received Neulasta on ___
- On ___, she had PET-CT scan which documented decreased
adenopathy and FDG avidity. Although a small new focus of FDG
uptake was noted in her spleen, the spleen was overall reduced
in size, and her liver appeared improved as well.
- ___ Commence cycle 3 R-CHOP
- Neulasta ___
.
PAST MEDICAL HISTORY:
1. Macular degeneration; legally blind.
2. Chronic renal failure.
3. Hypothyroidism.
4. Diabetes type II
5. Hypertension.
6. In ___, she was admitted to hospital with respiratory
infection due to H1N1 influenza A. She received 6 days of
Tamiflu
and Levaquin with improvement in symptoms. Myelosuppression
during her viral illness improved.
7. S/p hysterectomy at age ___
8. S/p appendectomy
9. S/p R thyroidectomy
10. Chronic diastolic CHF with preserved EF
Social History:
___
Family History:
Father - h/o esophageal cancer
Mother - h/o skin cancer
Sister - h/o breast cancer
Physical Exam:
Physical exam on Admission
VS: T 100 bp 120/60 HR 66 RR 18 SaO2 96 RA
GEN: looks fatigued, awake, alert
HEENT: EOMI, sclera anicteric, conjunctivae clear, OP moist and
without lesion
NECK: Supple
CV: Reg rate, normal S1, S2. No m/r/g.
CHEST: Resp unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABD: Soft, NT, ND, no HSM, bowel sounds present
MSK: normal muscle tone and bulk
EXT: No c/c, normal perfusion
SKIN: No rash, warm skin
NEURO: oriented x 3, normal attention, no focal deficits, intact
sensation to light touch
PSYCH: appropriate
Physical exam on Discharge
Objective:
Vitals - T97.9 BP 116/64 P RR 18 Sat: 95% on RA
GENERAL: NAD, laying in bed.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva,
patent nares, MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no mrg
LUNG: R Lung crackles in Lower and middle lobes. No w/r.
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
Pelvic: No suprapubic tenderness
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, strength ___ in all 4 ext, sensation
grossly intact
Pertinent Results:
___ 02:25PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 02:25PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 02:25PM URINE RBC->182* WBC-5 BACTERIA-FEW YEAST-NONE
EPI-<1
___ 12:30PM UREA N-52* CREAT-1.8* SODIUM-145
POTASSIUM-4.8 CHLORIDE-111* TOTAL CO2-23 ANION GAP-16
___ 12:30PM ALBUMIN-4.2 CALCIUM-8.8 PHOSPHATE-3.0
MAGNESIUM-1.9
___ 12:30PM WBC-0.4*# RBC-2.81* HGB-8.7* HCT-26.3* MCV-93
MCH-30.9 MCHC-33.2 RDW-15.4
___ 12:30PM NEUTS-8* BANDS-1 LYMPHS-78* MONOS-2 EOS-9*
BASOS-0 ATYPS-2* ___ MYELOS-0
___ 12:30PM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-OCCASIONAL
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL
TEARDROP-OCCASIONAL
___ 12:30PM PLT SMR-VERY LOW PLT COUNT-78*
.
CXR: no acute cardiopulmonary process
___ 05:46AM BLOOD WBC-4.0 RBC-2.79* Hgb-8.2* Hct-25.5*
MCV-91 MCH-29.5 MCHC-32.3 RDW-15.7* Plt ___
___ 05:46AM BLOOD Glucose-115* UreaN-18 Creat-1.4* Na-141
K-4.1 Cl-103 HCO3-31 AnGap-11
ASPERGILLUS ANTIGEN 0.1 <0.5
B-Glucan (-)
Brief Hospital Course:
#Neutropenic fever- initially, UTI had to be ruled out as
patient had a recent history of GU instrumentation s/p R
ureteral stent replacement. Patient was placed empirically on
vancomycin and cefepime. UA was not very impressive and urine
culture showed mixed bacterial flora (probably contaminant).
Source of infection was found on CXR on ___ which showed RLL
pneumonia. Interventional pulmonology saw patient in house and
could not find fluid in RLL to tap. Patient deverfesced on
hospital day on ___. The patient remainded afebrile, WBC
increased over 3,500, and Vanc/cefepime were d/c. Levaquin was
continued and pt is to complete ___s an outpt,
requiring 3 doses as an oupt.
#large B-cell transformation (Richter's transformation) of
chronic lymphocytic leukemia (CLL): Patient was found to be
pancytopenic upon admission and received multiple blood
transfusions. Patient continued zoster prophylaxis throughout
hospitalization and was stable. Patient was discharged with a
follow-up appointment with oncologist.
#Macular degeneration; legally blind - chronic, stable
#Chronic kidney disease III - IV. Baseline Cr approximately 1.7
- chronic, stable. Renally dosed all meds
#Hypothyroidism: stable throughout admission on synthroid.
#Chronic diastolic CHF with preserved EF:chronic, stable
Medications on Admission:
ALBUTEROL SULFATE - 90 mcg HFA Aerosol Inhaler - 2 puffs inhaled
Prior to pentamidine
ALLOPURINOL - 100 mg Tablet - 1 Tablet(s) by mouth once daily
for
14 days starting the day before starting each cycle of
chemotherapy
DICYCLOMINE - (Prescribed by Other Provider) - 10 mg Capsule -
1
Capsule(s) by mouth once as needed for abdominal bloating,
nausea, and loose stool.
DIPHENOXYLATE-ATROPINE - 2.5 mg-0.025 mg Tablet - 2 Tablet(s) by
mouth three times a day
ESSIAC - (Prescribed by Other Provider) (On Hold from
___
to unknown for avoid interactions with chemotherpay) - - 3
capsules each day - on hold
LEVOTHYROXINE [SYNTHROID] - 100 mcg Tablet - 1 Tablet(s) by
mouth
daily - No Substitution
OMEPRAZOLE [PRILOSEC] - (Prescribed by Other Provider) - 20 mg
Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth twice a
day
PENTAMIDINE [NEBUPENT] - 300 mg Recon Soln - 300 mg inhaled via
nebulizer every 4 weeks
PREDNISONE - 50 mg Tablet - 2 Tablet(s) by mouth daily for 4
consecutive days beginning the day following chemotherapy -
cnfirms taking this after last cycle
PROCHLORPERAZINE - 25 mg Suppository - 1 Suppository(s) rectally
every 8 hours as needed for vomiting
PROCHLORPERAZINE MALEATE - 5 mg Tablet - ___ Tablet(s) by mouth
tid 8 hours apart as needed for nausea
SCALP PROSTHESIS FOR CHEMOTHERAPY INDUCED ALOPECIA -
TRAMADOL - (Prescribed by Other Provider: Dr. ___ Dose
adjustment - no new Rx) - 50 mg Tablet - 1 Tablet(s) by mouth
twice a day as needed for leg pain
VALACYCLOVIR - 500 mg Tablet - 1 Tablet(s) by mouth twice a day
Medications - OTC
BIFIDOBACTERIUM INFANTIS [ALIGN] - (OTC) - 4 mg (1 billion
cell)
Capsule - 1 Capsule(s) by mouth once a day
CETIRIZINE - (Prescribed by Other Provider; Dose adjustment -
no
new Rx) - 10 mg Tablet - 1 Tablet(s) by mouth once as needed for
rash
VITAMIN A-VITAMIN C-VIT E-MIN [OCUVITE] - (Prescribed by Other
Provider) - Tablet - 2 Tablet(s) by mouth daily
Discharge Medications:
1. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
Two (2) puffs Inhalation prior to pentamidine.
2. allopurinol ___ mg Tablet Sig: One (1) Tablet PO every other
day: 14 consecutive days commencing 2 days before each cycle of
chemotherapy.
3. dicyclomine 10 mg Capsule Sig: One (1) Capsule PO QID (4
times a day) as needed for abdominal bloating.
4. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
6. pentamidine 300 mg Recon Soln Sig: Three Hundred (300) mg
Inhalation every 4 weeks.
7. prednisone 50 mg Tablet Sig: Two (2) Tablet PO once a day: 4
consecutive days beginning the day following chemotherapy.
8. prochlorperazine 25 mg Suppository Sig: One (1) Rectal every
eight (8) hours as needed for nausea.
9. prochlorperazine maleate 5 mg Tablet Sig: ___ Tablets PO
every eight (8) hours as needed for nausea.
10. tramadol 50 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for pain.
11. cetirizine 10 mg Tablet Sig: One (1) Tablet PO ONCE as
needed for rash.
12. Ocuvite Oral
13. valacyclovir 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours).
14. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q48H
(every 48 hours) for 2 doses: next dose ___, last dose ___.
Disp:*2 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
1. Pneumonia
Secondary:
1. Large B cell lymphoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ was a pleasure taking care of you during this admission. You
were admitted for fevers. You were found to have a pneumonia and
treated with antibiotics. Your blood counts were low, but
improved! You were switched to oral antibiotics and did well.
The following medications were changed during this admission:
- PLEASE START Levofloxacin 750mg every 48hours for 2 more
doses, to be completed on ___
- DECREASE the dose of Valacyclovir to 500mg daily (from twice
daily)
- DECREASE the dose of Allopurinol to 100mg every other daily
(instead of daily; for 14 consecutive days starting 2 days
before each cycle of chemotherapy to be discussed with Dr.
___
Please continue all other medications you were taking prior to
this admission.
Followup Instructions:
___
|
19609259-DS-15
| 19,609,259 | 22,815,668 |
DS
| 15 |
2189-12-14 00:00:00
|
2189-12-14 18:08:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Left arm numbness, transient
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ yo F with poorly controlled HTN, HLD, DM
(non-compliant with all medications x at least 3 weeks) who
presents with HA yesterday ___ followed by 10 minute episode of L
arm numbness/weakness today with BP 220/100 at OSH and OSH NCHCT
showing R frontal convexal SAH.
She just returned here to live with her daughter ~3 weeks ago.
She was well until yesterday ___ when she had gradual onset
diffuse headache which improved with Aleve but continued to keep
her up all night. She had no previous trauma. When she woke at
0900, her daughter checked her BP and saw that she was 200/60.
She subsequently developed a sense of L arm "cramping" - she
describes this as both a full arm numbness and sense of
weakness.
The numbness/weakness occurred all at once. There were no
paresthesiae. This episode lasted ~10 minutes. She was
transferred to the ___ where BP was 220/100. ___ there
showed a R frontal convexal SAH anterior to the precentral
gyrus.
She was given 100 mg of atenolol ___ of her prescribed dose)
and
10 mg IV Labetalol and transferred here. Here she received an
additional 10 mg IV labetalol with BP 200/80. She was
subsequently started on a nicardipine gtt with uptitration to
1.5
over the course of the evening. She notes that her HA resolved
during her ED stay here, concomitant with decrease in SBP to
160s.
Ms. ___ currently feels at her baseline without any
complaints.
Her daughter notes that Ms. ___ has been unsteady on her feet
since returning from ___ with a more tentative gait. She
otherwise has no history of any focal neurologic complaints.
On neuro ROS, the pt denies loss of vision, blurred vision,
diplopia, dysarthria, dysphagia, lightheadedness, vertigo,
tinnitus or hearing difficulty. Denies difficulties producing or
comprehending speech. No bowel or bladder incontinence or
retention. Otherwise as in HPI.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or
abdominal pain. No recent change in bowel or bladder habits.
No
dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
HTN (poorly controlled), HLD, DM on Metformin. Multiple
surgeries on L eye and now blind in that eye. There is no known
history of TIA, stroke, Afib, MI, CAD, or cancer.
Social History:
___
Family History:
There is no known family history of HTN, HLD, DM, TIA,
stroke, Afib, MI, CAD, or cancers.
Physical Exam:
==========================
ADMISSION EXAMINATION
==========================
Physical Exam:
Vitals: T:97.2 HR 63 BP 155/73 RR 18 SpO2 100% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, L cornea clouded
Neck: Supple
Pulmonary: Regular respirations
Cardiac: RRR
Abdomen: soft
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Done with daughter translating from ___. Alert, oriented x 3. Able to relate history without
difficulty. Attentive to questioning. Language is fluent per
daughter. Normal prosody. 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:
I: Olfaction not tested.
II: R pupil 3 to 2mm and brisk. L pupil obscured with corneal
clouding. VFF to confrontation in R eye.
III, IV, VI: EOMI without nystagmus.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to tuning fork 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.
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 throughout. No extinction
to
DSS. Romberg positive for fall backwards.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 1 1
R 2 2 2 1 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor noted. No dysmetria on FNF or
HKS bilaterally.
-Gait: Good initiation. Wide based tentive gait (daughter notes
that this is her baseline)
.
.
==========================
DISCHARGE EXAMINATION
==========================
Systolics 123 - 147 / Diastolics 51-68; heart rates 51-68
(atenolol held)
Awake, alert, fluent, interactive, appropriate, follows all
commands. Behaves normally with family and physicians. Face
symmetric, strength normal, gait is steady with prompt
initiation.
Pertinent Results:
==========================
Labs
==========================
___ 02:40PM BLOOD WBC-6.4 RBC-4.72 Hgb-10.2* Hct-31.1*
MCV-66* MCH-21.6* MCHC-32.8 RDW-14.6 RDWSD-33.9* Plt ___
___ 02:40PM BLOOD Neuts-54.7 ___ Monos-5.6 Eos-0.2*
Baso-0.6 Im ___ AbsNeut-3.52 AbsLymp-2.48 AbsMono-0.36
AbsEos-0.01* AbsBaso-0.04
___ 02:40PM BLOOD ___ PTT-28.4 ___
___ 02:40PM BLOOD Plt ___
___ 02:40PM BLOOD Glucose-119* UreaN-17 Creat-0.9 Na-139
K-4.2 Cl-102 HCO3-25 AnGap-16
___ 04:15AM BLOOD ALT-32 AST-23 LD(LDH)-175 CK(CPK)-107
AlkPhos-64 TotBili-0.4
___ 04:15AM BLOOD GGT-100*
___ 04:15AM BLOOD CK-MB-1 cTropnT-<0.01
___ 12:40AM BLOOD Calcium-8.3* Phos-3.6 Mg-2.1
___ 04:15AM BLOOD TotProt-7.5 Albumin-4.1 Globuln-3.4
Cholest-268*
___ 04:15AM BLOOD %HbA1c-6.6* eAG-143*
___ 04:15AM BLOOD Triglyc-121 HDL-57 CHOL/HD-4.7
LDLcalc-187*
___ 04:15AM BLOOD TSH-1.6
___ 04:15AM BLOOD CRP-9.9*
.
==========================
Imaging
==========================
CT/CTA head ___:
1. Stable right frontal intraparenchymal versus subarachnoid
hemorrhage.
2. No new hemorrhage or acute infarct.
3. No evidence ofaneurysm greater than 3 mm, dissection or
significant
luminal narrowing.
4. Nonocclusive atherosclerotic changes of bilateral cavernous
and
supraclinoid internal carotid arteries.
.
MRI brain ___:
1. Stable subarachnoid hemorrhage in the right central gyrus.
While no
definite mass identified, underlying mass is not excluded on
the basis of
this examination. Recommend followup imaging to resolution.
2. No definite acute intracranial infarct is seen. Please note
that left
pontine, left cerebellar, and left temporal punctate foci of
increased
diffusion signal without associated ADC hypointensity may
represent small
areas of blood products, however subacute infarcts are not
excluded on the
basis of this motion degraded examination. Recommend attention
on followup
imaging.
Brief Hospital Course:
============================
BRIEF HOSPITAL COURSE
============================
Mrs. ___ was admitted to the ___ neurology
service for a convexity subarachnoid hemorrhage causing
transient left arm numbness from ___ - ___. The etiology is
likely a combination of amyloid angiopathy and hypertension.
Repeat imaging showed a stable convexity SAH. There were
punctate areas of diffusion restriction, likely due to blood
products from amyloid angiopathy. Extremely small lacunes are
possible but the major risk factors in reducing risk of
recurrent lacunes are hypertension and diabetes; antiplatelets
offer more risk than benefit right now though this could be
revisited in the future. She is now neurologically normal. We
stopped her atenolol due to bradycardia and replaced it with
lisinopril 10mg. A visiting nurse ___ come to her home on
___ to check on her. I have asked them to call her PCP's
office if her systolic is over 140mmHg. Her LDL was also above
goal; I replaced her simvastatin 20mg HS with atorvastatin 40
HS. Her goal LDL is < 100 but I would not push it much below 70
as very low LDL may raise the risk of intracranial bleeding.
.
I sent her PCP ___ fax notification of her hospital course and
asked for her to be seen over the next ___ weeks. I have also
given her Dr. ___ number so that she can make an
appointment; she should be seen in the neurology clinic sometime
over the next ___ months. If ___ could remind her to make an
appointment at your office visit (if she has not done so
already) I would greatly appreciate it. If ___ have any
questions, ___ can reach Dr. ___ office at ___.
.
============================
TRANSITIONAL ISSUES
============================
# Subarachnoid hemorrhage/amyloid angiopathy:
- f/u with Dr. ___
- repeat MR brain at that time
- control HTN
.
# Hypertension: Switched from atenolol to lisinopril
- Home with ___
- Follow-up with PCP for BP control
.
# Hyperlipidemia: Switched simvastatin 20mg to atorvastatin 40mg
- Would re-check LDL in 1 month
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. MetFORMIN (Glucophage) 500 mg PO BID
2. Atenolol 150 mg PO DAILY
3. Simvastatin 20 mg PO QPM
Discharge Medications:
1. MetFORMIN (Glucophage) 500 mg PO BID
2. Lisinopril 10 mg PO DAILY
RX *lisinopril 10 mg 1 tablet(s) by mouth every morning Disp
#*30 Tablet Refills:*3
3. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth qPM Disp #*30 Tablet
Refills:*3
Discharge Disposition:
Home With Service
Facility:
___
___:
Convexity subarachnoid hemorrhage
Amyloid angiopathy
Hypertensive urgency
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ were admitted because of left arm numbness which was caused
by bleeding into the part of your brain that is responsible for
sensation in the arm. Your bleeding was caused by a combination
of high blood pressure and a disorder where your blood vessels
are more fragile than normal ("amyloid angiopathy"). We cannot
treat amyloid angiopathy, but we can help with your blood
pressure. We have stopped atenolol (your heart rate was going
too low which can be a side effect) and replaced it with a
medication called lisinopril. We will have a visiting nurse come
and check your blood pressure tomorrow. ___ did very well in the
hospital without any other complications so ___ are safe to go
home with your family.
Please call ___ to make a follow up appointment with
your new neurologist, Dr. ___ some time in the next few
months. Please call your primary care doctor as soon as the
office is open on ___ morning for a follow-up appointment
this week or next regarding your blood pressure medication.
Please call ___ immediately if ___ have any of the "warning
signs" below.
Followup Instructions:
___
|
19609275-DS-16
| 19,609,275 | 28,107,706 |
DS
| 16 |
2189-02-16 00:00:00
|
2189-02-16 09:12:00
|
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 Thigh Deformity
Major Surgical or Invasive Procedure:
Open reduction internal fixation of right femur fracture
History of Present Illness:
24 man s/p motorcycle vs. car. Patient was wearing helmet, when
a car crossed in front of him. GCS 15 at scene, hemodynamically
stable.
___ hemodynamically stable, right thigh deformity, GSC 15
Past Medical History:
None
Social History:
___
Family History:
Non contributory
Physical Exam:
89 180/90 18 98 RA
In Pain
RUE skin clean and intact
No tenderness, deformity, erythema, edema, induration or
ecchymosis
Arms and forearms are soft
No pain with passive motion
R M U ___
EPL FPL EIP EDC FDP FDI fire
2+ radial pulses
LUE
Pain over clavicle, closed
no pain with ROM of elbow, wrist
Arms and forearms soft
R M U ___
EPL FPL EIP EDC FDP FDI fire
2+ radial pulses
LLE skin clean and intact
abrasion over left knee
Thighs and legs are soft
No pain with passive motion
Saph Sural DPN SPN MPN LPN ___ FHL ___ TA PP Fire
1+ ___ and DP pulses
RLE
Thigh deformed, soft
abrasion over right knee
no pain with palpation of knee
S S DP SPN T ___ FHL ___ TA PP Fire
1+ ___ 1+ ___ rash over flank
Pertinent Results:
___ 09:50PM GLUCOSE-129* UREA N-15 CREAT-1.2 SODIUM-141
POTASSIUM-3.9 CHLORIDE-104 TOTAL CO2-27 ANION GAP-14
___ 09:50PM CALCIUM-8.9 PHOSPHATE-2.8 MAGNESIUM-1.5*
___ 09:50PM WBC-11.3*# RBC-4.67 HGB-12.8* HCT-41.5 MCV-89
MCH-27.6 MCHC-31.1 RDW-13.2
___ 09:50PM PLT COUNT-210
___ 03:44PM TYPE-ART PH-7.43 COMMENTS-GREEN TOP
___ 03:44PM GLUCOSE-146* LACTATE-2.1* NA+-141 K+-3.9
CL--97 TCO2-29
___ 03:44PM HGB-14.7 calcHCT-44
___ 03:44PM freeCa-1.10*
___ 03:40PM UREA N-15 CREAT-1.3*
___ 03:40PM estGFR-Using this
___ 03:40PM LIPASE-27
___ 03:40PM WBC-5.4 RBC-5.20 HGB-14.8 HCT-45.4 MCV-87
MCH-28.4 MCHC-32.6 RDW-13.4
___ 03:40PM PLT COUNT-215
___ 03:40PM ___ PTT-19.3* ___
___ 03:40PM ___
Brief Hospital Course:
The patient was admitted to the Orthopaedic Trauma Service for
repair of his right femur fracture. The patient was taken to
the OR and underwent an uncomplicated intramedullary nailing.
The patient tolerated the procedure without complications and
was transferred to the PACU in stable condition. Please see
operative report for details.
Patient also has a grade III left AC separation for which he
will be treated non operatively with a sling for comfort.
Post operatively pain was controlled with a PCA with a
transition to PO pain meds once tolerating POs. The patient
tolerated diet advancement without difficulty and made steady
progress with ___.
Weight bearing status:
Weight bearing as tolerated right lower extremity
Weight bearing as tolerated left upper extremity
The patient received ___ antibiotics as well as
Lovenox for DVT prophylaxis. The incision was clean, dry, and
intact without evidence of erythema or drainage; and the
extremity was NVI distally throughout. The patient was
discharged in stable condition with written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient will be continued on chemical DVT
prophylaxis for 4 weeks post-operatively. All questions were
answered prior to discharge and the patient expressed readiness
for discharge.
Medications on Admission:
Multivitamins
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
2. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Syringe
Subcutaneous QPM (once a day (in the evening)) for 4 weeks.
Disp:*28 Syringe* Refills:*0*
3. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig:
___ MLs PO Q6H (every 6 hours) as needed for Dyspepsia.
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. oxycodone 5 mg Tablet Sig: ___ Tablets PO Q3H (every 3 hours)
as needed for pain: Do not drink or drive while taking this
medication.
Disp:*120 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Right fermoral fracture
Left AC separation
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:
******SIGNS OF INFECTION**********
Please return to the emergency department or notify MD if you
should experience severe pain, increased swelling, decreased
sensation, difficulty with movement; fevers >101.5, chills,
redness or drainage at the incision site; chest pain, shortness
of breath or any other concerns.
-Wound Care: You can get the wound wet/take a shower starting
from 3 days post-op. 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 or by your primary care
provider in two weeks. No dressing is needed if wound continued
to be non-draining.
******WEIGHT-BEARING*******
Weight bearing as tolerated right lower extremity
Weight bearing as tolerated Left upper extremity (sling for
comfort)
******MEDICATIONS***********
- Resume your pre-hospital medications.
- You have been given medication for your pain control. Please
do not operate heavy machinery or drink alcohol when taking this
medication. As your pain improves please decrease the amount of
pain medication. This medication can cause constipation, so you
should drink ___ glasses of water daily and take a stool
softener (colace) to prevent this side effect.
-Medication refills cannot be written after 12 noon on ___.
*****ANTICOAGULATION******
- Take Lovenox for DVT prophylaxis for 4 weeks post-operatively.
Followup Instructions:
___
|
19609288-DS-5
| 19,609,288 | 25,166,538 |
DS
| 5 |
2119-11-09 00:00:00
|
2119-11-09 10:27:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
Anesthetics - ___ / Cephalosporins / methylparaben /
Penicillins / propylparaben / Warfarin
Attending: ___.
Chief Complaint:
headaches; MCA aneurysm
Major Surgical or Invasive Procedure:
___ Angiogram for coiling of R MCA aneurysm
History of Present Illness:
Ms. ___ is an ___ yo female with history of multiple SAH who
presents with pulsatile headache and throbbing behind her eyes.
Patient has had a lifelong history of headaches. She had a Right
sided SAH in ___ that was treated with a R crani and clipping,
a
"middle" SAH in ___ that was managed conservatively, and a L
sided SAH in ___ that was treated at ___ with coiling and a
crani for evacuation. She has remained neurologically intact and
independent. However, for the last week, her baselines headaches
have worsened and became pulsatile in nature. She also noticed
throbbing behind her eyes with blurring of her vision with
prolonged focus. She denies parasthesias, weakness, and
difficulty with speech. She presented to ___ today
where a CT demonstrated an MCA aneurysm and no SAH. She was
transferred to ___ for definitive care.
Past Medical History:
PMHx:
Chronic headaches
___
Anxiety
Hypertension
Social History:
___
Family History:
Two distant cousins on maternal side who died at ___ years of age
from aneurysmal bleeds.
Physical Exam:
PHYSICAL EXAMINATION ON ADMISSION:
98.4 88 155/56 18 95%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 4 -3 mm b/l EOMs intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension
Cranial Nerves:
I: Not tested
___: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift.
Sensation: Intact to light touch.
On Discharge:
A&Ox3
PERRL
EOMs intact
face symmetrical
tongue midline
Motor: ___ throughout
Groin: soft, no hematoma
dorsalis pedis pulses intact
Pertinent Results:
CAROTID/CEREBRAL ARTERIOGRAM ___
1. Right MCA bifurcation aneurysm measuring 6.7 x 7.6 x 10.5 mm
with a 6.___nd the neck incorporates a significant
portion of the inferior M2 division. This has subsequently been
subtotally coiled with intentional occlusion of the distal
two-thirds of the aneurysm including complete occlusion of dome
and consistent now with filling of the neck and ___
classification occlusion.
2. Previously clipped ACom aneurysm with no evidence of
residual ACom
aneurysm from this unilateral injection.
3. No evidence of thromboembolic complications.
CHEST (PA & LAT) ___
No evidence of acute cardiopulmonary process or atelectasis in
this patient with underlying emphysema
Brief Hospital Course:
The patient was admitted to the neurosurgery service from the ED
on the day of admission, ___.
On ___, the patient remained neurologically intact. She
complained of chest pain and experienced one episode of
tachycardia where her heart rate was elevated into the 160s for
several seconds prior to self-resolving. The chest pain
continued. An EKG and cardiac enzymes were obtained and the
cardiology service was consulted for further evaluation. She was
evaluated by the neurovascular team who recommended a coiling of
the aneurysm on ___. She was started on Plavix today.
On ___, continued with pain control and plan for angio ___
___.
On ___, She was stable and awaiting angiogram.
On ___, patient was taken to angiogram for coiling of right MCA
aneurysm. There were no intraoperative complications. She was
transferred to the PACU for recovery after her R groin was
angiocealed. Sheath remained in place in the L groin. On post op
exam, she was stable and remained in the PACU post operatively.
On ___, patient was neurologically intact on exam. L sheath was
removed and she remained on bedrest for 5 hours. She was
transferred to the floor in stable conditon. Patient reported R
eye discomfort, but denied any difficulty with vision. She was
give artifical tears with good relief.
On ___, patient remained intact. She was ambulating but
reported shortness of breath with exertion. A chest x-ray and
EKGs were ordered. EKG performed showed no changes from previous
EKG. Patient was stable on exam. ___ was consulted.
On ___, CXR showed question of underlying emphysema and patient
denied any further shortness of breath. She was encouraged to
follow up with her primary care physician for further
evaluation. ___ recommended home with home ___ and she was
discharged in stable condition.
Medications on Admission:
Medications prior to admission:
Ativan 0.5 mg q6h anxiety
Amlodipine 5 mg daily
Tramadol 50 mg QID prn pain
Metoprolol 50 mg BID
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. Aspirin 325 mg PO DAILY
RX *aspirin 325 mg 1 tablet(s) by mouth once a day Disp #*60
Tablet Refills:*3
3. DiphenhydrAMINE 25 mg PO HS
4. Lorazepam 0.5 mg PO Q6H:PRN anxiety
5. Simethicone 40-80 mg PO QID:PRN abdominal distention/gas
6. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
7. Metoprolol Tartrate 50 mg PO BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
R MCA Aneurysm
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
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 be instructed by your doctor to take one ___ a day
and/or Plavix. If so, do not take any other products that have
aspirin in them. If you are unsure of what products contain
Aspirin, as your pharmacist or call our office.
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:
___
|
19609842-DS-10
| 19,609,842 | 20,669,234 |
DS
| 10 |
2161-01-12 00:00:00
|
2161-01-16 18:17:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Loss of consciousness (unwitnessed), facial trauma
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
This is a ___ with a history of spontaneous subdural hematomas
(left sided and right-sided subdural hematoma, status post
evacuation in ___ then ___ psychiatric disorder NOS, alchol
use, seizures, chronic daily headache, who presents after an
unwitnessed syncopal event with bradycardia.
He reports being in his usual state of health last night. He
went out with friends and drank ___ beers. He returned home and
went to bed. He remembers waking up to walk to the bathroom to
urinate but next recalls his girlfriend knocking on the door. He
stood up and went to the door, then developed episodes of nausea
and vomiting. He had fallen in the bathroom, injuring his face,
prompting him to be evaluated at ___.
Once there, his initial NIHSS was 3. His labs were notable for
etoh level of 175, AST 84, ALT 49. Troponin I was normal, with
APAP, salicylate, glucose and urine tox screen negative. CT
imaging showed left ___ complex fracture and no acute
intracranial abnormality. He was transferred to ___ for
further evaluation.
With respect to his seizure history, he reports having been on
keppra in the past which he had stopped. He also previously had
been on zyprexa but has discontinued since moving to ___
as he has not yet established care with a new psychiatrist.
He also reports having a likely syncopal episode a few weeks ago
where he only remembers being on the ground with severe left
shoulder pain. He does not remember falling or what he was doing
prior to the fall. Also of note, he reports his brother passed
away at ___ yo with dilated cardiomyopathy. He reports seeing his
brother 'snoring in a chair' then when he returned to the room
finding he had passed.
In the ED initial vitals were: 98.8 61 117/68 14 94% RA.
On telemetry he was noted to have episodes of sinus bradycardia
and junctional escape rhythm down to 20bpm.
Labs were notable for Serum EtOH 68 but Serum ASA, Acetmnphn,
___, Tricyc Negative.
7.4 \ 12.8 / 305
/ 38.5 \
142 105 8 AGap=19
------------/ ___
4.1 22 1.0\
Lactate 2.5.
CT imaging revealed multiple in displaced fractures through
lateral and posterior aspects of the zygomatic process of the
left temporal bone with comminuted, displaced fractures
involving the anterior, lateral and posterior walls of the left
maxillary sinus with extension through left orbital floor
without evidence of inferior rectus muscle entrapment.
He was evaluated by ACS, Plastic Surgery, EP, Neurology and
Ophthalmology. The decision was made to admit to Cardiology.
Patient was given:
___ 09:06 PO OxycoDONE (Immediate Release) 5 mg
___ 14:50 PO Acetaminophen 650 mg
___ 14:50 PO OxycoDONE (Immediate Release) 5 mg
Vitals on transfer: 98.6 60 125/107 16 99%
On the floor, he reports improvement in pain symptoms after
getting oral oxycodone in the ED. He has no chest pain,
lightheadedness or chest pain. He notes ongoing blurry vision of
the left eye with his previously present floater in the right
eye.
Past Medical History:
L subdural hematoma s/p burr hole ___ at ___
R subdural hematoma requiring evacuation in ___
Alcohol use
Seizures
Chronic daily headaches
Depression
All:NKDA
Social History:
___
Family History:
Dilated cardiomyopathy and sudden cardiac death (brother at age
___
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
VS: T 98.6, HR 60, BP 125/107, RR 16, SpO2 99%/RA
GENERAL: Thin male in no acute distress. Oriented x3. Mildly
anxious appearing.
HEENT: NCAT. Edema of the left eyelid. Sensation changes over
left eye
NECK: Supple without JVP
CARDIAC: Bradycardic but appears regular. Soft I/VI systolic
murmur over RUSB
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: No clubbing or cyanosis. Trace edema at the ankles
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses weakly palpable and symmetric
DISCHARGE PHYSICAL EXAM
=======================
Vitals: T 97.8 HR 44-50 BP ___ RR 18 O2 100%/RA
Weight: 65.6kg
Weight on admission: 64.3kg
Telemetry: sinus bradycardia in the ___. Longest pause 2.6
seconds.
General: lying in bed; NAD. Mental status appears intact. Mood
and affect are appropriate.
HEENT: left maxillary region is edematous, tender to touch.
Sensation mildly diminished on the left side of the face as
compared to the right.
Lungs: CTAB, no w/r/c.
CV: regular rhythm, bradycardic. no m/r/g. S1+S2 audible.
Abdomen: soft, NTND
Ext: warm and well-perfused. No edema. Palpable radial and ___
pulses.
Pertinent Results:
ADMISSION LABS
==============
___ 08:39AM LACTATE-2.5*
___ 08:34AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG
___ 08:34AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 08:34AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 08:34AM URINE RBC-3* WBC-<1 BACTERIA-FEW YEAST-NONE
EPI-0
___ 08:34AM URINE MUCOUS-RARE
___ 06:57AM GLUCOSE-69* UREA N-8 CREAT-1.0 SODIUM-142
POTASSIUM-4.1 CHLORIDE-105 TOTAL CO2-22 ANION GAP-19
___ 06:57AM ALT(SGPT)-42* AST(SGOT)-55* ALK PHOS-64 TOT
BILI-0.4
___ 06:57AM CALCIUM-8.8 PHOSPHATE-3.3 MAGNESIUM-1.9
___ 06:57AM ASA-NEG ETHANOL-68* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 06:57AM WBC-7.4 RBC-3.87* HGB-12.8* HCT-38.5*
MCV-100* MCH-33.1* MCHC-33.2 RDW-13.1 RDWSD-47.6*
___ 06:57AM NEUTS-62.5 ___ MONOS-7.8 EOS-0.3*
BASOS-0.3 IM ___ AbsNeut-4.62 AbsLymp-2.12 AbsMono-0.58
AbsEos-0.02* AbsBaso-0.02
___ 06:57AM PLT COUNT-305
PERTINENT LABS
==============
___ 08:39AM LACTATE-2.5*
___ 08:34AM BLOOD Lactate-1.3
DISCHARGE LABS
==============
___ 07:10AM BLOOD WBC-5.5 RBC-3.98* Hgb-13.4* Hct-39.6*
MCV-100* MCH-33.7* MCHC-33.8 RDW-12.6 RDWSD-45.6 Plt ___
___ 07:10AM BLOOD Plt ___
___ 07:10AM BLOOD Glucose-82 UreaN-8 Creat-1.0 Na-139 K-4.0
Cl-102 HCO3-28 AnGap-13
___ 07:10AM BLOOD Calcium-9.0 Phos-3.8 Mg-1.8
IMAGING
=======
CT SINUS/MANDIBLE/MAXILLA (___)
SOFT TISSUES:
Anterolateral to the left mandible, there is subcutaneous
emphysema and
stranding with extension to the lateral wall of the left
maxillary sinus.
MAXILLOFACIAL BONES: Multiple, mildly displaced fractures are
noted through the maxillofacial bones, fractures through the
anterior, lateral, and inferior walls of the left maxillary
sinus. Multiple additional displaced fractures are seen through
the left zygomatic arch, including a fracture through the
posterior zygomatic arch extending into the left
temporomandibular joint (2:62). The lateral pterygoid plates
are intact.
MANDIBLE: The mandible is without fracture or temporomandibular
joint
dislocation. The temporomandibular joints are symmetric, without
significant degenerative change.
DENTITION: There are no dental fractures. There is no
remarkable periodontal disease, periapical lucency, or
odontogenic abscess.
SINUSES: Multiple fractures through the left maxillary sinus
are noted, as previously described. Air-fluid levels seen
within the left maxillary sinus. The remainder of the paranasal
sinuses are intact and clear. The ostiomeatal units are patent.
The mastoid air cells and middle ear cavities are clear.
NOSE: There is no nasal bone fracture. Nasopharyngeal soft
tissues are
unremarkable. There is no nasal septal hematoma.
ORBITS: Extensive left maxillary fractures involve the inferior
left orbital floor without evidence of inferior rectus muscle
entrapment. The orbits, including the laminae papyracea, are
otherwise intact. The globes are intact with non-displaced
lenses and no intraocular hematoma. There is no preseptal soft
tissue edema. There is no retrobulbar hematoma or fat stranding.
Allowing for imaging technique optimized for the face, the
limited included portion of the brain is grossly unremarkable.
IMPRESSION:
1. Multiple in displaced fractures through the lateral and
posterior aspects of the zygomatic process of the left temporal
bone with extension into the left temporomandibular joint.
2. Comminuted, displaced fractures involving the anterior,
lateral, and
posterior walls of the left maxillary sinus, with extension
through the left orbital floor. No evidence of inferior rectus
muscle entrapment.
XRAY GLENO-HUMERAL SHOULDER (___)
FINDINGS:
There is no fracture or dislocation involving the glenohumeral
or AC joint. There are minimal degenerative changes along the
inferior glenohumeral joint. No suspicious lytic or sclerotic
lesion is identified. No periarticular calcification or
radio-opaque foreign body is seen.
IMPRESSION:
No left shoulder fracture or dislocation.
CTA HEAD (___)
CT HEAD WITHOUT CONTRAST:
The patient is status post bilateral craniotomies. There is no
evidence of acute hemorrhage, edema, mass effect, loss of gray/
white matter
differentiation, or pathologic extra-axial collection.
Ventricles, sulci, and basal cisterns are normal in size.
Left zygomaticomaxillary complex fractures are again seen,
similar to the
facial bone CT performed earlier on the same day. These include
left orbital floor and left maxillary sinus wall fractures with
fluid in the left maxillary sinus, and a comminuted fracture of
the left zygomatic arch. The zygomatic arch fracture extends
into the glenoid fossa of the left temporomandibular joint, and
into the sphenozygomatic suture. The overlying soft tissue
swelling has decreased with interval resolution of the
subcutaneous gas, previously overlying the left maxilla and
masticator muscle. The temporomandibular joints are well
aligned in closed mouth position.
CTA HEAD:
The vessels of the circle of ___ and their principal
intracranial branches appear normal with no evidence of
stenosis, occlusion, or aneurysm. A 1 mm triangular-shaped
outpouching at the origin of the right posterior
communicating artery and a 2 mm triangular-shaped outpouching at
the origin of the left posterior communicating artery represent
infundibuli. There is also an infundibulum at the right
superior cerebellar artery origin.
The dural venous sinuses are patent.
IMPRESSION:
1. Normal head CTA.
2. No evidence for acute intracranial abnormalities.
3. Left maxillofacial fractures are again noted, assessed in
detail on the
preceding facial bone CT.
ECHOCARDIOGRAM (___)
The left atrium and right atrium are normal in cavity size. No
atrial septal defect is seen by 2D or color Doppler. The
estimated right atrial pressure is ___ mmHg. Normal left
ventricular wall thickness, cavity size, and global systolic
function (3D LVEF = 59 %). Transmitral and tissue Doppler
imaging suggests normal diastolic function, and a normal left
ventricular filling pressure (PCWP<12mmHg). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. The estimated
pulmonary artery systolic pressure is high normal. There is no
pericardial effusion.
IMPRESSION: Normal study. Normal biventricular cavity sizes
with preserved regional and global biventricular systolic
function. No structural heart disease or pathologic flow
identified.
EXERCISE STRESS TEST (___)
INTERPRETATION: This ___ year old man with hx of tobacco abuse,
subdural hematoma s/p evacuation and seizure disorder was
referred to
the lab after having syncopal episode for evaluation of HR
response to
exercise as patient found to have marked bradycardia and pauses
on
telemetry. He exercised for 15.5 minutes on ___ protocol and
stopped
due to fatigue. The peak estimated MET capacity is 15.6, which
represents an excellent exercise tolerance for his age. He did
not
report any chest, arm, neck or back discomfort throughout the
test. He
reported being dizzy in early recovery. No significant ST
segment
changes were seen throughout the test. Rhythm was sinus with
rare
isolated APBs. Baseline systolic HTN with blunted BP response to
exercise. Baseline sinus bradycardia with appropriate HR
response to
exercise and recovery.
IMPRESSION : Appropriate HR resposne to high level of exercise.
No
anginal symptoms or ischemic EKG changes. Excellent functional
capacity.
Brief Hospital Course:
___ with a history of spontaneous subdural hematomas (left sided
and right-sided subdural hematoma, status post evacuation in
___ then ___ psychiatric disorder NOS, alchol use, seizures,
chronic daily headache, who presents after an unwitnessed
syncopal event with bradycardia.
# Bradycardia: The patient presented with marked sinus
bradycardia with episodes of junctional escape. Etiology may be
vagal due to pain from facial fractures, although he remained
bradycardic despite improvement in pain symptoms, and this also
presumes a different etiology for the initial syncope. A blood
culture was obtained on admission to rule out endocarditis -
results still pending on discharge. Also concerning is that he
may have had a prior syncopal event causing him to fall and
injure his shoulder. He also has a first degree relative with a
history of dilated cardiomyopathy and death at a young age
(unclear the exact cause). His heart rate increased with
exertion (to the ___ and has not had evidence of heart block on
recorded telemetry or EKG. Echo on ___ was normal. Exercise
stress test on ___ was normal - patient was able to mount an
appropriate HR response to exercise. Persistently bradycardic
throughout admission - almost exclusively sinus brady. He was
fitted for ___ of Hearts monitor to go home with.
# Syncope/Fall: Patient presented after unwitnessed likely
syncopal event. Differential includes cardiogenic (given known
bradycardia above) versus seizure (given history of seizures and
discontinuation of home keppra) versus vagal event/micturition
syncope. Given patient's family history of dilated
cardiomyopathy and sudden cardiac death, concern for cardiac
etiology of syncope is high. All work-up during admission was
normal (echo, ETT, lab work). Neurology saw the patient on
admission and recommended starting keppra 1000mg BID and
continuing this until he could be seen as an outpatient by
neurology.
# Facial fractures: Occurred in the setting of syncopal event.
Has multiple facial fractures with orbital fracture on the left.
Plastic surgery evaluated and did not feel surgical intervention
was required, confirmed that there was no sign of entrapment.
Evaluated by Ophthalmology with decreased visual acuity to ___
with ___ edema. They did not perform an option or recommend
any treatment at that time, and he will follow-up with them as
an outpatient. Plastic surgery saw the patient, recommended
sinus precautions while in the hospital, and requested for him
to follow-up as an outpatient.
# ? Epilepsy: History of seizures in the setting of ___, now
with unwitnessed fall. Had previously been on keppra as an
outpatient but stopped taking it a while ago due to transitions
in care. Pt did not report any tongue-biting, loss of
continence, but does have fatigue and headache following
episodes of LOC. Evaluated by neurology on ___. See above
for neurology recommendations.
# Alcohol abuse: Tox screen positive for EtOH (last drink ___
pm). Patient was on CIWA scale, but never required Ativan and
did not have any evidence of withdrawal.
# Elevated lactate: Lactate of 2.5 on admission; decreased to
1.2 on ___ (morning after admission). Could be elevated in
the setting of bradycardia and resultant hypoperfusion, as well
as episodes of vomiting. Would also be elevated in the setting
of seizure activity. Resolved issue.
# Cigarette smoking: patient responded well to nicotine patch in
the hospital; will discharge with patch.
TRANSITIONAL ISSUES:
[ ] Follow-up ___ of Hearts monitor
[ ] Follow-up with primary care doctor, re-assess pain control.
Patient discharged with oxycodone 5mg q8h prn pain, # 10 pills
[ ] Per neurology recommendations, continue Keppra 1000mg BID
until he can see neurology as an outpatient
[ ] Follow-up with ophthalmology as an outpatient for ___
edema
[ ] Follow-up with plastic surgery for facial fractures
[ ] Recommend establishing care with psychiatry and social work
[ ] Please continue to support smoking cessation
[ ] Full code
Medications on Admission:
None.
Discharge Medications:
1. LevETIRAcetam 1000 mg PO BID
2. Nicotine Patch 14 mg TD DAILY
3. Oxycodone 5mg q8hrs PRN:pain (dispense 10 tabs)
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Sinus bradycardia
Secondary diagnosis:
Seizure disorder
Facial fractures
___ edema of the eye
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 ___ from
___ - ___ for an episode of fainting you had, which
resulted in multiple fractures in the bones of your face.
WHILE YOU WERE IN THE HOSPITAL:
===============================
- Your heart rate was monitored continuously
- You had an echocardiogram (ultrasound) of your heart
- You had an exercise stress test (on the treadmill)
- You were started on a medicine for seizures called Keppra
(levetiracetam)
- You were fitted with a heart monitor to wear when you go home
WHAT WILL YOU DO WHEN YOU LEAVE THE HOSPITAL?
=============================================
- Wear the heart monitor as described to you by the people who
showed you how to use it
- Follow-up with Dr ___ doctor) within 1 month of
discharge
- Call his office sooner if you have any more episodes of
passing out or losing consciousness.
- Keep taking the Keppra as prescribed. You will follow-up with
a neurologist in a few weeks.
- You will see an ohpthamologist (eye doctor) to follow-up with
your eye injury and blurry vision.
- You will see the plastic surgery team to follow-up the facial
fractures you sustained in your fall.
- You will see a psychiatrist to establish care.
It was a pleasure taking care of you during your time here at
___. If you have any further questions about your care here,
please don't hesitate to contact us. We wish you all the best
with your health!
Your ___ Cardiology Team
Followup Instructions:
___
|
19609862-DS-12
| 19,609,862 | 27,311,633 |
DS
| 12 |
2173-06-11 00:00:00
|
2173-06-11 17:39:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Pravastatin / lisinopril / donepezil
Attending: ___.
Chief Complaint:
hyperkalemia, ___
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with a PMH of hypertension, hyperlipidemia,
chronic kidney disease, Alzheimer's dementia, pre-diabetes, left
carotid stenosis s/p CEA and asymptomatic interstitial lung
disease who was sent to the ED by his PCP for ___ and
hyperkalemia.
The patient has been feeling well. He has no complaints at all.
He lives at home with his ___ year old wife and daughter (who
takes care of him). No recent weightloss, no falls, no SOB, no
palpitations, good appetite, no
diarrhea/constipation/nausea/vomiting. Family reports that he
has
been intermittently agitated which is somewhat improved by
Seroquel.
He went to his PCP yesterday for ___ check up. BMP was done to
monitor CKD and it showed a Cr of 2.7 and K of 6.7.
In ED:
Of note, in the ED endorsed recent sickness of fevers and
lightheadedness 3 days ago, did not see the doctor at this time,
symptoms and fevers resolved spontaneously.
Labs: Cr 2.7--> 2.3, K ___
Meds: Calcium gluconate, insulin, dextrose, LR 1L, 100/hr
EKG: sinus arrhythmia, normal T wave morphology.
Past Medical History:
Left carotid stenosis s/p CEA (?___)
anemia
HTN
hyperlipidemia
renal insufficiency (cr 1.4-1.6)
back pain
memory loss
Social History:
___
Family History:
No strokes, seizures, migraines
Physical Exam:
ADMISSION EXAM:
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: bibasilar rales. do not clear with cough. Breathing is
non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, face symmetric, gaze conjugate with EOMI, speech
fluent, moves all limbs, sensation to light touch grossly intact
throughout
PSYCH: pleasant, appropriate affect
DISCHARGE EXAM:
VS: ___ 2334 Temp: 98.4 PO BP: 151/77 HR: 69 RR: 18 O2 sat:
98% O2 delivery: RA
___ Dyspnea: 0 RASS: 0 Pain Score: ___
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: CTAB. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation.
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented to self, not oriented to location or
time.
Face symmetric, gaze conjugate with EOMI, speech fluent, moves
all limbs, sensation to light touch grossly intact throughout
PSYCH: pleasant, appropriate affect
Pertinent Results:
ADMISSION LABS
--------------
___ 12:54PM BLOOD WBC-6.7 RBC-3.65* Hgb-10.2* Hct-32.7*
MCV-90 MCH-27.9 MCHC-31.2* RDW-14.3 RDWSD-46.7* Plt ___
___ 08:00PM BLOOD Neuts-36.9 ___ Monos-7.9 Eos-5.4
Baso-0.4 Im ___ AbsNeut-2.45 AbsLymp-3.29 AbsMono-0.53
AbsEos-0.36 AbsBaso-0.03
___ 12:54PM BLOOD UreaN-57* Creat-2.7* Na-140 K-6.7* Cl-107
HCO3-22 AnGap-11
IMAGING
-------
Renal ultrasound ___:
1. No evidence of stones or hydronephrosis.
2. Few bilateral simple appearing cysts as described above.
MICROBIOLOGY
------------
___ 10:45 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
IMAGING:
___ RENAL ULTRASOUND:
1. No evidence of stones or hydronephrosis.
2. Few bilateral simple appearing cysts as described above.
DISCHARGE LABS
--------------
___ 09:00AM BLOOD WBC-4.8 RBC-3.36* Hgb-9.4* Hct-29.8*
MCV-89 MCH-28.0 MCHC-31.5* RDW-14.0 RDWSD-45.5 Plt ___
___ 09:00AM BLOOD Glucose-88 UreaN-32* Creat-1.8* Na-141
K-4.4 Cl-109* HCO3-24 AnGap-8*
Brief Hospital Course:
Mr. ___ is a ___ ___ male with a PMH of
hypertension, hyperlipidemia, chronic kidney disease,
Alzheimer's dementia, pre-diabetes, left carotid stenosis s/p
CEA and asymptomatic interstitial lung disease who was sent to
the ED by his PCP for ___ and hyperkalemia.
ACUTE/ACTIVE PROBLEMS:
# Acute kidney injury on CKD:
History of CKD with baseline Cr 1.4-1.6. On routine labs by PCP
___ elevated to 2.7. No clear precipitant, however he was
feeling ill a few days prior. His daughter says he does not
drink much at home. In ___, had similar presentation that
improved with fluids. Suspect ___ due to hypovolemia. Renal
ultrasound without hydronephrosis. Hydrated, and repeat Cr on
discharge was 1.8. He should have his creatinine rechecked upon
PCP ___.
# Hyperkalemia:
K 6.7 on routine labs on ___. 6.2 in ED now normalized after
stopping ___, hydrating and giving insulin/dextrose. Likely in
setting ___ plus ___ plus dehydration. Improved quickly with
interventions. K prior to discharge was normal. Losartan was
held on discharge, and it should be evaluated whether he can
restart this in the future.
# Hypertension: Hypertensive on admit in setting of stopping
___. Continued nifedipine (ER) 30, stopped metoprolol and
started carvedilol. Losartan was discontinued. Blood pressure
on discharge was SBP 140s, with plan to discharge with regimen
of carvedilol and nifedipine.
CHRONIC/STABLE PROBLEMS:
#Pre-diabetes: Hgb A1C 6.4%.
# Asymptomatic Interstitial Lung disease: Previously family
decided not to work up. Bibasilar crackles on exam on admission
likely due to ILD.
# Alzheimer's dementia with agitation: History of Alzheimers.
Son is HCP ___. Continued Seroquel 50mg qhs (Qtc 450).
# Carotid stenosis s/p CEA: Continued ASA. Patient is not on
statin, for unknown reasons.
TRANSITIONS OF CARE
-------------------
# ___: patient should follow up with his PCP within one
week of discharge. He should have his creatinine rechecked upon
PCP ___. Losartan was held on discharge, and it should be
evaluated whether he can restart this in the future. Carvedilol
is a new medication that was started, and his blood pressure
should be re-evaluated on PCP ___.
# Contacts/HCP/Surrogate and Communication: ___ (son)
___.
# Code status: full
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Losartan Potassium 25 mg PO DAILY
2. Metoprolol Succinate XL 25 mg PO DAILY
3. NIFEdipine (Extended Release) 30 mg PO DAILY
4. QUEtiapine Fumarate 50 mg PO QHS
5. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever
6. Aspirin 325 mg PO DAILY
7. Cetirizine 10 mg PO DAILY
8. Vitamin D ___ UNIT PO DAILY
9. Glycerin Supps ___AILY:PRN constipation
10. Senna 8.6 mg PO BID:PRN Constipation - First Line
Discharge Medications:
1. CARVedilol 6.25 mg PO BID
RX *carvedilol 6.25 mg 1 tablet(s) by mouth twice a day Disp
#*30 Tablet Refills:*0
2. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever
3. Aspirin 325 mg PO DAILY
4. Cetirizine 10 mg PO DAILY
5. Glycerin Supps ___AILY:PRN constipation
6. NIFEdipine (Extended Release) 30 mg PO DAILY
7. QUEtiapine Fumarate 50 mg PO QHS
8. Senna 8.6 mg PO BID:PRN Constipation - First Line
9. Vitamin D ___ UNIT PO DAILY
10. HELD- Losartan Potassium 25 mg PO DAILY This medication was
held. Do not restart Losartan Potassium until a doctor tells you
to do so
Discharge Disposition:
Home
Discharge Diagnosis:
Hyperkalemia
Acute kidney injury
Hypertension
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 Mr. ___,
You were admitted to the hospital for reduced kidney function
and elevated potassium levels in the blood. Your medications
were adjusted and you were given IV fluid hydration, and these
levels improved.
It is important that you take all medications as prescribed and
follow up with the appointments listed below.
It was a pleasure taking care of you!
Sincerely, your ___ Team
Followup Instructions:
___
|
19609862-DS-15
| 19,609,862 | 21,306,583 |
DS
| 15 |
2173-10-24 00:00:00
|
2173-10-27 10:40:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Pravastatin / lisinopril / donepezil
Attending: ___.
Chief Complaint:
s/p fall from second story window
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ who presents after he fell out of the ___ second story
window. Per family at the bedside, the patient was discharged
home from ___ on ___ a few days ago, after an extended
hospitalization for dementia and pneumonia. He was left upstairs
in his bed by his family and was found outside on the ground
crawling for the door. He was outside for an unknown amount of
time.
Past Medical History:
Left carotid stenosis s/p CEA (?___)
anemia
HTN
hyperlipidemia
renal insufficiency (cr 1.4-1.6)
back pain
memory loss
Social History:
___
Family History:
No strokes, seizures, migraines
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Physical exam:
GENERAL: Lethargic, somnolent
HEENT: NCAT
CV: RRR
PULM: nonlabored breathing on 4LNC
ABD: soft, NT/ND
Ext: Symmetric movements
DISCHARGE PHYSICAL EXAM:
========================
Gen: Alert,
Pertinent Results:
ADMISSION LABS:
===============
___ 11:30PM BLOOD WBC-9.7 RBC-3.34* Hgb-9.4* Hct-32.2*
MCV-96 MCH-28.1 MCHC-29.2* RDW-16.3* RDWSD-56.7* Plt ___
___ 11:30PM BLOOD ___ PTT-38.6* ___
___ 03:45PM BLOOD Glucose-107* UreaN-38* Creat-2.0* Na-140
K-5.4 Cl-108 HCO3-23 AnGap-9*
___ 06:08PM BLOOD ALT-21 AST-37 LD(LDH)-339* AlkPhos-73
TotBili-0.6
DISCAHRGE LABS:
===============
Not collected due to transition to hospice
Brief Hospital Course:
___ y/o M with history of Alzheimer's disease, chronic ILD, HTN,
and carotid stenosis with recent admission ___ for
aspiration pneumonia, who represented with several vertebral
fractures as well as likely aspiration pneumonia after fall with
unknown preceding circumstances. In the setting of ongoing
hypoxia, and decision to not escalate medical care, patient was
transitioned to comfort measures.
TRANSITIONAL ISSUES:
====================
[] Patient is being transitioned to comfort measures only.
Please ensure his medications are focused on symptom management
and improvement, with removal of medications no longer
beneficial.
ACTIVE/ACUTE ISSUES:
====================
#Goals Of Care
#Aspiration Pneumonia
#Hypoxic Respiratory Failure
#Interstitial Lung Disease
Patient had recent admission for aspiration pneumonia, and
represented after a fall with CT Torso showing evidence of
airspace disease consistent with likely aspiration pneumonia. He
was initially started on vanc/Zosyn for antibiotic coverage, but
will switched to Unasyn for planned 7 day course. However, on
___, patient was noted to have ongoing hypoxia, not improved
with diuresis, Narcan, or escalating oxygen therapies. After
extensive discussion with the HCP, they expressed that patient
likely would not like to escalate further interventions or
transfer to the ICU, and thus decision was made to transition
patient to comfort measures.
#Syncope
#Vertebral Fractures
Patient presented after a fall out of the second floor window
with acute fractures to T5 and T6 vertebral body and L1 and L2
transverse process fractures, and a minimally displaced left
inferior pubic ramus fracture. Both orthopedics and spine
evaluated the patient and did not feel he warranted surgical
intervention or other activity restraint outside of pain
management.
#Irregular Thoracic/Abdominal Aortic Thrombus
CT Torso from ___ noted extensive irregular, non-occlusive
thrombus involving the patient's thoracic/abdominal aorta. Given
his goals of care, further intervention was not pursued.
#Alzheimer's Dementia
Patient with severe dementia and reported episodes of agitation
during prior hospitalization. Patient was not agitated during
this admission, and instead was mostly somnolent, thought
possibly secondary to medication effects.
#Acute on Chronic Anemia, normocytic
Hemoglobin 7.1 on transfer, with baseline appearing to be ___.
No localizing signs of bleeding on exam. Most likely related to
dilution iso IVF (plt also dropped as below), chronic
infection/inflammation, and chronic renal disease. Stopped
trending labs in setting of ___ focused care.
#Thrombocytopenia
Plt on admission 161, now dropped to 107. Possibly related to
dilution as his Hgb also dropped and he was receiving high
amounts of IVF prior to transfer. Stopped trending labs in
setting of ___ focused care.
#Chronic Kidney Disease
#Hypocalcemia
#Hyperphosphatemia
Cr 2.1 on transfer, which appears in range of recent baseline
(~1.6-low 2s). Stopped trending labs in setting of ___
focused care.
CHRONIC ISSUES:
===============
# Hypertension
Discontinued carvedilol and nifedipine given ___ focused
care.
# Carotid artery stenosis
Did not continue ASA given discontinuation at last admission.
CORE MEASURES:
==============
# CODE: CMO
# CONTACT: ___ (Son) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. NIFEdipine (Extended Release) 30 mg PO DAILY
2. QUEtiapine Fumarate 100 mg PO QPM
3. Vitamin D ___ UNIT PO DAILY
4. CARVedilol 12.5 mg PO BID
5. Aspirin 81 mg PO DAILY
6. Cetirizine 10 mg PO DAILY
7. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild/Fever
8. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN Wheezing
9. Divalproex Sod. Sprinkles 125 mg PO BID
10. Glycerin Supps 1 SUPP PR PRN Constipation
11. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN Dyspnea
12. Milk of Magnesia 10 mL PO BID
13. QUEtiapine Fumarate 50 mg PO Q6H:PRN Mood
14. Ramelteon 8 mg PO QPM
15. Senna 17.2 mg PO DAILY
Discharge Medications:
1. HYDROmorphone (Dilaudid) 0.125 mg IV Q3H:PRN Pain - Moderate
RX *hydromorphone 1 mg/mL 0.125 mg IV Q3H:PRN Disp #*1 Ampule
Refills:*0
2. Sodium Chloride 0.9% Flush ___ mL IV Q8H and PRN, line
flush
3. Sodium Chloride 0.9% Flush ___ mL IV Q8H and PRN, line
flush
4. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild/Fever
5. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN Wheezing
6. Cetirizine 10 mg PO DAILY
7. Divalproex Sod. Sprinkles 125 mg PO BID
8. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN Dyspnea
9. QUEtiapine Fumarate 100 mg PO QPM
10. QUEtiapine Fumarate 50 mg PO Q6H:PRN Mood
11. Ramelteon 8 mg PO QPM
Should be given 30 minutes before bedtime
12. Senna 17.2 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY
=======
Aspiration Pneumonia
Hypoxic Respiratory Failure
Vertebral Fracture
SECONDARY
=========
Irregular Thoracic/Abdominal Aortic Thrombus
Aortic Thrombus
Interstitial Lung Disease
Alzheimer's Dementia
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:
Dear Mr. ___,
It was a pleasure taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
===================================
- You were admitted to the hospital after a fall.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
==========================================
- You were evaluated by our surgical teams who felt you did not
warrant surgical interventions.
- The decision was made to transition to more comfort focused
care.
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:
___
|
19609930-DS-21
| 19,609,930 | 21,213,907 |
DS
| 21 |
2200-11-03 00:00:00
|
2200-11-03 11:36:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
Bactrim
Attending: ___.
Chief Complaint:
intractable back pain, extreme left leg pain with associated
paresthesias
Major Surgical or Invasive Procedure:
1. L5 laminectomy.
2. L4 bilateral laminotomy, medial facetectomy and
foraminotomy.
History of Present Illness:
___ man who presents with intractable back pain. He has
had back pain for months that is felt to be secondary to
degenerative joint disease at L5 and S1 and has undergone
multiple injections of steroids for his back at the ___. He
underwent an MRI in ___ showing degenrative disease at
L4-L5 and L5-S1 and was scheduled for surgery for this in
___ at the ___. Over the last few weeks, the pain in
his left leg has become extreme and is associated with
paresthesias. He has had difficulty walking and cannot function
at home.
Past Medical History:
PMH:
Hypertension
Depression
PSH:
Appendectomy
Rotator Cuff Repair
Nasal Turbinate resection
Social History:
___
Family History:
none
Physical Exam:
Per Note Dated ___ per Ortho
Physical Exam:
Well appearing NAD.
___ strength bilatearlly
L2-S1 SILT
+ straight leg raise Right side
No clonus.
Babinski downgoing bilaterally
___
Physical Exam:
AFVSS
General: Well appearing, NAD, pleasant, comfortable
BUE:Strenth ___ Delt/Tri/Bic/WE/WF/FF/IO
tone normal, negative ___
2+symmetrical DTR, ___
BLE:Strenth ___ ___
2+symmetrical DTR, ___
tone normal, no clonus, no pain bilaterally with st.leg raise
All Extremities WWP, and good capillary refill
Heart:RRR
Lungs:Clear to ascultation, no adventitious breath sounds
Abdomen:soft, non-tender, bs's all four quadrants
Pertinent Results:
___ 01:50PM BLOOD WBC-10.4 RBC-5.17 Hgb-16.1 Hct-45.9
MCV-89 MCH-31.2 MCHC-35.1* RDW-12.4 Plt ___
___ 01:50PM BLOOD Neuts-78.8* Lymphs-15.8* Monos-3.9
Eos-0.6 Baso-0.9
___ 05:31PM BLOOD ___ PTT-26.2 ___
___ 01:50PM BLOOD Plt ___
___ 01:50PM BLOOD Glucose-111* UreaN-13 Creat-0.9 Na-139
K-3.3 Cl-99 HCO3-27 AnGap-16
Brief Hospital Course:
Patient was admitted to the ___ Spine Surgery Service and
taken to the Operating Room for the above procedure. Refer to
the dictated operative note for further details. The surgery
was without complication and the patient was transferred to the
PACU in a stable condition. TEDs/pnemoboots were used for
postoperative DVT prophylaxis. Intravenous antibiotics were
continued for 24hrs postop per standard protocol. Initial postop
pain was controlled with a PCA. Diet was advanced as tolerated.
The patient was transitioned to oral pain medication when
tolerating PO diet. Foley was removed on POD#2. Physical
therapy was consulted for mobilization OOB to ambulate.
Hospital course was otherwise unremarkable. On the day of
discharge the patient was afebrile with stable vital signs,
comfortable on oral pain control and tolerating a regular diet.
Medications on Admission:
Hydrochlorothiazide, Metoprolol, Rosuvastatin, Sertraline,
Oxycontin
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Col-Rite] 50 mg 2 capsule(s) by mouth twice
a day Disp #*30 Capsule Refills:*0
3. Hydrochlorothiazide 25 mg PO DAILY
4. Metoprolol Succinate XL 12.5 mg PO DAILY
5. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
Please do not operate heavy machinery, drink alcohol, or drive
RX *oxycodone 5 mg ___ capsule(s) by mouth every four (4) hours
Disp #*80 Tablet Refills:*0
6. Rosuvastatin Calcium 40 mg PO DAILY
7. Sertraline 50 mg PO DAILY
Discharge Disposition:
Home with Service
Discharge Diagnosis:
1. Lumbar disk herniation L4-L5.
2. L5 radiculopathy.
3. L4-L5 and L5-S1 lumbar stenosis with foraminal stenosis.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Lumbar decompression without fusion
You have undergone the following operation: Lumbar Decompression
Without Fusion
Immediately after the operation:
Activity: You should not lift anything greater
than 10 lbs for 2 weeks. You will be more comfortable if you do
not sit or stand more than ~45 minutes without moving around.
Rehabilitation/ Physical Therapy:
___ ___ times a day you should go for a walk
for ___ minutes as part of your recovery. You can walk as
much as you can tolerate.
___ Limit any kind of lifting.
Diet: Eat a normal healthy diet. You may have
some constipation after surgery. You have been given medication
to help with this issue.
Brace: You may have been given a brace. This
brace is to be worn when you are walking. You may take it off
when sitting in a chair or lying in bed.
Wound Care: Remove the dressing in 2 days. If
the incision is draining cover it with a new sterile dressing.
If it is dry then you can leave the incision open to the air.
Once the incision is completely dry (usually ___ days after the
operation) you may take a shower. Do not soak the incision in a
bath or pool. If the incision starts draining at anytime after
surgery, do not get the incision wet. Cover it with a sterile
dressing and call the office.
You should resume taking your normal home
medications.
You have also been given Additional Medications
to control your pain. Please allow 72 hours for refill of
narcotic prescriptions, so please plan ahead. You can either
have them mailed to your home or pick them up at the clinic
located on ___. We are not allowed to call in or fax
narcotic prescriptions (oxycontin, oxycodone, percocet) to your
pharmacy. In addition, we are only allowed to write for pain
medications for 90 days from the date of surgery.
Follow up:
___ Please Call the office and make an
appointment for 2 weeks after the day of your operation if this
has not been done already.
___ At the 2-week visit we will check your
incision, take baseline X-rays and answer any questions. We may
at that time start physical therapy.
___ We will then see you at 6 weeks from the
day of the operation and at that time release you to full
activity.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
Physical Therapy:
___ times a day you should go for a walk for ___ minutes as
part of your recovery. You can walk as much as you can
tolerate.
Limit any kind of lifting.
You should not lift anything greater than 10 lbs for 2 weeks.
You will be more comfortable if you do not sit or stand more
than ~45 minutes without getting up and walking around.
Treatments Frequency:
Remove the dressing in 2 days. If the incision is draining
cover it with a new sterile dressing. If it is dry then you can
leave the incision open to the air. Once the incision is
completely dry (usually ___ days after the operation) you may
take a shower. Do not soak the incision in a bath or pool. If
the incision starts draining at anytime after surgery, do not
get the incision wet. Cover it with a sterile dressing. Call
the office.
Followup Instructions:
___
|
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2194-12-11 00:00:00
|
2194-12-11 15:38:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
Iodinated Contrast Media - IV Dye
Attending: ___.
Chief Complaint:
L knee pain
Major Surgical or Invasive Procedure:
___ - ORIF L proximal tibia
History of Present Illness:
___ M w/ hx of EtOH abuse and alcoholic pancreatitis brought in
by EMS after being hit by car. Patient found on street by EMS.
Intoxicated and reports being hit by car. Complaining of left
leg pain. Patient verbally abusive to EMS as well as being
combative in the ED. Required multiple doses of Haldol/Ativan.
On my evaluation, patient is sedated. Arousable to noxious
stimuli but unable to provide any information.
Past Medical History:
- Sigmoid diverticulitis with concern for colovesicular fistula:
- Alcohol abuse: Denies history of seizures, DTs, or ICU
admissions for withdrawal. Denies legal or work-related
complications of EtOH use.
- Cocaine abuse
- Pancreatitis
- Hypertension
Social History:
___
Family History:
Mother and father with DM and hypertension. Mother died from
cardiac complciations of DM; father died from other
complications of DM.
No inflammatory bowel disease or colorectal cancer
Physical Exam:
General: Sedated but briefly arousable to painful stimuli.
Left lower extremity:
- Abrasion over left patella
- Compartments soft
- Knee and proximal tib/fib tender to palpation
- Grimaces with movement of left leg
- Unable to assess motor and sensory function as patient is
sedated.
- 1+ ___ pulses, WWP
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have L tibia plateau fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for ORIF L tibia plateau 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.
Medications on Admission:
HCTZ 50mg PO Daily
folic acid 1mg PO Daily
Thiamine 100mg PO Daily
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Docusate Sodium 100 mg PO BID
3. Enoxaparin Sodium 40 mg SC DAILY
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 40 mg/0.4 mL 1 syringe SC Daily Disp #*28 Syringe
Refills:*0
4. FoLIC Acid 1 mg PO DAILY
5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*60 Tablet Refills:*0
6. PHENObarbital Alcohol Withdrawal Dose Taper (Days ___ 12 mg
PO/NG BID Duration: 2 Doses
Start: After 22 mg BID tapered dose
This is dose # 3 of 4 tapered doses
RX *phenobarbital 15 mg 1 tablet(s) by mouth twice a day Disp
#*4 Tablet Refills:*0
7. PHENObarbital Alcohol Withdrawal Dose Taper (Days ___ 6 mg
PO/NG BID Duration: 2 Doses
Start: After 12 mg BID tapered dose
This is dose # 4 of 4 tapered doses
8. PHENObarbital Alcohol Withdrawal Dose Taper (Days ___ 22 mg
PO/NG BID Duration: 4 Doses
Start: Today - ___, First Dose: Next Routine Administration
Time
This is dose # 1 of 4 tapered doses
9. PHENObarbital Alcohol Withdrawal Dose Taper (Days ___ 22 mg
PO/NG BID Duration: 4 Doses
Start: After 22 mg BID tapered dose
This is dose # 2 of 4 tapered doses
RX *phenobarbital 16.2 mg 1 tablet(s) by mouth twice a day Disp
#*5 Tablet Refills:*0
10. Senna 8.6 mg PO BID
11. Thiamine 100 mg PO DAILY
12. Hydrochlorothiazide 50 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
L tibial plateau fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
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:
- Touchdown weight bearing affected extremity - ROM as tolerated
in unlocked ___ brace
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 injections 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.
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 and any new
medications/refills.
Physical Therapy:
TDWB affected extremity - ROM as tolerated in unlocked ___
Treatment Frequency:
See patient instructions
Followup Instructions:
___
|
19610016-DS-14
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| 14 |
2196-10-22 00:00:00
|
2196-10-22 19:25:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Iodinated Contrast Media - IV Dye / morphine
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a ___ male with history of EtOH use disorder,
recurrent diverticulitis, c/b colovesicula fistula, and HTN who
presents with alcohol intoxication, abdominal pain, vomiting,
diarrhea. Patient was intoxicated on initial interview. He
states
he has been having chills and subjective fever. He also states
he
has been having hematuria and dysuria for the past 2 days. His
pain is in the midline lower abdomen. Denies chest pain,
shortness of breath. Endorses drinking a pint of liquor daily,
last drink was at 0100 on ___. Interested in ___ rehab after
hospitalization.
In the ED, vitals were:
T 98.7, HR 87, BP 150/99, RR 18, 97% RA
Exam:
General: Comfortable, lying in bed, awake and alert, smells of
EtOH
Head/eyes: Normocephalic/atraumatic.
ENT/neck: Oropharynx within normal limits. Neck supple.
Chest/Resp: Breathing comfortably on room air. Lungs clear to
auscultation bilaterally.
Cardiovascular: Regular rate and rhythm. Normal S1 and S2.
GI/abdominal: Soft, diffusely tender worse in midline lower
abdomen
GU/flank: No CVA tenderness
Musc/Extr/Back: No peripheral edema. Moving all extremities
Skin: Warm and dry
Psych: Normal mood
Labs:
ALT: 13 AP: 148 Tbili: 0.2 Alb: 4.0
AST: 21 Lip: 488
WBC 5.8, Hgb 13.1, Plt 223, Hct 41.4
Na 146, K 4.0, Cl 109,
HCO3 21, BUN 15, Cr 0.9, Glu 83
___: 10.3 PTT: 30.1 INR: 0.9
Lactate:1.8 -> 2.8 -> 1.3
UA w/o e/o infection or hematuria
Studies:
CXR ___
FINDINGS:
Lung volumes are low. Small bibasilar opacifications. No large
pleural effusion or pneumothorax. No pulmonary edema.
Cardiomediastinal silhouette is unchanged.
IMPRESSION:
1. No pulmonary edema.
2. Bibasilar opacifications may reflect atelectasis.
CT ABD/PELVIS W/O CONTRAST ___
IMPRESSION:
1. Unchanged circumferential thickening of the sigmoid colon
with lack of fat plane between it and the bladder and unchanged
appearance of colovesicular fistula. Overall appearance is
unchanged. No definite findings of acute diverticulitis.
2. Slightly thickened bladder wall, which may be due to bladder
underdistension, reactive changes from the fistula or a
component of cystitis.
3. No CT evidence of pancreatitis.
He was given:
3L IVF, Zofran IV 4 mg, Dilaudid 0.5 mg IV x2, Folic acid 1 mg
IV, Thiamine 200 mg IV, Diazepam 10 mg PO
On arrival to the floor, he endorses ___ abdominal pain that
is
sharp and constant in his mid to lower abdomen for 2 days.
Associated nausea, vomiting, abdominal swelling beginning 2 days
ago. Diarrhea yesterday. Says he drinks a pint of EtOH daily.
Has
been drinking daily for many years and says he has gone through
withdrawal before. Denies history of withdrawal seizures or
hallucinations.
Past Medical History:
Diverticulitis
Colovesicula fistula
Hypertension
Alcohol use disorder
Left tibia plateau fx in ___ s/p repair
Social History:
___
Family History:
Mother and father with DM and hypertension. Mother died from
cardiac complciations of DM; father died from other
complications of DM.
No inflammatory bowel disease or colorectal cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: ___ 1711 Temp: 98.1 PO BP: 152/82 L Lying HR: 74
RR:
18 O2 sat: 96% O2 delivery: RA Dyspnea: 0 RASS: 0 Pain Score:
___
GENERAL: Alert and interactive. In no acute distress.
HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.
NECK: supple
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Bibasilar crackles, no increased work of breathing
ABDOMEN: Soft, mildly distended, ttp in the midline lower
abdomen
and mid to upper abdomen, no rebound or guarding
EXTREMITIES: No clubbing, cyanosis, or edema. 2+ peripheral
pulses.
SKIN: Warm. No rash.
NEUROLOGIC: AOx3. Moving all 4 limbs spontaneously. CN2-12
intact.
DISCHARGE PHYSICAL EXAM:
========================
VS:
General: Comfortable, lying in bed, awake and alert
Chest/Resp: Breathing comfortably on room air. Lungs clear to
auscultation bilaterally.
Cardiovascular: Regular rate and rhythm. Normal S1 and S2.
GI/abdominal: Soft, mildly tender in epigastric region. No
rebound or guarding.
Musc/Extr/Back: No peripheral edema. Moving all extremities. No
tongue tremor.
Skin: Warm and dry
Pertinent Results:
ADMISSION LABS:
===============
___ 03:14AM URINE MUCOUS-RARE*
___ 03:14AM URINE HYALINE-2*
___ 03:14AM URINE RBC-0 WBC-1 BACTERIA-FEW* YEAST-NONE
EPI-0
___ 03:14AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30*
GLUCOSE-70* KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 03:14AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 03:14AM PLT COUNT-223
___ 03:14AM NEUTS-52.5 ___ MONOS-11.8 EOS-1.0
BASOS-0.7 IM ___ AbsNeut-3.03 AbsLymp-1.95 AbsMono-0.68
AbsEos-0.06 AbsBaso-0.04
___ 03:14AM WBC-5.8 RBC-4.88 HGB-13.1* HCT-41.4 MCV-85
MCH-26.8 MCHC-31.6* RDW-16.4* RDWSD-50.7*
___ 03:14AM URINE UHOLD-HOLD
___ 03:14AM URINE HOURS-RANDOM
___ 03:14AM ALBUMIN-4.0
___ 03:14AM ALT(SGPT)-13 AST(SGOT)-21 ALK PHOS-148* TOT
BILI-0.2
___ 03:14AM ALT(SGPT)-13 AST(SGOT)-21 ALK PHOS-148* TOT
BILI-0.2
___ 03:14AM estGFR-Using this
___ 03:14AM GLUCOSE-83 UREA N-15 CREAT-0.9 SODIUM-146
POTASSIUM-4.0 CHLORIDE-109* TOTAL CO2-21* ANION GAP-16
___ 06:23AM LACTATE-1.8
___ 07:13AM ___ PTT-30.1 ___
___ 10:50AM PLT COUNT-203
___ 10:50AM WBC-5.3 RBC-5.02 HGB-13.5* HCT-42.5 MCV-85
MCH-26.9 MCHC-31.8* RDW-16.2* RDWSD-50.2*
___ 10:50AM CREAT-0.8
___ 11:12AM LACTATE-2.8*
___ 11:12AM ___ COMMENTS-GREEN TOP
___ 04:03PM LACTATE-1.3
REPORTS:
=========
___ CTAP
IMPRESSION:
1. Unchanged circumferential thickening of the sigmoid colon
with lack of fat
plane between it and the bladder and unchanged appearance of
colovesicular
fistula. Overall appearance is unchanged. No definite findings
of acute
diverticulitis.
2. Slightly thickened bladder wall, which may be due to bladder
underdistension, reactive changes from the fistula or a
component of cystitis.
3. No CT evidence of pancreatitis.
DISCHARGE LABS:
================
___ 09:11AM BLOOD WBC-6.1 RBC-5.63 Hgb-15.2 Hct-47.2 MCV-84
MCH-27.0 MCHC-32.2 RDW-15.6* RDWSD-47.0* Plt ___
___ 09:11AM BLOOD Glucose-100 UreaN-8 Creat-0.8 Na-144
K-4.8 Cl-105 HCO3-23 AnGap-16
___ 09:11AM BLOOD Calcium-9.4 Phos-3.2 Mg-2.1
Brief Hospital Course:
SUMMARY:
========
___ male with history of EtOH use disorder, recurrent
diverticulitis, c/b colovesicula fistula, and HTN who presents
with alcohol intoxication, abdominal pain, vomiting, and
diarrhea initially concerning for acute pancreatitis. He was
noted to have elevated lipase but did not meet clinical criteria
for pancreatitis (atypical abdominal pain and no radiographic
evidence of pancreatitis). His abdominal pain improved with
supportive care. He expressed interest in alcohol rehab after
leaving the hospital and was monitored for alcohol withdrawal
for 96 hours prior to discharge.
TRANSITIONAL ISSUES:
====================
[] Please continue outpatient counseling/support regarding
alcohol cessation. Prior to discharge, plan was for him to
attend the ___.
[] Will continue nutrient supplementation with folate, thiamine,
and multivitamin upon discharge given his alcohol use history.
[] CT abdomen pelvis on admission revealed: unchanged
circumferential thickening of the sigmoid colon with lack of fat
plane between it and the bladder and unchanged appearance of
colovesicular fistula. Follow up as clinically indicated.
[] Electrolytes pending on discharge; however, daily
electrolytes prior to discharge were wnl. Please follow up on
outpatient basis.
ACUTE ISSUES:
=============
# Abdominal pain c/f pancreatitis
# Non anion gap metabolic acidosis.
Presented with abdominal pain, nausea, and vomiting iso
long-time heavy alcohol use. Lipase elevated to 488 with last
lipase 46 in ___. Received 3L IVF, anti-emetic, and
dilaudid in the ED. CT w/o evidence of pancreatitis or acute
diverticulitis, though does have abdominal pain and lipase
elevation as above. Lactate elevated to 2.8 in the ED improved
to 1.3 with IVF. Metabolic acidosis with bicarb 21 likely due to
GI losses. Clinically he does not meet criteria for pancreatitis
given atypical abdominal
pain (centrally located in the lower to mid-upper abdomen
without epigastric tenderness), and no CT findings. In absence
of leukocytosis/fevers lower suspicion for diverticulitis. Prior
to discharge, abdominal pain resolved.
# Alcohol use disorder:
# At risk for alcohol withdrawal:
Patient endorses drinking pint of liquor daily. At very high
risk of withdrawal. Will require CIWA. Required diazepam 5xearly
in hospital course but did not require diazepam for remainder
days of his hospitalization. Should continue folate, thiamine,
and multivitamin upon discharge. Patient is motivated to stop
drinking alcohol and plans to attend the ___ facility
the following week after discharge.
# Hematuria
# H/o recurrent diverticulitis c/b colovesical fistula
Patient reported hematuria on admission. Of note he has a
history of colovesical fistula being monitored as an outpatient.
UA during this admission was without blood or RBCs. There was no
clinical suspicion for diverticulitis throughout this admission
given CT without definite acute findings of diverticulitis and
absence of fever, leukocytosis.
CHRONIC ISSUES:
===============
# Hypertension:
Continued home amlodipine.
CORE MEASURES
=============
#CODE: Full (confirmed)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
2. amLODIPine 5 mg PO DAILY
3. Senna 17.2 mg PO DAILY
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 tab-cap by mouth once a day Disp #*30
Capsule Refills:*0
3. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth once a
day Disp #*30 Tablet Refills:*0
4. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
5. amLODIPine 5 mg PO DAILY
RX *amlodipine 5 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
6. Senna 17.2 mg PO DAILY
RX *sennosides 8.6 mg 2 tablet(s) by mouth once a day Disp #*60
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: Unspecified abdominal pain not meeting
diagnostic criteria for pancreatitis; monitoring for alcohol
withdrawal
Secondary diagnosis: alcohol use disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at the ___
___.
Why did you come to the hospital?
- You came to the hospital because you had abdominal pain and
you were interested in going to alcohol rehab.
What did you receive in the hospital?
- You received some tests to determine the cause of your
abdominal pain. These tests did not show that you had
diverticulitis. We did not find any concerning cause for your
abdominal pain.
- You received fluids through the IV and nutrient
supplementation.
- You were closely monitored for alcohol withdrawal. You did not
have signs of withdrawal while in the hospital.
- You were seen by our social worker who provided you with
resources for alcohol rehab.
What should you do once you leave the hospital?
- Please do not drink alcohol ever again. Please follow-up with
alcohol rehab for further support with quitting drinking.
- Please take all medications as prescribed and follow-up with
your outpatient doctors as ___.
- Please call your primary care doctor Dr. ___ to schedule a
follow-up appointment for within the next week. You can call
___ to schedule this appointment.
We wish you all the best!
- Your ___ Care Team
Followup Instructions:
___
|
19610016-DS-4
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DS
| 4 |
2191-12-04 00:00:00
|
2191-12-04 21:05:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Iodinated Contrast Media - IV Dye
Attending: ___
Chief Complaint:
****PATIENT ELOPED PRIOR TO RECEIVING DISCHARGE INSTRUCTIONS AND
MEDICATIONS****
Abdominal Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ M with h/o cocaine use, EtOH abuse, frequent
ED visits, and high blood pressure who presented to the ED with
chest and abdominal pain. The chest pain began after he snorted
cocaine and drank 1L of vodka around 0200 today. He frequently
has chest pain after cocaine use. The pain was left sided on his
chest, associated with DOE. He has also had 3 days of bilateral
lower quadrant abdominal pain associated with nausea. He has not
been eating well. Patient denies any fevers, chills, headache,
dizziness or back pain. Patient's last bowel movement was this
morning.
In the ED, initial vs were: 10 98.9 100 122/78 16 98% ra. Labs
were remarkable for normal CBC and chem-7, alk phos elevation to
135, lipase 74, troponin x2 were negative. CXR and KUB were
obtained and unremarkable. Abdominal CT scan revealed mild
sigmoid colonic diverticulitis without fluid collection or
perforation. Patient was given Ativan in addition to
cipro/flagyl. Decision was made for admission given the
patient's poor outpatient follow-up. Vitals on Transfer: 0 98.5
81 127/71 18 100% RA
On the floor, vs were: T 97.4 P 80 BP 120/80 R 18 O2 sat 100%
RA. The patient is asking for solid food. Upset that we will
only allow clear liquids. He is also asking for something "for
the shakes." The patient endorses interest in outpatient alcohol
treatment program. Chest pain now resolved. He continues to have
mild abdominal pain.
Past Medical History:
Hypertension
Polysubstance abuse (Cocaine, ETOH)
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION EXAM:
Vitals: T 97.4 P 80 BP 120/80 R 18 O2 sat 100% RA
General: Alert, oriented, anxious appearing
HEENT: Sclera anicteric, MMM, oropharynx clear, poor dentition
Neck: supple, JVP not elevated, no LAD
Lungs: Bibasilar crackles, no wheezes or rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, obese, mildly tender to deep palpation in LLQ,
non-distended, bowel sounds present, no rebound tenderness or
guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. With outstretched hands, pt has mild tremor.
Skin: No wounds, rashes, or lesions
Neuro: No facial droop, no slurred speech, normal gait
DISCHARGE EXAM:
Afebrile, HR ___, BP 110s/70s, RR 14, O2 100% RA
General: Alert, oriented, NAD
Abd: Obese, soft, NTTP, NABS
Pertinent Results:
ADMISSION LABS:
___ 06:55AM BLOOD WBC-7.5 RBC-4.98 Hgb-14.4 Hct-42.7 MCV-86
MCH-29.0 MCHC-33.8 RDW-16.1* Plt ___
___ 06:55AM BLOOD Neuts-51.1 ___ Monos-9.5 Eos-2.2
Baso-0.8
___ 06:55AM BLOOD Glucose-135* UreaN-16 Creat-1.0 Na-144
K-4.0 Cl-102 HCO3-25 AnGap-21*
___ 06:55AM BLOOD ALT-36 AST-34 AlkPhos-135* TotBili-0.2
___ 06:55AM BLOOD Lipase-74*
___ 06:55AM BLOOD cTropnT-<0.01
___ 12:50PM BLOOD cTropnT-<0.01
___ 06:55AM BLOOD Albumin-4.5
DISCHARGE LABS:
___ 08:05AM BLOOD WBC-8.3 RBC-5.03 Hgb-14.6 Hct-43.7 MCV-87
MCH-29.1 MCHC-33.4 RDW-15.9* Plt ___
___ 08:05AM BLOOD Glucose-97 UreaN-12 Creat-1.0 Na-139
K-3.7 Cl-101 HCO3-29 AnGap-13
___ 08:05AM BLOOD ALT-29 AST-28 AlkPhos-107 TotBili-0.7
IMAGING:
KUB ___: Non-obstructive bowel gas pattern
CXR ___: Very low lung volumes with bibasilar atelectasis.
No pneumothorax.
Abd/Pelvis CT ___: Mild sigmoid colonic diverticulitis
without fluid collection or perforation
Brief Hospital Course:
Mr. ___ is a ___ M with a history of polysubstance abuse and
HTN, admitted for mild diverticulitis.
___ ELOPED PRIOR TO RECEIVING DISCHARGE INSTRUCTIONS AND
MEDICATIONS*****
# Diverticulitis: CT scan in the ED showed mild sigmoid
diverticulitis. Patient was treated with PO ciprofloxacin and
metronidazole with resolution of abdominal pain in less than 24
hrs. He was tolerating a regular diet on the day of discharge.
The patient informed us that he intended to return to daily
alcohol intake after discharge. We were concerned for alcohol
interaction with metronidazole, resulting
in noncompliance after discharge. We planned to discharge him
with a prescription for Augmentin to complete a 10 day course
(last day ___, however he ELOPED prior to receiving this
prescription.
# Hypertension: The patient has a history of HTN, treated with
HCTZ and atenolol. Due to his ongoing cocaine use and alcohol
use, both of these medications were stopped and he was switched
to diltiazem ___ while hospitalized, since CCB are first-line
antihypertensives in ___ Americans. His BP came down to SBP
of 100s after 3 doses of ___ diltiazem (30mg doses) and he felt
lightheaded. Therefore, we planned to discharge him on
amlodipine, however he ELOPED, prior to receiving this
prescription. We spent quite some time counseling him on the
risk of beta-blockers and ongoing cocaine use.
# Polysubtance Abuse: The patient has a history of polysubstance
abuse (cocaine and alcohol). He had chest pain on presentation
to the ED after snorting cocaine. Troponins x2 were negative and
EKG did not show ischemic changes. Social work provided the
patient with information on outpatient alcohol treatment
programs,
since the patient was not interested in inpatient detox. The pt
intends to continue drinking after hospital discharge.
TRANSITIONAL ISSUES:
THE PATIENT ELOPED PRIOR TO RECEIVING HIS DISCHARGE PAPERWORK OR
PRESCRIPTIONS. WE ATTEMPED TO REACH HIM AT THE TWO NUMBERS
LISTED IN OUR SYSTEM; ONE WAS OUT OF SERVICE AND THE OTHER HAD
NO RESPONSE.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Hydrochlorothiazide 25 mg PO DAILY
2. Atenolol 25 mg PO DAILY
Discharge Medications:
***THE PATIENT ELOPED PRIOR TO RECEIVING PRESCRIPTIONS FOR
DISCHARGE MEDICATIONS. BELOW ARE LISTED THE MEDICATIONS WE
INTENDED TO DISCHARGE HIM ON.***
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
Last day ___
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet by mouth
Twice daily Disp #*18 Tablet Refills:*0
2. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice daily Disp
#*60 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID:PRN constipation
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice daily Disp
#*60 Tablet Refills:*0
4. Amlodipine 5 mg PO DAILY
Follow up with your primary care doctor within 1 week
RX *amlodipine 5 mg 1 tablet(s) by mouth daily Disp #*14 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
*****PATIENT ELOPED WITHOUT RECEIVING DISCHARGE PAPERWORK OR
PRESCRIPTIONS******
PRIMARY:
-Mild sigmoid diverticulitis
SECONDARY:
-Polysubstance abuse
-Hypertension
Discharge Condition:
***** PATIENT ELOPED WITHOUT RECEIVING DISCHARGE PAPERWORK OR
PRESCRIPTIONS ******
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
***** PATIENT ELOPED WITHOUT RECEIVING DISCHARGE PAPERWORK OR
PRESCRIPTIONS ******
Dear Mr. ___,
It was a pleasure to care for you at ___
___. You were admitted because of a mild infection in
your intestines, called diverticulitis. We treated you with
antibiotics which you need to continue taking until ___.
In addition, we changed your blood pressure medication to a
once-a-day pill which will work better for you than the other 2
medications you were taking in the past (hydrochlorothiazide and
atenolol). Please STOP taking those 2 medicines. START taking 1
tablet of amlodipine per day. Follow-up with your primary care
doctor for ___ re-check of your blood pressure in the next week.
While you were hospitalized, a social worker met with you and
gave you information on outpatient alcohol treatment programs.
Followup Instructions:
___
|
19610016-DS-6
| 19,610,016 | 20,363,438 |
DS
| 6 |
2192-06-14 00:00:00
|
2192-06-14 22:51:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Iodinated Contrast Media - IV Dye
Attending: ___
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ with history of polysubstance abuse (etOH,
cocaine), hypertension, and diverticulitis who presents with
abdominal pain, nausea, and vomiting. He reports that his
abdominal pain is generalized and is sharp. He denies radiation
of his pain. This is associated with nausea and nonbloody,
nonbilious vomiting. His last bowel movement was 3 days ago
which he reports was a bit blacker than normal, but was not
tarry/sticky. He denies any recent diarrhea or hematochezia. No
fevers, chills, chest pain, shortness of breath, or dysuria. He
drinks 1L gallon of vodka per day, last at 8am. He also uses
cocaine which was last used 2 days ago (2.5g). The patient was
seen in the ED the day prior to admission requesting detox, but
left after becoming sober.
Of note, the patient reports being recently admitted to ___ for
diverticulitis. Colectomy was recommended at that time, but the
patient left without surgery.
In the ED initial vitals were 97.7 108 133/78 18 97%RA. Initial
labs were without leukocytosis, anemia, or electrolyte
disturbances. Creatinine was 0.9. Lipase was 86. UA was
unremarkable. A CTAP demonstrated mild uncomplicated acute
sigmoid diverticulitis; pancreas was unremarkable. The patient
was given ciprofloxacin and metronidazole prior to transport to
the floor.
On the floor, initial vital signs are 97.8 135/85 72 20 96RA.
The patient reported ___ pain and was "starving".
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:
Hypertension
Polysubstance abuse (Cocaine, ETOH) - pt. denies prior episode
of EtOH withdrawal seizures although he does endorse EtOH
Hallucinosis in the past.
Sigmoid Diverticulitis ___ episode ___, uncomplicated)
Social History:
___
Family History:
Notable for father with history of diabetes and prostate cancer.
Mother with history of stroke and cancer (unknown type). Denies
family history of GI cancers including colon cancer. Also denies
history of IBD including Crohns and UC.
Physical Exam:
PHYSICAL EXAM ON ADMISSION
Vitals: 97.8 135/85 72 20 96RA
GENERAL: NAD, well-appearing, non-toxic
HEENT: NCAT, MMM, OP clear
NECK: Cupple neck, no LAD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi,
ABDOMEN: Obese, +BS, tenderness in central abdomen without
rebound or guarding, no epigastric pain
EXTREMITIES: w/wp
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
PHYSICAL EXAM ON DISCHARGE
GENERAL: comfortable appearing, sitting up in bed
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi,
ABDOMEN: Obese, hypoactive, firm, moderate distension no
interval change, no TTP
EXTREMITIES: w/wp
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact. no tremor.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
LABS ON ADMISSION
-----------------
___ 12:00PM BLOOD WBC-7.4 RBC-5.51 Hgb-15.2 Hct-46.2 MCV-84
MCH-27.5 MCHC-32.8 RDW-16.3* Plt ___
___ 12:00PM BLOOD ___ PTT-30.4 ___
___ 12:00PM BLOOD Plt ___
___ 12:00PM BLOOD Glucose-113* UreaN-14 Creat-0.9 Na-136
K-4.0 Cl-100 HCO3-27 AnGap-13
___ 12:00PM BLOOD ALT-25 AST-30 AlkPhos-114 TotBili-0.5
___ 12:00PM BLOOD Albumin-4.3
___ 06:50AM BLOOD Calcium-9.0 Phos-4.1 Mg-2.1
PERTINENT RESULTS
-------------------
___ 07:00 42 LIPASE
___ 12:00 86* LIPASE
LABS ON DISCHARGE
___ 07:25AM BLOOD WBC-6.6 RBC-5.32 Hgb-14.7 Hct-45.7 MCV-86
MCH-27.6 MCHC-32.2 RDW-15.4 Plt ___
___ 07:25AM BLOOD Plt ___
___ 07:25AM BLOOD Glucose-93 UreaN-13 Creat-1.2 Na-139
K-4.5 Cl-106 HCO3-29 AnGap-9
___ 07:25AM BLOOD ALT-49* AST-40 AlkPhos-78 TotBili-0.4
___ 07:25AM BLOOD Calcium-9.0 Phos-3.4 Mg-2.4
IMAGING
----------
___ (SUPINE & ERECT ___
___
FINDINGS:
A single dilated loop of small bowel in the left lower quadrant
is in a
location adjacent to known recent diverticulitis. The bowel gas
pattern is
otherwise normal without evidence of obstruction. No pneumatosis
or
pneumoperitoneum. No radiopaque foreign body.
IMPRESSION:
Single dilated small bowel segment in the left lower quadrant
consistent with
focal ileus likely related to adjacent diverticulitis. No
evidence of
obstruction.
___ ABD & PELVIS W/O ___ ___
___
FINDINGS:
The lung bases are clear. Limited imaging of the heart reveals
no pericardial
effusion or cardiomegaly. Coronary artery calcification is
present.
CT ABDOMEN: Evaluation of the solid organs is limited without
intravenous
contrast. The liver, gallbladder, pancreas, spleen and adrenal
glands are
normal. The kidneys are without stones or hydronephrosis.
There is no retroperitoneal or abdominal adenopathy. No free air
or free fluid
is present. The aorta is normal in caliber.
The stomach and intra-abdominal loops of small bowel are normal
caliber and
appearance. The appendix is visualized in the right lower
quadrant appears
normal.
Fat stranding surrounds a diverticulum in the sigmoid colon
consistent with
acute diverticulitis. There is no adjacent fluid collection or
free air. The
inflammatory diverticulum is close to the bladder. More
generally there is
diverticulosis throughout the colon, including moderate sigmoid
diverticulosis.
CT PELVIS: The remainder of the bowel is normal. The bladder is
normal. There
is no free pelvic fluid. There is no inguinal or pelvic
adenopathy. Mild
diastasis is noted at the umbilicus.
OSSEOUS STRUCTURES: No concerning osteoblastic or osteolytic
lesion
identified. Moderate degenerative changes affect L3-L4 through
L5-S1 facet
joints.
IMPRESSION:
Findings consistent with acute uncomplicated sigmoid
diverticulitis.
MICROBIOLOGY
--------------
Collection DateTestsResult
___ 10:30 HELICOBACTER ANTIGEN DETECTION, STOOLPND
___ VANCOMYCIN RESISTANT
ENTEROCOCCUS-PENDINGINPATIENT
___. difficile DNA amplification
assay-FINAL; FECAL CULTURE-PENDING; CAMPYLOBACTER
CULTURE-PENDING; FECAL CULTURE - R/O YERSINIA-PENDING; FECAL
CULTURE - R/O E.COLI ___:H7-FINALINPATIENT
___ 10:34 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
FECAL CULTURE (Pending):
CAMPYLOBACTER CULTURE (Pending):
FECAL CULTURE - R/O YERSINIA (Pending):
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___:
NO E.COLI 0157:H7 FOUND.
___ CULTUREBlood Culture,
Routine-FINALINPATIENT
___ CULTUREBlood Culture,
Routine-FINALINPATIENT
Brief Hospital Course:
___ with history of polysubstance abuse, hypertension, and
uncomplicated diverticulitis who presents with abdominal pain,
nausea, and vomiting for three days.
BRIEF HOSPITAL COURSE
ACTIVE ISSUES
# DIVERICULITIS: CT noncontrast scan on admission showed mild
uncomplicated diverticulitis. Pt treated initially with
augmentin PO. Due to ongoing nausea/vomiting and abdominal pain,
patient transitioned to IV unasyn. Patient is to finish his 10
day course of antibiotics with cipro/flagyl (Day ___ - End
Date ___. Patient's course complicated by nonresolving nausea,
vomiting and abdominal pain. CT with contrast deferred due to
history of anaphylaxis with IV contrast and no fevers or
laboratory abnormalities concerning for abscesses. KUB negative
for small bowel obstruction or free air, but revealing for focal
ileus.This improved with with IVF, bowel rest. Patient was
ambulatory, passing normal BM's and flatus at time of discharge.
No nausea or vomiting upon discharge and tolerating a regular
diet. Patient previously evaluated at ___ for diverticulitis and
was offered surgery but declined at the time. As he is willing
to consider surgical consultation, this appointment was arranged
for the patient at time of discharge. Patient was counseled not
to drink while taking flagyl.
#POLYSUBSTANCE ABUSE: Per patient, drinks at least 1 pint of
vodka (lately one gallon of vodka) and an "8-ball" (3.5 grams)
of cocaine daily. Patient maintained on CIWA scale upon
admission with peak CIWA scores of 13. No delirium tremens or
hallucinations. Pt seen by social work and discharged to a
___ Core program program in ___ for
continued sobriety.
TRANSITIONAL ISSUES
--------------------
[] Patient to finish cipro/flagyl for ten day course (Day ___ - End Date ___
[] Patient to follow up with outpatient surgery for correction
or recurrent diverticulitis
[] Patient to maintain alcohol and cocaine sobriety
post-discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Hydrochlorothiazide 25 mg PO DAILY
Discharge Medications:
1. Hydrochlorothiazide 25 mg PO DAILY
2. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*1
3. Thiamine 100 mg PO DAILY
RX *thiamine HCl 100 mg 1 tablet(s) by mouth once a day Disp
#*30 Tablet Refills:*1
4. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*1
5. Ciprofloxacin HCl 500 mg PO/NG Q12H
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth q12hr Disp #*6
Tablet Refills:*0
6. MetRONIDAZOLE (FLagyl) 500 mg PO TID
RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day
Disp #*9 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
--------------------
RECURRENT DIVERTICULITIS
GASTRITIS
ETOH ABUSE
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted for nausea and abdominal pain. You were
treated for diverticulitis with pain medication and bowel rest.
Please follow up with your primary care provider and the surgeon
with have scheduled for you to assess you for continued
management of your diverticulitis. Please finish taking your
antibiotics for the diverticulitis as prescribed and do not
drink alcohol as this can make you very sick especially while
taking these antibiotics.
Inpatient alcohol rehabilitation program:
You have been given list and information about Alcohol detox
programs.
You were accepted at the ___ Core program,
___ (___). Please continue to
follow up on your sobriety, and we wish you the best at the
___ program in ___.
It was a pleasure taking care of you at ___. We wish you well.
Sincerely,
Your Team at ___
Followup Instructions:
___
|
19610016-DS-8
| 19,610,016 | 26,106,109 |
DS
| 8 |
2193-01-04 00:00:00
|
2193-01-04 17:06:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Iodinated Contrast Media - IV Dye
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ with a history of alcoholism and recurrent
sigmoid diverticulitis who presents with two days of abdominal
pain. He reports that he was in his usual state of health until
two days ago, when he developed severe ___ periumbilical and
bilateral lower quadrant pain. The pain was sharp and did not
radiate. It did not change with positioning, and he was not able
to eat for the past two days. The pain was relieved with
alcohol, and he reports drinking 2 pints of brandy per day for
the past two days. At baseline, he drinks one pint per day. He
had associated nausea and one episode of emesis on the day prior
to presentation (___). He denies fevers, chills, constipation,
diarrhea, bright red blood per rectum, or changes to stool
color. Given his history of diverticulitis, he presented to
___ ED for further evaluation. His last drink was the evening
of ___, about one hour prior to presentation to the emergency
room. He had also used crack-cocaine on the evening prior to
admission.
In the ED, initial vitals: 97.6 110 147/86 18 98%
He was noted to be intoxicated with severe abdominal pain. He
underwent CT abdomen and pelvis that showed mild stranding in
the sigmoid likely secondary to diverticulitis, bladder wall
thickening adjacent to prior intraperitoneal abscess suspicious
for colovesical fistula though no free air in the urinary
bladder, and mesentary stranding consistent with panniculitis.
He was evaluated by the colorectal service, who felt that he was
not a good surgical candidate given active alcohol and cocaine
use and poor adherence. He was given IV morphine and
metronidazole and ciprofloxacin and transfered to the medicine
floor for further evaluation.
On arrival to the floor, pt is sober. He reports that his
abdominal pain has improved. He denies nausea and reports
significant hunger but otherwise feels well. He denies anxiety,
visual or auditory hallucinations. Denies chest pain, shortness
of breath, or palpitations. He notes that he feels tremulous.
Past Medical History:
Sigmoid diverticulitis:over ten admissions in the past ___
years to the ED at ___ and ___ for diverticulitis, most
recently in ___. He was scheduled to follow-up with
surgery in clinic to assess need for surgery given recurrent
episodes of diverticulitis but reports that he was afraid of
surgery and did not follow up.
Alcohol abuse: Reports drinking 1pint brandy/day for "months"
Multiple ED presentations for intoxication. Denies history of
seizures, DTs, or ICU admissions for withdrawal. Did not require
benzodiazepines during ___ hospitalization. Does not feel that
EtOH is a problem for him and is not interested in detox. Denies
legal or work-related complications of EtOH use.
Cocaine abuse
Pancreatitis
Hypertension
Social History:
___
Family History:
Mother and father with DM and hypertension. Mother died from
cardiac complciations of DM; father died from other
complications of DM.
Physical Exam:
Admission Physical Exam
=Vitals:T97.2, BP 147/95, HR70, O2 100 RA
General: AAOx3, comfortable appearing, in NAD, nontoxic
HEENT: NCAT, EOMI, PERRL. Sclera anicteric, conjunctiva pink.
MMM. OP clear. No tremor on tongue protrusion.
Neck: supple, no LAD, JVP at the level of the collarbone when
patient lying flat; not visible at 45 degrees
Lungs: CTAB, no wheezes or rales
CV: RRR, normal S1 and S2, no m/g/r
Abdomen: Normal, active bowel sounds. Distended abdomen with
tenderness to light palpation over periumbilical and bilateral
lower quadrant, L>R. No rebound tenderness, no guarding.
GU: no foley
Ext: WWP. 2+ peripheral pulses. No edema. Fine tremor in left
hand with arm extension.
.
Discharge Physical Exam: ELOPED
Pertinent Results:
Laboratory Results
-
___ 02:45AM BLOOD WBC-6.4 RBC-4.89 Hgb-13.4* Hct-38.8*
MCV-79* MCH-27.3 MCHC-34.5 RDW-16.7* Plt ___
___ 02:45AM BLOOD Neuts-51.2 ___ Monos-5.4 Eos-1.6
Baso-0.8
___ 02:45AM BLOOD Glucose-132* UreaN-9 Creat-0.7 Na-148*
K-4.1 Cl-108 HCO3-23 AnGap-21*
___ 02:45AM BLOOD ALT-30 AST-43* AlkPhos-105 TotBili-0.2
___ 02:45AM BLOOD Lipase-68*
___ 04:24PM BLOOD Albumin-3.3* Calcium-8.6 Phos-3.1 Mg-1.6
Imaging Results
-CT ABD & PELVIS W/O CONTRAST Study Date of ___ 2:37 AM
1. Mild stranding surrounding the sigmoid may represent mild
diverticulitis.
2. Severe focal urinary bladder wall thickening along the
anterior aspect of the urinary bladder adjacent to a region of a
prior intraperitoneal abscess which communicated with the
affected sigmoid colon raises concern for severe reactive
cystitis versus developing colovesical fistula. There is no free
air in the urinary bladder to suggest patent fistula. Further
assessment with cystoscopy is recommended.
3. Mild diffuse stranding of the root of the mesentery is
compatible with
panniculitis, likely reactive to the recurrent peritoneal
inflammation.
EKG Results
-___: No evidence of ischemia, normal sinus rhythm.
Brief Hospital Course:
Primary Reason for Hospitalization
=
___ with multiple admissions for uncomplicated sigmoid
diverticulitis and EtOH abuse presents with two days of
abdominal pain and imaging findings concerning for
diverticulitis vs reactive cystitis. Abdominal pain may also be
secondary to gastritis in the setting of heavy alcohol use.
Patient was intoxicated upon presentation but had no signs of
withdrawal. Overnight on ___, patient complained at pain at the
IV site and requested that his IV be discontinued. Nursing
removed his IV. The patient was scheduled for EGD the morning of
___, but he refused to have a new IV placed in anticipation of
the procedure. After his refusal, he left the hospital. Nursing
was made aware and contacted security, who could not locate the
patient. The patient's two contact numbers from ___ were called
but were disconnected. A message was left for the patient's
brother with the request that he call ___ with any
information about the patient.
-
ACTIVE PROBLEMS:
# Abdominal Pain: The patient was admitted with two days of
abdominal pain. Imaging showed mild sigmoid diverticulitis as
well as reactive cystitis and possible developing colovesical
fistula. UA demonstrated pyuria. The periumbilical nature of the
pain as well as the patient's longstanding alcohol abuse were
concerning for gastritis. He was followed by the colorectal
service, who determined that he was a poor surgical candidate
given history of poor compliance and lack of signs of acute
abdomen. The patient was treated with ciprofloxacin and
metronidazole for diverticulitis and omeprazole, maloox,
lidocaine for gastritis. He received tylenol and tramadol for
pain. He remained afebrile with no peritoneal signs throughout
admission.
-
#EtOH Intoxication: Patient intoxicated upon presentation to the
ED; his maximum CIWA score was 9. He received no diazepam. He
was seen by social work but refused their consultation.
-
#Hypertension: BP ___ during this hospitalization.
He was maintained on his home hydrochlorothiazide
-
#Microcytic Anemia: Pt had a microcytic anemia on presentation
(Hct 38.8, MCV79). Iron studies revealed mixed anemia of chronic
disease and iron deficiency anemia. His anemia was most likely
secondary to irritative gastritis causing slight GI bleed and
chronic inflammation from diverticulitis. He was treated with
omeprazole and antibiotics as above.
-
## Transitional Issues: Patient eloped.
-The patient had a CT scan that showed cystitis possibly in the
setting of developing colovesical fistula. There was no evidence
of free air in the bladder on imaging to suggest patent fistula,
and the patient did not have any symptoms of fistula such as
stool or gas in urine or sepsis from infection. Urology felt
there was no intervention needed during hospitalization and that
he should follow-up with colorectal surgery for further
evaluation
-Patient will need follow-up with colorectal surgery to
determine if surgery is necessary given repeated episodes of
diverticulitis
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Hydrochlorothiazide 25 mg PO DAILY
Discharge Medications:
ELOPED
Discharge Disposition:
Home
Discharge Diagnosis:
Diverticulitis
Cystitis
Gastritis
EtOH Intoxication
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure to care for you while you were a patient at
___. As you know, you were
admitted for abdominal pain. You had imaging of your abdomen
that showed inflammation in your colon where you have had
diverticulitis in the past as well as inflammation in the wall
of your bladder. You were treated with antibiotics for this
inflammation as well as with medications to treat inflammation
in the lining of your stomach. You received pain medication for
your abdominal pain. You were closely monitored to ensure that
you did not withdraw from alcohol while you were in the
hospital.
Please follow-up with your primary care physician after hospital
discharge. Please continue to take the medications to protect
the lining of your stomach.
If you develop more abdominal pain, nausea, vomiting, diarrhea,
dark or bloody stools, gas or brown material in your urine,
fevers, or any other concerning signs, please do not hesitate to
return to care.
We wish you all the best,
Your care team at ___
Followup Instructions:
___
|
19610301-DS-5
| 19,610,301 | 24,984,005 |
DS
| 5 |
2169-08-10 00:00:00
|
2169-08-10 07:50:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
LLE pain
Major Surgical or Invasive Procedure:
LLE external fixation
History of Present Illness:
___ year healthy woman who had a mechanical trip and fall down 4
stairs while traveling in ___. She landed on her side with
her left leg and ankle under her. Immediate onset of severe left
ankle pain and deformity, with gradual onset of edema and
ecchymosis. No bleeding or laceration noted. Denies any numbness
or weakness. Went to a local ER in ___ where they attempted
to reduce a bimall fracture under sedation and casted her.
Today, she presented to Dr. ___ and was referred in
for urgent ex-fix. She is still in significant pain, but the
pain level has not changed.
Past Medical History:
Hypothyroidism
Essential tremor
Social History:
Denies tobacco, +social alcohol, denies recreational drugs, very
active
Physical Exam:
LLE in ex fix
dressing c/d/I
SILT S/S/SP/DP/T
Firing ___
+2 pulses distally
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have left bimalleolar ankle fracture-dislocation and was
admitted to the orthopedic surgery service. The patient was
taken to the operating room on ___ for left ankle external
fixation, 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
non-weight bearing in the left lower extremity, and will be
discharged on Aspirin for DVT prophylaxis. The patient will
follow up with Dr. ___ (___) per routine. A thorough
discussion was had with the patient regarding the diagnosis and
expected post-discharge course including reasons to call the
office or return to the hospital, and all questions were
answered. The patient was also given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient expressed readiness for discharge.
Medications on Admission:
Levothyroxine
Propranolol prn
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Docusate Sodium 100 mg PO BID
3. Levothyroxine Sodium 125 mcg PO DAILY
4. Milk of Magnesia 30 ml PO BID:PRN Constipation
5. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain
Discharge Disposition:
Home
Discharge Diagnosis:
left bimalleolar ankle fracture-dislocation
Discharge Condition:
AAOx3, mentating appropriately, NVI
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- non-weight bearing LLE
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take aspirin 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.
- Please remain in your dressing and do not change unless it is
visibly soaked or falling off.
Physical Therapy:
non weight bearing left lower extremity
Treatments Frequency:
change dressing every 3 days.
Twice daily pin site care: 50-50 hydrogen peroxide-water mixture
applied to pin sites with a q tip
Followup Instructions:
___
|
19610730-DS-8
| 19,610,730 | 23,631,960 |
DS
| 8 |
2175-05-23 00:00:00
|
2175-05-23 14:29:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with recent STEMI on ___ c/b cardiac arrest
out-of-hospital (now s/p emergent cath with DES x1 to LAD at
___, discharged ___, presenting for
evaluation of ___ chest discomfort over precordium. The patient
reports that he thinks this is from the chest compressions
during CPR. It has been present ever since that time (i.e. prior
to last discharge), however the sensation has not improved over
the past few days so he wanted to make sure it wasn't another
heart attack.
Regarding the patient's recent STEMI:
- Cardiac arrest out-of-hospital
- Received thrombolytics in the field
- Received rescue PCI post-thrombolytics at ___
___ w/ DES x1 to LAD.
- Echo showed inferior and inferolateral hypokinesis with
preserved LV systolic function (EF 55%).
- Peak troponin was 11.53, CK-MB 382.8 (CK 5121)
In the ED, initial vitals: T 98.5, 66, 110/70, 18, 99%RA
- Labs notable for: TropT 0.56, MB 2, otherwise CBC and
chem-panel wnl, UA wnl.
- Imaging notable for: bedside echo with no pericardial
effusion per ED attending note and a grossly preserved EF. CXR
with no acute intrathoracic process.
On arrival to the floor, pt describes the discomfort as "like
feeling as if he needs to burp". Exacerbated by lying flat.
Relieved by sitting forward. No change with exertion (stairs,
walking). The discomfort has been stable since time of his cath.
He has been compliant with all of his cardiac medications.
Past Medical History:
- CAD s/p STEMI on ___ (c/b cardiac arrest; s/p 1x DES to
LAD at ___
- IBS
Social History:
___
Family History:
Grandmother died at age ___ of a heart attack. Mother with CAD in
___. No other family history of heart problems.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vitals: T 98.1, 112/71, 66, 14, 99%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, neck supple, JVP
not elevated
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2. No murmurs. No
friction rub present in either supine position or sitting
leaning forward.
Abdomen: soft, non-tender, non-distended
Ext: Warm, well perfused, no cyanosis or edema
Neuro: A&Ox3. Grossly intact.
DISCHARGE PHYSICAL EXAM:
========================
Vitals: Tmax=98.7 HR=65-70 BP=93-112/58-71 RR=16 O2=96-100% on
RA
I/O= 480/300 (8hrs), (24hrs)
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, neck supple, JVP
not elevated
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2. No murmurs. No
friction rub present in either supine position or sitting
leaning forward.
Abdomen: soft, non-tender, non-distended
Ext: Warm, well perfused, no cyanosis or edema
Neuro: A&Ox3. Grossly intact.
Pertinent Results:
PERTINENT LABS:
===============
___ 07:30PM BLOOD WBC-6.5 RBC-4.91 Hgb-14.7 Hct-43.5 MCV-89
MCH-29.9 MCHC-33.8 RDW-13.0 RDWSD-42.1 Plt ___
___ 07:30AM BLOOD Glucose-82 UreaN-17 Creat-1.0 Na-141
K-4.1 Cl-105 HCO3-24 AnGap-16
___ 07:30PM BLOOD CK-MB-2
___ 07:30PM BLOOD cTropnT-0.56*
___ 07:30AM BLOOD CK-MB-2 cTropnT-0.61*
Brief Hospital Course:
___ year-old man s/p STEMI ___ c/b cardiac arrest, received
lytics and now s/p 1x DES to LAD, presenting with ongoing stable
low grade chest pain that is unchanged in quality since
discharge. ECG without any signs of ischemia or pericarditis.
His pain was intermittent while inpatient with only several
brief, isolated episodes w/ ___ pain w/o associated dyspnea,
radiation, nausea, or diaphoresis. Troponins were 0.56 -> 0.61
from reported peak of 11 during primary admission. CK-MB 2 x2.
Pain was felt to be primarily musculoskeletal with possible
component of mild post-infarct pericarditis. Bedside ultrasound
in the emergency room showed no pericardial effusion and intact
systolic function. Discharged home with cardiology follow-up as
schedueled.
TRANSITIONAL ISSUES:
[] Consider repeat TTE to evaluate systolic function
[] On DAPT, please follow-up for at least 12 months
# CONTACT: ___ (mother, ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Clopidogrel 75 mg PO DAILY
4. DICYCLOMine 20 mg PO TID:PRN IBS
5. Famotidine 20 mg PO BID
6. Metoprolol Succinate XL 25 mg PO DAILY
7. Fluticasone Propionate NASAL 1 SPRY NU DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Clopidogrel 75 mg PO DAILY
4. DICYCLOMine 20 mg PO TID:PRN IBS
5. Famotidine 20 mg PO BID
6. Fluticasone Propionate NASAL 1 SPRY NU DAILY
7. Metoprolol Succinate XL 25 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Musculoskeletal chest pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___
___ was a pleasure taking care of you at the ___
___!
Why was I admitted to the hospital?
-You were admitted because you had persistent chest pain.
What happened while I was in the hospital?
-Your blood work showed you did not have another heart attack
What should I do after leaving the hospital?
-Avoid taking ibuprofen or naproxen for chest pain, you can take
Tylenol if needed
-Please keep your follow-up appointment with Dr. ___ as
scheduled below
-Moderate activity is fine, please call your doctor if you
experiences shortness of breath or chest pressure/pain with
activity
-Continue taking all your medications as previously prescribed.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Your ___ Healthcare Team
Followup Instructions:
___
|
19610932-DS-17
| 19,610,932 | 21,921,213 |
DS
| 17 |
2188-02-25 00:00:00
|
2188-02-25 14:41:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Codeine / Darvon / Nafcillin / Tofranil / Chlorpromazine /
Thorazine
Attending: ___.
Chief Complaint:
R distal femur fracture
Major Surgical or Invasive Procedure:
R distal femur open reduction internal fixation
History of Present Illness:
HPI: ___ with a complicated past medical history including
sepsis secondary to an epidural abscesses and bilateral septic
knees as well as rheumatoid arthritis, on methotrexate and
prednisone and osteoporosis presenting status post fall with a
right distal femur fracture. Patient was walking down porch
steps and tripped on a can falling unto her right knee. Patient
was unable to stand after the fall. Patient went to ___ and
was evaluated with right leg films and a CT scan which showed a
distal femur fracture. As patient gets her care here, she
requested transfer.
Patient was planing a right total knee replacement with Ayresf
for right valgus knee.
Past Medical History:
HTN
Rheumatoid arthritis
depression
migraine
hiatal hernia
anxiety
spinal stenosis
lumbar radiculopathy
myofascial pain
MSSA bacteremia
.
SURGICAL:
#L2-S1 laminectomy, foraminotomy, facetectomy, irrigation, for
severe spinal stenosis and epidural abscess on ___.
#C2-C7 laminectomy, irrigation for epidural abscess. C3-C7
posterior instrumentation and fusion for cervical instability on
.
___.
#Aspiration of retropharyngeal abscess.
#Chest tube placement for pulmonary empyema.
#Bilateral knee arthrocentesis, partial synovectomy, surgical
debridement and washout for septic joints on ___.
#Debridement of postoperative lumbar wound, decompression of
L4-L5 and repair of dural leak on ___.
Social History:
___
Family History:
Mother with CAD, duodenal ulcers. Father with CAD died of
esophageal CA with mets to the brain. Breast cancer in paternal
aunt.
Physical Exam:
A&O x 3. Calm and comfortable.
RLE: tenderness and swelling at the knee. superficial abrasion
over anterior knee. Thigh and leg compartments soft
Saphenous, Sural, Deep peroneal, Superficial peroneal SILT
___ FHS ___ TA Peroneals Fire
1+ ___ and DP pulses
Brief Hospital Course:
The patient was admitted to the Orthopaedic Trauma Service for
repair of a R distal femur fracture. The patient was taken to
the OR and underwent an uncomplicated R femur ORIF. The patient
tolerated the procedure without complications and was
transferred to the PACU in stable condition. Please see
operative report for details. Post operatively pain was
controlled with a PCA with a transition to PO pain meds once
tolerating POs. The patient tolerated diet advancement without
difficulty and made steady progress with ___.
The patient was transfused 4 units of blood for acute blood loss
anemia.
Weight bearing status: touchdown weightbearing right lower
extremity.
The patient received ___ antibiotics as well as
lovenox for DVT prophylaxis. The incision was clean, dry, and
intact without evidence of erythema or drainage; and the
extremity was NVI distally throughout. The patient was
discharged in stable condition with written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient will be continued on chemical DVT
prophylaxis for 2 weeks post-operatively. All questions were
answered prior to discharge and the patient expressed readiness
for discharge.
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. Duloxetine 60 mg PO DAILY
3. Enoxaparin Sodium 40 mg SC QPM Duration: 2 Weeks
RX *enoxaparin 40 mg/0.4 mL please inject subcutaneously into
abdomen every night Disp #*14 Syringe Refills:*0
4. Hydrochlorothiazide 12.5 mg PO BID
hold for SBP <120
5. Lisinopril 10 mg PO BID
hold for SBP <120
6. Multivitamins 1 TAB PO DAILY
7. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN pain
Hold if oversedation, rr<12, saO2<93%, confusion, somnolence.
Hold when on PCA.
RX *oxycodone 5 mg ___ tablet(s) by mouth every ___ hours Disp
#*60 Tablet Refills:*0
8. PredniSONE 7.5 mg PO DAILY
9. Sarna Lotion 1 Appl TP TID:PRN pruritis
10. Sulfameth/Trimethoprim DS 1 TAB PO DAILY
11. Verapamil SR 240 mg PO Q12H
Hold if HR<60, SBP<100
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
R distal femur fracture
Discharge Condition:
stable
Discharge Instructions:
Wound Care: You can get the wound wet/take a shower starting
from 3 days post-op. 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 continued to be non-draining.
******WEIGHT-BEARING*******
touch down weight bearing right lower extremity
******MEDICATIONS***********
- Resume your pre-hospital medications.
- You have been given medication for your pain control. Please
do not operate heavy machinery or drink alcohol when taking this
medication. As your pain improves please decrease the amount of
pain medication. This medication can cause constipation, so you
should drink ___ glasses of water daily and take a stool
softener (colace) to prevent this side effect.
-Medication refills cannot be written after 12 noon on ___.
*****ANTICOAGULATION******
- Take Lovenox for DVT prophylaxis for 2 weeks post-operatively.
Physical Therapy:
touchdown weightbearing right lower extremity. Full range of
motion
Treatments Frequency:
dry dressing changes as needed while incision is draining
Followup Instructions:
___
|
19611364-DS-15
| 19,611,364 | 29,098,863 |
DS
| 15 |
2147-05-20 00:00:00
|
2147-05-23 17:13:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lisinopril / latex
Attending: ___.
Chief Complaint:
AMS
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo F with PMH of several PEs- on coumadin, HTN, chronic leg
cramping and dementia presenting today after being found at
daycare to have a low BP, low heart rate and AMS. The patient is
unable to provide much of a history, which the daughter says is
a change from her baseline.
Patient's daughter got a phone call that her mother became
acutely confused with mumbling speach and closed her eyes. Her
HR was noted to be in the ___ and when her daughter picked her
up she was mumbling and possibly having visual hallucinations.
She was unable to walk to the car and needed wheelchair
assistance due to weakness. She was taken from daycare to home
by daughter, where her ___ also noted a low BP and HR. The
patient was then seen by her PCP, who took orthostatics which
were noted to be abnormal per the daughter. In the PCP's office,
she also complained of chest pain and left thigh crampiness
which is new for her. PCP sent them to the ED for evaluation.
Upon arrival to the ED, the patient states that her legs are
crampy. She denies chest pain, SOB, HA, n/v/diarrhea, dysuria.
She endorses a full appetite.
In the ED initial vitals were: 97.7, 51, 153/60, 18, 100% ra
- Labs were significant for hct of 35.6, INR of 1.6, and an
eosinophil count of 4.9. Head CT was negative for acute
intracranial process, CXR was negative as well.
- Patient was given 1L NS and IV hydralazine 10mg x1 for BP of
197/66.
Vitals prior to transfer were: 70, 157/60, 18, 99% RA
On the floor, patient reports that she feels okay but does not
know why she is in the hospital. All history is from daughter
who is at bedside.
Review of Systems:
(+) per HPI, chills, constipation
(-) fever, night sweats, headache, vision changes, rhinorrhea,
congestion, sore throat, cough, shortness of breath, no current
chest pain, abdominal pain, nausea, vomiting, diarrhea, BRBPR,
melena, hematochezia, dysuria, hematuria.
Past Medical History:
PULMONARY EMBOLISM ___
NOCTURNAL LEG CRAMPS
DEMENTIA -- With behavioral disturbance (worsening irritability)
PERIPHERAL NEUROPATHY -- Left leg burning pain
OSTEOARTHRITIS
HYPERTENSION
GAIT DISORDER -- Poor balance
PROTEINURIA
H/O VERTIGO
H/O DEEP VEIN THROMBOSIS ___ LLE
CHOLECYSTECTOMY
APPENDECTOMY
Social History:
___
Family History:
Positive for PE in niece, dementia and malignancy.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vitals - 97.5, 112/56, 70, 22, 99% RA
GENERAL: NAD, thin elderly female lying in bed initially asleep
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
patent nares, MMM, good dentition (dentures)
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, normal S1/S2, ___ systolic murmur heard best at
the RUSB. No gallops or rubs.
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: Soft. Nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema. Slight TTP of BLE, no appreciable erythema or
swelling.
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact. Strength ___ for upper and lower
extremity extensors and flexors bilaterally. Sensation intact to
light touch. Gait not assessed. AAO x1-2 (self and ___, did
not know she was in a hospital)
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
========================
Vitals - 98.2 120/48, 63, 18, 99% RA
GENERAL: NAD, thin elderly female lying in bed initially asleep,
but AAOx2-3 (name, place, month but not year, unclear about
reason for hospitalization) after waking.
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
patent nares, MMM, good dentition (dentures)
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, normal S1/S2, ___ systolic murmur heard best at
the RUSB. No gallops or rubs.
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: Soft. Nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema. Slight TTP of BLE, symmetric edema of the lower
extremities.
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact. Strength ___ for upper and lower
extremity extensors and flexors bilaterally. Sensation intact to
light touch. Gait not assessed.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
PERTINENT LAB RESULTS:
========================
___ 03:05PM BLOOD WBC-4.7 RBC-4.00* Hgb-12.1 Hct-35.6*
MCV-89 MCH-30.2 MCHC-34.0 RDW-14.7 Plt ___
___ 07:00AM BLOOD WBC-4.4 RBC-3.80* Hgb-11.5* Hct-34.0*
MCV-90 MCH-30.2 MCHC-33.7 RDW-14.6 Plt ___
___ 03:05PM BLOOD Neuts-54.6 ___ Monos-4.7 Eos-4.9*
Baso-0.5
___ 03:05PM BLOOD ___ PTT-30.3 ___
___ 07:00AM BLOOD ___ PTT-31.2 ___
___ 03:05PM BLOOD Glucose-90 UreaN-21* Creat-1.0 Na-138
K-3.9 Cl-103 HCO3-28 AnGap-11
___ 07:00AM BLOOD Glucose-77 UreaN-22* Creat-1.0 Na-140
K-4.2 Cl-106 HCO3-26 AnGap-12
___ 03:05PM BLOOD ALT-9 AST-18 AlkPhos-55 TotBili-0.2
___ 03:05PM BLOOD Calcium-8.9 Phos-2.6* Mg-2.1
___ 07:00AM BLOOD Albumin-2.9* Calcium-8.5 Phos-3.1 Mg-2.0
___ 03:05PM BLOOD TSH-1.9
___ 03:18PM BLOOD Lactate-0.8
IMAGING/STUDIES:
=================
___: CT HEAD NON CON
There is no acute intracranial hemorrhage,acute infarction, mass
or midline shift. There is no hydrocephalus. A 9 mm hypodensity
in the left caudate head is consistent with a lacunar infarction
which appears chronic. Visualized
paranasal sinuses and mastoid air cells are clear. There is no
fracture.
IMPRESSION:
No acute intracranial process. Chronic appearing lacunar infarct
in the left caudate head.
___: CXR
There is no focal consolidation, pleural effusion or
pneumothorax. The
cardiomediastinal and hilar contours are normal.
IMPRESSION:
No acute cardiopulmonary process.
Brief Hospital Course:
Mrs. ___ is a ___ with PMH signficant for several PEs- on
coumadin, HTN, chronic leg cramping and dementia who presents
with one day of altered mental status and lethargy at her senior
daycare, now returned to baseline mental status and found to
have AMS from likely recent medication changes and increased use
of diazepam.
ACUTE ISSUES:
=========
#Altered mental status/ lethargy:
Differential of AMS is vast including infection, cardiac causes,
electrolyte abnormalities or seizure and post-ictal state. CXR
negative for PNA and no leukocytosis makes infection less
likely. Recent use of diazepam with increased dosing and recent
medication change of chloroquine are suspect as a cause of this
AMS. CT head negative was negative. Her telemetry after
admission remained free of any acute events, and her mental
status returned to baseline. At discharge she was AAOx3, with
daughter confirming return to baseline mental status. Medication
changes were made at discharge to prevent recurrent altered
mental status.
#HTN:
BP at time of admission 112/56 but was as high as 197/66 in the
ED for which she received IV hydralazine 10mg x1. Her home
amlodipine was recently discontinued (unclear as to when this
was).
Recommend outpatient followup with PCP.
CHRONIC ISSUES:
===========
#H/O VTE:
Has had multiple PEs and DVTs in the past, most recent being in
___. Currently on warfarin. INR subtherapeutic at 1.6
at time of admission. She was continued on her home warfarin
dose and advised to continue trending INR as outpatient with her
PCP. No indication of pulmonary embolism on exam.
#Chronic leg cramping/ peripheral neuropathy:
Ongoing for the last few months. Patient and daughter very
adamant about avoiding excessive medication. Currently using
chloroquine off label for leg cramping and attempting to remain
well hydrated. Discontinued chloroquine given the recent start
date and high likelihood this is related to altered mental
status.
#Dementia:
Long standing, likely Alzheimer's type and possibly vascular
dementia given evidence of old lacunar infarct on CT. Continued
Donepezil.
#Constipation:
On bowel regimen.
TRANSLATIONAL ISSUES:
================
- Follow up with PCP ___ 1 week of discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB, chest tightness
2. Chloroquine 250 mg PO DAILY
3. Diazepam ___ mg PO Q12H:PRN muscle spasm
4. Divalproex (DELayed Release) 125 mg PO QHS
5. Donepezil 10 mg PO DAILY
6. Gabapentin 300 mg PO BID
7. Gabapentin 600 mg PO HS
8. Meclizine 12.5 mg PO TID:PRN vertigo
9. Tiotropium Bromide 1 CAP IH DAILY
10. Warfarin 3 mg PO 3X/WEEK (___)
11. Acetaminophen 500 mg PO Q8H
12. Warfarin 4.5 mg PO 4X/WEEK (___)
Discharge Medications:
1. Acetaminophen 500 mg PO Q8H
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB, chest tightness
3. Donepezil 10 mg PO DAILY
4. Tiotropium Bromide 1 CAP IH DAILY
5. Warfarin 3 mg PO 3X/WEEK (___)
6. Warfarin 4.5 mg PO 4X/WEEK (___)
7. Diazepam ___ mg PO Q12H:PRN muscle spasm
8. Divalproex (DELayed Release) 125 mg PO QHS
9. Gabapentin 300 mg PO BID
10. Gabapentin 600 mg PO HS
11. Lidocaine 5% Patch 1 PTCH TD QAM
Apply to each leg in areas of cramps
RX *lidocaine 5 % (700 mg/patch) Apply to affected area QAM Disp
#*30 Patch Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Altered mental status
Secondary diagnoses:
Dementia
H/o PE on coumadin
Hypertension
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. ___,
It was a pleasure taking care of you at ___
___. You were admitted for confusion. It may be that
you had a bad response to one of your medications -- possibly
choroquine. We recommend that you not take this medication in
the future. Your mental status improved throughout the day, and
you were discharged home; a visiting nurse ___ come for a few
days to monitor your vital signs.
Other medications on your list that can cause patients problems
with balance and cognition include gabapentin and diazepam; you
can discuss with your PCP whether these medications are needed.
We wish you the very best!
Your ___ care team
Followup Instructions:
___
|
19611364-DS-18
| 19,611,364 | 26,346,102 |
DS
| 18 |
2152-04-05 00:00:00
|
2152-04-05 19:30:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
lisinopril / latex / donepezil / venlafaxine
Attending: ___
Chief Complaint:
worsening dizziness and headache
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is an ___ female with a past medical history of
rheumatoid arthritis, hypertension, Alzheimer's with behavioral
disturbance, history of PE and DVT while on warfarin now on
Lovenox who presented to the hospital after dizziness and
headache that been persistent and severe.
Per patient's daughter who provides most of the history she was
in her usual state of health until about 4 ___ on ___. At this
time patient informed her daughter that she did not feel well
and
was going to lay down. She was endorsing some dizziness and
headache. For the rest of the day she stayed in bed and slept
did not get up to eat dinner. The next morning at 6 AM her
daughter was awoken by screaming this patient started to
experience severe headache and dizziness. This prompted her to
take her into the hospital. She was taken to outside hospital
where she had a CT head that was negative for any bleed or large
territory infarct. She was then transferred for further care.
Patient is unable to describe her headache very well but at one
point does tell me that she had some right-sided head and face
pain. Per her daughter this is typical she is not able to
describe symptoms very well but just says that her headache is
in
her head. She did describe her vertigo a little bit more and
says that it was room spinning vertigo. It was persistent and
did not change with position. Her daughter also tells me that
patient was constantly saying that she felt like she was falling
even when she was lying down. Patient was unable to ambulate
due
to the symptoms and had to be carried out of the house by her
daughter and granddaughter.
In addition patient was noted to have a new lesion on her tongue
is unclear what this is less patient did not have this a day
before per her daughter. She has no history of oral lesions or
cold sores. She also has been complaining of a lot of shoulder
and hip pain which is unlike her. Her daughter says that she
has
been having some issues with the wrist but otherwise has not
been
complaining of any joint or hip pain typically. On the morning
prior to admission patient also was noted to have diffuse
sweating overnight. Her daughter did not take her temperature
so
she does not know if she had a fever but she was subjectively
very warm. Per daughter she has not been complaining of any
vision changes, double vision or cuts in her vision other than
this morning when patient was having a severe headache with
dizziness she told her daughter that she was unable to see her
when she was standing in her right visual field. Overall
patient's daughter notes that she is more confused than normal
and is having more difficulty speaking.
Patient typically does not get headaches and does not complain
of
pain very often but the daughter. Of note she has a recent
history of a significant DVT and PE while she was
supratherapeutic on Coumadin. At this time patient was switched
to Lovenox. Her family and brief review of records there is no
clear etiology for her hypercoagulability.
ROS: Patient is unable to answer a lot of detailed review of
systems questions. Her daughter as discussed in HPI patient was
endorsing a headache, room spinning vertigo that was not
positional, vomiting with dizziness, inability to ambulate,
complaining of new shoulder and hip pain, has a lesion on her
tongue, possibly fever overnight but unclear.
Her daughter denies that she is been complaining or she is noted
any weakness, sensory changes, vision changes other than that
brief episode the patient stated that she could not see her
daughter. ___ that she has been complaining of any cough,
chest pain, shortness of breath, abdominal pain, dysarthria,
diarrhea or constipation
Past Medical History:
PULMONARY EMBOLISM ___
NOCTURNAL LEG CRAMPS
DEMENTIA -- With behavioral disturbance (worsening irritability)
PERIPHERAL NEUROPATHY -- Left leg burning pain
OSTEOARTHRITIS
HYPERTENSION
GAIT DISORDER -- Poor balance
PROTEINURIA
H/O VERTIGO
H/O DEEP VEIN THROMBOSIS ___ LLE
CHOLECYSTECTOMY
APPENDECTOMY
Social History:
___
Family History:
Positive for PE in niece, dementia and malignancy.
Physical Exam:
Physical Exam on Admission:
Vitals: 97.6, HR 64, BP 165/68, RR16, 98%
RAGeneral: Awake, cooperative though at times has difficulty
following directions, NAD though appears fatigued.
HEENT: NC/AT, no scleral icterus noted, MMM, vesicular appearing
lesion on right side of her tongue
Neck: Supple, No nuchal rigidity
Pulmonary: Normal work of breathing
Cardiac: warm, well-perfused
Abdomen: soft, non-distended
Extremities: No ___ edema
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, seems fatigued and sleepy, oriented to
self, unable to tell me the month or the year, says it is winter
when given options for seasons. She is unable to name anything
on the stroke card though this may be limited by her not having
her glasses. For cactus she says that it is a man and 2
children, father she calls a plant, looks to her daughter
frequently for assistance, her language is technically fluent
though at times vague and lacking meaning. She when she is
describing the cookie picture says that someone is falling and
that water is overflowing but is unable to say what child is
falling off of or what he is reaching for though again could be
limited by patient's not having her glasses. She is able to
read
all the sentences on the stroke card with some paraphasic errors
such as "I got some from work" rather than I got home from work.
She is able to follow simple axial and appendicular commands but
has a lot of difficulty with multistep commands.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus though difficult to get patient to sustain gaze in one
direction or the other for a prolonged period of time. Visual
fields appear full to finger wiggle though difficult in the
setting of patient's inattention
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline with good excursions. Strength
full with tongue-in-cheek testing.
-Motor: Normal bulk, tone throughout. Mild right pronation
without clear drift
No adventitious movements, such as tremor, noted. No asterixis
noted.
Unable to do formal confrontational testing due to patient's
mental status and, additional testing is limited by pain,
grossly
she is antigravity in her bilateral upper and lower extremities
spontaneously and can hold them antigravity for greater than 10
seconds in her upper extremities and greater than 5 in her
lowers, she is at least 4 in bilateral upper extremity deltoid
triceps and wrist extensors though deltoids are limited by pain
and there is give way in the other muscle groups, lower
extremities IP's are least of 3 the patient did not give me any
resistance and push down, she is able to bend her knees and
sustained this position, she is ___ out of 5 in dorsi and plantar
flexion bilaterally
-Sensory: Difficult to perform formal sensory exam given
patient's mental status, grossly she has no deficits or
asymmetry
to light touch and pinprick
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 0
R 2 2 2 2 0
Plantar response was flexor bilaterally.
-Coordination: Again difficult in the setting of her mental
status, finger-to-nose testing was slow and uncoordinated with
at
times overshoot though not consistent each time, unable to
perform heel-to-shin testing due to patient's understanding of
task
-Gait: Deferred given headache and fatigue patient frequently
trying to cover her head up to go to sleep during our exam
======================
Physical Exam at discharge:
Unchanged as above, with some increase in attention and
cooperating with motor and coordination exam finding no focal
deficits.
Pertinent Results:
___ 06:00AM BLOOD WBC-4.4 RBC-3.47* Hgb-10.5* Hct-31.4*
MCV-91 MCH-30.3 MCHC-33.4 RDW-13.4 RDWSD-44.4 Plt ___
___ 05:07PM BLOOD WBC-5.6 RBC-4.03 Hgb-12.1 Hct-35.8 MCV-89
MCH-30.0 MCHC-33.8 RDW-13.4 RDWSD-43.9 Plt ___
___ 05:07PM BLOOD Neuts-55.8 ___ Monos-5.2 Eos-0.5*
Baso-0.4 Im ___ AbsNeut-3.13 AbsLymp-2.12 AbsMono-0.29
AbsEos-0.03* AbsBaso-0.02
___ 06:00AM BLOOD ___ PTT-35.5 ___
___ 06:00AM BLOOD Glucose-83 UreaN-17 Creat-0.8 Na-141
K-3.3* Cl-108 HCO3-26 AnGap-7*
___ 05:07PM BLOOD Glucose-93 UreaN-21* Creat-0.8 Na-142
K-3.6 Cl-107 HCO3-23 AnGap-12
___ 05:07PM BLOOD ALT-10 AST-19 LD(LDH)-221 CK(CPK)-58
AlkPhos-70 TotBili-0.2
___ 05:07PM BLOOD cTropnT-<0.01
___ 05:07PM BLOOD CK-MB-2 cTropnT-<0.01
___ 06:00AM BLOOD Albumin-2.7* Calcium-8.4 Phos-2.2* Mg-1.8
Cholest-141
___ 06:00AM BLOOD %HbA1c-5.2 eAG-103
___ 06:00AM BLOOD Triglyc-50 HDL-43 CHOL/HD-3.3 LDLcalc-88
___ 05:07PM BLOOD TSH-2.2
___ 05:07PM BLOOD CRP-18.8*
___ 05:07PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 06:00AM BLOOD HERPES SIMPLEX VIRUS 1 AND 2 (IGG)-Test
___ 05:43PM BLOOD SED RATE-Test
___ 09:44PM URINE Color-Straw Appear-Clear Sp ___
___ 09:44PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 09:44PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
EKG: Sinus rhythm with a rate of 60, no T wave inversions or ST
changes
Radiologic Data:
CTA head and neck
CT HEAD WITHOUT CONTRAST:
There is no evidence of infarction,hemorrhage,edema,ormass. The
ventricles and sulci are prominent, indicative of age-related
involutional change. Periventricular and subcortical white
matter hypodensities are nonspecific but likely reflect the
sequelae of chronic microvascular ischemic disease.
The CTA head and neck examination is severely motion degraded.
Within these confines:
CTA HEAD: There is mild-to-moderate focal narrowing of the
basilar artery, may be exaggerated in setting of motion
degradation (602:29). Otherwise, the remainder of the more
central vessels of the circle of ___ and their principal
intracranial branches appear patent without evidence of
flow-limiting stenosis, occlusion, or aneurysm formation, in the
setting of a motion limited exam. There is a thin linear
hypodensity in the left transverse sinus, which does not have
the
typical imaging appearance of arachnoid granulation tissue
(3:212). Findings may suggest a nonocclusive dural venous sinus
thrombus.
CTA NECK: Moderate calcification of the right carotid bulb.
Dominant right vertebral artery system. Otherwise no evidence of
flow-limiting stenosis or occlusion of the visualized carotid
and
vertebral arteries.
MRI
IMPRESSION:
1. No acute intracranial abnormality, specifically no acute
infarct,
intracranial mass, hemorrhage
2. The reported filling defect in the left transverse and
sigmoid sinus is not
appreciated on this exam, and likely represent an artifact. No
evidence of
dural thrombosis specifically in the left transverse and sigmoid
sinuses.
BILAT LOWER EXT VEINS
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
Brief Hospital Course:
Ms. ___ is a ___ female with a past medical history of
rheumatoid arthritis, hypertension, Alzheimer's with behavioral
disturbance, history of PE and DVT while on warfarin now on
Lovenox who presented to the hospital after dizziness and
headache that been persistent and severe. She was admitted to
the neurology stroke service for concern of central/stroke
etiology of vertigo after it lasted for greater than 24 hours.
Her admitting exam was nonspecific as patient was uncooperative.
Patient was given Ativan for a MRI, with resolution of symptoms.
Patient's symptoms continue to be intermittent in nature, and
___ maneuver was positive (with head to the right) and
Epley maneuver was performed. MRI was negative for acute
ischemic event. Work-up included bilateral lower extremity
duplexes which were negative, ECG which showed sinus rhythm, MRI
which showed no acute infarct or acute intracranial
abnormalities. And no evidence of venous sinus thrombosis. CTA
found "Moderate narrowing (at least 60%) at the right aortic
bulb, and mild narrowing (at least 30%) at the left aortic bulb
with associated atherosclerotic calcified plaque. Moderate
calcification involving the bilateral cavernous and supraclinoid
segments of the ICA without evidence of flow-limiting stenosis."
Infectious etiology work-up with no leukocytosis, no fevers, and
negative UA and chest x-ray, making infectious etiology less
likely. Final diagnosis likely BPPV with admission secondary to
high preadmission probability of central vertigo. Patient
clinically improving at time of discharge; her only deficit was
paroxysmal vertigo with head turn. Patient started on meclizine
and Epley maneuver for ongoing treatment.
Transitional issues:
[] Outpatient monitoring of CTA vascular stenosis findings.
[] Being discharged on meclizine, monitor use and titrate off
medication.
[] LDL of 88. Follow-up herpes simplex IgG peripheral pending.
[] Hypertension management.
[] Consider titrating off some of her psychotropic medications
and her history of dementia and age.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN SOB
2. amLODIPine 10 mg PO DAILY
3. Enoxaparin Sodium 80 mg SC DAILY
Start: Today - ___, First Dose: Next Routine Administration
Time
4. Gabapentin 600 mg PO BID
5. Memantine 10 mg PO BID
6. PredniSONE 5 mg PO DAILY
7. Sertraline 50 mg PO DAILY
8. Tiotropium Bromide 1 CAP IH DAILY
9. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
10. Vitamin D 400 UNIT PO DAILY
11. Multivitamins 1 TAB PO DAILY
12. Ensure (food supplemt, lactose-reduced) oral Q4H:PRN
13. Complex B-100 (vitamin B complex;<br>vitamin B complex-folic
acid) 400 mcg oral DAILY:PRN
Discharge Medications:
1. Meclizine 12.5 mg PO Q8H:PRN Dizziness
RX *meclizine 12.5 mg 1 tablet(s) by mouth every six (6) hours
Disp #*30 Tablet Refills:*3
2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
3. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN SOB
4. amLODIPine 10 mg PO DAILY
5. Complex B-100 (vitamin B complex;<br>vitamin B complex-folic
acid) 400 mcg oral DAILY:PRN
6. Enoxaparin Sodium 80 mg SC DAILY
Start: Today - ___, First Dose: Next Routine Administration
Time
7. Ensure (food supplemt, lactose-reduced) 1 oral Q4H:PRN as
needed
8. Gabapentin 600 mg PO BID
9. Memantine 10 mg PO BID
10. Multivitamins 1 TAB PO DAILY
11. PredniSONE 5 mg PO DAILY
12. Sertraline 50 mg PO DAILY
13. Tiotropium Bromide 1 CAP IH DAILY
14. Vitamin D 400 UNIT PO DAILY
15.Outpatient Physical Therapy
Vestibular ___ and Epley Maneuver. For treatment of
Benign paroxysmal vertigo, unspecified ear ICD 10 Code ___
Discharge Disposition:
Home
Discharge Diagnosis:
Benign paroxysmal positional vertigo (BPPV)
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 worsening dizziness and
headache. There was concern this may have been due to a stroke.
However your MRI showed you did not have a stroke.
We believe your dizziness was due to a condition called Benign
Positional Paroxysmal Vertigo (BPPV). This should improve on its
own. Vertigo is typically brief in people with BPPV, lasting
seconds to minutes. Vertigo can be triggered by moving the head
in certain ways.
The best way to treat BPPV is with the Epley maneuver, which we
performed in the hospital. Youtube can also be helpful for
instructions. For now, try to perform the maneuver 3 times per
day.
We will prescribe you a medication called Meclizine, which can
be helpful for vertigo as well. We will also provide you with a
referral for physical therapy, who can help with the maneuvers.
-Start taking meclizine 12.5 mg as needed up to 3 times a day
for treatment of your dizziness.
-Outpatient physical therapy where Epley maneuver can be
performed to treat your vertigo.
Please take your other medications as prescribed.
Please follow up with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
19611364-DS-19
| 19,611,364 | 23,816,785 |
DS
| 19 |
2152-04-13 00:00:00
|
2152-04-13 17:03:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
lisinopril / latex / donepezil / venlafaxine
Attending: ___.
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is an ___ year old woman with a history of RA, well
controlled hypertension, Alzheimer's with behavioral
disturbance,
history of DVT and PE on therapeutic lovenox who presents for
acute onset behavioral alteration.
Patient was in her usual state of health this morning. She ate
breakfast normally, was talking normally, and got in the car to
drive to see Dr. ___ primary care doctor for ___ follow-up
visit after her discharge from the hospital. While she was in
the car she was speaking normally, and she was even reading in
the backseat her daughter notes. When they got to the office,
when she was seated into Dr. ___ she became very quiet.
Her daughter notes that she was not responding to questions
reliably, and sometimes she would just say that she was "getting
tired". By the time Dr. ___, patient had her eyes
closed
and was not answering any questions. She did not fall out of
her
chair or have any loss of consciousness. There was no noted
shaking or automatisms. Her daughter thought that there might
have been a right facial droop while she was in the doctor's
office which she had not noted before. When Dr. ___, he
found that ___ was very different from her usual self, as she
was not participating, and her speech was "babbling" And so they
decided to transfer her to the ED. The ambulance was taking a
long time, so they ended up feeling her across the street and
presenting directly to the ED where a code stroke was called.
Her initial ___ stroke scale in the ED was a 14 for partial
gaze,
facial palsy (unclear which side), drift of both upper
extremities. She was not participatory with finger-to-nose or
with testing of aphasia. After CT head was completed, ___
stroke
scale repeated which was a 4. She scored points for not knowing
the month or her age, mild right facial palsy, limb ataxia on
the
right (though this may have been limited by patient
understanding
of task). With more time, patient's exam continued to improve
to
the point that she could describe the stroke card in good detail
in both ___ and ___, name objects on the stroke card and
describe their function, and was able to follow almost all
commands. However, she intermittently would have a short period
of time where she did not make any sense according to her
daughter as she spoke in ___. For example she was saying
things like "I came here to get to the book". When the patient
was asked about the episode, She says that she recalls seeing
the
doctor, but he could not understand her.
Patient was unable to participate in review of systems
questions.
Daughter reports that patient has not mentioned any concerning
neurologic symptoms. There has been no concern for further
dizziness. ___ has been quite healthy, has not had any fevers
at home, no dysuria or foul-smelling urine, no cough, no chest
pain or trouble breathing. Family reports that she is not back
to
baseline.
Notably, patient was recently admitted to the neurology stroke
service for persistent and severe dizziness and headache. She
was given Ativan for MRI, which led to resolution of her
symptoms. Her symptoms were noted to be intermittent in nature,
and she was found to have a positive ___ maneuver with
head turn to the right. MRI was negative for an acute ischemic
event. She had a work-up that included bilateral lower
extremity
duplex which was negative, EKG in sinus rhythm, and CTA which
showed a chronic left vertebral occlusion. She had a complete
infectious work-up which was negative. Overall presentation was
thought to be most likely secondary to BPPV.
Past Medical History:
Alzheimer's with behavioral disturbance (worsening irritability)
PERIPHERAL NEUROPATHY -- Left leg burning pain
RA
HYPERTENSION - well controlled
GAIT DISORDER -- Poor balance
H/O VERTIGO
DVT, PE with coumadin failure on lovenox (daughter not sure why
DVT/PE)
CHOLECYSTECTOMY
APPENDECTOMY
Social History:
___
Family History:
Positive for PE in niece, dementia and malignancy.
Physical Exam:
On Admission
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Normal work of breathing
Cardiac: RRR, warm, well-perfused
Abdomen: soft, non-distended
Extremities: No ___ edema.
Skin: no rashes or lesions noted.
***Repeat exam ~30 minutes after code stroke. Mild R NLFF had
resolved at this point.
Neurologic:
-Mental Status: Alert, can tell me her name but not her birthday
(she usually knows her birthday), does not know year or location
(normal for her). She was inattentive but could follow simple
commands. She could repeat "today is a sunny day in ___.
Normal prosody. She could name chair, called glove "what ___ put
on your hand" and feather ___ may clean with it" difficult to
say if this was because she couldn't think of the ___ word.
Able to read without difficulty. Speech was not dysarthric. Able
to follow both midline and appendicular commands. Difficult to
test for apraxia because she had a hard time understanding what
I
was asking. No evidence of neglect.
CN
I: not tested
II,III: VFF to confrontation, pupils 4mm->2mm bilaterally
III,IV,VI: EOMI, no ptosis. No nystagmus
V: sensation intact V1-V3 to LT
VII: Facial strength intact/symmetrical, symm forehead wrinkling
VIII: hears finger rub bilaterally
IX,X: palate elevates symmetrically, uvula midline
XI: SCM/trapezeii ___ bilaterally
XII: tongue protrudes midline, no dysarthria
Motor: Decreased bulk. Paratonia noted. No pronator drift.
Delt Bi Tri WE FE Grip IO
C5 C6 C7 C6 C7 C8/T1 T1
L 5 ___ 5 5 5
R 5 * ___ 5 5
IP Quad Hamst DF PF
L2 L3 L4-S1 L4 S1/S2
L 5 5 5 5 5
R 5 5 5 5 5
Reflex: No clonus
Bi Tri Bra Pat An Plantar
C5 C7 C6 L4 S1 CST
L ___ 2 ___ Flexor
R * ___ ___ Flexor
*unable to test due to IV causing pain
-Sensory: Withdraws to noxious throughout. She could feel
vibration stronger at the knees than the ankles bilaterally. Too
inattentive to perform more detailed sensory testing. Could not
tell if she extinguishes to DSS.
-Coordination: Could not test FNF on the right due to IV causing
pain. She missed the target on the left once with FNF, but with
re-direction was able to perform task with no ataxia.
-Gait: deferred
At discharge
-Mental Status: Awake alert but disoriented. She was attentive
and following simple commands. Appears confused but pleasant.
Speech was not
dysarthric. Able to follow both midline and appendicular
commands. Daughter noted that she is at baseline mental status
CN
EOMI, PERRL. Speech is not dysarthric. Face is symmetric.
Motor: Strength is ___ in all muscle groups
-Sensory: Intact to light touch
-Coordination: deferred -Gait: deferred
Pertinent Results:
___ 08:05AM BLOOD WBC-4.1 RBC-4.14 Hgb-12.4 Hct-37.4 MCV-90
MCH-30.0 MCHC-33.2 RDW-13.4 RDWSD-44.1 Plt ___
___ 04:42PM BLOOD Neuts-56.8 ___ Monos-7.0 Eos-2.1
Baso-0.4 Im ___ AbsNeut-2.94 AbsLymp-1.73 AbsMono-0.36
AbsEos-0.11 AbsBaso-0.02
___ 08:05AM BLOOD Plt ___
___ 08:05AM BLOOD Glucose-83 UreaN-16 Creat-0.8 Na-143
K-3.9 Cl-107 HCO3-27 AnGap-9*
___ 04:42PM BLOOD ALT-9 AST-19 AlkPhos-65 TotBili-0.2
___ 08:05AM BLOOD Calcium-9.2 Phos-2.9 Mg-1.7
___ 04:42PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 03:45PM BLOOD RedHold-HOLD
Brief Hospital Course:
Mrs. ___ is an ___ year old woman with Alzheimer's disease who
was admitted to the neurology department because of concern for
seizure versus stroke.
Mrs. ___ on ___ was at an appointment with her primary
physician when she began to not respond to her physician and was
uttering nonsensical speech. There was concern that she
potentially had eye deviation (but direction uncertain) and
right facial weakness. She was transferred to the ED and a code
stroke was called. She had CT perfusion did not reveal area of
reduced blood flow in the brain. Mrs. ___ rapidly improving
examination on presentation and imaging studies suggested
against stroke. Mrs. ___ was admitted to the neurology service.
She was monitored with CVEEG and there were no epileptiform
discharges or seizures. She had generalized slowing. Mrs. ___
had an MRI of the brain which did not reveal a stroke. Mrs. ___
has significant generalized atrophy. We are uncertain what lead
to Mrs. ___ presentation. We feel that her symptoms were
likely behavioral secondary to her advanced dementia, but cannot
ultimately rule out that she had a seizure. We will hold on
starting an anti seizure medication for now. We have told her to
represent to the hospital if she has additional events
concerning for seizures, particularly if she has abnormal
movements.
Also, she was noted to have one event of nonsustained
bradycardia with dropped beats not associated with change in PR
interval. Patient was asymptomatic during the episode.
Discussed with patient's daughter at bedside and advised to
follow-up with PCP. ___ consider cardiology referral if she
were to have more episodes in future.
Mrs. ___ should continue to engage in her usual activities once
she is discharged. She should continue to participate in day
care activities without restriction.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 300 mg PO BID
2. Multivitamins 1 TAB PO DAILY
3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
4. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB
5. amLODIPine 10 mg PO DAILY
6. Complex B-100 (vitamin B complex;<br>vitamin B complex-folic
acid) 400 mcg oral Other
7. Enoxaparin Sodium 80 mg SC Frequency is Unknown
Start: Today - ___, First Dose: Next Routine Administration
Time
8. Memantine 10 mg PO DAILY
9. Sertraline 50 mg PO DAILY
10. Tiotropium Bromide 1 CAP IH DAILY
11. Vitamin D 400 UNIT PO DAILY
Discharge Medications:
1. Enoxaparin Sodium 70 mg SC DAILY
2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
3. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB
4. amLODIPine 10 mg PO DAILY
5. Complex B-100 (vitamin B complex;<br>vitamin B complex-folic
acid) 400 mcg oral Other
6. Gabapentin 300 mg PO BID
7. Memantine 10 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. Sertraline 50 mg PO DAILY
10. Tiotropium Bromide 1 CAP IH DAILY
11. Vitamin D 400 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Alzheimer's disease with behavioral disturbance
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mrs. ___,
___ presented to the hospital because of concern that ___ might
have had either a stroke or a seizure. We performed imaging of
your brain which did not reveal a stroke and monitored your
brain waves and there was no evidence of abnormal brain waves.
We feel that your episode of unresponsiveness was likely
secondary to fluctuations in your mentation given your advanced
Alzheimer's disease, but ultimately cannot rule out that ___ had
a seizure. We will hold on starting an anti seizure medication
for now. We will have ___ follow up in neurology clinic to be
followed regularly. We will call ___ in the next few days to
work to schedule this appointment.
We have not made any changes in your home medications.
Mrs. ___ should continue to engage in her usual activities once
she is discharged. She should continue to participate in day
care activities without restriction.
Thank ___ for allowing us to care for ___,
___ Neurology Team
Followup Instructions:
___
|
19611589-DS-3
| 19,611,589 | 27,643,931 |
DS
| 3 |
2174-11-26 00:00:00
|
2174-11-28 11:32:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
thiopental
Attending: ___.
Chief Complaint:
___
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ is a ___ male on aspirin 81mg daily with history
of renal transplant in ___ and recent hospitalization for
failure to thrive who presents to ___ on ___
s/p fall earlier today. CT Head at ___ showed right ___ with 6mm
MLS; patient received keppra and fentanyl and was transferred to
___ via medflight.
Per patients wife, history of recent falls over the past year
due to diffuse muscle weakness. He was recently admitted to an
outside hospital for failure to thrive after refusing to eat.
He has been home since ___, but continues to have impaired
gait and dizziness. Per his wife, the patient has also been
evaluated for a hematological disorder; his daughter has
hemophilia and his father had an unnamed transfusion-dependent
anemia. The patient had a left rotator cuff repair aborted
intraoperatively due to bleeding.
Today, he was getting out of a car and dropped his phone; he
fell onto his buttocks reaching for the phone, then fell over
striking the back of his head on the driveway. He denies LOC.
He c/o headache, but denies dizziness, nausea/vomiting, weakness
or paresthesia.
Past Medical History:
PMHx:
questionable bleeding disorder
Renal transplant ___ ago
Diabetes
HTN
HLD
PSHx:
Renal transplant ___
Appendectomy
L rotator cuff repair aborted due to bleeding
Social History:
___
Family History:
Daughter has hemophilia
Physical Exam:
Admission Exam:
Gen: WD/WN, comfortable, NAD.
HEENT: In cervical collar
Extrem: warm and well perfused
Neuro:
Mental Status: Awake, alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech is fluent with good comprehension.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3mm to
2mm bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Decreased bulk throughout; normal tone bilaterally. No
abnormal movements, tremors. Strength L deltoid ___ (baseline
due
to rotator cuff injury, L ___ ___ (baseline due to ankle
injury), otherwise full power ___ throughout. UTA pronator drift
Sensation: Intact to light touch
Discharge exam:
Vitals: 97.9, 140-160/80s, 70-100, 18, 97% RA
General- Alert, weak appearing man sitting in chair eating food
speaks slowly
HEENT- Sclera anicteric, MMM, oropharynx with mild erythema
Neck- soft w/ ecchymoses
Lungs- Rare expiratory wheeze, no rales or rhonchi
CV- Regular rate and rhythm, normal s1 and s2, soft systolic
murmur
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU- no foley
Ext- Scattered ecchymoses on neck, legs, bilateral arms but
soft, 2+ b/l DP and radial pulses
Neuro- CNs2-12 intact, ___ strength left deltoid, strength
otherwise intact. sensation intact to light touch.
Pertinent Results:
ADMISSION LABS
--------------
___ 08:55PM BLOOD WBC-11.5* RBC-3.35* Hgb-10.0* Hct-30.7*
MCV-92 MCH-29.9 MCHC-32.6 RDW-14.6 RDWSD-48.2* Plt ___
___ 08:55PM BLOOD Neuts-86.8* Lymphs-6.1* Monos-5.4
Eos-0.2* Baso-0.1 Im ___ AbsNeut-9.95* AbsLymp-0.70*
AbsMono-0.62 AbsEos-0.02* AbsBaso-0.01
___ 08:55PM BLOOD ___ PTT-23.9* ___
___ 05:50AM BLOOD ___ 05:50AM BLOOD FacVIII-112 Fact IX-199*
___ 08:55PM BLOOD Glucose-199* UreaN-29* Creat-0.7 Na-135
K-4.1 Cl-103 HCO3-20* AnGap-16
___ 05:50AM BLOOD ALT-18 AST-11 LD(LDH)-254* AlkPhos-58
Amylase-35 TotBili-0.4
___ 05:50AM BLOOD TotProt-4.5* Albumin-3.0* Globuln-1.5*
Calcium-8.7 Phos-3.0 Mg-1.6 Iron-36*
___ 05:50AM BLOOD calTIBC-243* Ferritn-127 TRF-187*
DISCHARGE LABS
--------------
___ 06:00AM BLOOD WBC-7.3 RBC-2.76* Hgb-8.3* Hct-25.6*
MCV-93 MCH-30.1 MCHC-32.4 RDW-14.6 RDWSD-49.1* Plt ___
___ 04:58AM BLOOD Glucose-127* UreaN-17 Creat-0.7 Na-135
K-4.5 Cl-100 HCO3-25 AnGap-15
___ 04:58AM BLOOD Calcium-8.5 Phos-2.8 Mg-1.9
___ 05:24AM BLOOD TSH-4.5*
___ 05:24AM BLOOD T4-4.7
___ 05:50AM BLOOD PEP-HYPOGAMMAG
___ 04:58AM BLOOD Cyclspr-131
___ 05:09PM URINE Color-Yellow Appear-Clear Sp ___
___ 05:09PM URINE Blood-NEG Nitrite-NEG Protein-100
Glucose-300 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 05:09PM URINE RBC-2 WBC-2 Bacteri-NONE Yeast-NONE
Epi-<1
___ 05:09PM URINE CastHy-12*
___ 05:09PM URINE Mucous-RARE
MICROBIOLOGY
-------------
___ Blood Culture: NGTD
IMAGING
-------
___ ___
1. Bilateral cerebral subdural hematomas, increased on the left
with
suggestion of hyperacute bleeding. No significant mass-effect,
shift of
midline structures, or evidence of downward herniation. Close
follow-up
recommended.
2. No definite fracture.
3. Sinus disease with left mastoid air cell and middle ear
opacification.
___ CT c-spine
1. No acute fracture. Subtle alignment abnormality at C4-5 and
C5-6 likely chronic due to underlying degenerative disease.
Multilevel degenerative changes of the imaged spine.
2. Sinus disease, left mastoid and middle ear opacification
better assessed on same-day head CT.
3. Please refer to same-day head CT for intracranial findings.
___ NCHCT
1. Compared to ___ at 21:29, no new or enlarging
hemorrhage.
2. Unchanged subdural hematomas tracking along the left aspect
of the falx and along the left tentorium cerebelli. Unchanged
right convexity subdural hematoma. Unchanged minimal right to
left midline shift.
3. Unchanged paranasal sinus and left mastoid opacification, as
described
above.
___ CTA chest
1. 4 mm solid nodule in the right lower lobe. This can be
re-evaluated on
follow up or dedicated imaging in ___ year may be obtained.
2. Incompletely characterized ill defined hypodensities in the
dome and the right lobe of the liver. Correlation with prior
imaging if available or MRI if patient can tolerate or multiple
phasic liver CT can be obtained for further evaluation.
___ Video Oropharyngeal swallow
There is trace penetration with thin liquids, but no evidence of
aspiration.
Barium passes freely through the oropharynx and esophagus
without evidence of obstruction.
Brief Hospital Course:
Mr. ___ is a ___ gentleman with ESRD s/p renal transplant
in ___ and COPD a/w SDH after mech fall with hospital course
complicated by aspiration pneumonia and FTT now much improved
requiring rehab for deconditioning.
# Subdural hematoma: Presented with a mechanical fall, and
transferred for a right subacute SDH, which was found to be
stable on on repeat ___. Intervention was not performed due
to the stability of the bleed and the high-risk nature of the
procedure. He was initially on strict BP restrictions, with a
goal SBP < 140, which was then liberalized to SBP < 160. BP was
controlled with amlodipine 10 mg daily, and hydral and
nifedipine drip prn. He did not have any new neuro deficits, but
did have a headache that was treated with acetaminophen. He was
started on Keppra for 7 days for seizure prophylaxis
(___). He will need repeat head CT and neurosurgery
follow up in 4 weeks ___ patient should call to
schedule both, according to neurosurgery team. He is not to be
restarted on any anti-platelets or anticoagulation until
discussing with neurosurgery.
# Concern for Bleeding disorder: Family reported bleeding
disorder and patient reports history of coagulation workup at
___. Per report, PCP stated that there was no documented
bleeding disorder. Heme-Onc was consulted and recommended factor
levels (normal) and SPEP (hypogammaglobulinemia). Workup showed
no evidence of bleeding disorder. If there are future concerns
for bleeding, he can be arranged to see Hematology for platelet
aggregation studies.
# Aspiration pneumonia with transient hypoxia: On ___ AM, he
became tachycardic and short of breath with increased work of
breathing and hypoxia to ___ requiring oxygen. CTA chest (___)
was negative for PE but concerning for aspiration events,
showing significant filling of left main bronchus. Further, wife
says he'd been having aspiration events at rehab. Sudden dyspnea
and desaturation with witnessed aspiration is more consistent
with chemical pneumonitis but given frailty, he was started on
broad antibiotics (vanc/cefepime/azithro) and then narrowed to
CAP coverage for 7 days with amoxicillin/azithromycin to finish
a 7 day course (___). MRSA swab was negative. He was
evaluated by the speech language pathology (SLP) team, who
performed an evaluation and video swallow, both of which were
normal. He has no dietary restrictions, and is cleared for
regular diet and thin liquids.
# Failure to thrive:
# Weight loss
# Gait instability:
Over the past ___ years, he has had multiple falls, weight loss,
anhedonia, decreased interest in moving, and muscle atrophy as
per report from wife. He achieved new baseline after 6 weeks of
rehab, after which time he was able to walk with minimal
assistance and regained weight up to 128 lbs. In late ___,
he started to decompensate again due to back pain and recent
falls. He was evaluated by ___ who recommended rehab. He was also
evaluated by Nutrition, who recommended Glucerna TID and a MVI
with minerals
# Tachycardia: He was started on his home metoprolol tartrate by
neurosurgery for tachycardia. The indication is a little unclear
but he was intermittently tachycardic when it was held for a
short period without any other signs or symptoms to suggest
etiology. Patient should discuss with his primary care doctor
for further evaluation and the necessity of the medication.
# Renal transplant: He has a history of chronic kidney disease
due to hypertension and diabetes and was dialysis dependent
since ___. He had a deceased donor kidney transplant from two
pediatric kidneys in ___. He is maintained on triple
immunosuppression. He was seen by our Renal Transplant team. He
was continued on MMF 500 mg BID and prednisone 10 mg. His
cyclosporine 12 hour trough levels were elevated (165) so the
home dose was reduced 75 mg BID to 50mg BID with subsequent
levels in range (Cyclosporine level 131) per renal transplant
team. He has a follow up appointment with Nephrology Associates
in ___ Office on ___.
# Hx of nocardia: He was diagnosed with pulmonary nocardia
infection and has been on suppressive Bactrim therapy since,
which was continued here. He appears to be nauseous on Bactrim,
as per report by family. We discussed with outpatient physician
___ informed us that patient had culture+ nocardia and
is at risk for recurrence given immunosuppression. He did not
feel that holding the Bactrim would improve the nausea, but felt
it would be reasonable to try. We will continue with Bactrim
given risk of recurrence and lack of alternative agents.
Non-active issues:
# Gout: Continued home allopurinol ___ mg daily
# CAD: Held home aspirin 81 mg and zetia. Continued simvastatin
10 mg daily. Aspirin was not restarted on discharge due to
subdural hematoma, and should not be restarted without
neurosurgery approval.
# BPH: Continued home doxazosin 4 mg daily
# Hypothyroid: Continued home levothyroxine 50 mcg daily. Was
found to have a slightly elevated TSH, which should be rechecked
as an outpatient
# DM2: Held home metformin. Treated with a HISS
# COPD: Held home meds. Continued alb neb and inhaler.
# ?GERD: Held home prevacid 30 mg daily. Continued pantoprazole
40 mg daily
TRANSITIONAL ISSUES
-------------------
#Subdural hematoma
[ ] Patient to make follow up appointment with Dr. ___
___ 4 weeks from discharge (___) by calling ___
[ ] Repeat Head CT in 4 weeks before appointment with
___
- Do not take Aspirin or Plavix due to concern for bleed without
clearance by neurosurgery
- No activity restriction
#Pneumonia: Aspiration event but covering community acquired
organisms
[ ]Complete 7day course of amoxicillin/azithromycin (___)
#No evidence of bleeding disorder.
- No need for follow-up with hematology. However, if he develops
further bleeding in future, can set up appointment with Heme for
platelet aggregation studies
#Renal transplant
[ ] f/u with his nephrologist, has an appointment with
Nephrology Associates in ___ Office on ___
[ ] Titrate cyclosporine as needed, reduced cyclosporine from
75mg bid to 50mg bid
#Tachycardia
- continue home metoprolol but follow up with PCP to address
long term need
#Hypertension
- SBP goal < 160 for SDH: consider adding second blood pressure
agent, such as losartan
#Hypothyroid
[ ] rechecking TSH in 4 weeks at it was elevated at 4.5 (but
normal T4 4.7)
#Failure to thrive
[ ] Nutrition recs: Glucerna TID, MVI with minerals
RADIOGRAPHIC ABNORMALITIES REQUIRING FOLLOW-UP - Patient
notiefied. PCP notified via letter
#Lung nodule: 4mm solid nodule in RLL
[ ] F/up imaging of lung nodule in ___ year with CT
#Liver lesion: Ill defined liver lesion on CTA chest
[ ] consider getting MRI or CT triphasic if Cr tolerates to
evaluate more closely
#Discharge Cr: 0.7
#Discharge Weight: 61.1kg
#Code: Full code confirmed
#Communication: Wife ___ ___
___ on Admission:
allopurinol ___ daily
amlodipine 5mg daily
Cardura 4mg BID
cellcept 500mg BID
levothyroxine 50mcg daily
Lidoderm 1 patch daily
metformin 500mg QHS
mirtazapine unknown dose
neural (name brand ___ 75mg BID
prednisone 10mg daily
prevacid 30mg BID
proair 2 puffs BID PRN
simvastatin 10mg daily
symbicort 1 puff daily
vitamin D3 2000units daily
zetia 10mg PO daily
Metoprolol 50mg BID
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
2. Amoxicillin 500 mg PO Q8H Duration: 1 Day
last day on ___
3. Azithromycin 500 mg IV Q24H Duration: 1 Day
on ___
4. Docusate Sodium 100 mg PO BID
5. HydrALAZINE ___ mg IV Q6H:PRN sbp greater than 160
6. amLODIPine 10 mg PO DAILY
7. CycloSPORINE (Neoral) MODIFIED 50 mg PO Q12H
8. Allopurinol ___ mg PO DAILY
9. Doxazosin 4 mg PO BID
10. Ezetimibe 10 mg PO DAILY
11. Lansoprazole Oral Disintegrating Tab 30 mg Other BID
12. Levothyroxine Sodium 50 mcg PO DAILY
13. MetFORMIN (Glucophage) 500 mg PO QHS
14. Metoprolol Tartrate 50 mg PO BID
15. Mirtazapine 15 mg PO QHS
16. Mycophenolate Mofetil 500 mg PO BID
17. PredniSONE 10 mg PO DAILY
18. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
BID:PRN
19. Simvastatin 10 mg PO QPM
20. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
21. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
22. Vitamin D ___ UNIT PO DAILY
23. HELD- Aspirin 81 mg PO DAILY This medication was held. Do
not restart Aspirin until instructed to by your Neurosurgeon
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES
-----------------
Stable Subdural hematoma due to fall
Aspiration pneumonia due to presumed gram negative organism
Failure to Thrive
Bleeding disorder NOS
SECONDARY DIAGNOSES
-------------------
Renal Transplant medication management
Sinus tachycardia of unclear etiology
Nausea due to medication side effect
Norcardia prophylaxis
Pulmonary nodule in Right lower lobe
Liver mass not otherwise specified
Clinically insignificant Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
You came in after a fall with a subdural hematoma. Neurosurgery
evaluated you, found it was stable, and decided it did not
require surgical treatment. Please do not use aspirin or any
blood thinners without clearance from Neurosurgery.
Because of your bruising, the team was concerned you might have
a bleeding disorder and did an extensive workup. Fortunately we
found you did not have a bleeding disorder.
You may have developed a pneumonia during the hospitalization
that we treated with antibiotics to be safe.
We reduced the dosage of your cyclosporine to 50mg twice a day
based on the blood levels.
Please follow up with your neurosurgeon and nephrologist. We
wish you a speedy recovery.
Sincerely,
YOUR ___ CARE TEAM
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
***Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
***You have been discharged on Keppra (Levetiracetam). This
medication helps to prevent seizures. Please continue this
medication as indicated on your discharge instruction. It is
important that you take this medication consistently and on
time.
***You have been prescribed Dilantin (Phenytoin) for
anti-seizure medicine, take it as prescribed and follow up with
laboratory blood drawing in one week. This can be drawn at your
PCPs office, but please have the results faxed to ___.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
You may have difficulty paying attention, concentrating, and
remembering new information.
Emotional and/or behavioral difficulties are common.
Feeling more tired, restlessness, irritability, and mood
swings are also common.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
Headaches:
Headache is one of the most common symptom after a brain
bleed.
Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
Mild pain medications may be helpful with these headaches but
avoid taking pain medications on a daily basis unless prescribed
by your doctor.
There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason
Followup Instructions:
___
|
19611909-DS-10
| 19,611,909 | 26,061,152 |
DS
| 10 |
2160-12-05 00:00:00
|
2160-12-05 12:34:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
AVM
Major Surgical or Invasive Procedure:
___ Cerebral angiogram with Onyx embolization
___ Left craniotomy for ___ evacuation
History of Present Illness:
___ with no significant past medical history, who went to lay
down after telling his wife he was not feeling well after
painting. He asked his wife for a glass of water then became
unresponsive. EMS was called and he was taken to OSH where he
was intubated. He was transferred to ___ for further care.
Past Medical History:
Wife denies, states at recent physical he had elevated liver
enzymes. Denies HTN.
Social History:
___
Family History:
Father- HTN
Cousin- died young of seizure
Physical Exam:
On admission:
PHYSICAL EXAM:
Gen: Intubated, sedated
HEENT: Intubated, no signs of trauma
Neuro:
Patient is intubated, sedated. Off sedation patient has a RUE
tremor/twitching noted. No EO, no commands, no verbal
interaction. Pupils are 3-2mm reactive, + cough, + gag, BUE
extensor posturing, BLE withdraws.
On Discharge:
AOx2 to person and "Hospital"
Following commands x4,
Full strength in UEs bilat
Right ___ ___ in IP/H; ___ in ___
Left ___ ___ throughout
Pertinent Results:
___ CXR:
FINDINGS:
Frontal radiographs of the chest demonstrate normal heart size.
The ET tube terminates 6 cm above the carina. The
cardiomediastinal silhouette and hilarcontours are normal. The
lungs are clear. No pleural effusion or pneumothorax. No
displaced rib fracture identified.
IMPRESSION:
ET tube in appropriate position.
___ CTA
1. Unchanged left frontal intraparenchymal hemorrhage and left
subdural
hematoma as described in detail above, causing mass effect and
shifting of the normally midline structures towards the right
with mild effacement of the right quadrigeminal cistern and
effacement of the sulci.
2. Left frontal arteriovenous vascular malformation with
prominent draining veins.
___ Angiogram with embolization
Arteriovenous malformation of the left anterior cranial fossa
primarily
supplied by the anterior cerebral artery with some contribution
from the left middle cerebral artery. The nidus itself measures
about 1.5 x 2 cm and does not have any feeding vessel aneurysms.
___ NON CONTRAST HEAD CT:
IMPRESSION:
1. Interval evacuation of a left-sided subdural hemorrhage with
resulting
pneumocephalus and only minimal amount of bloods at the
evacuation bed.
Rightward subfalcine herniation is significantly improved from
pre-operative exam.
2. Left frontal intraparenchymal hemorrhage is not
significantly changed in size or appearance compared with
pre-operative exam. Embolization material noted in the region
left frontal of AVM malformation.
___ CXR
FINDINGS: NG tube is coiled in the stomach. The ET tube is 5.6
cm above the carina. There is some scarring in the right lower
lung. There is no focal infiltrate.
___ NON CONTRAST HEAD CT:
IMPRESSION: Status post left frontal craniotomy with left
frontal
intraparenchymal hemorrhage, and a small left subdural
hemorrhage, resulting in 4 mm of midline shift.
___ CXR
FINDINGS: Comparison is made to prior study from ___.
Endotracheal tube and feeding tube are again seen. The feeding
tube has
backed out and the side port is now above the GE junction. The
tip is just at the GE junction. The feeding tube could be
advanced 10 to 15 cm for more optimal placement. Heart size is
within normal limits. The lungs appear clear. There are no
pneumothoraces.
___ Head CT noncontrast:
1. No evidence of new intracranial hemorrhage.
2. Status post left frontal craniotomy with left frontal
intraparenchymal
hemorrhage and small left subdural hematoma with associated
midline shift, unchanged from ___.
___ Cerebral Angiogram
___ CT head (portable)
1. Mild increase in midline shift to the right. Medial
displacement of the left uncus not clearly seen on prior CT
studies.
2. No evidence of new hemorrhage.
___ ___:
IMPRESSION:
1. No evidence of new intracranial hemorrhage.
2. Status post left frontal craniotomy with stable left frontal
intraparenchymal hemorrhage and surrounding edema and resolution
of
postsurgical pneumocephalus. Midline shift is essentially
unchanged from
___.
___ EEG:
This is an abnormal continuous ICU monitoring study because of
the presence of a continuous polymorphic slow wave abnormality
broadly across the left hemisphere maximum in the more anterior
and central head regions but occasionally extends across the
midline to the right central region. This activity seemed to be
associated with a blunting of the frequency of the background
rhythm also on the left within normal appearing background on
the right. There were no clear interictal discharges and no
sustained events.
___ EEG:
This is an abnormal continuous ICU monitoring study because of
the presence of a continuous polymorphic slow wave abnormality
broadly across the left hemisphere maximum in the more anterior
and central regions but occasionally extends across the midline
to the right central region. This is indicative of significant
focal cerebral dysfunction. There were no epileptiform
discharges or electrographic seizures.
___ CT Head w/o contrast:
1. Status post left frontal craniotomy and embolization of AVM
with no significant interval change in large left frontal
intraparenchymal hemorrhage and surrounding edema. Midline
shift is unchanged.
Brief Hospital Course:
The patient was admitted to neurosurgery on ___. He was found
to have a left IPH and SDH with 11mm of midline shift. He found
to have a left frontal AVM on CTA. He was taken to angio for
embolization of the AVM. He was then taken to the OR for left
craniotomy for ___ evacuation. Subgaleal JP drain was placed.
The patient was taken to SICU post op. Post op head CT showed
evacuation of SDH with stable frontal IPH, embolization material
was seen in left frontal region of AVM malformation. The patient
remained intubated overnight. On ___ NCHCT was stable. JP drain
was removed. Keppra was increased to 1,000 mg BID. Systolic
blood pressure was kept strict less than 140. On ___ the patient
was febrile to 100.9F. Sputum gram stain showed GNR, GPC culture
was still pending. The patient was not started on antibiotics
while awaiting culture results. WBC was 9.3. He was extubated
successfully. He was preoped for angio on ___. On ___ his exam
was slightly improved as he was able to lift his RUE
antigravity. He underwent a portable head CT which was stable
and after review it was determined that he would undergo
cerebral angiogram for embolization. On ___, the patient's exam
remained stable. He underwent a cerebral angiogram with
embolization without complication.
On the morning of ___, Mr. ___ was found to be more somnolent on
exam and intermittently following commands. A portable CT head
was ordered, which was stable. On the same day, his bilateral
femoral sheaths were discontinued.
On ___ he was brighter on exam, and was mobilized with ___.
On ___ patient had a decline in his mental status, on
examination in the morning, he was unable to answer questions
about place and date, a CT was performed that showed a larger
left frontal hemorrhage. Patient was transferred to the ICU.
On ___ patient remained in the ICU. EEG was placed. Systolic
blood pressure was liberalized to less than 160. He continued to
work with physical therapy. speech and swallow evaluated the
patient and cleared him for a soft solid nectar thick liquid
diet. A multipodus boot was also applied to his RLE for foot
drop.
On ___ patient was slightly brighter on exam. EEG results
showed no seizure or epileptiform activity. The EEG leads were
removed. His Keppra was continued to 1 gram BID. On ___, the
patient continued to do well. His motor exam remained stable,
but notable for ___ strength in his anterior tibialis,
gastrocnemius, and extensor hallus longus. He was seen by
speech and swallow and due to continued improvement, his diet
was advanced to regular solids and thin liquids. He was
transferred to the inpatient ward that afternoon.
On ___ Speech upgrade to thin liquids, regular solids. Patient
transferred to floor.
On ___ Dr. ___ was stable, ___ showed no interval
changes, Anesthesia performed pre-op tests and the patient was
consented by both Neurosurgery and Anesthesia.
On ___ No events for Dr. ___ the day.
At the time of discharge on ___ he is tolerating a regular
diet, afebrile with stable vital signs.
He will return on ___ for surgical resection of the AVM.
Medications on Admission:
None
Discharge Medications:
1. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
2. LeVETiracetam 1000 mg PO BID
3. Docusate Sodium 100 mg PO BID
4. Bisacodyl 10 mg PO/PR DAILY
5. Acetaminophen 650 mg PO Q6H:PRN fever, pain
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
L frontal AVM
L frontal IPH
L ___
Cerebral edema
Discharge Condition:
Mental Status: Confused - sometimes.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
Have a friend/family member check your incision daily for
signs of infection.
Take your pain medicine as prescribed.
Exercise should be limited to walking; no lifting, straining,
or excessive bending.
Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
**You have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
Clearance to drive and return to work will be addressed at
your post-operative office visit.
Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
Followup Instructions:
___
|
19612002-DS-5
| 19,612,002 | 20,748,883 |
DS
| 5 |
2134-04-03 00:00:00
|
2134-04-04 14:14:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
dicloxacillin / Bactrim
Attending: ___.
Chief Complaint:
Melena, Dyspnea on Exertion
Major Surgical or Invasive Procedure:
___: Upper endoscopy
___: Colonoscopy negative for GI bleed; 1.5 cm polyp in her
sigmoid was removed
History of Present Illness:
___ h/o HTN, hyperthyroidism, heart block requiring
biventricular ICD placement, CHF with EF 35%, mitral/tricuspid
valve repair, and afib who presents with DOE for 3 weeks, cough,
and melena for 2 weeks. Patient reports that some people were
sick with bronchitis at work, and she first thought that she had
bronchitis or PNA. She was prescribed albuterol and a Z-pack 5
days ago without improvement. For the past 3 weeks, her DOE has
gotten worse, she now has to hyperventilate when walking to the
bathroom, which is new for her.
Baseline -- walked to work before last ___. Patient's PCP
continued albuterol prn, drew an INR as the patient was
endorsing black stools and GERD-like symptoms, and INR was
reportedly about 4 over 1 week ago. PCP asked patient to stop
warfarin (5mg for afib) from last ___ until this upcoming
___. Pt was asked to come into ER for Hgb 7.2, but she
declined. Patient reports loose stools for 2 weeks, which
improved for a few days and now are back. No blood in stool, but
stools are black in setting of peptobismol use. No fevers, no
chills, no pain anywhere in her body. Lightheadedness, ___.5 weeks ago, tripped over something on the
floor and landed on knees, no head strike, no LOC. No hx clots.
In the ED, initial vitals were:
Pain 0 97.7 60 122/34 18 100% RA
Hgb foudn to be 6.3, with MVC 110.
Guiaic: melanotic, guaiac positive. 2U RBC transfusion started
in ER.
Vitals prior to transfer were:
Pain 0 98.2 60 96/37 22 100% RA
Upon arrival to the floor, pt has no pain or discomfort. Main
complaint before was dizziness and SOB with exertion or being
upright/standing. Still having some cough but slightly better
after Z-pak recently. Some loose stools in last few days,
black/tarry looking; no BRB. No HA, CP, SOB, abdom pain
currently.
Past Medical History:
-Complete heart block after surgery ___ s/p ICD BiVentricular
pacer, redo in ___ (EF ___
-CHF after surgery in ___ with EF of 35 in ___
-Afib on coumadin
-Hyperthyroidism
-Osteopenia
-Osteoporosis
Social History:
___
Family History:
+CAD. Both parents died in fire age<___. No
history of thyroid disease
Physical Exam:
ON ADMISSION:
Vitals: 97.9 100/94 60 16 100%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MM slightly dry, oropharynx clear
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs
Lungs: Mostly clear to auscultation bilaterally, minimal wheezes
upper fields b/l, no crackles
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, no edema
ON DISCHARGE:
Vitals: 97.5-98.5 100s-130s/50s-70s ___ 96-100%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MM slightly dry, JVD not elevated, no
LAD
CV: soft heart sounds, RRR, normal S1 + S2, no murmurs
Lungs: CTAB, no crackles, wheezing or rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present
GU: No foley
Ext: Warm, well perfused, no edema, very thin extremities
Pertinent Results:
ON ADMISSION:
___ 04:00PM BLOOD WBC-5.7 RBC-1.82* Hgb-6.3* Hct-20.0*
MCV-110* MCH-34.6* MCHC-31.5* RDW-15.9* RDWSD-62.5* Plt ___
___ 04:00PM BLOOD Neuts-77.1* Lymphs-9.8* Monos-11.7
Eos-0.2* Baso-0.5 NRBC-0.3* Im ___ AbsNeut-4.42
AbsLymp-0.56* AbsMono-0.67 AbsEos-0.01* AbsBaso-0.03
___ 04:00PM BLOOD ___ PTT-28.3 ___
___ 04:00PM BLOOD Ret Aut-6.1* Abs Ret-0.11*
___ 04:00PM BLOOD Glucose-120* UreaN-25* Creat-1.3* Na-135
K-4.6 Cl-94* HCO3-22 AnGap-24*
___ 04:00PM BLOOD ALT-19 AST-40 LD(LDH)-275* AlkPhos-53
TotBili-1.5 DirBili-0.4* IndBili-1.1
___ 04:00PM BLOOD Albumin-4.4 Calcium-8.9 Phos-3.1 Mg-1.4*
Iron-27*
___ 04:00PM BLOOD calTIBC-458 VitB12-482 Folate-8.1
___ Ferritn-25 TRF-352
___ 04:04PM BLOOD Lactate-2.1*
ON DISCHARGE:
___ 06:30AM BLOOD WBC-5.0 RBC-3.00* Hgb-9.5* Hct-30.8*
MCV-103* MCH-31.7 MCHC-30.8* RDW-20.1* RDWSD-74.3* Plt ___
___ 06:30AM BLOOD ___ PTT-26.2 ___
___ 06:30AM BLOOD Glucose-87 UreaN-19 Creat-1.3* Na-140
K-4.8 Cl-104 HCO3-17* AnGap-24*
___ 06:30AM BLOOD Calcium-8.5 Phos-3.1 Mg-1.5*
OTHER:
CXR: No acute cardiopulmonary process. No significant interval
change.
Brief Hospital Course:
#Anemia: Initially presented with Hgb 6.3. She received H/H 2u
pRBCs and Hgb increased to 9.1, remained stable during hospital
course. She was also placed on PPI BID for h/o bleeding PUD.
Anemia acute on chronic iron def anemia, likely ___ GI bleed
given melena and recent h/o supratherapeutic INR. INR likely
elevated from z-pak. Macrocytosis likely from reticulocytosis
given RI>2 vs. alcohol. EGD and colonoscopy showed no source of
bleed, removed polyp during colonoscopy.
#Dyspnea: Appeared to be exertional, likely ___ anemia with
possible contribution from bronchitis. She noted improvement
after pRBC infusion. She did have h/o nonproductive cough and
was s/p recent Z-pak. CXR clear on admission and pt satting very
well. Low c/f PNA given lack of convincing sxs and no
consolidation seen on CXR. Also low c/f pulm edema given clear
CXR and no signs of volume overload.
___: On admission Cr 1.4, baseline <1. Likely prerenal from
hypoperfusion and poor po intake in setting of acute anemia. SBP
also was low in the 100s although later >130s s/p pRBC infusion.
She was given NS boluses and Cr trended. On discharge Cr still
1.3 but she had been NPO and refused to stay for monitoring or
further evaluation.
#)Atrial Fibrillation: CHADS2VASC:2. Held home coumadin for GI
procedures
#)Systolic heart failure without previous exacerbation: EF
previously 35%. No pulm edema on admission CXR or exam.
Discharge weight in ___ was 52.7kg. Held home losartan
50mg PO daily given low BPs and ?GIB
#)Hyperthyroidism: Continued home methimazole.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. selenium 100 mcg oral DAILY
2. Losartan Potassium 100 mg PO DAILY
3. Magnesium Oxide 400 mg PO BID
4. Methimazole 2.5 mg PO DAILY
5. Warfarin 2.5 mg PO 5X/WEEK (___)
6. Warfarin 5 mg PO 2X/WEEK (MO,FR)
7. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheeze
8. Nicotine Lozenge 4 mg PO Q2H:PRN craving
9. Vitamin D Dose is Unknown PO DAILY
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheeze
2. Nicotine Lozenge 4 mg PO Q2H:PRN craving
3. Magnesium Oxide 400 mg PO BID
4. Methimazole 2.5 mg PO DAILY
5. Losartan Potassium 100 mg PO DAILY
6. selenium 100 mcg oral DAILY
7. Vitamin D ___ UNIT PO DAILY
8. Warfarin 2.5 mg PO 5X/WEEK (___)
9. Warfarin 5 mg PO 2X/WEEK (MO,FR)
Discharge Disposition:
Home
Discharge Diagnosis:
Anemia, likely from GI 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 ___ because you were experiencing
shortness of breath. It was likely from low red blood level.
Your symptoms improved significantly after blood transfusion. It
was thought that your anemia was from a gastrointestinal bleed,
especially since your INR level recently too high. An upper
endoscopy and colonoscopy did not find a source of bleeding. A
polyp(an outgrowth of the lining of your bowel) was found on
colonoscopy, which was removed. You will be sent the results of
the biopsy. Since your blood level is still low, please follow
up with your primary care physician.
You can restart your warfarin. Please follow-up with your PCP
and gastroenterologist as described below.
Be well and take care,
Your ___ Care Team
Followup Instructions:
___
|
19612002-DS-6
| 19,612,002 | 25,270,343 |
DS
| 6 |
2134-06-25 00:00:00
|
2134-06-28 20:44:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
dicloxacillin / Bactrim
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
___: Transesophageal echo
History of Present Illness:
___ female with history of Afib on Coumadin, systolic
heart failure (EF 35-55%), previous mitral and tricuspid valve
annuloplasty ___, BiV ICD, hyperthyroidism and anemia (previous
GI Bleed w/o source identified) who presents with shortness of
breath. Patient states that she started having dyspnea on
exertion about ___ months ago. Symptoms have been progressively
getting worse to the point to which she is now short of breath
with minimal exertion (using the restroom, getting to the sink,
etc). She also endorses PND with an 8lb weight gain (baseline
112-114lbs, now ___. She has had some chest tightness but
denies any active chest pain, pressure, palpitations, or
lightheadedness. ROS otherwise neg for fevers, vomiting,
diarrhea.
In the ED initial vitals were: T 98.2 BP 140s-160s/60s-90s, RR
18, 98% RA. Initial labs: Trop <0.01, BNP1031, WBC 4.5, H/H
8.5/29.3, Plt 109, Chemistry panel BUN 24, Cr 0.8, K 3.9,
lactate 2.2, INR 1.8, lipase 69, LFTs AST 45/ALT 26. CTA Chest
was negative for PE, but new bilateral pleural effusions (R>L),
and pulmonary edema; enlarged L Atrium. She was given Lasix 20mg
IV, nitro SL 0.4mg, ASA 324mg, and albuterol, ipratropium nebs.
On the floor, she was well-appearing but minimal exertion did
lead to shortness of breath. She confirmed the history as above
and an exam was notable for elevated JVP to ___rackles bilaterally, RRR, a loud ___ holosystolic murmur that
radiates to the axilla, distended abdomen with fluid wave, and
1+ peripheral edema to the knees.
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, syncope or presyncope.
Past Medical History:
-Complete heart block after surgery ___ s/p ICD BiVentricular
pacer, redo in ___ (EF ___
-CHF after surgery in ___ with EF of 35 in ___
-Afib on coumadin
-Hyperthyroidism
-Osteopenia
-Osteoporosis
Social History:
___
Family History:
+CAD. Both parents died in fire age<___. No
history of thyroid disease
Physical Exam:
Physical Exam on Admission:
VS: T= 98.2 BP=150s-160s/60s-90s HR= 60s-80s RR= 18 O2 sat 98%
RA
GENERAL: Well-appearing man, in NAD.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple
CARDIAC: RRR, a loud ___ holosystolic murmur that radiates to
the axilla, elevated JVP to ___ of her neck
LUNGS: No chest wall deformities, crackles bilaterally, not
tachypneic.
ABDOMEN: Soft, obese NTND. distended abdomen with fluid wave. No
HSM.
EXTREMITIES: Warm, 1+ edema symmetrically and bilateral to
knees.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric
=
=
=
=
=
=
=
=
=
================================================================
Physical Exam on Discharge:
VS: T= 98.2 BP=100s-110s/50-60s HR= 50s-60s RR= 18 O2 sat 98% RA
52.4kg
I/O:
8H ___
24H 1440/2550
GENERAL: Well-appearing man, in NAD.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple
CARDIAC: RRR, a loud ___ holosystolic murmur that radiates to
the axilla. Flat JVP.
LUNGS: No chest wall deformities, CTAB, not tachypneic.
ABDOMEN: Soft, obese NTND. distended abdomen with fluid wave. No
HSM.
EXTREMITIES: Warm, trace extremity edema to mid shin.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric
Pertinent Results:
Labs on Admission:
___ 06:50AM BLOOD WBC-4.5 RBC-3.10* Hgb-8.5* Hct-29.3*
MCV-95 MCH-27.4# MCHC-29.0* RDW-17.5* RDWSD-59.7* Plt ___
___ 06:50AM BLOOD ___ PTT-31.8 ___
___ 06:50AM BLOOD Glucose-123* UreaN-24* Creat-0.8 Na-144
K-3.9 Cl-105 HCO3-26 AnGap-17
___:50AM BLOOD proBNP-1031*
___ 06:50AM BLOOD ALT-26 AST-45* AlkPhos-100 TotBili-0.5
___ 06:50AM BLOOD Albumin-4.0 Calcium-8.2* Phos-3.8 Mg-1.3*
___ 06:50AM BLOOD D-Dimer-742*
___ 06:59AM BLOOD Lactate-2.3*
=
=
=
=
=
=
================================================================
Labs on Discharge:
___ 05:40AM BLOOD WBC-6.1 RBC-3.44* Hgb-9.3* Hct-32.0*
MCV-93 MCH-27.0 MCHC-29.1* RDW-17.7* RDWSD-59.7* Plt ___
___ 05:40AM BLOOD Plt ___
___ 12:40PM BLOOD Glucose-126* UreaN-33* Creat-1.1 Na-134
K-5.2* Cl-97 HCO3-24 AnGap-18
___ 12:40PM BLOOD Calcium-8.8 Phos-4.2 Mg-2.3
=
=
=
=
=
=
================================================================
Clinical Imaging/Studies:
___: TTE
There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is mildly depressed (LVEF= 40 %). Right
ventricular chamber size and free wall motion are normal. The
number of aortic valve leaflets cannot be determined. The mitral
valve leaflets are mildly thickened. A mitral valve annuloplasty
ring is present. Moderate (2+) mitral regurgitation is seen. A
tricuspid valve annuloplasty ring is present. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
Compared with the prior study (images reviewed) of ___,
current echocardiogram is focused so full assessment of valves
was not performed. In that context, mitral regurgitation is less
severe and mitral/tricuspid repair sites could not be adequately
assessed. Overall left ventricular function is more vigorous.
___: CXR
FINDINGS:
There is no change in the cardiomegaly and central pulmonary
vascular
congestion but there appears to be less interstitial prominence
likely
reflecting resolution of interstitial edema. Small bilateral
pleural
effusions seen on recent CT are not well appreciated on this
study.
Left pulse generator with electrodes within the right atrium,
right ventricle,
and coronary sinus is in expected and unaltered position.
Mitral and
tricuspid valve replacements are again noted. Sternal wires are
intact.
___: RUQ U/S
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The
contour of the
liver is smooth. There is no focal liver mass. The main portal
vein is patent
with hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD
measures 4 mm.
GALLBLADDER: There is no evidence of stones or gallbladder wall
thickening.
PANCREAS: The partially visualized pancreas body appears within
normal limits.
SPLEEN: Normal echogenicity, measuring 8.2 cm.
KIDNEYS: The partially visualized kidneys are unremarkable.
IMPRESSION:
Normal sonographic appearance of the liver. No ascites.
___: TEE
Conclusions
Overall left ventricular systolic function is normal
(LVEF>55%). There are simple atheroma in the descending thoracic
aorta. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion. No masses or vegetations are seen
on the aortic valve. No aortic regurgitation is seen. A mitral
valve annuloplasty ring is present. The motion of the mitral
valve prosthetic leaflets appears normal. The transmitral
gradient is normal for this prosthesis. No mass or vegetation is
seen on the mitral valve. Mild to moderate (___) mitral
regurgitation is seen. A tricuspid valve annuloplasty ring is
present. The pulmonary artery systolic pressure could not be
determined. There is no pericardial effusion.
IMPRESSION: Well seated mitral valve annuloplasty ring with
normal gradient and mild to moderate mitral regurgitation. Well
seated tricuspid valve annuloplasty ring with trivial tricuspid
regurgitation. Normal left ventricular systolic function. Simple
atheroma in the descending aorta.
___: CTA Chest
IMPRESSION:
1. No pulmonary embolism or acute aortic process.
2. Mild cardiomegaly, small bilateral pleural effusion, and mild
interstitial
pulmonary edema.
3. Status post mitral and tricuspid valve replacement.
4. LAD coronary artery calcification.
___: EKG
Atrial sensed and ventricular paced rhythm. Likely underlying
rhythm is atrial
fibrillation. Compared to the previous tracing of ___ there
are no
significant changes.
Brief Hospital Course:
___ female with history of Afib on Coumadin, systolic
heart failure (EF 35-55%), previous mitral and tricuspid valve
annuloplasty ___, BiV ICD, hyperthyroidism and anemia (previous
GI Bleed w/o source identified) who presents with shortness of
breath ___ acute on chronic systolic heart failure exacerbation
with bilateral pleural effusions.
#Acute on chronic systolic heart failure w/ bilateral pleural
effusions: Patient has been having exertional dyspnea for the
last ___ months with increasing weight gain, +PND, now SOB worse
and occurs with minmal exertion. During this admission, her BNP
was elevated and her clinical exam was significant for JVP ___ibasilar crackles and a loud holosystolic murmur
with 2+ edema to the knee. At the time of admission, her weight
was 122lbs with a dry weight of 112 lbs. We progressively
diuresed her with Lasix 20mg IV over several days with good UOP.
She subsequently became euvolemic and her pleural effusions
improved. We obtained a TEE to evaluate the etiology of this HF
exacerbation, and it demonstrated a well seated mitral valve
annuloplasty ring with normal gradient and mild to moderate
mitral regurgitation. It also showed a well seated tricuspid
valve annuloplasty ring with trivial tricuspid regurgitation.
The severity of the regurgitation does not appear to be
significant enough to cause this exacerbation. It is possible
that she needs a new BiV ICD and that is the cause of this HF
exacerbation. Other contributing factors include continuous ETOH
abuse, and poor dietary/medication compliance. At the time of
discharge, she was back at baseline dry weight of 52.4 kg. She
was discharged on Lasix PO 20mg every other day, home losartan.
#Valvular disease: Ms. ___ has a history of valvular
disease and is s/p mitral/tricuspid valvular annuloplasty in
___. Clinically she had a loud holosystolic murmur radiating to
the axilla that was concerning for worsening valvular function
leading to her heart failure exacerbation. However, a repeat TEE
demonstrated a well seated mitral valve annuloplasty ring with
normal gradient and mild to moderate mitral regurgitation. A TTE
demonstrated a left ventricular systolic function is mildly
depressed (LVEF= 40 %). While her MR is worse at 2+, this is
unlikely to be significant enough to be the main cause of her
heart failure exacerbation.
#Afib on Coumadin: She has a history of atrial fibrillation on
coumadin. Her INR was 1.8 on admission and was subtherapeutic.
We started her on Coumadin 5mg followed by uptitrating it to
7.5mg in an attempt to bring her INR to therapeutic levels. At
the time of discharge, her INR remained 1.8, and she will bridge
with Lovenox while continuing Coumadin 7.5mg. She will obtain an
INR check as an outpatient on ___.
#BiV ICD: Ms. ___ had ___ BiV ICD in
place and it was recently interrogated in ___. She is ___
paced in the RV, which is the only functional lead at this time.
Interrogation summary significant for: 1. ICD function normal
with acceptable lead measurements and battery status. See report
for full detail. 2. Programming changes: Output decreased to 2.5
V 3. Follow-up scheduled: Pt does not have landline so can not
remotely monitor 6 month clinic/concurrent with ___. Please
consider re-evaluation of her BiV ICD and it may need to be
replaced given that only one the RV lead is functional.
#ETOH Abuse: Ms. ___ has a history of ETOH abuse, and
endorses drinking ___ martini's per evening. Due to her risk, we
put on her a CIWA protocol but she did not score or receive any
diazepam for withdrawal symptoms. We obtained an RUQ U/S to
evaluate for possible cirrhosis and it was normal.
#Anemia: She is anemic at baseline and H/H ranges from ___. She
was previously admitted for a GIB that was s/p EGD and
colonoscopy that did not identify any source of bleeding. We
trended her CBC during this admission and the hemoglobin was
stable.
#Thrombocytopenia: Ms. ___ has chronically low platelets
in the 120s-150s.
Plt now ___. etiology unclear. Baseline low in 130s-150s.
-continue to trend platelets
#Hypomagnesemia: Initial mag 1.3. We repleted it and his was
resolved.
#Hyperthyroidism: We continued her home methimazole.
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
================================================================
TRANISITIONAL ISSUES:
1. Repeat INR and electrolytes on ___
2. Continue lovenox bridge until INR therapeutic. Please
re-adjust her Coumadin dose as needed to maintain goal INR
level.
3. Please consider re-evaluation of her BiV ICD and it may need
to be replaced given that only one the RV lead is functional.
4. Please follow-up regarding her systolic heart failure
exacerbation and continue to counsel her about ETOH abuse and
medication/dietary adherence.
5. Discharge weight 52.4kg
# CODE: Full
# CONTACT: Brother ___, ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Warfarin 2.5 mg PO 6X/WEEK (___)
2. Warfarin 5 mg PO 1X/WEEK (MO)
3. Losartan Potassium 100 mg PO DAILY
4. Atenolol 25 mg PO DAILY
5. Methimazole 2.5 mg PO DAILY
6. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Losartan Potassium 100 mg PO DAILY
2. Methimazole 2.5 mg PO DAILY
3. Warfarin 7.5 mg PO DAILY16
RX *warfarin [Coumadin] 2.5 mg 3 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
4. Nicotine Patch 14 mg TD DAILY
RX *nicotine [Nicoderm CQ] 14 mg/24 hour apply to arm daily Disp
#*21 Patch Refills:*0
5. Vitamin D 1000 UNIT PO DAILY
6. Furosemide 20 mg PO EVERY OTHER DAY
start ___
RX *furosemide 20 mg 1 tablet(s) by mouth everyother day Disp
#*30 Tablet Refills:*0
7. Enoxaparin Sodium 80 mg SC DAILY
Start: ___, First Dose: Next Routine Administration Time
RX *enoxaparin 80 mg/0.8 mL 80 mg SC daily Disp #*10 Syringe
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
1. acute systolic congestive heart failure exacerbation
2. status post mitral annuloplasty
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___
___.
You were admitted with worsening heart failure. While you were
here, we gave you diuretics, which are medications to help you
urinate. First, we did this through your IV and then we switched
you to an oral regimen. You will take furosemide (also known as
Lasix) every other day starting tomorrow, ___.
You underwent echocardiogram of your heart which showed that it
is pumping a little weaker than the average person's heart. This
is called heart failure. Please continue all your medications as
prescribed.
Your INR was not therapeutic. Because of this, you need to give
yourself lovenox shots until your INR becomes therapeutic. Your
Coumadin will be 7.5mg PO daily until it is re-checked. Please
get this checked by ___.
At discharge, you weighed 52.4 kg. Weigh yourself daily and
notify your cardiology team if your weight increases more than
3lbs in one day.
We wish you all the best,
Your ___ Cardiology team
Followup Instructions:
___
|
19612052-DS-14
| 19,612,052 | 27,779,768 |
DS
| 14 |
2140-04-18 00:00:00
|
2140-04-18 17:21:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
Admission labs:
___ 09:47AM BLOOD WBC-9.6 RBC-4.75 Hgb-13.8 Hct-42.8 MCV-90
MCH-29.1 MCHC-32.2 RDW-15.9* RDWSD-52.1* Plt ___
___ 09:47AM BLOOD Neuts-76.7* Lymphs-14.8* Monos-6.8
Eos-0.5* Baso-0.6 Im ___ AbsNeut-7.38* AbsLymp-1.42
AbsMono-0.65 AbsEos-0.05 AbsBaso-0.06
___ 09:47AM BLOOD ___ PTT-21.8* ___
___ 09:47AM BLOOD Glucose-125* UreaN-20 Creat-1.0 Na-137
K-5.0 Cl-105 HCO3-17* AnGap-15
___ 09:47AM BLOOD Calcium-9.0 Phos-3.8 Mg-2.1
___ 09:47AM BLOOD proBNP-8861*
___ 06:34AM BLOOD %HbA1c-5.2 eAG-103
___ 07:20AM BLOOD Triglyc-102 HDL-46 CHOL/HD-2.3 LDLcalc-38
___ 07:00AM BLOOD TSH-7.1*
___ 07:00AM BLOOD Free T4-1.5
Discharge labs:
___ 06:36AM BLOOD WBC-8.7 RBC-4.31 Hgb-12.5 Hct-38.9 MCV-90
MCH-29.0 MCHC-32.1 RDW-15.6* RDWSD-51.8* Plt ___
___ 06:05AM BLOOD Glucose-89 UreaN-24* Creat-0.9 Na-139
K-3.9 Cl-105 HCO3-22 AnGap-12
TTE ___:
LA volume index severely increased, right atrium mildly
enlarged. Normal LV wall thickness and cavity size. Regional
variation with systole and inferior and posterior wall severely
hypokinetic. LV EF 30%. Normal RV cavity size with severe global
free wall hypokinesis. 1+ AR, 3+ MR, 3+ TR, mild pulmonary
artery systolic hypertension.
pMIBI:
The patient was referred for a vasodilator pharmacologic stress
test but chose to walk on the treadmill instead of receiving
medication.
Exercise protocol: Modified Gervino protocol
Exercise duration: 1.25 minutes
Reason exercise terminated: She received greater than 100
present of APMHR
Resting heart rate: 86
Resting blood pressure: 100/70
Peak heart rate: 148
Peak blood pressure: 110/70
Percent maximum predicted HR: 104%
Symptoms during exercise: No arm, neck, back, or chest
discomfort was reported by the patient throughout the study.
ECG findings: No significant ST segment changes during exercise
or in recovery.
The rhythm was AFib throughout with RVR to low-level exercise.
Rare isolated VBPs.
1. Reduced left ventricular systolic function.
2. Global hypokinesis with no distinct myocardial perfusion
defects at the level of exercise achieved.
3. Normal left ventricular cavity size.
Brief Hospital Course:
___ HOSPITAL COURSE:
======================
Ms. ___ is a ___ with minimal past medical hisotry who
presented with 1 week of dyspnea on exertion, found to have new
onset A. Fib with RVR. She was started on ___
and her dose was titrated up to acheive adequate rate control.
As part of her workup she had a TTE that showed reduced EF (30%)
and severe hypokinesis of the inferior/posterior walls and RV
free wall hypokinesis. She underwent a pMIBI which did not show
any perfusion defects, but showed severe global hypokinesis,
more consistent with a tachymyopathy. Prior to discharge, she
was taken for TEE with cardioversion with return to NSR with
APCs. She was continued on metoprolol at a lower dose following
cardioversion and her rates remained within normal range. The
patient was started on goal directed medical therapy for HFrEF
prior to discharge.
TRANSITIONAL:
=============
[] The patient was found to have new onset A fib with RVR that
required up to 62.5mg metoprolol q6h to maintain rate control.
She underwent cardioversion with return to NSR but there was
concern for a brief return to A fib on tele. Please follow up
patient's heart rate for recurrence of A fib with RVR and adjust
metoprolol dosing as needed.
[] Diagnosed with HFrEF during this admission, thought to be
caused by a tachymyopathy. Ensure she is euvolemic (obtain
standing weight) at next visit. Discharge weight 124lbs.
[] She was started on Lasix 20mg PO qd and lisinopril 2.5mg qd
and should have her Cr and K checked 1 week after discharge. Her
discharge K/Cre were 3.9/0.9.
[] The patient's home ASA for primary prevention was stopped in
the setting of starting ___ and due to a pMIBI that did not
show any myocardial perfusion defects.
ACUTE ISSUES:
=============
# A.Fib w RVR
CHADSVASc 3. Patient was admitted for dyspnea, found to be in A
fib with RVR. CTA negative for PE. TSH mildly elevated at 7.1
with normal free T4. TTE with new reduced EF and severely
enlarged L atrium with 3+ MR. ___ started on ___ and
uptitrated on metoprolol for rate control and was requiring
higher doses of metoprolol. The highest dose she required was
62.5mg q6h metoprolol tartrate. However, due to ongoing
intermittent tachycardia despite high dose metoprolol, decision
was made for cardioversion this admission with TEE. She
tolerated the cardioversion well and had conversion back to NSR
with APCs and 1st degree AV delay. It was thought that the AV
delay was related to the high doses of metoprolol that she had
received. She was monitored on tele and switched to metoprolol
succinate 100mg qd and tolerated it well.
# Acute HFrEF
The patient was noted on admission to have bilateral mild
pleural effusions and was diuresed with improvement in her
dyspnea. On TTE, patient was then found to have new HFrEF with
severe hypokinesis of the inferior/posterior walls and RV free
wall hypokinesis. She had no reported history of CAD and her
lipid panel and A1c were within normal limits. She underwent a
pMIBI which did not show any perfusion defects, but showed
severe global hypokinesis, more consistent with a tachymyopathy.
She underwent TEE with cardioversion on ___ for control of her
A fib and was started on goal directed medical therapy (with
metoprolol and lisinopril) prior to discharge. As there was no
evidence of CAD on the pMIBI and she was started on ___ for
A fib, her home ASA was stopped.
CHRONIC ISSUES:
===============
# Osteopenia:
She was continued on home vitamin D and calcium.
#CONTACT: ___, brother, ___
#CODE: Full (presumed)
Attending Attestation:
Patient seen and examined on day of discharge. Greater than 30
minutes spent on discharge planning and care coordination on day
of discharge. - ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Vitamin D 3000 UNIT PO DAILY
3. Calcitrate (calcium citrate) 500 mg oral DAILY
Discharge Medications:
1. ___ 5 mg PO BID
RX ___ [Eliquis] 5 mg 1 tablet(s) by mouth twice a day
Disp #*6 Tablet Refills:*0
2. Furosemide 20 mg PO DAILY
3. Lisinopril 2.5 mg PO DAILY
4. Metoprolol Succinate XL 100 mg PO DAILY
5. Calcitrate (calcium citrate) 500 mg oral DAILY
6. Vitamin D 3000 UNIT PO DAILY
7.Outpatient Lab Work
Obtain BMP with Magnesium and fax results to: Dr ___.
Fax: ___.
ICD-10-CM Diagnosis Code I50.2, systolic heart failure
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIANGOSIS:
===================
Atrial fibrillation with rapid ventricular response
SECONDARY DIAGNSOSIS:
Acute heart failure exacerbation
Pulmonary edema
Cardiac tachymyopathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at the ___
___!
WHY WAS I IN THE HOSPITAL?
==========================
- You were admitted because you were having difficulty breathing
and were found to have a rapid heart rate.
WHAT HAPPENED IN THE HOSPITAL?
==============================
- You were given medication to slow your heart rate. We also
performed a "cardioversion" to shock your heart into a normal
rhythm.
- You were found to have fluid buildup in your lungs so you were
given a water pill to help you pee off the extra fluid.
- We took imaging of your heart and found that your heart is not
beating as strongly as it used to. We did a scan and found no
evidence of disease in the blood vessels of your heart. It is
thought that the heart was weak from beating at a rapid rate for
a while.
WHAT SHOULD I DO WHEN I GO HOME?
================================
- Be sure to take all your medications and attend all of your
appointments listed below.
- Weigh yourself daily in the morning after going to the
bathroom. Please call your MD if you gain more than 3 lbs in one
day or more than 5 lbs in a week.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19612066-DS-5
| 19,612,066 | 23,940,035 |
DS
| 5 |
2115-10-03 00:00:00
|
2115-10-03 12:42:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Iodinated Contrast Media - IV Dye / Dilaudid / Hycodan (with
homatropin) / morphine / most opiods
Attending: ___.
Chief Complaint:
Nausea and vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ s/p whipple & G-J tube c/b IVC injury &repair for Ampullary
adenoma w/low-grade dysplasia discharged to rehab ___
presents back with nausea and vomiting.
Patient was admitted to the ___ surgery service from
___ after undergoing a Whipple for her ampullary
adenoma. Patient had a complex hospital course with sustaining
an
IVC injury during her surgery with successful repair.
Past Medical History:
cerebral palsy
myasthenia ___
hyperlipidemia
obesity
PSH:
laparoscopic cholecystectomy
choledochoduodenostomy ___
Whipple procedure ___
Social History:
___
Family History:
Ovarian cancer in maternal grandmother, lung cancer in paternal
uncle
Physical ___:
Prior Discharge:
VS: 98.1, 108, 120/80, 17, 96% RA
GEN: NAD, pleasant
CV: Sinus tachycardia
PULM: CTAB
ABD: Subcostal incision with midline extension. Right end of the
wound with moist-to-dry dressing. The mid part of incision with
moist-to-dry dressing covered by ABG. RLQ with JP drain to bulb
suction, site with
drain sponge dressing. LUQ with G/J-tube, site with Allevyn
Trach Dressing.
Groin: Rash on perineum area.
EXTR: Warm, positive pp.
Pertinent Results:
___ 10:42AM BLOOD WBC-9.3 RBC-2.69* Hgb-8.3* Hct-25.8*
MCV-96 MCH-30.9 MCHC-32.2 RDW-16.2* Plt ___
___ 10:42AM BLOOD Glucose-107* UreaN-11 Creat-0.7 Na-135
K-3.6 Cl-101 HCO3-22 AnGap-16
___ 10:42AM BLOOD ALT-21 AST-18 LD(LDH)-200 AlkPhos-98
TotBili-0.3
___ 10:42AM BLOOD Lipase-63*
___ 10:51AM BLOOD Lactate-1.8
___ 09:32AM ASCITES ___
___ KUB:
IMPRESSION: Non-obstructive bowel gas pattern.
___ CXR:
IMPRESSION:
1. No acute cardiopulmonary process.
2. Right PICC tip is in the lower SVC.
Brief Hospital Course:
The patient s/p Whipple procedure on ___ for low grade
duodenal adenoma. Her recovery was complicated by
pancreatico-biliary leak, pneumatosis coli and persistent nausea
with dry hives. She was discharged in ___
___ on ___ in stable condition, and was
transferred back in ___ on ___ secondary to nausea and
vomiting.
The patient was admitted to Surgical Oncology Service. Tubefeed
was restarted with rate 10 cc/hr and was well tolerated.
Patient' s KUB and CXR were grossly normal. JP drain amylase was
high and she was started on Octreotide. Patient also was started
on Reglan to help with gastric motility. Patient was stable and
was discharged back in Rehab in stable condition. The
instructions were provided to increase tubefeeds slowly without
challenging the patient.
Medications on Admission:
Acetaminophen (Liquid) 650 mg NG Q6H:PRN fever/pain This is a
new medication to treat your pain or fever
Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID This is
a new medication to treat your
DiphenhydrAMINE 12.5 mg IV Q8H:PRN itching This is a new
medication to treat your itching
HYDROmorphone (Dilaudid) 0.5 mg IV Q3H:PRN breakthrough pain
Please give before wound VAC change This is a new medication to
treat your pain
Insulin SC Sliding Scale Fingerstick q6h Insulin SC Sliding
Scale using HUM Insulin This is a new medication to treat your
your hyperglycemia
Lorazepam 0.5 mg IV Q6H:PRN anxiety, insomnia This is a new
medication to treat your anxiety/insomnia
MethylPREDNISolone Sodium Succ 5 mg IV EVERY OTHER DAY This is
a new medication to treat your
Metoclopramide 10 mg IV Q8H This is a new medication to
increase gastric motility
Miconazole 2% Cream 1 Appl TP BID This is a new medication to
treat your yeast infection
OxycoDONE Liquid ___ mg PO Q3H:PRN pain This is a new
medication to treat your post op pain
Piperacillin-Tazobactam 4.5 g IV Q8H Last day ___ This is a
new medication to treat your infection
Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line flush
This is a new medication to treat your PICC
Vancomycin 1000 mg IV Q 12H Last day ___ This is a new
medication to treat your infection
UNCHANGED Medications/Orders Physician ___
___ 50 mg PO HS You were taking this medication at
home and you should continue it at the same dose (how much) and
frequency (how often).
Baclofen 10 mg PO Q24H You were taking this medication at home
and you should continue it at the same dose (how much) and
frequency (how often).
eletriptan HBr 40 mg oral PRN headache You were taking this
medication at home and you should continue it at the same dose
(how much) and frequency (how often).
Hydrochlorothiazide 12.5 mg PO DAILY You were taking this
medication at home and you should continue it at the same dose
(how much) and frequency (how often).
HydrOXYzine 10 mg PO TID You were taking this medication at
home and you should continue it at the same dose (how much) and
frequency (how often).
Prochlorperazine 25 mg PO BID:PRN nausea You were taking this
medication at home and you should continue it at the same dose
(how much) and frequency (how often).
Simvastatin 40 mg PO QPM You were taking this medication at
home and you should continue it at the same dose (how much) and
frequency (how often).
Discharge Medications:
1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN pain
2. Amitriptyline 50 mg PO HS
3. Baclofen 10 mg PO DAILY
4. Hydrochlorothiazide 12.5 mg PO DAILY
5. HYDROmorphone (Dilaudid) 0.5 mg IV Q6H:PRN breakthrough pain
Please give before wouns VAC change
6. HydrOXYzine 10 mg PO TID
7. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using HUM Insulin
8. Metoclopramide 10 mg IV Q6H
9. Octreotide Acetate 100 mcg SC Q8H
10. Piperacillin-Tazobactam 4.5 g IV ONCE Duration: 1 Dose
stop on ___
11. Simvastatin 40 mg PO DAILY
12. Vancomycin 750 mg IV Q 12H
stop on ___. Lorazepam 0.5 mg PO Q6H:PRN anxiety/nausea/insomnia
14. DiphenhydrAMINE 12.5 mg IV Q8H:PRN itching
15. OxycoDONE Liquid ___ mg PO Q3H:PRN pain
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
1. Ampullary adenoma with low grade dysplasia
2. Persistent sinus tachycardia
3. Intermittent nausea and vomiting
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid
(___).
Discharge Instructions:
You were admitted to the surgery service at ___ for surgical
resection of your ampullary adenoma. Your surgery was
complicated by inferior vena cava injury, which was repaired.
You was found to have pneumatosis coli on CT scan and you were
treated with antibiotics. You have done well in the post
operative period and are now safe to be discharged in Rehab to
complete your recovery with the following instructions:
.
Please ___ Dr. ___ office at ___ if you have any
questions or concerns.
.
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, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
.
Incision Care:
*Wound VAC will be changed every 72 hours by ___ nurses.
*Please ___ your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
.
JP Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*Maintain suction of the bulb.
*Note color, consistency, and amount of fluid in the drain. ___
the doctor, ___, or ___ nurse if the amount
increases significantly or changes in character.
*Be sure to empty the drain frequently. Record the output, if
instructed to do so.
*You may shower; wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
.
G/J-tube:
Keep G-tube to gravity drainage. If you able to tolerate, cap
the tube and uncap to gravity drainage if you feel nausea.
J-tube: Continue with tube feed. Flush J-tube with 50 cc of tap
water Q6H.
Change drain sponge daily and prn. Monitor for signs and
symptoms of infection or dislocation.
.
PICC Line:
*Please monitor the site regularly, and ___ your MD, nurse
practitioner, or ___ Nurse if you notice redness, swelling,
tenderness or pain, drainage or bleeding at the insertion site.
* ___ your MD or proceed to the Emergency Room immediately if
the PICC Line tubing becomes damaged or punctured, or if the
line is pulled out partially or completely. DO NOT USE THE PICC
LINE IN THESE CIRCUMSTANCES.Please keep the dressing clean and
dry. Contact your ___ Nurse if the dressing
Followup Instructions:
___
|
19612206-DS-14
| 19,612,206 | 22,169,742 |
DS
| 14 |
2133-06-06 00:00:00
|
2133-06-06 18:31:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Erythromycin Base
Attending: ___.
Chief Complaint:
Fevers
Major Surgical or Invasive Procedure:
colonoscopy ___
endoscopy ___
History of Present Illness:
___ F with phmx of schizoaffective disorder, DM2 (on
metformin), HTN and FUOs who was recently admitted (___) for
untreated UTI in the setting of fevers, nausea and vomiting who
now presents with worsened fevers and report of black stools.
Initially saw PCP for ___ of N/V and fevers on ___ and urine
culture was positive for Klebsiella (pan sensitive except
macrobid). PCP was unable to reach pt until ___ when she was
instructed to go to the ED and get treated- was treated w/ cipro
and discharged home to complete a 12 day course. Patient reports
has been taking cipro but suffering recurrent fevers as high as
102.7 and 103.7. Of note, patient has had w/u for FUO (still
unclear etiology) w/ fevers as high as 101 since ___.
Also reports 3 episodes of black BMs this AM and loose stool. No
prior episodes of diarrhea. No syncope, + weakness. Poor
appetite, but has been taking POs. No N/V or abd pain. No flank
or back pain. Does report some urinary incontinence & urgency
for the past several weeks, no hematuria, dysuria, or frequency.
In the ED, initial VS: 98.4 ___ 18 100%. Pt's labs
notable for UA w/ bacteria and 69 WBCs, creatinine 1.3, WBC 22,
lactate 4.3, hct 29.6. Given complaint of black stools rectal
done which showed greenish stools, guiac negative. Underwent CT
Abd/Pelvis which was negative for stones and acute process.
Received 2 L IVF, CTX and vancomycin, as well as tylenol ___ mg
and later 650 mg. Lactate down to 1.4. Patient admitted to
medicine for further management. VS on transfer were: 99.2
152/75 96 ra 24 pulse 98.
On arrival to the medical floor, patient appears comfortable and
denies pain. Vitals were T: 103.2 P: 124 BP: 161/71 RR: 20 SaO2:
100% on Room air.
REVIEW OF SYSTEMS:
Denies night sweats, headache, vision changes, rhinorrhea,
congestion, sore throat, cough, shortness of breath, chest pain,
abdominal pain, nausea, vomiting, constipation, BRBPR,
hematochezia, dysuria, hematuria.
Past Medical History:
-FUO: developed after pt was hospitalized for PNA in early
___. The patient has had recurrent, unexplained fevers
up to 101 since then. She was referred by her PCP to an ID
specialist, whose exam was notable for diffuse LAD, and whose
ddx included IBD, tuberculosis or other granulomatous infection
(although pt is PPD negative), possibly sarcoid.
-Schizoaffective Disorder - managed on valproate, olanzapine and
fluvoxamine.
-NIDDM - diagnosed at age ___ attributed to zyprexa. Managed on
metformin, as of ___. According to PCP note on that date,
pt's diabetes was "uncontrolled" and pt stated she did not check
her sugars or know what a diabetic diet was. ___ HbA1c:
6.3%.
-HTN
-HLD: most recent LDL:78, HDL: 25
-Hypothyroidism - etiology unknown. Managed on levothyroxine.
-GERD
-Seasonal allergies
-OSA - pt desatted to low ___ in EDobs overnight. Requires and
uses CPAP at home.
- Anemia - noted to have Hgb of 8.7 at most recent PCP ___
(___). Pt intends to follow up with PCP about this; will
likely undergo outpatient colonscopy.
Past Surgical History
___: Catherization for removal of blood clots in fingers. Pt
was subsequently on Coumadin for 6mo. Per pt, source of clot was
never found (per pt: ?shoulder).
Social History:
___
Family History:
Family History:
Paternal grandmother: breast cancer
___ grandfather: strokes
___ grandfather and 7 great-uncles: MI in ___
Mother: anxiety, PMR
Physical Exam:
Admission:
VS - T: 103.2 P: 124 BP: 161/71 RR: 20 SaO2: 100% on Room air.
GENERAL - Alert, interactive, overweight, in NAD
HEENT - PERRLA, EOMI, sclerae anicteric, dry MM, OP clear except
for bits of food
NECK - Supple
HEART - tachycardic but regular, nl S1-S2, no MRG
LUNGS - CTAB, no wheezes/rales/ronchi, good air movement, resp
unlabored, no accessory muscle use
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
BACK - no flank or CVA tenderness
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs III-XII grossly intact, muscle
strength and sensation grossly intact
Discharge:
VS 98.1-101.2, 121-152/70s, 70-80s, 100%RA
GEN awake, Alert, oriented, no acute distress
HEENT NCAT MMM EOMI sclera anicteric although right medial slera
injected, OP clear
NECK supple, no JVD, no LAD
PULM Good aeration, CTAB no wheezes, rales, ronchi
CV RRR normal S1/S2, no mrg
ABD soft NT ND normoactive bowel sounds, no r/g
BACK: Patient without tenderness in CV angle.
EXT WWP 2+ pulses palpable bilaterally, no c/c/e
No inguinal adenopathy
NEURO CNs2-12 intact, motor function grossly normal
SKIN no ulcers or lesions
EYE: No erythema or injection in eyes, PERRL, EOMI
Pertinent Results:
___ 04:15PM BLOOD Neuts-78.1* Lymphs-11.6* Monos-9.1
Eos-0.8 Baso-0.4
___ 04:15PM BLOOD WBC-22.0*# RBC-3.26* Hgb-10.7* Hct-29.6*
MCV-91 MCH-32.9*# MCHC-36.2*# RDW-15.0 Plt ___
___ 08:10AM BLOOD WBC-13.3* RBC-2.77* Hgb-8.1* Hct-25.3*
MCV-91 MCH-29.3# MCHC-32.2# RDW-15.6* Plt ___
___ 09:41AM BLOOD WBC-9.3 RBC-2.72* Hgb-7.7* Hct-24.5*
MCV-90 MCH-28.3 MCHC-31.4 RDW-15.4 Plt ___
___ 09:00PM BLOOD Hct-23.6*
___ 09:00AM BLOOD WBC-10.2 RBC-2.98* Hgb-8.1* Hct-26.4*
MCV-89 MCH-27.3 MCHC-30.7* RDW-15.5 Plt ___
___ 07:35AM BLOOD WBC-9.7 RBC-2.98* Hgb-8.6* Hct-26.8*
MCV-90 MCH-28.8 MCHC-31.9 RDW-15.9* Plt ___
___ 07:15AM BLOOD WBC-11.0 RBC-2.78* Hgb-7.8* Hct-25.3*
MCV-91 MCH-28.1 MCHC-30.9* RDW-15.8* Plt ___
___ 07:45AM BLOOD ___ PTT-28.9 ___
___ 09:41AM BLOOD Ret Aut-1.6
___ 07:45AM BLOOD Lupus-PND
___ 07:45AM BLOOD ACA IgG-PND ACA IgM-PND
___:15PM BLOOD Glucose-150* UreaN-11 Creat-1.3* Na-136
K-4.0 Cl-93* HCO3-28 AnGap-19
___ 08:10AM BLOOD Glucose-104* UreaN-6 Creat-0.9 Na-139
K-3.8 Cl-104 HCO3-26 AnGap-13
___ 07:35AM BLOOD Glucose-101* UreaN-6 Creat-0.9 Na-140
K-3.6 Cl-106 HCO3-27 AnGap-11
___ 09:41AM BLOOD Glucose-105* UreaN-8 Creat-0.9 Na-141
K-3.6 Cl-104 HCO3-30 AnGap-11
___ 09:00AM BLOOD Glucose-92 UreaN-6 Creat-0.9 Na-139 K-3.5
Cl-101 HCO3-32 AnGap-10
___ 07:35AM BLOOD Glucose-79 UreaN-7 Creat-0.9 Na-140 K-3.8
Cl-99 HCO3-33* AnGap-12
___ 07:15AM BLOOD Glucose-170* UreaN-7 Creat-0.9 Na-139
K-3.6 Cl-97 HCO3-29 AnGap-17
___ 04:15PM BLOOD ALT-11 AST-19 AlkPhos-87 TotBili-0.4
___ 09:41AM BLOOD LD(LDH)-170
___ 07:35AM BLOOD Calcium-8.5 Phos-2.9# Mg-2.1
___ 07:15AM BLOOD Calcium-8.2* Phos-2.9 Mg-1.9
___ 04:15PM BLOOD Albumin-3.7
___ 09:41AM BLOOD calTIBC-257* Hapto-399* Ferritn-204*
TRF-198*
___ 07:45AM BLOOD dsDNA-PND
___ 09:41AM BLOOD IgG-1043 IgA-440* IgM-147
___ 09:41AM BLOOD HIV Ab-NEGATIVE
___ 09:05AM BLOOD Type-ART pO2-64* pCO2-43 pH-7.47*
calTCO2-32* Base XS-6
___ 04:37PM BLOOD Lactate-4.8*
___ 08:04PM BLOOD Lactate-1.4
___ 09:05AM BLOOD Lactate-0.8
Test Result Reference
Range/Units
FREE KAPPA, SERUM 31.2 H 3.3-19.4 mg/L
FREE LAMBDA, SERUM 42.3 H 5.7-26.3 mg/L
FREE KAPPA/LAMBDA RATIO 0.74 0.26-1.65
___ 09:43PM URINE Color-Yellow Appear-Clear Sp ___
___ 09:43PM URINE Blood-SM Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 09:43PM URINE RBC-6* WBC-2 Bacteri-NONE Yeast-NONE
Epi-0
___ 06:30PM URINE CastHy-24*Micro:
___ 6:30 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
YEAST. <10,000 organisms/ml.
___ 9:43 pm URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 4:15 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 4:20 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
Blood cultures pending x2
___ 7:45 am SEROLOGY/BLOOD
RAPID PLASMA REAGIN TEST (Pending):
Reports:
ECG Study Date of ___ 4:34:44 ___
Sinus tachycardia. Diffuse non-specific ST-T wave changes.
Compared to the previous tracing of ___, the heart rate is
increased. Other findings are similar.
CHEST (PA & LAT) Study Date of ___ 5:22 ___
IMPRESSION: Low lung volumes, mild cardiomegaly.
CTU (ABD/PEL) W/&W/O CONTRAST Study Date of ___ 5:54 ___
IMPRESSION: No acute intra-abdominal process. Multiple
prominent
retroperitoneal and mesenteric lymph nodes, are similar in size
than the
recent CT Torso from ___. Recommend follow up CT in three
months to
ensure resolution.
Tissue: GI BX'S (5 JARS) Procedure Date of ___
DIAGNOSIS:
1. Stomach, biopsy (A):
Within normal limits.
2. Polyps, fundus, biopsy (B):
Fragments of fundic gland polyp.
3. Duodenum, biopsy (C):
Within normal limits.
4. Terminal ileum, biopsy (D):
Within normal limits.
5. Random colon biopsy (E):
Within normal limits.
Endoscopy:
Normal mucosa in the esophagus
Medium hiatal hernia
Polyps in the fundus (biopsy)
Erythema in the stomach (biopsy)
Normal mucosa in the duodenum (biopsy)
Otherwise normal EGD to third part of the duodenum
Recommendations: Follow up biopsy results
Colonoscopy:
Diverticulosis of the ascending colon
Stool in the throughout colon
(biopsy, biopsy)
Otherwise normal colonoscopy to cecum and terminal ileum
Recommendations: Follow up biopsy results
repeat screening colonoscopy in the next year given poor prep
Brief Hospital Course:
___ yo F w/ h/o schizoaffective disorder, FUO, DM type 2, HTN and
recent UTI who presents with recurrent fevers.
#) FUO with anemia and anterior uveitis: Unclear etiology
although likely sarcoidosis given episode of anterior uveitis
(unclear if granulomatous) versus other possible rheumatologic
process. Also possible is malignant. Less likely is
infectious: possible mycobacteria though PPD negative versys
fungal disease with body cavity lymphadenopathy. Patient has
been seen by Dr. ___ ___ w/ temps as high as
101 and w/u significant for ESR 128, CRP 81 w/ body cavity
lymphadenopathy. Pt did have E. nodosum at that time but
resolved quickly.
During this hospitalization, EGD/colonoscopy were done given
concern for underlying malignancy leading to FUO, biopsies from
both scopes were negative with no gross findings except for
polyp/erythema in the stomach. Blood cultures were negative x2
and pending x2. HIV was negative, RPR was pending.
Patient was initially treated with ceftriaxone for presumed
failure of PO Cipro, although urine culture was only significant
for yeast and repeat UA ___ evening not suggestive of UTI and
ceftriaxone stopped.
Laboratory results were significant for an Ig panel (normal, IgA
slightly elevated at 440 IgG 1043, IgM 147,), UPEP (pending),
free kappa/lambda (both slightly elevated), blood smear, hapto
(399, high), LDH (170), HIV (negative), Ferritin 204, TFF 198,
pending methylmalonic acid, UPEP, culture data.
- Pending: dsDNA, ssa/ro, ssb/la, rnp, ___ lupus
anticoagulant, anticardiolipin IgG and IgM, beta-2-glycoprotein1
Patient's fevers continued during hospitalization and were
treated symptomatically with Tylenol prn fever >101 and sx. We
enjoyed consultation with the heme/onc and rheumatology
services.
We will hold on NSAIDs for now given previous GI upset and will
hold on prednisone to hopefully get PET and ? biopsy a node.
Patient was discharged with plans for an outpatient PET CT.
#) R>L anterior uveitis: injected sclera, tenderness on
palpation. pupils wnl. EOMI wnl. On ___ AM showed
elevated eye pressure. We appreciated Eye Center appointment.
Per their recommendations:
- Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q12H
- PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP RIGHT EYE QID
- Timolol Maleate 0.5% 1 DROP RIGHT EYE BID
- f/u outpatient opth
- HLA B27 (although no arthritis symptoms)
- RPR pending
#) Initial concern for urinary tract infection/?pyelonephritis:
Patient with persistently dirty UA on admission despite taking
PO Cipro. Does have fever and WBC elevation but does not have
other systemic symptoms of pyelonephritis (i.e. nausea or
vomiting) that she had last time. No nidus for continued
infection as CT is negative for anatomic abnl or stones. Unclear
if fevers are entirely related to UTI given h/o FUO. Positive
CVA tenderness on admission. no CVA tenderness on ___ and ___
exam. Gave fluconazole ___ for vaginal candidiasis.
#) Altered level of alertness: On ___ morning was found to be
sleepy and hard to be awakened. There was concern for CO2
retention vs hypoventilation. she didn't use her CPAP overnight
and was being used only in the morning. Neuro exam was intact
and she remained AOx3. ABG was not suggestive of CO2 retention
and her PH was slightly alklemic at 7.47. She spontaneously
improved after sitting her up, opening up the lights and talking
to her. She was awake and talking over the phone on
re-evaluation. No significant change in her labs. No further
episodes were noted.
#) ___: Creatinine of 1.3 from baseline around 0.8. Likely
prerenal due to poor PO intake and dehydration from fevers given
lactate and hylaine casts on initial UA. This resolved with
fluids and Cr 0.9 ___
#) DM type 2: Well controlled w/ recent A1c of 6.3 in ___.
We held metformin given recent contrast load and checked QID ___
and ISS
#) HTN: normotensive. We continued home lisinopril and
metoprolol
#) Schizoaffective disorder: We continued home divalproex ER
1500 mg qHS and home olanzapine and fluvoxamine
#) OSA: We continued home CPAP
#) Transitional:
- Repeat CT abdomen ___ to ensure resolution of abdominal lymph
nodes (likely not needed given PET CT on ___.
- Numerous serologies including RPR, HLA B27 and
hypercoagulability work up pending at time of discharge
(Pending: dsDNA, ssa/ro, ssb/la, rnp, ___ lupus
anticoagulant, anticardiolipin IgG and IgM,
beta-2-glycoprotein1).
Medications on Admission:
olanzapine 15mg PO QHS
divalproex ER 1500mg PO QHS
fluvoxamine 200mg QHS
metformin 1000mg PO BID
lisinopril 40mg PO
metoprolol succinate 25mg PO
pravastatin 80mg PO
levothyroxine 112micrograms PO
allegra 180mg PO daily
omeprazole 20mg PO BID
zofran 8 mg PO prn
Discharge Medications:
1. olanzapine 15 mg Tablet Sig: One (1) Tablet PO at bedtime.
2. divalproex ___ mg Tablet Extended Release 24 hr Sig: Three
(3) Tablet Extended Release 24 hr PO at bedtime.
3. fluvoxamine 100 mg Tablet Sig: Two (2) Tablet PO at bedtime.
4. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
5. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
6. pravastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
7. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Allegra 180 mg Tablet Sig: One (1) Tablet PO once a day.
9. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
10. ZOFRAN ODT 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea.
11. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day.
12. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q12H
(every 12 hours): Right eye.
Disp:*2 bottles* Refills:*0*
13. prednisolone acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic QID (4 times a day): Right eye.
Disp:*2 bottles* Refills:*0*
14. timolol maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic BID
(2 times a day): Right eye.
Disp:*2 bottles* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY:
fevers of unknown origin
urinary tract infection
anterior uveitis
SECONDARY: OSA, diabetes, GERD, Hyperlipidemia, hypertension,
Diabetes, hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted because you have had continued fevers as an
outpatient. We treated you for a urinary infection with
antibiotics, but your fevers continue.
You underwent a colonoscopy and upper endoscopy as a part of
your workup which did not reveal the source of the fevers
(biopsies were normal). Also, you were evaluated for red eyes
and were found to have an inflammatory eye condition called
anterior uveitis, for which you have been started on eye drops
and will see Ophthalmology as an outpatient.
The cause for your fevers is still unclear but you are safe to
be discharged home with plans for continued outpatient workup
and management, including an outpatient scan this ___ (please
see appointments below).
We made the following changes to your medications:
Please START Timolol Maleate 0.5% 1 DROP RIGHT EYE every 12
hours.
Please START Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES
every 12 hours
Please START PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP RIGHT
EYE 4 times daily
Followup Instructions:
___
|
19612206-DS-16
| 19,612,206 | 25,835,250 |
DS
| 16 |
2136-05-26 00:00:00
|
2136-05-26 12:17:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Erythromycin Base
Attending: ___.
Chief Complaint:
Colitis
Major Surgical or Invasive Procedure:
Flex Sigmoidoscopy with biopsy
History of Present Illness:
___ year old Female with a history of ischemic and granulomatous
colitis, immunosuppressed on methotrexate for sarcoidosis who
presents with 24 hours of frank hematochezia. The patient
reports developing acute nausea and vomitting after eating some
cookies her husband made, early of the morning of the day prior
to admission. The patient the developed frank hematochezia with
bright red blood, and reports over 20 BMs dring the day. She
states she did not have any melena either during the episode or
preceding it. She reports some intermittant subjective fevers
(to the point she was under an electric blanket at home when it
was in the ___ outside). She initially presented to the ___
___, and was noted to be markedly tachycardic in
the 140s so was transferred to the ___.
In the ED her initial vitals were Tm 100.5, Tc 1002, 122,
135/82, 16, 96%. She was given IV fluids, and underwent CT scan
which was notable for colitis. In addition she had a chest x-ray
concerning for atelectasis vs. pneumonia, although this was a
portable AP study. A GI consult was obtained in the ED, who
concured that she needs stool studies, and admission.
Of note she is followed by ___ clinic, and was seen by Dr. ___
earlier in the week, without changes to her medications.
Past Medical History:
- Sarcoidosis
- Type 2 DM (HbA1c 7.8% in ___
- Schizo-affective disorder
- Uveitis / scleritis
- Granulomatous colitis
- GERD
- Hypothyroidism
- Anxiety
- OSA
- Hyperlipidemia
- HTN
- OA
- Osteopenia
- Diverticulosis
- Hemorrhoids
Social History:
___
Family History:
Mother living with anxiety, hypertension, irritable bowel,
polymyalgia rheumatica.
Father is living with hypertension, CLL, and mild kidney
disease.
Physical Exam:
Admision Exam:
VSS: 98.8, 128/78, 82, 16, 98%
GEN: NAD
Pain: ___
HEENT: EOMI, MMM, - OP Lesions
PUL: CTA B/L
COR: RRR, S1/S2, - MRG
ABD: Diffuse TTP/ND, - rebound, - guarding, +BS, - CVAT
EXT: - CCE
NEURO: CAOx3, Non-Focal
Discharge Exam:
**************
VS: T: 98.4 HR 73 BP 102/58 RR 18 97%RA
GEN: NAD, sitting comfortably in bed
HEENT: EOMI, PERRLA, MMM
CV: RRR nl s1s2 no m/r/g
Resp: CTAB no w/r/r
Abd: Soft, NT, ND +BS
Ext: no c/c/e
Pertinent Results:
Admission Labs
9:00AM BLOOD WBC-20.0* RBC-4.16* Hgb-11.6* Hct-34.0* MCV-82
MCH-27.9 MCHC-34.1 RDW-16.9* Plt ___
___ 10:50PM BLOOD WBC-19.5*# RBC-4.40 Hgb-12.4 Hct-35.7*
MCV-81* MCH-28.0 MCHC-34.6 RDW-16.7* Plt ___
___ 09:00AM BLOOD Neuts-80.3* Lymphs-11.4* Monos-7.2
Eos-0.9 Baso-0.2
___ 10:50PM BLOOD Neuts-79.9* Lymphs-10.9* Monos-8.1
Eos-0.7 Baso-0.3
___ 10:50PM BLOOD ___ PTT-28.1 ___
___ 09:00AM BLOOD Glucose-161* UreaN-11 Creat-0.9 Na-135
K-4.1 Cl-102 HCO3-25 AnGap-12
___ 10:50PM BLOOD Glucose-155* UreaN-15 Creat-0.9 Na-137
K-4.5 Cl-100 HCO3-25 AnGap-17
___ 10:50PM BLOOD ALT-20 AST-25 AlkPhos-86 TotBili-0.5
___ 09:00AM BLOOD Calcium-9.1 Phos-3.6 Mg-1.5*
___ 10:50PM BLOOD Albumin-3.8 Calcium-9.4 Phos-3.5 Mg-1.6
___ 10:58PM BLOOD Lactate-1.3
___ 01:30AM URINE Color-Straw Appear-Clear Sp ___
___ 01:30AM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
___ 01:30AM URINE RBC-5* WBC-4 Bacteri-NONE Yeast-NONE
Epi-3
___ 11:50 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
___ 1:30 am URINE
URINE CULTURE (Pending):
Discharge Labs:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
___ 06:50 8.9 3.79* 10.4* 30.7* 81* 27.4 33.8 16.3*
278
Reports:
CHEST (PORTABLE AP) Study Date of ___ 10:46 ___
IMPRESSION:
Heterogeneous right lower lobe opacity may represent
superimposed vessels
however differential includes early pneumonia. Clinical
correlation is
recommended. If concern consider repeat radiograph with better
positioning. for further evaluation.
CTA ABD & PELVIS Study Date of ___ 12:31 AM
IMPRESSION:
1. Colitis involving the descending and sigmoid colon with
diffuse bowel wall thickening, fat stranding and mucosal hyper
enhancement. Differential includes ischemic, inflammatory, and
ischemic etiologies.
2. No brisk active extravasation.
3. Multiple reactive lymph nodes within the abdomen/pelvis.
Flex sig ___:
Impression: Normal mucosa in the sigmoid colon (biopsy)
There was some blood in the rectum. The mucosa was irrigated
carefully. There was no mass or ulcer. The blood may be
secondary to mucosal trauma from recent enemas.
Otherwise normal sigmoidoscopy to 35 cm
Recommendations: Follow up biopsy results.
Further recommendations per inpatient team.
Sigmoid biopsy: Unremarkable except for some superficial luminal
hyperplastic proliferation.
Brief Hospital Course:
___ year old woman with sarcoidosis on methotrexate and
granulomatous colitis followed by Dr. ___ also has a
history of ischemic colitis admitted with left sided abdominal
pain and BRBPR, CT imaging revealed left sided colitis.
# Acute Sigmoid Colitis
# Acute Blood loss anemia
# BRBRP
# Leukocytosis
The differential is broad including ischemic, granulomatous or
diverticulitis. Hemodynamically stable without active GI
bleeding at present however Hct downtrending though within range
of prior Hct. She was treated broadly with Ciprofloxacin,
Metronidazole and Vancomycin given both her marked leukocytosis
and immunosuppresion. General surgery was consulted in ED and
felt there was no evidence of acute ischemia or surgical
process. GI consulted who performed a Flex Sig, showing normal
appearing mucosa s/p biopsy and small amount of blood. Biopsy
was unremarkable. Stool cultures were sent which were negative
for C. diff and no growth to date. Her antibiotics were
discontinued and her diet was advanced. She was instructed to
use Imodium as needed if her diarrhea was very frequent. She
was scheduled to follow-up with her outpatient GI Dr. ___.
# Type II Diabetes
Controlled without Complications. Held Glipizide in house and
treated with HISS.
# Sarcoidosis
Continued methotrexate every ___, MTX level was
undetectable.
# Hyperlipidemia
Continued Pravastatin
# GERD
Continued Omeprazole
# Benign Hypertension
Continued Metoprolol and lisinopril. Her calcium channel
blocker was changed to amlodipine as it was more affordable for
her.
# Schizoaffective Disorder
Continued Divalproex, olanzopine, fluvox, trazodone
# Hypothyroidism
Continued levothyroxine
# Obstructive Sleep Apnea
CPAP
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Divalproex (EXTended Release) 1000 mg PO QHS
2. Fluticasone Propionate NASAL 2 SPRY NU DAILY
3. Fluvoxamine Maleate 200 mg PO HS
4. FoLIC Acid 1 mg PO DAILY
5. GlipiZIDE 5 mg PO DAILY
6. Aspart 4 Units Breakfast
Aspart 4 Units Lunch
Aspart 4 Units Dinner
Aspart 4 Units Bedtime
NPH 13 Units Breakfast
NPH 13 Units Dinner
7. Levothyroxine Sodium 112 mcg PO DAILY
8. Methotrexate 15 mg PO QTUES
9. Metoprolol Succinate XL 25 mg PO DAILY
10. nisoldipine 8.5 mg oral DAILY
11. OLANZapine 15 mg PO QHS
12. Omeprazole 20 mg PO BID
13. Pravastatin 10 mg PO QPM
14. TraZODone 50-100 mg PO QHS:PRN insomnia
15. Lisinopril 40 mg PO DAILY
16. calcium carbonate-vitamin D3 1,000 mg(2,500 mg)-800 unit
oral BID
17. Ferrous Sulfate 325 mg PO DAILY
18. Acetaminophen ___ mg PO Q8H:PRN pain
Discharge Medications:
1. Divalproex (EXTended Release) 1000 mg PO QHS
2. Fluticasone Propionate NASAL 2 SPRY NU DAILY
3. Fluvoxamine Maleate 200 mg PO HS
4. FoLIC Acid 1 mg PO DAILY
5. Levothyroxine Sodium 112 mcg PO DAILY
6. Methotrexate 15 mg PO QTUES
7. Metoprolol Succinate XL 25 mg PO DAILY
8. OLANZapine 15 mg PO QHS
9. GlipiZIDE 5 mg PO DAILY
10. Amlodipine 2.5 mg PO DAILY
RX *amlodipine 2.5 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
11. Aspart 4 Units Breakfast
Aspart 4 Units Lunch
Aspart 4 Units Dinner
Aspart 4 Units Bedtime
NPH 13 Units Breakfast
NPH 13 Units Dinner
12. Lisinopril 40 mg PO DAILY
13. Acetaminophen ___ mg PO Q8H:PRN pain
14. Omeprazole 20 mg PO BID
15. Pravastatin 10 mg PO QPM
16. TraZODone 50-100 mg PO QHS:PRN insomnia
17. calcium carbonate-vitamin D3 1,000 mg(2,500 mg)-800 unit
oral BID
18. Ferrous Sulfate 325 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Active:
- Colitis
- Rectal Bleeding
- Acute blood loss anemia
Chronic:
- Collagenous colitis
- Sarcoidosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms ___,
It was a pleasure treating you during this hospitalization. You
were admitted to ___ with rectal bleeding and pain found to
have colitis. You were treated with antibiotics initially and a
Flex Sigmoidoscopy did not show any inflammation in your colon.
Biopsy of the colon showed no significant abnormalities. Your
antibiotics were discontinued and your symptoms improved. You
should follow up closely with your PCP and gastroenterologist.
Followup Instructions:
___
|
19612206-DS-17
| 19,612,206 | 24,199,635 |
DS
| 17 |
2138-01-19 00:00:00
|
2138-01-20 11:02:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Erythromycin Base / miconazole
/ Ilotycin
Attending: ___.
Chief Complaint:
Nausea/vomiting/diarrhea
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ with history of schizoaffective disorder and sarcoidosis
presents with fevers/nausea/vomiting and diarrhea x1-2 days.
Patient describes symptoms as sudden in onset and associated
with diffuse, lower abdominal pain.
Patient notes that vomiting and diarrhea was without blood. Has
had no sick contacts. No chest pain or dyspnea. No paresthesisa.
No myalgia or arthralgia. Patient notes that she has baseline
essential tremor that has worsened with acute illness.
In the ED, initial vitals:
T 104.6 HR 134 BP 85/45 R 22 SpO2 97% RA
- Labs were notable for:
Lactate 4.5->2.3
ALT 244 AST 170 TBil 0.7
WBC 10.4 Hgb 15 Plt 144
___: 12.8 PTT: 23.8 INR: 1.2
Fibrinogen: 303
- Imaging:
___ CT Abd & Pelvis With Contrast
1. No evidence of acute intra-abdominal process.
2. Apparent wall thickening of the bladder may be due to
underdistention, correlate with urinalysis
3. Misty mesentery and prominent para-aortic and iliac chain
lymph nodes are nonspecific, presumed reactive.
___ Chest (Portable Ap)
Low lung volumes. No evidence of acute cardiopulmonary process.
- Patient was given:
3L NS, Piperacillin-Tazobactam 4.5 g, ___ 04:46 IV
Vancomycin 1 mg and IV Acetaminophen IV 1000 mg
On arrival to the MICU the patient was AAOx3 and neasueated with
1 episode of green, non-bloody emesis.
Past Medical History:
DM2 on insulin
Schizoaffective disorder
Sarcoidosis on prednisone 5mg and MTX q ___
HTN
HLD
Depression
Social History:
___
Family History:
coronary artery disease. "heart attacks"
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: T 102.8 HR 107 BP 134/62 R 21 ___ NC
GENERAL: Tired, NAD
HEENT: Dry mucous membranes, sclerae anicteric
___: Regular without murmurs
RESP: No increased wob, mild, bibasilar crackles, without
wheezing or crackles
ABD: Mild lower quadrant tenderness to palpation without rebound
or guarding
EXT: warm, without edema
NEURO: CN II-XII grossly intact, strength ___ UE and ___ b/l,
Regular tremor LUE
DISCHARGE PHYSICAL EXAM:
========================
VITALS: 97.9 PO BP 127 / 82 HR 58 RR 18 pOx 95% RA
GENERAL: awake, appears comfortable
HEENT: moist mucous membranes, sclerae anicteric, EOMI, no OP
lesions
___: Regular without murmurs
RESP: No increased wob, mild, bibasilar crackles, without
wheezing or crackles
ABD: obese, soft, not distended, non tender to palpation
without rebound or guarding, BS+
EXT: warm, without edema
NEURO: awake, alert, oriented to person, place, time, reason
for hospitalization, clear speech, follows multi-step commands,
normal short-term recall
PSYCH: flat affect, calm, cooperative
Pertinent Results:
ADMISSION LABS:
=================
___ 02:42AM BLOOD WBC-10.4* RBC-4.75 Hgb-15.0 Hct-45.4*
MCV-96 MCH-31.6 MCHC-33.0 RDW-13.1 RDWSD-45.3 Plt ___
___ 02:42AM BLOOD Glucose-234* UreaN-17 Creat-1.1 Na-135
K-5.1 Cl-93* HCO3-28 AnGap-19
___ 02:42AM BLOOD ALT-244* AST-170* AlkPhos-74 TotBili-0.7
___ 02:42AM BLOOD TSH-7.3*
___ 02:42AM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
STOOL STUDIES:
===============
___:
CLOSTRIDIUM DIFFICILE.
Positive for toxigenic C difficile by the Cepheid nucleic
amplification assay.
STOOL VIRAL MOLECULAR NoroGI NoroGII
___ 10:16 NEGATIVE1 POSITIVE *2
DISCHARGE LABS:
===============
___ 07:50AM BLOOD WBC-9.7 RBC-3.90 Hgb-12.5 Hct-36.8 MCV-94
MCH-32.1* MCHC-34.0 RDW-13.8 RDWSD-46.3 Plt ___
___ 07:50AM BLOOD ___
___ 07:50AM BLOOD Glucose-135* UreaN-6 Creat-0.7 Na-140
K-3.8 Cl-100 HCO3-30 AnGap-14
___ 07:50AM BLOOD ALT-287* AST-216* LD(LDH)-249 AlkPhos-80
TotBili-0.3
___ 07:50AM BLOOD Albumin-3.1* Calcium-8.8 Phos-3.8 Mg-1.6
IMAGING/STUDIES:
================
CT ABD/PELV ___:
1. No evidence of acute intra-abdominal process.
2. Apparent wall thickening of the bladder may be due to
underdistention,
correlate with urinalysis.
3. Soft tissue stranding within the mesentery and prominent
para-aortic and iliac chain lymph nodes are nonspecific,
presumed reactive. However, given that these are more numerous
in number than would be expected in the normal range, a follow
up CT of the abdomen and pelvis is recommended in 6 months, to
ensure stability or resolution.
RECOMMENDATION(S): 6 month follow up CT of the abdomen and
pelvis is
recommended.
Brief Hospital Course:
___ is a ___ woman history of diabetes and schizoaffective
disorder presented with ___ day history of nausea, vomiting and
diarrhea found to be febrile, hypotensive with elevated lactate
in ED, and then C.diff and norovirus positive. Initially
admitted to the ICU, where she improved with volume
resuscitation, stress dose steroids, and initiation of PO
vancomycin. Transferred to the floor where she continued gradual
improvement until discharge.
.
#C. DIFF: C. diff positive- husband reports she was taking Cipro
___ weeks ago (although patient denied this, and stated her
husband has a poor memory). No leukocytosis and CT abdomen with
only reactive lymph nodes. Patient also on chronic
immunosuppression, as well as BID omeprazole, both of which
could have played a role in why she was C. diff positive. She
was started on PO vancomycin on ___. Her diarrhea gradually
improved. Plan to continued vancomycin 125 mg q6h for 2 week
course (last day of abx will be ___
.
#NOROVIRUS: Noro positive- accounts for nausea/vomiting/diarrhea
at presentation in conjunction with c. diff. She was given
volume resuscitation in ICU until she tolerated PO. Vomiting
resolved rapidly. Nausea gradually improved. Diarrhea gradually
improved as well. She was advised that it may take days to
weeks for her abdomen to feel completely back to normal after
gastroenteritis with Noro.
.
#SARCOIDOSIS: On prednisone 5 mg daily and MTX q ___.
Given acute illness and hypotension on presentation she was
given stress dose steroids (15 mg prednisone for 3 days) for
acute adrenal insufficiency prior to transitioning back to her
home prednisone regimen on ___. She was not given a dose of
MTX on ___, due to ongoing diarrhea from
combination of C. diff and norovirus. She can resume her MTX
regimen at the discretion of her primary ___ MD who
manages her sarcoidosis.
.
#TRANSAMINITIS: ALT 244 AST 170, TBil 0.7 on admission. Given
ratio of ALT>AST, this was c/w for ___. Other causes such as
cholangitis or other infectious etiologies were thought to be
unlikely given lack of leukocytosis and normal abdominal
imagining. Transaminases decreased after aggressive fluid
resuscitation in ICU, but on day of discharge, with patient
feeling well, they were elevated at approximately the same level
as they were on admission. This suggests a chronic process,
perhaps NASH or MTX. We would advise repeat LFTs in ___ weeks,
following recovery from her current acute illness, with
additional work-up as needed at that time.
.
#COAGULOPATHY: INR 1.2. No signs of bleeding, may be due to poor
PO intake, however, elevated LFTs and thrombocytopenia may
suggest underlying hepatic dysfunction. Albumin 2.9. INR was
stable and was 1.2 on the day of discharge. We would advise
repeat coags in ___ weeks, following recovery from her current
acute illness, with additional work-up as needed at that time.
.
#Thrombocytopenia: Unclear baseline, plt on admission 144. As
above, given elevated INR and LFTs, may have underlying hepatic
dysfunction though CT abd/pelvis does not note significant
steatosis or cirrhosis. Likely related to acute infection vs.
chronic suppression from medications or chronic liver disease.
We would advise repeat CBC in ___ weeks, following recovery from
her current acute illness, with additional work-up as needed at
that time.
.
#DM: reportedly on insulin at home. Unclear regimen. Was on
insulin sliding scale while inpatient with FSGs relatively
well-controlled. We subsequently identified her outpatient
regimen and she was started on NPH AM & ___ with Novolog BID
standing plus sliding scale at bedtime (there had been an error
on admission, where she was given a new MRN which, prior to
identification of the error, made it difficult to identify he
prior medications, PMHx, past labs, etc.).
.
#Essential tremor: per patient seems exacerbated from baseline
since acute illness. Improved over course of her
hospitalization. Negligible at time of discharge.
.
# OSA: on CPAP at home.
.
# Schizoaffective disorder: Pt is seen by Psychiatrist- Dr.
___ and Psychoanalyst- Dr. ___
___ (___). Per med rec, she is Depakote 100mg qhs,
presumably for mood disorder. We continued home meds of
Depakote and Fluvoxamine. SW was consulted at patient's
request.
.
# HTN: Resumed BP meds amlodipine and Toprol after hypotension
resolved. Held lisinopril on admission, and her BP remained wnl
while inpatient, so lisinopril was not resumed at the time of
discharge. She should have repeat BP within 1 week and
lisinopril can be resumed as needed.
.
# Hypothyroidism: TSH wnl. Continued home levothyroxine.
.
# Home situation: it seems she is the primary caretaker of her
husband, who is himself on disability with multiple medical
problems. She requested social work assistance, and was visited
by the ___ team on several occasions during this hospitalization.
.
# Additional transitional issues:
- Will require 6 mo. follow up CT abdomen recommended for
"misty mesenteric lymph nodes"
.
.
.
.
.
Time in care: 75 minutes in patient care, patient counseling,
care coordination and other discharge-related activities today.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN cough/wheezing
2. amLODIPine 2.5 mg PO DAILY
3. Divalproex (EXTended Release) 1000 mg PO DAILY
4. econazole 1 % topical BID:PRN rash
5. Fluticasone Propionate NASAL 2 SPRY NU DAILY
6. Fluvoxamine Maleate 200 mg PO HS
7. FoLIC Acid 1 mg PO DAILY
8. Levothyroxine Sodium 112 mcg PO DAILY
9. Metoprolol Succinate XL 25 mg PO DAILY
10. OLANZapine 17.5 mg PO QHS
11. Lisinopril 20 mg PO DAILY
12. Acetaminophen ___ mg PO Q8H:PRN pain
13. Omeprazole 20 mg PO BID
14. TraZODone 50-100 mg PO QHS:PRN insomnia
15. calcium carbonate-vitamin D3 1,000 mg(2,500 mg)-800 unit
oral BID
16. Ferrous Sulfate 325 mg PO DAILY
17. NPH 20 Units Breakfast
NPH 16 Units Dinner
Novolog 4 Units Breakfast
Novolog 4 Units Dinner
Insulin SC Sliding Scale using Novolog Insulin
18. Fexofenadine 180 mg PO DAILY
19. Methotrexate 25 mg SC 1X/WEEK (WE)
20. Aspirin 81 mg PO DAILY
21. Cyanocobalamin 500 mcg PO DAILY
22. PredniSONE 5 mg PO DAILY
23. Simvastatin 20 mg PO QPM
Discharge Medications:
1. vancomycin 125 mg oral Q6H Duration: 10 Days
RX *vancomycin 125 mg 1 capsule(s) by mouth every 6 hours Disp
#*40 Capsule Refills:*0
2. NPH 20 Units Breakfast
NPH 16 Units Dinner
Novolog 4 Units Breakfast
Novolog 4 Units Dinner
Insulin SC Sliding Scale using Novolog Insulin
3. Acetaminophen ___ mg PO Q8H:PRN pain
4. Albuterol Inhaler ___ PUFF IH Q6H:PRN cough/wheezing
5. amLODIPine 2.5 mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. calcium carbonate-vitamin D3 1,000 mg(2,500 mg)-800 unit
oral BID
8. Cyanocobalamin 500 mcg PO DAILY
9. Divalproex (EXTended Release) 1000 mg PO DAILY
10. econazole 1 % topical BID:PRN rash
11. Ferrous Sulfate 325 mg PO DAILY
12. Fexofenadine 180 mg PO DAILY
13. Fluticasone Propionate NASAL 2 SPRY NU DAILY
14. Fluvoxamine Maleate 200 mg PO HS
15. FoLIC Acid 1 mg PO DAILY
16. Levothyroxine Sodium 112 mcg PO DAILY
17. Methotrexate 25 mg SC 1X/WEEK (WE)
18. Metoprolol Succinate XL 25 mg PO DAILY
19. OLANZapine 17.5 mg PO QHS
20. Omeprazole 20 mg PO BID
21. PredniSONE 5 mg PO DAILY
22. Simvastatin 20 mg PO QPM
23. TraZODone 50-100 mg PO QHS:PRN insomnia
24. HELD- Lisinopril 20 mg PO DAILY This medication was held.
Do not restart Lisinopril until ___ are seen by your PCP and
have your BP checked
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
Norovirus gastroenteritis
C. diff colitis
Severe sepsis
Acute adrenal insufficiency
Transaminitis - mild
Thrombocytopenia - mild
Coagulopathy - mild
SECONDARY:
Sarcoidosis on chronic MTX and prednisone
HTN
OSA
Uncontrolled diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mrs. ___,
___ were admitted to the hospital with nausea, vomiting,
diarrhea, and low blood pressure. ___ were initially treated in
the ICU with holding your home BP medications, with IV fluids,
and with anti-nausea medications. Your stool tested positive
for a type of bacteria called C. diff, so ___ were started on an
oral antibiotic for treatment of this (vancomycin). ___ also
tested positive for a viral infection called Norovirus.
Ultimately, your blood pressure improved and your vomiting
resolved and ___ were transferred out of the ICU. Your diarrhea
gradually resolved and on the day of discharge ___ were
tolerating food and not having frequent diarrhea. ___ will need
to take this antibiotic for until ___ to complete a total
course of 2 weeks.
Of note, your home lisinopril was held during this
hospitalization, and not resumed on discharge because your blood
pressure was not elevated. Please see ___ primary care
physician ___ 1 week to have your blood pressure checked and
potentially resume this medication.
Of note, due to your recent severe illness and ongoing diarrhea,
___ did not receive your weekly dose of methotrexate on
___. Please contact your Rheumatologist to
discuss when ___ should resume methotrexate injections.
___ have several new mild abnormalities on laboratory testing
that appear to be new compared to your prior labs. Please
follow up with Dr. ___ in ___ weeks to have your labs
rechecked outside of the setting of acute illness.
It was a pleasure caring for ___ while ___ were at ___, and we
wish ___ a full and speedy recovery.
Sincerely,
The ___ Medicine Team
Followup Instructions:
___
|
19612206-DS-19
| 19,612,206 | 21,121,819 |
DS
| 19 |
2138-08-01 00:00:00
|
2138-08-06 15:14:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Erythromycin Base / miconazole
/ Ilotycin
Attending: ___
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
___: CT guided lymph node biopsy of retroperitoneal lymph
node
History of Present Illness:
___ with h/o sarcoidosis, IDDM, HTN presenting with fevers.
She
has had rising fevers over the past three days at home: 2 days
ago, 99; yesterday 102; today 103.2. Patient reports that she
has
not been in her baseline for the last 2 weeks. She has been
feeling more tired, with "sensation of fever", chills, sweating,
decreased appetite and mild shortness of breath. Patient reports
that she has had some of those symptoms in her previous
sarcoidosis flare. She takes MTX 25mg and prednisone 5 mg and
has
been stable on these doses. She was recently in the ED and MICU
admission on ___ with fevers and suspected UTI versus CNS
infection c/b hypotension thought to be due to adrenal crisis
versus septic shock (thought to be less likely, cultures
pending). She was noted to have thrombocytopenia and increased
retroperitoneal lymphadenopathy and has been referred to
Hematology for biopsy. She has also been referred to GI for
colonoscopy to evaluate for ischemic colitis for a history of
bloody stools. Patient reports that she had not had any new
episodes of rectal bleeding. Patient endorses intermittent
abdominal pain, productive cough with yellowish sputum and
urinary frequency. Patient denies nausea, vomit, chest pain,
dysuria, hematuria, weakness/numbness or. She denies sick
contacts, bug bites, exposures, recent travel, new foods.
In the ED, initial vitals: 101.3 105 22 146/80 94 RA
- Exam notable for:
Large echymoses on lower abdomen around insulin injection sites;
___, pink non-tender non-blanching rash on anterior lower
extremities from ankles to mid-shin bilaterally.
- Labs notable for:
WBC RBC Hgb Hct MCV MCH MCHC RDW RDWSD Plt Ct
12.2* 3.83* 11.9 35.1 92 31.1 33.9 13.4 43.6 140*
Neuts Lymphs Monos Eos Baso NRBC ImGran AbsNeut
57.8 19.6 18.2* 2.6 0.6 0.2 1.2 7.07
AbsLymp AbsMono AbsEos AbsBaso
2.40 2.22* 0.32 0.07
___ PTT ___
12.9 26.6 1.2
Glucose UreaN Creat Na K Cl HCO3 AnGap
134 6 0.8 141 3.3 97 26 18
Lactate 1.6
MICROSCOPIC URINE EXAMINATION
RBC WBC Bacteri Yeast Epi
1 9 NONE NONE 1
- Imaging notable for:
CHEST XRAY
Patient is rotated to the left. Left lung base atelectasis is
noted. There are small bilateral pleural effusions. Lungs are
otherwise clear without consolidation or edema. The
cardiomediastinal silhouette is within normal limits. No acute
osseous abnormalities.
- Pt given: Tylenol, ondansetron
- Vitals prior to transfer: 102.9 96 20 127/83 96RA
Past Medical History:
DM2 on insulin
Schizoaffective disorder
Sarcoidosis on prednisone 5mg and MTX q ___
HTN
HLD
Depression
Social History:
___
Family History:
Mother - anxiety, HTN, IBS, polymyalgia rheumatic
Father - HTN, CLL
MGF - stroke
PGF - stroke
PGM - breast cancer, Alzheimer's disease, Crohn's disease
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: 102.7 114/69 HR 96 RR 18 95 2L
General: Alert, oriented, no acute distress
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, distended, non-tender at deep palpation
Ext: Warm, well perfused, no edema.
Skin: pink non-tender rash on anterior lower extremities from
ankles to mid-shin bilaterally.
Neuro: Grossly intact.
DISCHARGE PHYSICAL EXAM:
VS: 98.4 126 / 77 90 18 94 Ra
General: Alert, laying in bed, oriented, anxious-appearing but
in
no acute distress
CV: RRR, normal S1 + S2, no m/r/g
Lungs: CTAB, no wheezes/rales/rhonchi
Abdomen: Soft, distended. Large echymoses on lower abdomen
around
insulin injection sites.
Ext: Warm, well perfused, no edema.
Skin: pink non-tender rash on anterior lower extremities from
ankles to mid-shin bilaterally.
Neuro: Grossly intact. Moving all extremities with purpose.
Pertinent Results:
ADMISSION LABS:
___ 04:00PM BLOOD WBC-9.4 RBC-3.90 Hgb-12.4 Hct-36.5 MCV-94
MCH-31.8 MCHC-34.0 RDW-13.7 RDWSD-46.2 Plt ___
___ 04:00PM BLOOD Neuts-66.5 Lymphs-15.3* Monos-14.8*
Eos-2.1 Baso-0.6 Im ___ AbsNeut-6.26* AbsLymp-1.44
AbsMono-1.39* AbsEos-0.20 AbsBaso-0.06
___ 04:00PM BLOOD Plt ___
___ 11:40AM BLOOD Glucose-134* UreaN-6 Creat-0.8 Na-141
K-3.3 Cl-97 HCO3-26 AnGap-18*
INTERIM LABS:
___ 07:50AM BLOOD ALT-16 AST-17 LD(LDH)-294* AlkPhos-58
TotBili-0.4
___ 01:20PM BLOOD CRP-94.3*
___ 06:50AM BLOOD HIV Ab-NEG
___ 04:00PM BLOOD Valproa-60
___ 11:48AM BLOOD Lactate-1.6 K-4.2
MICROBIOLOGY:
___: Lyme IgG/IgM - negative
___ 6:50 am Blood (EBV)
**FINAL REPORT ___
___ VIRUS VCA-IgG AB (Final ___: POSITIVE
BY EIA.
___ VIRUS EBNA IgG AB (Final ___: POSITIVE
BY EIA.
___ VIRUS VCA-IgM AB (Final ___:
NEGATIVE <1:10 BY IFA.
IMAGING:
___: CT Guided Lymph Node Biopsy: Successful CT-guided biopsy of
the enlarged left retroperitoneal lymph node. Core-biopsy sample
sent for pathology and microbiology. No immediate postprocedural
complications.
___: CT Chest with Contrast: Enlarged mediastinal, axillary and
upper retroperitoneal lymph nodes as
documented above. Please refer to detailed report for more
information.
DISCHARGE LABS:
___ 06:35AM BLOOD WBC-12.0* RBC-3.69* Hgb-11.7 Hct-35.1
MCV-95 MCH-31.7 MCHC-33.3 RDW-14.3 RDWSD-48.5* Plt ___
___ 06:35AM BLOOD Plt ___
___ 06:35AM BLOOD Glucose-155* UreaN-7 Creat-0.9 Na-141
K-4.3 Cl-97 HCO3-29 AnGap-15
___ 06:35AM BLOOD Calcium-8.9 Phos-3.4 Mg-1.8
Brief Hospital Course:
SUMMARY
========
___ w/ PMHx of sarcoidosis (on pred and MTX at home), IDDM, HTN,
HLD presented with rising fevers several days, night
chills/sweating and decreased appetite, with recent progression
of retroperitoneal and mesenteric lymphadenopathy concerning for
sarcoid vs. lymphoma vs. infectious etiology. A CT chest
confirmed additional spread the mediastinal, axillary and upper
retroperitoneal lymph nodes. Her presentation was not entirely
consistent with her prior sarcoid flares, which manifested with
bilateral uveitis, erythema nodosum, and fevers. To narrow the
differential, a lymph node biopsy was performed to obtain an
infrarenal, para-aortic lymph node (retroperitoneum).
TRANSITIONAL ISSUES
=================
- She was discharged with prescriptions for blood sugar test
strips as well as lancets and syringes for insulin
administration at home given that she had been reusing her old
lancets and syringes.
- There was initial confusion regarding medications:
-- Patient reported being on 10mg PO BID of buspirone, but per
prior records had been given 5mg PO BID, which was continued
during this admission
-- Patient reported being on weekly fluconazole for
prophylaxis against yeast infection, which was confirmed and
continued this admission
- Follow-up with rheumatology and her PCP both about ongoing
care of her sarcoidosis as well as results and further
management of her biopsy results
- Initial preliminary pathology review showed fragments of
lymphoid tissue with granulomata showing some central necrosis
and surrounding areas with lymphocytes and plasma cells. Bug
stains for microorganisms were ordered as well as flow cytometry
and immunohistochemistry studies to further evaluate for
involvement by a lymphoproliferative disorder are pending.
Results will not be available until ___ per pathology. No
initial signs of overt malignancy were seen, but the pathologist
will need all of the data to definitively exclude the
possibility of lymphoma.
ACUTE/ACTIVE PROBLEMS:
#Fever AND
#Lymphadenopathy
Etiology of fever was not clear on presentation. The
differential diagnosis included a sarcoidosis flare given her
history of sarcoid, versus an infectious etiology (in the
setting of immunosuppression on prednisone) versus lymphoma. A
UA+urine culture, blood culture, and CXR were all negative
regarding her infectious workup. Consideration was given to a
sarcoidosis flare since her past flares manifested with fever
responsive to prednisone increases. She received a stress dose
of prednisone dose for three days and went back to her home
dose. She continued to have fevers, was cultured for blood and
urine and has since not grown any microorganisms. Her previous
CT (___) showed retroperitoneal and mesenteric lymphadenopathy
with mild mesenteric stranding. RP LNs increased in size since
___ CT concerning for lymphoma per rheum as well (Dr.
___ ___. Rheumatology recommended holding her home
methotrextate until further information regarding her lymph node
biopsy was obtained. Results of the lymph node biopsy are
pending.
#Sarcoidosis
Her initial diagnosis was in ___, when she presented with
bilateral uveitis, fever, erythema nodosum and lymphadenopathy.
She was given stress dose steroids triple that of her home dose
of 4mg (15mg for 3 days). Rheumatology was consulted as above
and they recommended holding her methotrexate. In the past her
flares have manifested as uveitis, erythema nodosum, and fever,
however these were not present on this admission except for
fever.
CHRONIC/STABLE PROBLEMS:
#Schizoaffective disorder: The patient is seen by Psychiatrist
Dr. ___ and Psychoanalyst- Dr. ___ (___). We continued depakote and olanzapine.
Per patient, she reported she was also on buspar 10mg BID,
however, the psychiatrist could not be reached and the dose
could not be confirmed. A recent admission showed she was on 5mg
of buspar and she received 5mg BID daily.
#HTN
She was normotensive in-house therefore home amlodipine,
metoprolol, lisinopril were held.
#Hypothyroidism: TSH normal on this admission. She was continued
on home levothyroxine.
#Anxiety: She was continued on home depakote, olanzapine, and
fluvoxamine.
#OSA: She was continued on CPAP. She occasionally refused to
wear her CPAP at night.
> 30 minutes was spent in discharge planning and coordination
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Cyanocobalamin 500 mcg PO DAILY
2. Divalproex (EXTended Release) 1000 mg PO QHS
3. FoLIC Acid 1 mg PO DAILY
4. Levothyroxine Sodium 112 mcg PO DAILY
5. Nystatin Ointment 1 Appl TP DAILY
6. OLANZapine 5 mg PO QHS
7. Omeprazole 20 mg PO BID
8. PredniSONE 4 mg PO DAILY
9. Simvastatin 20 mg PO QPM
10. TraZODone 100 mg PO QHS
11. Ezetimibe 10 mg PO DAILY
12. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg
calcium- 200 unit oral BID
13. Aspirin 81 mg PO DAILY
14. GlipiZIDE XL 10 mg PO DAILY
15. metHOTREXate sodium 25 mg/mL injection 1X/WEEK (WE)
16. Fluconazole 150 mg PO 1X/WEEK (WE)
17. Fluvoxamine Maleate 200 mg PO QHS
Discharge Medications:
1. Fexofenadine 60 mg PO BID
2. Fluticasone Propionate NASAL 1 SPRY NU BID
3. BusPIRone 5 mg PO BID
4. Aspirin 81 mg PO DAILY
5. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg
calcium- 200 unit oral BID
6. Cyanocobalamin 500 mcg PO DAILY
7. Divalproex (EXTended Release) 1000 mg PO QHS
8. Ezetimibe 10 mg PO DAILY
9. Fluconazole 150 mg PO 1X/WEEK (WE)
10. Fluvoxamine Maleate 200 mg PO QHS
11. FoLIC Acid 1 mg PO DAILY
12. GlipiZIDE XL 10 mg PO DAILY
13. novolin n 25 Units Breakfast
novolin n 18 Units Bedtime
novolog 12 Units Breakfast
novolog 12 Units Lunch
novolog 12 Units Dinner
Insulin SC Sliding Scale using Novolog Insulin
14. Levothyroxine Sodium 112 mcg PO DAILY
15. Nystatin Ointment 1 Appl TP DAILY
16. OLANZapine 5 mg PO QHS
17. Omeprazole 20 mg PO BID
18. PredniSONE 4 mg PO DAILY
19. Simvastatin 20 mg PO QPM
20. TraZODone 100 mg PO QHS
21. HELD- metHOTREXate sodium 25 mg/mL injection 1X/WEEK (WE)
This medication was held. Do not restart metHOTREXate sodium
until your rheumatologist recommends resuming it.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS: Lymphadenopathy
SECONDARY DIAGNOSES: Sarcoidosis, Schizoaffective disorder,
hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You came to ___ because of fevers. You were found to have
enlarged lymph nodes in your chest and abdomen. Lymph nodes are
required for immunity and for fighting infection. Please see
more details listed below about what happened while you were in
the hospital and your instructions for what to do after leaving
the hospital.
It was a pleasure participating in your care. We wish you the
best!
Sincerely,
Your ___ Care Team
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL:
- We increased your home dose of prednisone for 3 days
- We checked a chest xray, blood, and urine cultures for any
signs of infection
- A lymph node biopsy was performed to assess the cause of your
fevers
- Medications for fever and pain control were given
WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL:
- Please follow up with your primary care doctor and other
health care providers (see below). Please follow-up with
Rheumatology and with your primary care doctor.
- Please do not re-use lancets or syringes for insulin.
- Please take all of your medications as prescribed (see below).
- Seek medical attention if you have recurrent fevers, nausea,
vomiting or other symptoms of concern.
Followup Instructions:
___
|
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